Go-around Safety Forum

18 June 2013
Brussels:
Findings and Conclusions

With the help of:

Issued: 26 June 2013

Go-around Safety Forum – Findings and Conclusions Issued: 26 June 2013

CONTENTS

Executive Summary ..................................................................................................1

Chapter 1 Introduction ..............................................................................................2

1.1 What is the purpose of this report? ...........................................................................................2
1.2 The safety aspects of go-around ..............................................................................................2
1.3 Flight Safety Foundation Go-around Initiative...........................................................................3
1.4 The objectives of the Go-around Forum ...................................................................................3
1.5 Participants ...............................................................................................................................4
1.6 Outline of the Forum results......................................................................................................4

Chapter 2 Findings ....................................................................................................5

Chapter 3 Strategies for Go-around Safety Improvement.....................................8

3.1 Strategies to ensure go-around decision making .....................................................................8
3.2 Strategies to ensure go-around safe operational execution .....................................................9
3.3 Communication Strategies ........................................................................................................9

Chapter 4 General Industry Conclusions .............................................................10

Chapter 5 Aircraft Operation Conclusions ............................................................11

Chapter 6 Air Traffic Management Related Conclusions .....................................13

Chapter 7 Aircraft Manufacturers Conclusions ....................................................15

Chapter 8 Regulatory Authorities Conclusions ...................................................16

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Executive Summary

This report describes the background, objectives, and outcomes of the Go-around Safety
Forum, initiated by the Flight Safety Foundation, The European Regions Airline Association
and EUROCONTROL that took place on 18 of June 2013 in EUROCONTROL Brussels.

The Go-around Safety Forum was launched to support the Flight Safety Foundation go-
around safety initiative and to help the early implementation actions for the European Action
Plan for the Prevention of Runway Excursions (EAPPRE), issued in January 2013.

The principal Forum conclusions included the following:

Go-around is a normal phase of flight and pilots should be encouraged to go-around
when conditions warrant. However, promoting go-around as a normal flight phase does
not mean that there are no safety issues associated with it.

The majority of accidents over the last 10 years have occurred during the approach,
landing and go-around flight phases. In 2011 68% (63) of accidents in commercial
aviation occurred during these phases of flight. 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. Yet, less than 5% of unstabilised approaches lead to a go-
around. No other single decision could have as great an impact on the overall aviation
industry accident rate.

One in ten go-around reports record a potentially hazardous go-around outcome,
including exceeded aircraft performance limits or fuel endurance.

The height at which a go-around is initiated during an approach presents different
challenges and risks. Procedures and training should explicitly address this.
The Forum discussed in-depth the issues related to go-around decision making, go-around
execution, go-around training and ATM aspects of safe go-around and formulated a series of
conclusions to respond to the following eight safety improvement strategies:

S1 Enhance crew dynamic situational awareness.

S2 Refine the go-around policy (stable approach parameters and stable approach
height).

S3 Minimise the subjectivity of go-around decision making.

S4 Ensure that go-around training and awareness appropriately reflect different risk
execution scenarios.

S5 Review go-around policy, procedures and documentation to maximize their
effectiveness, clarity and understanding.

S6 Ensure that low relevant experience of one or both crew does not prejudice the
effectiveness of cross monitoring during approach, landing and go-around.

S7 Communicate the go-around issue to industry leaders.

S8 Communicate the go-around issue to operational stakeholders.

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Chapter 1
Introduction

1.1 What is the purpose of this report?

This report describes the background, objectives, and outcomes
of the Go-around Safety Forum, initiated by the Flight Safety
Foundation, The European Regions Airline Association and
Documenting and
EUROCONTROL. The Forum took place on 18 of June 2013 in
communicating.
EUROCONTROL Brussels and was held in partnership with
European Commercial Safety Team (ECAST), ICAO, IFATCA,
UK CAA, UK NATS, IATA, ECA and DGAC (France).

1.2 The safety aspects of go-around

Go-around (GA) is a normal phase of flight and the operational
Go-around is a safe risk associated with this phase should be comparable to those
phase of flight and like related to other phases.
any phase of flight it has Promoting go-around as a normal flight phase does not mean
safety aspects. that there are no safety issues associated with it. The safety risk
associated with go-around should be considered.

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Indeed, several independent studies, as well as multi-year

statistics, confirm what aviation experts have known for many
years - the lack of go-arounds is the leading risk factor in
approach and landing accidents and is the primary cause of
landing runway excursions.

More disturbing is the magnitude of the go-around decision

making statistics - within the studies only 1.4% to 3% of
unstable approaches lead to a go-around.

Furthermore, when a go-around occurs – it is often poorly

performed. In fact, although runway excursion accident
numbers are much higher than go-around accidents, it is the
go-around accidents that are, percentage wise, more fatal.

1.3 Flight Safety Foundation Go-around Initiative

Realising the importance of reducing the go-around contribution
to the safety risk, the Flight Safety Foundation launched a
dedicated initiative to address two problem areas:

Mitigate all industry runway excursions due to unstable
approaches. Reduce the number of inappropriate decisions
to not go-around by 50% in 5 years. Achieving a high level
Addressing Decision of compliance with unstable approach go-around policies
Making and Execution. where the instability is known to the flight crews, and the go-
around is warranted by the unstable approach criteria, will
mitigate industry runway excursions.

Reduce the accident rate during go-arounds by 80% in 10
years. Ensuring flight crew awareness of associated risks,
and execution competency will mitigate industry go-around
accidents.

1.4 The objectives of the Go-around Forum

The Go-Around Safety Forum (GASF) was launched to support
the Flight Safety Foundation go-around safety initiative and to
help the early implementation actions for the European Action
One day, One Issue, One Plan for the Prevention of Runway Excursions (EAPPRE),
Co-ordinated Outcome issued in January 2013. Targeting operational and safety
Event. professionals the intention was to hold a one-day event, with a
clear focus on go-around safety aspects which would lead to
the creation of an event report and supporting awareness
material.

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1.5 Participants

276 Participants
20%
Go-around Safety Forum
was attended by 276
participants. The reach Aircraft Operators
1% ANSP's
to front line operators 3% 47% Authorities
was significant: there Manufacturers
were 117 pilots and 9% Training Organisations

controllers. Other

20%

From where
2% 2%
3%
5%
Participants to the Go- 8% Europe
around Safety Forum North America
came from 5 Continents. Middle East
Asia
Africa
South America
80%

1.6 Outline of the Forum results

The Forum results were summarised in a series of Findings and
eight Strategies were developed to help structure the response
Findings, Strategies and to the Findings into Conclusions. These Conclusions were
Conclusions grouped according to their predominant relevance for a
particular audience and addressed to the Industry in general, to
Aircraft Operators, ANSPs and Regulatory Authorities..

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Chapter 2
Findings

REF FINDINGS

Go-arounds occur with an average rate of 1-3 per 1000 approaches. There is a large variation of
F1
go-around rates among different aircraft operators and operational environments.

Go-around is a normal phase of flight and pilots should be encouraged to go-around when
F2 conditions warrant. However, promoting go-around as a normal flight phase does not mean that
there are no safety issues associated with it.

The majority of accidents over the last 10 years have occurred during the approach, landing and
F3 go-around flight phases. In 2011 68% (63) of accidents in commercial aviation occurred during
these phases of flight.

The lack of go-around decision is the leading risk factor in approach and landing accidents and is
F4 the primary cause of runway excursions during landing. Yet, less than 5% of unstabilised
approaches lead to a go-around.

No other single decision could have as great an impact on the overall aviation industry accident
F5
rate.

One in ten go-around reports record a potentially hazardous go-around outcome, including
F6
exceeded aircraft performance limits or fuel endurance.

Go-around is relatively rare manoeuvre for most commercial pilots. On average, a short haul pilot
F7 may make a go-around once or twice a year and a long haul pilot may make one every 2 to 3
years. This might partially explain pilot reluctance to perform a go-around.

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Encouraging pilots to be “go-around minded” is essential for operational safety and an analogy
F8
may be drawn with “go-minded” after V1 is passed during take off.

Making a go-around carries risks which include:

Ineffective initiation of go-around can lead to Loss of Control (LOC)

Failure to maintain control during go-around can lead to LOC, including abnormal contact with
F9 the RWY, or to Controlled Flight Into Terrain (CFIT)

Failure to fly required track can lead to CFIT or Mid Air Collision (MAC)

Failure to maintain traffic separation can lead to MAC

Wake turbulence generated may create a hazard to another aircraft that can lead to LOC

The height at which a go-around is initiated during an approach can present different challenges
and risks:

F10
At high altitude above the approach minima

At the approach minima

At low height below the approach minima

A FSF study concluded that flight crews that continued an unstable approach to a landing (UA
F11 Pilots), vs. crews that decided to go around, scored lower on all 9 dynamic situational awareness
constructs, and demonstrated significantly less discussion about potential threats

Based on a FSF study, pilots who continued approaches unstable, compared with those who go
around, are less compliant with checklist use and standard calls. Most pilots do not feel they will
F12
be reprimanded for non compliance with GA policies and additionally do not feel company go
around criteria is realistic. Most pilots feel regret after continuing to land unstable.

Based on a FSF study, flight crews who continued approaches unstable were more comfortable
F13 operating on the margin of the safety envelope, and find little failsafe in protective crew norms and
processes. They will use a convenient, easy justification for non compliance.

A FSF study determined that most pilots believe their company instability criteria for a go around
is unrealistic and their personal thresholds are below 1000 feet for profile and around 500 feet for
F14 energy management. UA pilots scored lower on most of the 9 dynamic situational awareness
constructs. There is little disincentive for non compliance, nor incentive for compliance to GA
policies

F15 Low experience of one or both pilots is associated with difficulty in flying go-arounds.

Violating approach minima is associated with subsequent go-arounds with a reduced safety
F16
margin.

It is necessary for operators to be aware of the extent to which go-arounds are flown and the
F17
reasons for them as well as the extent to which those flown are safe.

A just culture must prevail if problems in go-around safety are to be sufficiently understood and
F18
addressed.

Extreme energy states make unsafe execution of go-arounds more likely and this situation can be
F19
exacerbated by a failure to understand how to manage aircraft pitch.

F20 The safety of a go-around is compromised by a delay in deciding to commence one where the

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aircraft becomes unstabilised below a mandatory Stabilised Approach ‘Gate’.

The decisions which precede unsafe go-arounds are often made other than at pre-determined
F21
procedural decision points.

F22 Pilot go-around training needs to be fully integrated with an Operator’s SMS.

F23 Pilot monitoring effectiveness is often poor and can affect the safe execution of go-arounds.

F24 Lack of a proper understanding of automation can affect go-around safety.

Pilot understanding of how their pitch control system works is not always apparent during go-
F25
arounds.

The potential for traffic and/or wake vortex conflict during a go around is sometimes reduced if
F26
situational awareness of other traffic in the vicinity was available to pilots.

The transition to a go-around from a circle-to-land approach is sufficiently rare and complex that
F27 maintaining competency will usually require an unrealistic amount of recurrent training in
proportion to other requirements.

F28 The extent of controller training in respect of go-around risk management is variable.

Controllers sometimes provide instructions which may prevent pilots from making a stabilised
F29
approach and thereby create an increase in the number of go-arounds.

Go-around procedures can be complex at a time of high workload for pilots. Go-around
procedures are not always published. Tactical de-confliction of go-around can place high
F30
demands on controllers. There are multiple approach/MAP procedures for the same RWY at
many airports.

Due to rapidly changing weather and RWY conditions the pilot doesn’t always have the latest
F31
information on which to base a landing/go-around decision.

Too much information in one transmission (explanation of reason and executive instruction) can
F32 lead to confusion. Late go-around instructions and changes to published MAP, unless these
clearly simplify it, increase workload for pilots.

There is an over willingness of pilots to accept ATC instructions. Controllers sometimes issue
instructions which are not compatible with aircraft performance. Controllers sometimes issue
F33 instructions at times of high pilot workload. Use of unpublished go around/MA tactical instructions
at/after go around initiation can place high demands on pilots. There is no direct link between
Aircraft Operator and ATC go-around training/awareness.

Current pilot go-around procedures may not adequately address all the circumstances in which an
F34 ad hoc go-around decision may be made, especially if this ia above 1000 ft aal or below a
decision to continue made at DA/MDA.

F35 Go-around operational challenges are not adequately reflected in current regulatory requirements.

Go-arounds are an integral component of TWR/APP service provision but are not explicitly
F36 covered in all aspects of Common Core Content for controller training published by
EUROCONTROL.

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Chapter 3
Strategies for Go-around
Safety Improvement

3.1 Strategies to ensure go-around decision making

Strategy 1 Enhance Crew Dynamic Situational Awareness.

Refine the go-around Policy (stable approach parameters and

Strategy 2
stable approach height).

Strategy 3 Minimise the Subjectivity of go-around decision making.

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3.2 Strategies to ensure go-around safe operational

execution

Strategy 4. Ensure that go-around training and awareness appropriately

reflect different risk execution scenarios.
Review go-around policy, procedures and documentation to
Strategy 5.
maximise their effectiveness, clarity and understanding.

Ensure that low relevant experience of one or both crew does

Strategy 6. not prejudice the effectiveness of cross monitoring during
approach, landing and go-around.

3.3 Communication Strategies

Strategy 7. Communicate the go-around safety issue to industry leaders.

Communicate the go-around safety issue to operational

Strategy 8.
stakeholders.

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Chapter 4
General Industry
Conclusions

REF Strategy Finding CONCLUSION

EUROCONTROL Agency should review the ATCO Training Common

S4, S7, Core Content to consider the applicability of adding specific objectives
GEN1 F36
S8 and supporting comments related to ATCO responsibilities regarding
go-around/Missed Approach.
Aircraft Operators and ATC should improve the mutual understanding of
GEN2 S4, S5 F33
each other’s go-around practices/procedures.
S4,S7,
GEN3 F33 The Industry partners should develop a go-around training aid.
S8

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Chapter 5
Aircraft Operation
Conclusions

REF Strategy Finding CONCLUSION

Develop SOPs to discuss instability threat factors during approach briefings

AO1 S1 F11
prior to descent.
Develop SOPs to (briefly) state critical instability factors strategically
AO2 S1, S3 F11
throughout the approach.
Develop ‘active’ communications procedures for each approach that are
AO3 S1, S3 F11 ‘objective’, ‘progressive’, and ‘sequential’, similar in concept to EGPWS or
TCAS systems.
Ensure unstabilised approach and go-around policies are clear, concise and
AO4 S1, S2 F12
unambiguous, including follow up procedures for non-compliance.
Avoid directive or suggestive calls that may compromise on going decision
AO5 S1, S3 F13 1
making, e.g., announcing, “Landing” at minimums.
Re-define the stable approach criteria and stable approach height(s). In
AO6 S2 F14 redefinition there is a valid argument to separate the profile (vertical and
2
lateral) from the other stable approach criteria.

1
A note, concerning this conclusion, has been recorded: The call out “Land” at minima informs the other pilot about the aircraft
is in condition to land and that the PF intends to go on. Considering that a go-around can be initiated at any point including after
the landing, changing standard call-out which is already in use does not appear to show a safety benefit.

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3
Provide ongoing training to enhance psychosocial awareness and
AO7 S1 F11 management, the components and their contribution to non-compliance
during the approach phase.
Cross monitoring effectiveness must recognise the importance integrating
AO8 S6 F15 low experience pilots into effective contribution to go around decision and
execution.
Pilots and their employers should understand that approach minima
AO9 S5 F16 violation, is unacceptable because the evidence indicates that if a go-around
then has to be made, the chances of a successful transition are reduced.
The incidence of go-arounds should be continually tracked by Aircraft
Operators based on a requirement for all PICs to file on the day of
AO10 S5 F17
occurrence reports which explain the circumstances of the go-around. This
will provide context to triggered OFDM events.
Operations Manuals must contain a strongly worded policy statement which
shows that, provided a full explanatory report is provided on any go-around
AO11 S5 F18 made, no punitive action will follow. In addition, any ‘feedback’ will be
provided in writing and be incapable of interpretation by a dispassionate
expert observer as prejudicial to future operational safety.
Pilots must be able to demonstrate that they are able to safely execute go-
AO12 S4 F19 arounds commenced from high energy and low energy states at the point
where the go-around decision is indicated.
Pilots must be able to exercise tactical judgment as well as procedural
compliance when deciding to go-around below the mandatory stabilised
AO13 S4, S5 F20 approach gate so that safe execution is not prejudiced by an inappropriate
delay in the decision. Validation of this must be achieved by realistic training
scenarios.
Go-Around training should include a range of operational scenarios,
including go-arounds from positions other than DA/MDA and the designated
AO14 S4 F21
Stabilised Approach Gate. Scenarios should involve realistic simulation of
surprise, typical landing weights and full power go-arounds.
Include lessons learned from operational events/incidents into go-around
AO15 S4 F22
training.
Clear guidance should be provided to pilots on how to act in respect of the
three stages of cross-monitoring during approach, landing and go around i.e.
AO16 S4 F23
- noticing/alerting/taking control. Observing members of augmented crews
should have a clear understanding of their monitoring role.
Pilot training to execute GA in automatic modes should be explicitly included
S1, S4,
AO17 F24 and Aircraft Operator automation policy should address the go-around
S5
procedure.
Pilots should have a clear understanding of how the pitch control system
works on the aircraft type they fly. This should be validated by both
AO18 S4 F25
theoretical testing and suitable simulator exercises conducted with full rather
than reduced power/thrust available at typical landing weights.

2
A note, concerning this conclusion, has been recorded about the value of (1) at least one ‘should’ gate prior to a ‘,must’ gate
and (2) a mandatory gate as low as practicable (500ft)
3
Relating to the interrelation of social factors and individual thought and behaviour

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Chapter 6
Air Traffic Management Related
Conclusions

REF Strategy Finding CONCLUSION

Procedures which allow communication with aircraft operating on the

same frequency at international airports carried out in languages other
ATM1 S1, S5 F26 than English should be reviewed by means of a safety case to establish
if they can contribute to loss of pilot situational awareness of potentially
conflicting traffic during go-arounds.
A high priority should be accorded to the provision of RNP approach
and missed approach procedures where current procedures involve
ATM2 S5 F27 circle-to-land and active radar surveillance of a transition to a go-around
is not available. Consideration should be given to withdrawing circle-to-
land procedures at aerodromes where neither option is available.
ANSPs should review and if necessary enhance the provision of go-
ATM3 S4 F28
around risk awareness training for controllers.
Ensure that the importance of a stabilised approach and compliance
with final approach procedures is included in training and briefing for air
traffic control staff (European Action Plan for the Prevention of Runway
ATM 4 S4, S5 F29 Excursions Recommendation 3.3.1)
Implementation Advice - Training should include:
 Appropriate speed control instructions
 Timely descent instructions

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 The importance of avoiding late change of runway or type of approach

 Assigning a landing RWY with no significant tailwind component
 Avoidance of vectoring too tightly onto final approach and intercepting glide
path from above
 Providing crew correct information about distance to touchdown
The agency responsible for procedure design should ensure that
straightforward go-around procedures are available and published for
each runway These go-around procedures should be designed in
consultation with pilots who will be expected to use them.
Implementation Advice:
 The MAP procedure for each runway should be the same or similar
ATM 5 S5 F30  Avoid low first stop altitude and early turn in the missed approach
procedure (e.g. below 2000ft)
 Avoid conditional go-around/MAP procedures, e.g. “after xxx but not later
yyy…”
 Avoid lack of procedural de-confliction of the missed approach path from
other traffic and wake turbulence exposure, especially for late go-arounds
 Perform risk assessment if both RNP and conventional missed approach
procedures are published
Flight crew should receive updated weather and RWY conditions
information on final approach. Contingency arrangements/procedures
should exist for use in windshear conditions.
Implementation Advice:
ATM 6 S4, S5 F31  More relevant & quicker update of weather related information - visibility,
wind, RWY status change, e.g. quantity of water on the RWY
 Improved information to be provided to crews on tailwinds, windshear and
significant wind variation, including reports from preceding aircraft
 RWY information should include FODs, animals on RWY, technical
problems on the ground, laser interference, etc
Guidance should be developed for controllers regarding content and
timings of go-around instructions.
Implementation Advice:
 Consider whether the go-around instruction should be in a separate
transmission to the explanation for the instruction
ATM 7 S5 F32  ATCO should specify any non-standard MAP when issuing the approach
clearance
 ATCO should avoid last minute changes/instructions
 Once a go-around is initiated, unnecessary RTF should be avoided
 Pilot should inform ATC as soon as possible if deviations from the
published go-around-procedure become required
ANSPs should establish a formal interface between pilots and
controllers where issues can be explored and a joint understanding can
be reached.

ATM8 S4, S5 F33 Implementation Advice:

 Pilots can be invited to attend controllers’ training sessions and vice versa
 Facilitated open days for pilots at ATC Units and familiarisation flights for
ATCOs
 Joint CRM training

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Chapter 7
Aircraft Manufacturers
Conclusions

REF Strategy Finding CONCLUSION

Consider whether it is practicable to develop automated stable approach

AM1 S1, S3 F11
monitor and alerting systems.
Ensure that go-around procedures presented in aircraft pilot training and
aircraft operating manuals are applicable to go-arounds commenced at
AM2 S5 F34
any stage on final approach up to and including landings rejected after
touchdown.

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Chapter 8
Regulatory Authorities
Conclusions

REF Strategy Finding CONCLUSION

Review the go-around training requirements and regulatory

REG1 S4 F11 developments for pilots and ATCOs to ensure that the conclusions of
this report are properly reflected.

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