For those wondering how did it happen a review of Garuda GA200 might be in order,the 737 touched down at an airspeed of 221 knots, 87 knots faster than landing speed for 40 degrees flap and ran off the end at 110 knots, though they did have the gear down in this case.
1.Absorption. A state of being so focused on a specific task that other tasks are disregarded.
2.Fixation: A state of being locked onto one task, or one view of a situation, even as evidence accumulates that attention is necessary elsewhere, or that the particular view is incorrect.
3.The ‘tunneling or channelizing’ that can occur during stressful situations, which is an example of fixation. Note: The term ‘fixation’ has been chosen to describe the PIC’s state of alertness, which provides a clearer idea of ‘being locked onto one task’, than ‘absorption’. Several ‘findings’ support this ‘tunneling or channelized’ condition, for example:
•The PIC’s attention became fixated on landing the aircraft. The concept of fixation is reinforced because he asked the copilot a number of times to select flaps 15 and asked if the landing checklist had been completed.
•The PIC did not respond to the 15 GPWS alerts and warnings and the two calls from the pilot monitoring to go-around. The PIC did not change his plan to land the aircraft, although the aircraft being in unstabilized condition. The other tasks that needed his attention were either not heard or disregarded. The auditory information about other important things did not reach his conscious awareness.
•The PIC said ‘The target is 6.6 ILS, we will not reach it’. The PIC flew an unstabilized approach. He also realized the abnormal situation when he commented ‘Wah, nggak beres nih!’ (‘Oh, there is something not right’). So, the PIC’s intention to continue to land the aircraft, from an excessively high and fast approach, was a sign that his attention was channelized during a stressful time.
•The PIC also asked several times for the copilot to select flaps 15. During interview he said to investigator that ‘his goal was to reach the runway and to avoid severe damage’. He ‘heard, but did not listen to the other voice (GPWS), and flaps 15 and speed 205 was enough to land’. The PIC experienced a heightened sense of urgency, and was motivated to escape from what he perceived to be a looming catastrophe, being too high to reach the runway (09 threshold). He fixated on an escape route, ‘which seem most obvious’, aiming to get the aircraft on the ground by making a steep descent. His decision was flawed, and in choosing the landing option rather than the go around, fixated on a dangerous option.
•The PIC was probably emotionally aroused, because his conscious awareness moved from the relaxed mode ‘singing’ to the heightened stressfulness of the desire to reach the runway by making an excessively steep and fast, unstabilized approach.
Hazardous States of Awareness
Inattention, or decreased vigilance, is often cited in ASRS reports, and has been a contributor to operational errors, incidents, and accidents. Decreased vigilance manifests itself in several ways, which can be referred to as hazardous states of awareness. These states include:
•Absorption is a state of being so focused on a specific task that other tasks are disregarded. Programming the FMS to the exclusion of other tasks, such as monitoring other instruments, would be an example of absorption. The potential for absorption is one reason some operators discourage their flight crews from programming the FMS during certain flight phases or conditions (e.g., altitude below 10,000 feet).
•Fixation is a state of being locked onto one task or one view of a situation even as evidence accumulates that attention is necessary elsewhere, or that the particular view is incorrect. The ‘tunneling’ that can occur during stressful situations is an example of fixation. For example, a pilot may be convinced that a high, unstabilized approach to landing is salvageable even when other flight crew members, air traffic control, and cockpit instrument strongly suggest that the approach cannot be completed within acceptable parameters. The pilot will typically be unaware of these other inputs and appear to be unresponsive until the fixation is broken. Fixation is difficult to self-diagnose, but it may be recognizable in someone else.
•Preoccupation is a state where one’s attention is elsewhere (e.g., daydreaming). Decreased vigilance can be caused or fostered by a number of factors, including:
•Fatigue, which has been the subject of extensive research and is well recognized as a cause of decreased vigilance.
•Underload, which is increasingly being recognized as a concern. Sustained attention is difficult to maintain when workload is very low.
•Complacency. Automated systems have become very reliable and perform most tasks extremely well. As a result, flight crews increasingly rely on the automation. Although high system reliability is desired, these high reliability effects flight crew monitoring strategies in a potentially troublesome way. When a failure occurs, or when the automation behavior violates expectations, the flightcrew may miss the failure, misunderstand the situation, or take longer to assess the information and respond appropriately. In other words, over reliance on automation can breed complacency, which hampers the flight crew’s ability to recognize a failure or unexpected automation behavior.
http://knkt.dephub.go.id/knkt/ntsc_a...%20Release.pdf