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Accident Analysis

Out Of Sequence

Go-Around Haste Makes Waste
As cautionary tales go, this one has a little bit of everything. It vindicates the safety adages that make up aviation�s conventional wisdom. It reminds us that the skills that have fallen into disuse since we completed our training will be the skills we need most when trouble arises. And it demonstrates how quickly a flight�even one that is moments from being safely completed�can turn out badly if we insist on pushing our luck out of impatience or impulsiveness.

A mental error or two won�t necessarily bring on an accident, even if you subscribe to the old chain-of-events theory of accidents. Once a mistake is made, pilots have other lines of defense, including their flying skill and knowledge of the route, alternates, and flight conditions. Piloting skill presumably has been tested and reviewed on occasion. Knowledge of route, destination, and alternates is ordained by regulations and good operating practice. Deficiency in one of these categories can usually be overcome by proficiency in the others. On the other hand, if your skill in performing an emergency technique is lacking, the deficiency may remain hidden until such time as fate, or your own less-than-optimal decision making, requires you to cope with that kind of emergency.

If you have had to perform a go-around lately, consider yourself lucky. If you carried off your go-around with textbook precision, consider yourself rare. As a flight instructor, I�ve observed that many pilots, once out on their own, don�t revisit the old training rituals very often. In their pattern of routine flying, quick and accurate responses to adversity decay. Pilots who can still fly a good instrument approach or handle their airplane nicely in a howling crosswind often become startled and fumble when the need to execute an emergency go-around crops up on short notice. This lack of proficiency in a relatively routine procedure is the ticking time bomb waiting to bring many pilots to the threshold of trouble. So much more the pity when the accident happens within sight of the destination and when the mental mistake that starts the accident chain in motion is triggered by something so treacherous, and avoidable, as impatience or pique.

On March 5, 1992, a Piper Arrow was being sequenced for arrival at the 11,438-foot-long runway at Bangor, Maine. There was other traffic inbound, and the pilot had been advised to expect a delay.

While maneuvering a few miles south of the airport, the pilot looked down and spotted a 2,000-foot private grass strip. According to the National Transportation Safety Board�s report, the pilot inquired if the strip was available, and when told that it was, he opted to discontinue his arrival at Bangor to land at the small strip instead. Quoting from the NTSB document: �As he touched down, he realized there were ice patches on the runway and elected to go around. The pilot raised the flaps to the full up position and applied takeoff power. Shortly past the departure end of the runway, the airplane struck a tree and fell to the ground. After sliding along the ground, the airplane struck a garage and a parked car.�

Very little time could have elapsed between the decision to land at the grass strip and the actual execution of that landing. Probably not sufficient time, with all that was happening out there, to inspect the landing surface and properly plan the arrival. And there were some obvious things to be wary of�ice on the ground is not unusual in Maine in the month of March. (For more information on cautionary measures to take before visiting private air strips, see �Private Airports: The Lore and the Lowdown,� AOPA Flight Training, March 2001.)

If you ever devise a last-minute alternative to your original plan, it makes sense to be alert to potentially troublesome conditions and quickly devise a plan of escape, just in case. That escape would be a rejected landing. Going over the procedure in your mind before attempting to land would seem appropriate. But the problem with an abrupt change of plans is the time constriction you inflict upon yourself. So you need to be proficient in the techniques you might need before you decide to change your plans.

The go-around or balked landing procedure is something that can be practiced at will, and it has some probability of occurring on any flight�even one conducted exactly as designed. Pilot�s operating handbooks (POHs) aren�t always terribly detailed on the procedures to be used, if they address the issue at all. But two things are given: Power must be applied first to transition to the climb, and an abrupt retraction of fully deflected flaps (the most common go-around error) may cause the airplane to settle back to the ground or just stay on the ground until it�s too late to clear obstacles at the end of the runway.

Although many older POHs are mum on the use of flaps in a go-around, other procedures give the observant pilot a clue as to the aircraft�s behavior when transitioning from one configuration to another. When taking off from a short field in an Arrow, 25 degrees of flaps is the recommended configuration. Then, �slowly retract the flaps while climbing out,� says one edition of the aircraft�s POH. Compare that to what the pilot did�and what many pilots might do under similar stress if the correct response is not pre-programmed into their thinking.

Statistically, this accident contained few surprises. �The majority of accident sequences begin during phases of flight that take up relatively little flight time but contain the highest number of critical tasks and the highest task complexity,� notes the 1999 Nall Report, a study of trends and factors involved in general aviation accidents published by the AOPA Air Safety Foundation. It notes that while the takeoff and landing phases account for only 5 percent of a typical cross-country flight, 60 percent of the accidents on cross-countries occurred in those phases.

A sudden change of plans in a critical phase of flight can take its toll in a variety of ways. This was illustrated in rather grim fashion by an accident in Des Moines, Iowa. On November 3, 2000, the pilot of a Luscombe 8a was flying the assigned arrival leg when he abruptly requested a change of landing runway. According to the NTSB report, �A witness on the ground said the airplane made a tight turn in toward the runway and immediately turned to final with a very steep bank�� At that point, the airplane plunged to the ground. Why? The report doesn�t draw conclusions but notes that a Boeing 737 had landed on the newly assigned runway seconds earlier. Whether wake turbulence or loss of control while maneuvering was to blame, the sudden change of plans left the flight vulnerable to surprise adversity.

In a side note to flight instructors, the 1999 Nall Report raises the issue of �substitution risk.� This is the notion that risks minimized in training at the expense of competent instruction may come back to haunt pilots later when they are out on their own.

The NTSB record does not speak to the training experienced by the pilots in the accidents described here. But the cause-and-effect relationship between the failed go-around and the resulting mishap in Maine is an object lesson for any pilot. Resolve to review the procedure for your airplane now and practice it under safe conditions�solo or in the company of a qualified instructor�at the next opportunity.

Dan Namowitz
Dan Namowitz
Dan Namowitz has been writing for AOPA in a variety of capacities since 1991. He has been a flight instructor since 1990 and is a 35-year AOPA member.

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