The Flight Safety Foundation says 54 percent of all accidents could potentially be avoided if the flying pilot had executed a timely go-around, simply bringing up the power and returning for another attempt at landing, often because the first approach was in some way unstable. The FSF recently learned that 83 percent of runway excursions studied over the past 16 years could also have been avoided if only the crew had gone around. In January, the crew of a Boeing 747 waited too long to attempt a go-around during a botched approach to Manas International airport in Kyrgyzstan. The aircraft crashed during the go-around, killing all four crewmembers and 35 people on the ground.
The recent FSF study Go Around Decision-Making and Execution Project, research conducted by the Presage Group, discovered again that data on go-arounds has shown no improvement (the foundation’s research survey was answered by 2,340 pilots worldwide). Just 3 percent of unstable approaches result in a go-around, meaning 97 percent of the time pilots believe they can pull off a safe landing despite a host of indicators to the contrary. Reinforcing this behavior is that some crews do manage to keep the airplane on the runway after touchdown following an unstable approach. Less experienced pilots in the cockpit watch more senior aviators and the seed is planted for the next event.
Improving the rate of flight crews complying with a company go-around policy, assuming a company has a policy, of course, offers significant potential to reduce the number of approach and landing accidents. So why are professionally trained flight crews ignoring their company go-around policy and why do management teams seem unable or unwilling to do anything about it? The FSF’s go-around study released last week was designed to answer these questions.
No doubt there’s some risk involved in executing the go-around maneuver supported by data showing loss of control event numbers rise during the maneuver. Also at issue, go-arounds are seldom practiced in the simulator the way they’re actually encountered on the line. While a look-back at accident and incident data offers investigators the factors that contribute to go-around policy non-compliance, what’s still missing is the psychology that explains why pilots behave the way they do when it comes to admitting a mistake.
For the go-around execution research, the FSF conducted an accident and incident review that included a “non-random selection of 64 published accident and serious incident reports about go-around events involving transport category aircraft between 2000 and 2012. In some cases, the safety of the go-around was central to the accident or incident investigation; in others, the aftermath of the go-around was the main purpose of the investigation. The events involved single-aisle jets (64 percent), twin turboprops (20 percent) and twin-aisle jets (16 percent).” Researchers categorized the 64 go-around events as either non-risk bearing (21), moderate (25) or high risk (18) events, with each also being segmented by outcome, either loss of control inflight, controlled flight into terrain or midair collision.
The study assumed that an effective go-around policy would include three primary elements. First that is be well thought out and clearly written. There was also an assumption that the company will apply the policy consistently and finally, that the front-line employees successfully buy into the policy and the process created to make it work.
The report’s key findings aren’t pretty and line up with other elements of safety policy reported by some line pilots. The study says, industry operations people simply accept non-compliance in go-around policy as a part of everyday life. Exacerbating the problem is crew member and management’s poor understanding of the actual risks involved in non-compliance, leading to poor decision-making in the cockpit. Pilots say they often don’t comply because the policies make little sense. Data confirms another risk, that one in 10 go-arounds lead to a hazardous outcome and that current pilot training does not adequately address the challenges of the maneuver based on the variability of the point at which it might begin. The study found that pilot experience in aircraft type greatly affects outcomes, as does the complex controller-pilot communication encountered during the maneuver. In other words, pilots compound earlier errors when the often last-minute go-around decision is finally made, a time when the aircraft is also close to the ground.
Fixing this unique problem won’t be easy, but researchers believe it will be easier if the industry approaches answers to the go-around problem as a collective whole, rather than each company attempting to fix the problem on its own. Based upon the three drivers of a solid go-around policy, the FSF research reinforces the need for the policy to make operational sense, which will demand that thousands of flight crew members be brought into the discussion early on. The study emphasizes that flight department leadership teams must do more than offer lip service to their role in non-compliance as well as ensuring compliance with the policies they create.
While implementing automated stable approach and landing alert systems on aircraft where possible will certainly help, key to solving the problem is establishing more realistic simulator training that better mirrors the demands of flying the line.
The full Go-Around Decision Making and Execution report is available at the FSF website.