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Go-Around Decision-Making and Execution Project Final Report to Flight Safety Foundation Go-Around Decision-Making and Execution Project Tzvetomir Blajev, Eurocontrol (Co-Chair and FSF European Advisory Committee Chair) Capt. William Curtis, The Presage Group (Co-Chair and FSF International Advisory Committee Chair) MARCH 2017 1 Acknowledgments We would like to acknowledge the following people and organizations without which this report would not have been possible: • Airbus • Johan Condette — Bureau d’Enquêtes et d’Analyses • Air Canada Pilots Association • Capt. Bertrand De Courville — Air France (retired) • Air Line Pilots Association, International • Capt. Dirk De Winter — EasyJet • Airlines for America • Capt. Stephen Eggenschwiler — Swiss • The Boeing Company • Capt. Alex Fisher — British Airways (retired) • Eurocontrol • Alvaro Gammicchia — European Cockpit Association • FSF European Advisory Committee • Harald Hendel — Airbus • FSF International Advisory Committee • Yasuo Ishihara — Honeywell Aerospace Advanced • Honeywell International Technology • International Air Transport Association • David Jamieson, Ph.D. — The Presage Group • International Federation of Air Line Pilots’ Associations • Christian Kern — Vienna Airport • The Presage Group • Capt. Pascal Kremer — FSF European Advisory Committee • Guillaume Adam — Bureau d’Enquêtes et d’Analyses • Richard Lawrence — Eurocontrol • John Barras – FSF European Advisory Committee • Capt. Harry Nelson — Airbus • Tzvetomir Blajev — Eurocontrol • Bruno Nero — The Presage Group • Karen Bolten — NATS • Zeljko Oreski — International Federation of Air Traffic Controllers’ Associations • Capt. Phil Boorman — Air Canada • Capt. Ed Pooley — FSF European Advisory Committee • Bernard Bourdon — European Aviation Safety Agency • Martin Smith, Ph.D. — The Presage Group • Job Bruggen — Luchtverkeersleiding Nederland (Air Traffic Control the Netherlands) • Dragica Stankovic — Eurocontrol • Capt. Giancarlo Buono — International Air Transport • Michel Tremaud —Airbus (retired) Association • Capt. Dave Virgin — Air Canada • Jim Burin— Flight Safety Foundation (retired) FLIGHT SAFETY FOUNDATION | GO-AROUND DECISION-MAKING AND EXECUTION PROJECT 1 | 2 Table of Contents 1. Acknowledgments .............................................1 6. Go-Around Execution ..........................................34 2. Table of Contents ..............................................2 6.1 Methodology ............................................34 6.2 Analysis: Go-Around Execution ..............................35 3. Executive Report ...............................................3 6.3 Findings: Go-Around Execution .............................36 3.1 The Go-Around Noncompliance Problem .......................3 6.4 Strategies for Corrective Action: Go-Around Execution ...........37 3.2 Research and Analysis ......................................3 6.5 Recommendations: Go-Around Execution .....................38 3.3 Significant Findings .......................................3 3.4 Recommendations ........................................4 7. Flight Safety Foundation Future Work .............................40 3.5 Action Taken .............................................5 8. Project Conclusion .............................................40 3.6 Project Conclusion (Executive Report) .........................5 9. Works Cited ..................................................41 4. Background ...................................................6 10. Appendices ..................................................42 5. Go-Around Decision Making ......................................7 10.1 Glossary ................................................42 5.1 Flight Crew ..............................................7 10.2 Decision Making Recommendations — Mapping ..............43 5.1.1 Methodology and Information Collection ................7 10.3 Analysis: New Stabilized Approach and Go-Around Guidelines, 2017 5.1.2 Flight Crew Event Recall — Study Segmentation .........7 (proposed for industry validation) ...........................44 5.1.3 Pilot Go-Around Thresholds — Study Segmentation ......8 10.3.1 Stabilized Approach and Go-Around Decision Guidelines 5.1.4 Pilot Respondent Sampling ...........................8 (2017) Design Rationale .............................45 5.2 Management Study .......................................9 10.3.2 Approach Gates ....................................45 5.2.1 Management Respondent Sampling ....................9 10.3.3 Achieving Collective Situational Awareness Through Active Communication ..............................48 5.3 Industry Sensing .........................................10 10.3.4 Pre-Descent Approach and Landing, and Pre-Approach, 5.4 Analysis: Pilot Decision Making .............................11 Briefing Guidance ..................................49 5.4.1 Overview of Results ................................11 10.4 Analysis: Revised Safe Landing Guidelines, 2017 (proposed for 5.4.2 Pilot Situational Awareness Profile ....................15 industry validation) .................................51 5.4.3 Pilot Thresholds for Going Around .....................17 10.4.1 FSF Safe Landing Guidelines (2017) Design Rationale .....51 5.4.4 Varying Objective Levels of Unstable Approach Risk.......18 10.4.2 Longitudinal Limit Awareness (Runway TDZ and Distance) . 52 5.4.5 Complete Prescriptive Policies vs. Predominately Prescriptive 10.4.3 Lateral Limit Awareness (Runway Centerline) ...........52 Policies ..........................................19 10.4.4 Environmental Variability and Adjustments to 5.4.6 Stable Approach Criteria, Gates, Callouts and Established Policies ................................53 Decision Points ....................................21 10.4.5 Situational Awareness and Communication .............54 5.5 Analysis: Management Decision Making ......................22 10.5 FSF Recommended Elements of a Stabilized Approach (2000) [for 5.5.1 Overview of Results ................................22 reference] ..............................................54 5.5.2 Manager Situational Awareness Profile .................23 5.5.3 Segmentation Analysis..............................25 5.5.4 Industry Sensing ...................................28 5.6 Findings: Go-Around Decision Making ........................29 5.7 Strategies for Corrective Action: Go-Around Decision Making .........................................30 5.8 Recommendations: Go-Around Decision Making ...............31 FLIGHT SAFETY FOUNDATION | GO-AROUND DECISION-MAKING AND EXECUTION PROJECT 2 | 3 Executive Report his executive report is intended for those who require an source for the development of easier-to-use operator refer- understanding of the problem, a brief overview of how the ence products such as guidelines and checklists. Tproject research and analysis were conducted, and a list- ing of the significant findings and recommendations. Readers 3.2 Research and Analysis and front line managers who may need or want more details of Many ALAs have been investigated thoroughly over time, and the problem, research and analysis, and a complete listing of much is known about contributing factors. What is lacking, findings and recommendations can refer to the full report that however, is an understanding of the psychology of noncompli- follows. ance. Research and analysis of go-around decision making have been conducted primarily from the psychosocial science 3.1 The Go-Around Noncompliance Problem perspective to gain an understanding of the psychological Approach and landing is the most common phase of flight for drivers of noncompliance, and to identify corrective steps that aviation accidents, accounting annually for approximately 65 can be taken, based on science. This is the first industry analy- percent of all accidents. A Flight Safety Foundation study of sis of its type for this specific problem. The Presage Group 16 years of runway excursions determined that 83 percent conducted the research and analysis, based on its situational could have been avoided with a decision to go around. In model of nine distinct constructs, or attributes, from two other words, 54 percent of all accidents could potentially be global studies via web-based surveys; one survey analyzed prevented by going around. It is generally felt that an unstable the psychology of noncompliance by flight crewmembers, and approach is the primary cause of landing excursions. However, the other examined the psychology of management’s actions within this 16-year period, just over half of the landing excur- in handling company go-around policies. Detailed analysis can sions followed a fully stable approach; in these instances, be found in the full report. the flight became unstable only during landing. A critical For the go-around execution research, an accident and industry policy designed to help prevent such accidents is incident review was conducted that included a non-random the go-around policy. Interestingly, and sadly, the collective selection of published accident and serious incident re- industry performance of complying with go-around policies ports about go-around events involving transport category is extremely poor — approximately 3 percent of unstable aircraft between 2000 and 2012. A total of 64 go-around approaches result in go-around policy compliance. Why is a events were included. In some, the safety of the go-around critical policy designed to prevent the most common type of was central to the accident or incident investigation; in oth- accident ignored by flight crews, and
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