International Journal of Aviation,

Aeronautics, and Aerospace

Volume 9 Issue 1 Article 1

2022

The Five Hazardous Attitudes, A Subset of Complacency

Peter S. Neff
Middle Tennessee State University, peter.neff@mtsu.edu

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Scholarly Commons Citation

Neff, P. S. (2022). The Five Hazardous Attitudes, A Subset of Complacency. International Journal of
Aviation, Aeronautics, and Aerospace, 9(1). https://doi.org/10.15394/ijaaa.2022.1677

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 Neff: The Five Hazardous Attitudes, A Subset of Complacency

The definition of complacency embodies the characteristics of being self-

satisfied with the circumstances even when a person is unaware of potential dangers
(Mirriam-Webster, 2022). The uninformed self-satisfaction characteristic of
complacency frequently manifests itself through a compliance drift or a
normalization of deviance. Checklists might be performed from memory without
the requisite read and verify protocol. A repetitive deviance that has become
institutionalized might make the difference between a professional performance
and a hazardous performance. Complacency might be perceived as the overarching
human factors hazardous attitude with the Federal Aviation Administration (FAA)
identified five hazardous attitudes of anti-authority, impulsivity, invulnerability,
macho, and resignation a subset of complacency.
The FAA lists 12 common causes of human factors errors prevalent in the
aviation workplace with complacency listed in the number two spot on the list.
Complacency is characterized as overconfidence gained through the repetitive
performance of a task (FAA Safety Team, n.d.). In the cockpit, repetitive tasks
describe the rhythm and choreography of challenge-response or read and verify
checklist completion protocols which might lead to the memorization of the
checklists. Completion of the repetitive tasks through memorization can lead to
normalization of deviance and complacency.
In the case of the GIV flight crew taking off in Bedford, MA., the
normalization of deviance manifested itself in the repetitive failure of the crew to
unlock the flight controls in the After Start checklist and to perform a flight control
check in the Taxi checklist on 98% of their previous 175 flights (National
Transportation Safety Board [NTSB], 2015) resulted in the death of seven people.
In this accident sequence, the flight crew appeared to lose focus in the
performance of the task at hand. The voice recorder recorded the crew discussing a
phone call (NTSB, 2015) prior to starting the engines. By completing the five
checklists required from start to takeoff from memory and with less than 100%
focus, the crew performed in a hazardous manner. A professional performance of
completing the checklists using a challenge-response methodology would have
resulted in the correction of the task error of not unlocking and checking the flight
controls.
In the case of the GIII accident in Aspen, CO., the crew’s actions indicated
complacency in committing several critical errors during the flight. The crew never
associated the pending mountainous night fall with the prohibition of executing the
non-precision approach to the airport (NTSB, 2001). The crew failed in the
thorough preparation for the flight during the flight planning phase to recognize
that the approach was a circling approach due to the high rate of descent required
on the final segment of the approach. The crew completed the tasks in their usual
manner. They did not check any airport information beyond getting the weather.
These actions violated the procedures outlined in 14 CFR part 91 (FAA, 2021a)

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that required the crew to become familiar with all aspects of the flight. This
superficial preflight seems to be the expected norm and represented a complacent
practice on the part of the crew. In combination with several other factors, the
accident resulted in 17 fatalities.
Complacency functions as an overarching human factor for the five
hazardous attitudes. Overconfidence is a foundational element of complacency with
a subset of an attitude that lacks the holding of oneself to a higher standard of
performance. This attitude relates to a lack of proficiency and to the acceptance of
lower individual standards. A pilot must challenge oneself to learn new things about
the airframe and the standard operating procedures or regulations that are a
rudimentary part of continuous learning, eliminating complacency, and demanding
higher standards of performance. If a pilot is complacent, it is not a matter of if a
pilot will exhibit one or more of the hazardous attitudes, but when.
Five Hazardous Attitudes

The FAA has identified five hazardous attitudes that have the potential to
influence the pilots’ ability to respond to “people, situations, or events” in a manner
conducive to aviation safety (FAA, 2017a, p. 2-5). According to the FAA, the
hazardous attitudes precipitate poor judgement in all flight regimes. The five
hazardous attitudes are represented in Table 1.

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 Neff: The Five Hazardous Attitudes, A Subset of Complacency

Table 1

Five Hazardous Attitudes

Note. Table 1 is reproduced based on Figure 2-4 (FAA, 2017a, p.2-5)

Hazardous Attitudes Explained

Attitude
Merriam-Webster (n.d.) provides a definition of attitude that embodies the
concept of a predisposed response to certain stimuli. The stimuli could be
situations, objects, or authority. As with the majority of professions, a pilot’s
positive, negative, or neutral attitude affects performance and decision making. By
extension, pilot attitude is directly foundational to aviation safety.
Anti-Authority
Anti-authority exemplifies more depth than the usual antidote of follow the
rules. Pilots with an anti-authority attitude often discriminate between legitimate

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authority and illegitimate authority (Leach, 2005). Legitimate authority is

perceived to be federal regulations or standard operating procedures written by a
recognized authority such as the FAA or the pilot’s employer. Illegitimate authority
is perceived to emanate from organizations or persons who do not have delegated
authority. The norms of the group do not attribute trustworthiness to the
manipulation of the individual or the organization attempting to influence the group
(Leach, 2005).
Impulsivity
Impulsivity is commonly defined as the need to do something immediately.
The action usually occurs prior to an analysis of the situation and an action to solve
or mitigate an issue. Maintain aircraft control, analyze the situation, and take the
proper action are emergency situation principles (Hostage, 2016). Components of
the analysis include training and experience applied through a prioritization and
compartmentalization protocol (Hostage, 2016). An old adage suggests that a pilot
should “wind the clock” in the face of an emergency. This action, or euphonism,
provides an outlet for the adrenalin surge and allows the pilot to focus and initiate
the analysis process. The end result should be the application of the correct
procedure rather than a random action with inappropriate results (e.g., shutting
down the incorrect engine).
Invulnerability
Invulnerability captures the concept in aviation, as in life, that accidents
happen to others, but they will not happen to the individual with the invulnerable
attitude. This attitude does not account for an analysis of the risks and an
appreciation of possible outcomes predicated by an action. Actions must occur
based on an analysis of the facts at hand informed by training, experience, and
mission requirements. Accidents/incidents can and do happen to others, but they
can also happen you. The saying pilots are often taught during flight training and
attributed to E. Hamilton Lee in 1949 captured the antidote to invulnerability with
a simple representation that there are old pilots, and there are bold pilots, but there
are no old, bold pilots.
Macho
Macho is often associated with competition among members of a
profession. Men and women attempt through their actions to demonstrate
professional superiority. The competition is thought to be the result of confidence
in one’s ability to perform any task associated with the profession. Success breeds
confidence, however to often confidence exceeds ability (Rossier, 1999). The
macho attitude precludes completing a risk analysis identification of the hazards
involved. Rather, it is based on a continuous need for a pilot to continually prove
himself or herself to be the best (Rossier, 1999). Rossier linked stress and a macho
attitude to the syndromes of either get-home-itis or a hurry-up mentality. The best
antidote for a macho attitude is the elimination of physical stressors such as fatigue

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 Neff: The Five Hazardous Attitudes, A Subset of Complacency

and the few minutes it takes to investigate the potential hazards of the flight and to
complete a risk analysis.
Resignation
Resignation manifests itself when a pilot is faced with a situation that the
pilot believes is beyond their capabilities or out of their control. The feeling of not
being able to change the situation, resignation, is hazardous to life and limb in
aviation. Frequently, the hazardous attitude of resignation is precipitated by
physical or mental stressors (Rossier, 1999). In order to counter the feeling of
resignation, pilots must reduce physical and mental stressors to meet their fiduciary
responsibilities to their passengers and to exert control of the situation and effect
positive change.
Gulfstream III, Aspen, Colorado_AAB-0203
Accident Summary
The accident occurred when an Avjet Corporation operated Gulfstream III
executed the approach to runway 15 in an attempt to land at the Aspen-Pitkin
County Airport in Aspen, Colorado March 29, 2001 (NTSB, 2001). The flight
originated at the Los Angeles International Airport (LAX) and operated under the
auspices of 14 Code of Federal Regulations (CFR) part 135 on an instrument flight
plan to Aspen-Pitkin County Airport (ASE). The aircraft impacted the terrain 2,400
feet short of the runway resulting in the deaths of all 15 passengers, 1 flight
attendant, and 2 pilots (NTSB, 2001).
Anti-Authority
Circling Approach
The FAA issued a Notice to Airmen (NOTAM) stating that a circling
approach was not authorized “at night for runway 15 at ASE [Aspen]” (NTSB,
2001, p. 29). The first officer was made aware that a circling approach to runway
15 at the Aspen airport was not authorized at night when he received his weather
briefing from a Hawthorne, CA Flight Service Station specialist. Additionally, the
approach title, VOR/DME-C, is designated as a circling approach by the letter “C”
versus RWY 15 that would denote a straight-in approach. The flight crew was not
authorized to execute the approach after 1855 local time (NTSB, 2001). In violation
of the FAA directives, the flight crew executed the approach.
The FAA designates an approach as a circling approach if the final approach
course does not fall within 30° of the runway direction or if the descent rate on the
final approach segment exceeds 400 feet per mile (FAA, 2017b, p. 4-11. The Aspen
VOR/DME-C is designated as a circling approach due to the excessive descent rate
required on the final segment of the approach from the final approach fix to the
runway threshold crossing height (NTSB, 2001). The accident crew executed the
approach even though it was not authorized to do so.
Additionally, the flight crew intentionally violated 14 Code of Federal
Regulations (CFR) 91 part 175(c) that required the flight crew to execute a missed

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approach at the missed approach point if the crew could not maneuver the aircraft
for a safe landing using normal rates of descent (FAA, 2021). Further, the flight
crew had been advised that previous aircraft had missed the approach due to a lack
of required visual references at the missed approach point. The crew knew that at
the time they were executing the approach, the required visual references to
complete a safe landing were not present. They continued past the missed approach
point without the required visual references.
Avjet Operations Documents
The NTSB noted that Avjet company policy required “…that the pilot-in-
command will ensure that the flight is conducted in complete compliance with all
Federal, Local, and Company regulations and policies” (NTSB, 2001, p. 24). The
practical application of these regulations, policies, and best practices is published
in company manuals as standard operating procedures (SOP).
In the case of the accident crew, the cockpit voice recorder (CVR) did not
record a briefing of either the instrument approach procedure or the missed
approach procedure (NTSB, 2001). The CVR tape revealed that the captain did not
brief any of the other related required items for the approach to include the speeds,
the aircraft configuration, and the process of executing the approach (NTSB, 2001).
The lack of a detailed crew briefing by the captain was a clear violation of the SOP.
Impulsivity
Night
The definition of night is found in 14 CFR part 1.1 (FAA, 2021). The
regulation establishes the beginning of night as the point where the sun is
“geometrically 6° below the horizon” (NTSB, 2001, p. 30). On the date of the
accident, the flight crew initiated the VOR/DME-C approach to runway 15 at ASE
at 1856:06; 1 minute 6 seconds after the end civil twilight and the beginning of
night. The instrument approach was not authorized at night.
Visibility
Previous traffic had executed the approach legally. However, the crews
missed the approach due to the reduced visibility caused by snow showers at the
airport (NTSB, 2001). Even armed with this knowledge, the crew impulsively
initiated the approach outside of the legal parameters and unreasonably expected to
see the airport visually.
Aircraft Configuration
The aircraft configuration alarm sounded for about 9 seconds after 1901.21
indicating the deployment of flight spoilers with the landing gear and flaps fully
extended (NTSB, 2001). The NTSB also determined that the engine power was set
at 55% N2 (NTSB, 2001). This configuration violates the Gulfstream GIII Flight
Manual that required a minimum N2 of 64% with the landing gear and flaps
extended in order to ensure sufficient power response time to initiate and execute a
successful go-around (NTSB, 2001).

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 Neff: The Five Hazardous Attitudes, A Subset of Complacency

Invulnerability
Initiating the Approach
When the first officer first selected the Aspen Approach frequency, the
accident crew heard a preceding crew of a Canadair Challenger request another
approach. The accident crew asked the approach controller whether the Challenger
crew was executing practice approaches. The approach controller replied that the
Challenger crew was executing a missed approach due to their inability to see the
runway at the missed approach point (NTSB, 2001). The accident crew knew that
they would most likely be unable to see the runway at the missed approach point.
At the missed approach point they did not see the runway, and they continued
beyond the missed approach point and descended below the minimum descent
altitude without visual contact with the runway. They were deluded by their feeling
of invulnerability that everything would work out for them. They impacted the
ground killing everyone aboard a few minutes later.
Macho
Plan Continuation Errors
Velázquez (2016) identified Get-There-Itis (as cited in Dismukes, 2007) as
a pilot behavior trap (p. 29) that affects pilot decision making. The PAVE checklist
“E” addresses plan continuation error through a risk analysis schema reminding
pilots to minimize the negative effects of External pressures. In the case of the
accident flight crew, the customer was sitting on the jumpseat during the approach.
This dynamic placed an extreme external pressure element to perform on the part
of the flight crew. The highly experienced pilots disregarded the conservative
decision to miss the approach when they did not have sufficient visual reference
with the runway environment to complete the landing. Instead, the crew
dangerously continued the approach below the published minimums in the
expectation that the weather was not going to impede them, and their superior flying
capabilities would result in a satisfactory landing and task completion.
Unfortunately for this crew and their passengers, the flight ended by impacting the
ground well short of the runway (NTSB, 2001).

Resignation
Missed Callouts
The captain initiated the non-precision, circling VOR DME or GPS-C
approach to Aspen, CO after the time the approach was authorized. Although the
reported weather and the controlling weather at the time the crew initiated the
approach was above landing minimums, the approach was not authorized after the
end of civil twilight (NTSB, 2001). Additionally, the crew was aware that preceding
traffic had missed the approach. There was no assertive discussion on the part of
the first officer to persuade the captain that the best and legal course of action was
to fly to and land at their alternate.

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By initiating the approach after the night restriction and for a landing in
compliance with local noise regulations, the captain was not in compliance with
Avjet’s policy of compliance with all local regulations (NTSB, 2001). The first
officer did not attempt to persuade the captain that initiating the approach violated
federal, local, and company policy, and they should execute a missed approach and
proceed to their alternate.
During the approach, the first officer was required by company operational
policy to make several callouts as part of his pilot monitoring duties. The first
officer failed to make any of these required callouts. Additionally, when the captain
flew the aircraft into an unusual 40° bank less than 200 feet above the ground, just
prior to ground impact (NTSB, 2001), the first officer did not advise the captain of
the excessive bank angle nor did the first officer take control of the aircraft and
attempt a go around to extricate them from the soon to be fatal circumstances. The
first officer’s resignation that the crew was going to execute an unauthorized
approach into known weather that would prevent a visual night landing regardless
of his input to the contrary was a classic manifestation of the resignation hazardous
attitude.
Failure to Comply
The flight crew failed to comply with 14 CFR part 91.103 that requires that
prior to departure for any flight, the crew must be familiar with all available
information covering all phases of flight. In the case of the accident crew, they did
not discuss the ramifications of the approach into Aspen, CO. The crew was
informed that circling minimums were not authorized at night (NTSB, 2001).
Although the approach course was straight-in because it was aligned within 30° of
the runway, the approach was classified as a circling approach because it required
an excessive rate of descent on the final segment of the approach.
If the approach to runway 15 in Aspen was a straight-in approach, it would
be denoted as the VOR DME or GPS 15 approach. Therefore, the approach
designation, VOR DME or GPS-C, should have keyed the crew that the approach
was classified as a circling approach because the approach name ended in a letter
versus a runway designation.
The crew was complacent in recognizing the implications of the preceding
traffic missing the approach because they failed to acquire the runway visually at
the missed approach point. The accident crew was complacent in that they did not
apply critical thinking to consider the effects of the weather, the mountainous
terrain, the visual illusions created by mountain night time, and the high descent
rate required by the non-precision approach. The crew was resigned to the fact that
they did not have control of the situation, and they did not act to terminate the
approach. This was complacent in meeting their fiduciary responsibility to their
customers, their company, and their fellow crew members. The result was a fatal
accident that could have been prevented by a non-complacent crew.

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Gulfstream G-IV Bedford, Massachusetts – AAR-1503

Accident Summary
The NTSB accident report succinctly summarizes the accident in the
following description.
On May 31, 2014, about 2140 eastern daylight time, a Gulfstream
Aerospace Corporation G-IV, N121JM, registered to SK Travel, LLC, and
operated by Arizin Ventures, LLC, crashed after it overran the end of
runway 11 during a rejected takeoff at Laurence G. Hanscom Field,
Bedford, Massachusetts. The airplane rolled through the paved overrun area
and across a grassy area, collided with approach lights and a localizer
antenna, passed through the airport’s perimeter fence, and came to a stop in
a ravine. (NTSB, 2015, p. vii)
Anti-Authority
Lack of Checklist Discipline
The NTSB review of the aircraft quick access recorder (QAR) exposed the
fact that the crew failed to check the flight controls as required by the After Starting
Engines checklist on this flight and on 98% of the previous 175 flights (NTSB,
2015). The NTSB also found that the flight crew had been flying together over the
previous seven years, and the crew routinely did not use checklists nor did the crew
use the industry best practice of performing checklists using a challenge-response
format (NTSB, 2015).
An NTSB review of the G-IV aircraft flight manual (AFM) identified five
checklists that should have been accomplished by the flight crew during the period
from engine start to takeoff (NTSB, 2015). There is no evidence that any of these
checklists were accomplished. Additionally, two of the checklists contained items
that would have alerted the flight crew that the flight controls were locked. The
NTSB (as cited in Dismukes, et al. 2006) noted that 20% of flight crew accidents
are the result of highly trained crews committing an error of omission. The
completion of checklists in aviation provides a defense against errors of omission
in routine and abnormal circumstances. They are foundational to the development
and application of standard operating procedures (FAA, 2004).
The second in command (SIC) on this flight was the Chief Pilot and the
Director of Maintenance. These positions are required for 14 CFR part 135 air
carrier certification and operations by 14 CFR part 119.69 (FAA, 2021). It is
particularly egregious that this flight crew did not follow the best operating
practices and standard operating procedures developed by the SIC himself through
his position of executive leadership in the company. Seven people might still be
alive today if the crew had followed the protocal developed for safe operations.
Impulsivity
Missed Chances

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The flight crew decided to disregard the advisory message Rudder Limit and
to initiate the takeoff without determining the cause of the advisory light. The usual
reasoned response to any abnormal or unusual cockpit indication should be to
determine a reason for the indication. The accident crew chose to minimize the
advisory with a conversation that did not include any investigation regarding cause
(NTSB, 2015). After the crew initiated the takeoff roll, the loading of the elevator
and the subsequent movement of the elevator toward the neutral position did not
occur and went unrecognized by the flightcrew. This movement of the elevator
from 13° trailing edge down to 0° trailing edge down at 60 KIAS indicates that the
elevator has moved to the neutral position due to airflow over the control surface
and is functioning in a normal manner (NTSB, 2015). If the flight crew had
recognized this movement and rejected the takeoff in the low speed takeoff regime
below 80 KIAS, the accident could have been prevented.
The flight crew also missed a second chance to abort the takeoff when the
SIC called V1 6.2 seconds after the 80 Kt callout. The speed, V1, is considered the
takeoff decision speed and represents the last speed at which the aircraft can be
aborted safely in the remaining runway. During the takeoff roll, the crew was
preoccupied with the thrust lever annomoly and with the locked flight controls.
Additionally, the PIC attempted to use an unapproved procedure to free the flight
controls in this high speed regime between 80 KIAS and V1. Other than the standard
callouts, the SIC appeared to offer no input regarding the PIC’s actions during this
phase of flight (NTSB, 2015).
Invulnerability
Lack of Situational Awareness
According to the NTSB accident report, AAR1503, when the aircraft taxied
onto the runway, the rudder limit light illuminated with the associated RUDDER
LIMIT advisory message appearing on the engine instrument and crew advisory
system display (EICAS). The crew discussed the light, but did not resolve the
problem. This light was the first indication that there was an issue with the flight
control system. Other than discussing and resolving the issue, the crew ignored the
advisory light and continued the takeoff.
The crew neglected other clues during the takeoff roll that if they were
noted, analyzed, and acted upon would have prevented the accident. The crew did
not note that the elevator did not move to the neutral 0° position at approximately
60 KIAS from 13° down at the beginning of the takeoff (NTSB, 2015). This lack
of movement should have been a clear indication that the flight controls were
locked.
The SIC continued to make the 80 KIAS, V1, and VR calls while the PIC
was struggling with the flight control issue. It appears that the SIC manifested his
invulnerability as overconfidence in the successful resolution of the issue in time
to preclude any mishap.

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Macho
Wanton Disregard
This flight crew had been flying together for seven years (NTSB, 2015).
The NTSB found that “the pilots had neglected to perform complete flight control
checks before 98% or their previous 175 takeoffs” (NTSB, 2015, p. vii). This data
reveals a consistent disregard for industry best and standard practice.
This crew was routinely noncompliant with the SOP that required the
performance of the five checklists in the start to takeoff phases of flight.
Disengaging the flight control lock is an item on the Starting Engines checklist
(NTSB, 2015). Checking the flight controls for free and unrestricted movement is
an item on the After Starting Engines checklist (NTSB, 2015). The Lineup checklist
in use by the flight crew included a note to remind the pilots to confirm the
movement of the elevator to the 0° neutral position at 60 KIAS.
It is worthy to note that the company chief pilot was the SIC on this flight.
The company did not have a flight data monitoring (FDM) program in place nor
did it have a surveillance program where qualified outside observers monitored
flight crew for compliance to SOP and standard industry best practices (NTSB,
2015).
The accident flight crew that included the chief pilot as the SIC had
completed 172 takeoffs and developed a normalization of devience of not checking
the flight controls prior to flight. The purposeful failure to complete the five
checklists in the engine start to takeoff phase of flight represents procedural drift
(Decker, 2006). The procedural mismatch manifests itsel in a macho approach of
attempting to prove oneself better than the average pilot who relies on the checklist
as a last chance safety measure. In the case of the GIV accident at Bedford,MA, the
macho attitude contributed to the death of seven people.
Resignation
Reliance on Automation and Silence
The most disturbing indication of resignation on the part of the PIC was
manifested through his use of autothrust. The PIC manually advanced the thrust
levers for takeoff. The PIC was not manually able to attain takeoff thrust due to the
gust lock/throttle interlock (NTSB, 2015). Instead of initiating a rejected takeoff at
a very slow speed, the PIC engaged the autothrust; confident the computer would
complete the task. The effective pressure ration (EPR) required for takeoff was not
attained by the autothrust for the same reason. This action demonstrates a clear
indication of resignation on the part of the human pilot by relying on the automation
to accomplish the task. Additionally, the action of the PIC indicates complacency
manifested by the lack of systems knowledge on the mechanics of the gust lock
system.
The actions of the SIC during the takeoff roll indicate an attitude of
resignation as well. The SIC provided no input into identifying the potential issue

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with now two obvious hints that the flight controlls were locked. The SIC continued
to make the standard callouts of 80 KIAS, V1 and VR (NTSB, 2015). If the SIC was
an active participating crew member, the SIC should have expressed concern about
the flight control issues presented by the aircraft. Instead, the SIC was resighned to
be along for the ride without active participation in crew problem solving. If a
rejected takeoff was initiated at any point from the RUDDER LIMIT advisory to
11 seconds after the recognition that the flight controls were locked as the PIC
attempted to rotate the aircraft, the aircraft could have been safely stopped on the
runway (NTSB, 2015). The SIC provided no input or assistance and appeared
resigned to the outcome; a fatal crash taking seven lives.

Conclusions
According to Kern (n.d.), “Our industry (operations and ATC) is becoming
infected with complacency, casual noncompliance, and sloppiness” (slide 8).
Complacency is an appropriate overarching human factors attitude that embodies
as a subset the five hazardous attitudes. Beatty (2016) correctly maintained that a
complacent attitude is a potentially foundational cause of aircraft accidents. He
further implied that any organization must apply the principles of continuous
learning and improvement in order to combat complacency bread by past successes.
SKYbrary (2018) defined complacency as a sense of approval of the situation that
implies a lack of awareness of potential hazards due to lack of experience or due to
inadequate situational awareness.
Both of these accidents represent complacency and the sub-set of the five
hazardous attitudes. In the case of the Aspen, CO accident, the crew was
complacent in-flight planning that eventually led to the execution of an
unauthorized approach. The crew violated numerous regulations and company
policies through their actions. At some point during the flight and on the approach,
the crew demonstrated each of the five hazardous attitudes toward an action they
were performing. Their unprofessional actions did not meet the fiduciary standards
implicit in the crew-passenger relationship. The result was an unacceptable 17
fatalities.
Sumwalt (NTSB, 2015) sought to explain why the crew of the Bedford, MA
runway overrun accident acted the way they did. He noted that both crew members
completed recurrent training at a highly respected training provider within the
previous 12 months. Both crew members completed training satisfactorily implying
that they knew how to operate the aircraft in accordance with the published
regulations requiring checklist compliance and compliance with the aircraft flight
manual.
The crew had been flying together for seven years. Sumwalt postulated that
overconfidence based on routinely operating together did not require them to follow
the required operating protocols. Complacency based on their overconfidence

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precipitated the five hazardous attitudes prevalent in the accident. The flight crew
did not hold themselves to the standards expected of them by their passengers. Their
unprofessional action characterized by complacency and the subset of the five
hazardous attitudes resulted in the unacceptable outcome of seven fatalities.
Recommendations
Further research into the subject of complacency is warrented.
Complacency is listed on the 12 human factors most often cited as contributions to
an aircraft accident. It is the overarching issue of which the five hazardous attitudes
are a subset.
Aviation operators should implement a set of protocols that require periodic
outside review of the established operational policies and standard operating
procedures. Some of these programs are in existance in the form of contract training
organizations. The protocols should be expanded to include follow up line checking
in between visits to the recurrent training facility.
A professional working attitude should be instilled in employees so that
they meet the high standards expected by passengers. This attitude should be
internally generated during training and stimulated by a desire to be knowledgeable
about the aircraft, the regulations, and the standard operating procedures.
Additionally,it is imperative that flight crew members hold themselves to the
highest physical and mental standards. Aviation professionals have a fiduciary
resposibility to set high expectations and meet them for themselves and their
passengers. The requirement for safe operations and the complexity of the industry
demand it.

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