Safety Forum: Too Few Go-arounds Executed
No one who flies has ever questioned the safety benefits of a stabilized final approach, whether it’s in VFR or IFR weather. Most airline and business aviation operators define a stabilized approach as one in which the aircraft is properly configured–on airspeed and on altitude–no closer to the ground on final than 500 feet. Anything else essentially demands a missed approach–a go-around in pilot vernacular–or at least it should. The July 6 crash of an Asiana Boeing 777 at San Francisco International Airport already appears to be one more statistic in a long string of accidents in which a failure to execute a go-around is the final link to snap in the accident chain of events.
“The lack of a go-around decision is the leading risk factor in approach and landing accidents and is the primary cause of runway excursions during landing,” according to speakers at the recent Go-Around Forum in Brussels. In fact, data presented at the forum indicates that only 1.4 to 3 percent of unstable approaches lead to a go-around. The question, of course, is why pilots choose to salvage a bad approach rather than try another that might lead to a better outcome.
The Brussels forum, sponsored by the Flight Safety Foundation (FSF), the European Regions Airline Association (ERA) and Eurocontrol, was held to support the FSF’s goal of reducing the go-around accident rate by 80 percent in the next 10 years. The FSF forum concluded that go-arounds should be considered a normal phase of flight and that crews should be encouraged to use the option when it’s warranted.
But go-arounds carry some risk. One in 10 go-around attempts records a potentially hazardous outcome, including exceeding aircraft performance limits. The forum said go-around maneuvers are often flown poorly and more likely to be fatal than the more common runway excursion accident.
Ed Pooley, a pilot and a member of the FSF’s European Advisory Committee, presented results of a random look at 66 go-around-induced accidents that occurred between 2002 and 2013. Among those, 10 fatal crashes killed more than 600 people. He noted that the go-around itself was usually the consequence of something that went wrong on the approach. “Significant procedure non-compliance was likely to precede the go-around attempt,” he said. “A significant violation of approach minimums was applicable in half the fatal accidents.”
Nearly three quarters of all go-around decisions were made when the aircraft was below 500 feet agl. Crew experience levels were also a factor in 12 of 19 high-risk events and in eight of 10 fatal accidents. Interestingly, five of 10 fatal accidents were preceded by the pilot’s busting approach minimums with little negative input from the other pilot. Finally, most of the go-arounds in which an accident was recorded were flown manually by the flying pilot.
Pooley identified six go-around safety issues prevalent in most of the accidents: ineffective go-around initiation; the crew’s losing control during the go-around; the crew’s failure to fly the required track; ATC did not maintain separation from other aircraft; significant low-level wind shear; and wake turbulence created by the go-around aircraft itself creating a risk for another aircraft.
Few Go-around Attempts
FSF forum presenter Capt. Bill Curtis discussed the results of an Airbus Go-Around study that showed while 4 percent of all approaches could be considered unstable, only 3 percent of crews flying an unstable approach actually executed a go-around. In other words, 97 percent of those pilots continued with a bad approach. Eighty-three percent of those accidents could have been prevented with a go-around, Curtis said. Fifty-four percent of all transport-category accidents in 2011 could have been prevented if the crew had decided to try again. The question remains: why do accidents related to a failure to execute a go-around continue to happen?
Dr. Martin Smith, a social-science researcher at Canada’s Presage Group, presented research findings based on interviews with 2,400 pilots who were asked the same 60 questions about the social, cultural and organizational dynamics of a go-around or lack of one. “If you want to study the psychology of decision making in our industry,” he said, “look at situational awareness, a pilot’s view of the world outside and inside the cockpit and he sees his colleagues. The very first filter of granular decision making is pilot awareness.”
Smith identified nine characteristics of pilots unlikely to execute a go-around. These high-risk pilots were significantly less likely to discuss potential approach risks. They generally perceived much less risk on unstable approaches, perhaps because most believed their company go-around policy was unrealistic. They also did not feel they would be reprimanded for an unstable approach. “There is a collective new norm that has been created to continue the [unstable] approach,” Smith said. Surprisingly, this high-risk group–especially those who had botched a few go-arounds–felt regret for their behavior. “If they had it all to do over again, they would handle things differently,” Smith said.
To encourage more crews to make the decision to execute a go-around and to improve the safety of the procedure, Smith said, “We need to establish strategies for mitigation such as enhancing dynamic situational awareness, redefining go-around policies and establishing a [concrete] go-around critical decision point that minimizes the subjectivity of go-around decision making.” Additional strategies include ensuring go-around training and awareness appropriately reflect different risk-execution scenarios and that low relevant experience by either or both pilots does not prejudice the effectiveness of cross-monitoring during all phases of flight. Most important is the need to communicate the value of go-around safety training to industry and operational stakeholders.