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Go-arounds gone wrong

Why does a procedure performed during every training session often go so poorly when needed in the wild?

In June 2019 a Boeing 737 executed a go-around from a two-mile final to Runway 27 at Bristol Airport (EGGD) in the United Kingdom.
Photography by Mike Fizer.
Photography by Mike Fizer.

After the crew properly began the go-around and initiated a climb, the aircraft’s flight path reversed, and it descended to within 500 feet of the surface before the crew recognized the situation and corrected the flight path.

In December of the same year another 737 (flown by a different airline) also executed a go-around from final approach, this time to Paris’s Orly Airport (LFPO). Again, the crew completed the initial go-around steps properly only to have the procedure deteriorate quickly, with the airplane ultimately losing 700 feet of altitude while experiencing terrain awareness and warning system (TAWS) “Bank Angle” and “Don’t Sink” aural alerts, a stall-warning stick shaker, and a flap overspeed.

Two months later, an Airbus A350 performed a go-around from the same runway at Orly. Once more, the go-around commenced with the proper steps from the crew, yet once more the situation rapidly deteriorated. Rather than properly leveling at 2,000 feet while executing a 60-degree turn to the left, the aircraft climbed straight ahead and exceeded the missed approach altitude by 800 feet. Before the aircraft was ultimately brought under control, a low airspeed warning was triggered, followed by the aircraft descending through 2,000 feet to 1,550 feet msl before climbing back up to the cleared altitude.

Unfortunately, these three events, occurring in under a year’s time, are far from unusual. The French BEA (aviation safety bureau) found that in 2019, at Paris-Orly alone, eight go-arounds resulted in deviations of more than 200 feet from the cleared altitude. A large study looking into the problem of poor “aeroplane state awareness during go-around” (ASAGA) found more than 20,000 recorded events, involving mainly Boeing and Airbus aircraft. Several common features were identified across these events; one of the most prevalent contributed to the three listed above. Surprise.

The 737 landing at Bristol was directed to perform the go-around by the tower, as was the 737 landing at Orly. In both cases the crew was taken by surprise by the clearance. The A350 received a spurious “Go around, windshear alert” warning at 1,000 feet above field elevation. Given the benign conditions of 11 knots wind with no convective activity near the field, the crew was surprised by the warning; nonetheless the captain ordered the go-around to the first officer acting as the pilot flying, who quickly fell behind the aircraft.

These incidents provide a fascinating contrast between the go-arounds practiced ad nauseum during simulator and in-aircraft recurrent training, versus those performed in the heat of battle. Given both how much better crews do with go-arounds in training, and that ASAGA events tend to start with the correct procedural steps, we can infer pilots know well the memorized steps of go-around procedures but fall apart when presented with the cognitive load of managing the transition back to straight and level flight, especially after experiencing a “startle” in the form of an unexpected go-around.

Executing a go-around in a simulator is virtually always triggered by one of two scenarios: reaching minimums without obtaining the runway visually, or a ground vehicle or aircraft pulling on the runway while the trainee is on very short final. As both a two-engine and single-engine go-arounds are required maneuvers during a pilot-in-command proficiency check, pilots come to expect regular go-arounds during recurrent training and checking, and could not be less surprised when required to execute one. Contrast this with “line flying.” The BAE estimates that a pilot will execute one go-around for every 250 to 500 flights—for long-haul pilots such as the crew of the A350 that equates to a go-around only once per five to 10 years. An owner pilot making 50 to 75 flights per year could expect a similar interval, making the surprise of a go-around virtually guaranteed when it makes its infrequent appearance.

Management of pitch when hand-flying the initial steps of a go-around needs to be a primary focus of the pilot.What, then, can a pilot do to stack the odds in their favor should a surprise go-around be necessary? Most critically, the foundation of a well-flown go-around is the same as for any of the common checkride maneuvers: a perfectly memorized and executed profile. Performing a go-around requires taking the aircraft from a configured, descending, and low-airspeed state to one that is climbing, clean, and at much higher speed. Additionally, the lateral course being flown must be changed, often along with the source of the underlying navigation signal (e.g. from ground-based localizer to GPS-driven flight management system [FMS]).

The optimal steps to affect the necessary changes to flight path, energy, configuration, and navigation have been precisely scripted by the manufacturer, and need to be relentlessly drilled by pilots before, during, and between training sessions. A common light jet’s go-around procedure will have the pilot reciting, “Pickle, power, pitch, flaps 15, positive rate, gear up, FMS, nav, flight level change 200, safe airspeed, flaps up,” with commensurate actions for each call-out. Omissions or transposition of the order of steps can result in serious unintended outcomes, so the profile must be practiced until execution is second nature.

A graphic from the United Kingdom's Air Accidents investigation Branch shows the flight track of a Boeing 737 at Bristol Airpot (EGGD) in June 2019. The go-around sequence should be practiced until it’s second nature. Illustration by Charles Floyd. The Airbus A350’s go-around at Orly included a late turn that put it within 1.7 nautical miles laterally of another aircraft. n the Boeing 737 incident at Orly, the Takeoff/Go-Around mode was engaged at 401 feet msl, or 117 feet agl (1). After beginning a climb, the airplane began a rapid descent (2), with a ground proximity “Don’t Sink” warning (3), before stabilizing in altitude (4) and climbing again.

The airline events show, however, that even when the rote procedural steps are properly executed, a go-around can quickly fall apart, often in a matter of seconds. It is here that fundamental stick and rudder skills are critical for a safely flown go-around. The BEA found common factors in mis-flown go-arounds were poor management of the aircraft state during confusing presentations and of the aircraft’s automation. Often the aircraft was being hand-flown during flight director guidance contrary to that needed (e.g. commanding a descent when the aircraft needed to climb); this can be highly disorienting for pilots conditioned to precisely follow the flight director.

Pilots, then, need to be able to tune out, or better yet, de-select, flight director guidance when it presents confusing commands, and more directly step into direct attitude control of the aircraft. Maintaining a pitch attitude between 7.5 and 10 degrees nose up will typically provide a “just-right” state of climb when coupled with appropriate airspeed management.

Management of pitch when hand-flying the initial steps of a go-around needs to be a primary focus of the pilot; the combination of increasing airspeed and configuration changes will necessitate large trim inputs or the aircraft will not stay at the desired attitude.

Adding to the difficulty in maintaining a constant pitch attitude is the effect of adding thrust. The location of the engines above the aircraft’s center of gravity means the large thrust addition from approach to go-around setting will result in a pronounced nose-down force on the airplane.

As this typically takes two to three seconds to materialize as the engines spool up, it is common for a pilot to set an appropriate climb attitude as thrust is being added, only to look away from the PFD, for example to engage new FD modes, just as the nose is pushed down significantly. I commonly see pilots inadvertently level off during this transition, sometimes for a significant track distance before pitch is corrected.

Airspeed management goes hand in hand with pitch management during the initial go-around transition and should be one of the major scan items for the pilot. Initial acceleration will be low, between the engines needing time to spool up and the high drag state present before the flaps and gear have retracted. But again, in just a few seconds the engines will have reached full thrust, and most of the gear and flap drag will be gone. Now the aircraft is accelerating rapidly at a time many pilots are not scanning the PFD and as the nose is pushed down by the thrust addition. The higher performing light jets in production can accelerate so quickly that the electric trim input cannot keep up; with trim set for a slower speed than present the airplane will now want to pitch up, reversing the input needed just seconds before.

Having a just-right target airspeed in mind, then, is just as critical as a target pitch, as is being ready for a judicious power reduction when approaching said speed. Especially when light at the end of a flight or in low density altitude conditions, the thrust levers may need to quickly come back half-way or more to maintain speed during level-off, or even while still climbing for more powerful jets.

For most light jets 180 knots indicated airspeed (KIAS) is a perfect go-around speed—giving a 20-knot buffer below the maximum speed to be flown in the immediate vicinity of a Class C or D airport, and 20 to 30 knots above the lowest speed the aircraft should be flown in a clean configuration.

Only with the vertical energy state under control should attention shift to the task of lateral path management. Depending on the avionics suite installed, and how the manufacturer specs the configuration of a given avionics suite, pressing the go-around button may put the flight director immediately into coupled lateral navigation tracking of the missed approach path, or it may command a simple wings-level roll mode.

If flying an aircraft with the later function, it is critical that the proper lateral mode is selected as soon as possible; otherwise the aircraft can quickly drift 10 to 20 degrees from the necessary heading on the initial missed segment, potentially putting the aircraft into conflict with aircraft operating from a parallel runway.

Because of the A350’s late turn it passed within 1.7 nautical miles laterally and 75 feet vertically of an aircraft departing Orly’s Runway 24.

Finally, preparation for a well-flown go-around should start while the aircraft is still in cruise flight, during the approach briefing. Most pilots properly brief the navigational elements of the missed approach (e.g. “runway heading to 600 feet, then left turn direct to the ABC VOR”) but neglect to brief the aircraft-specific elements of clean up and mode changes that will occur. Mentally rehearsing these required steps, combined with touching the corresponding control or button will make the rare go-around that much less startling should it be called for.

Neil Singer

Neil Singer is a corporate pilot, designated examiner, and instructor in Embraer Phenoms and Cessna Citations. He has more than 10,000 hours of flight time with more than 20 years of experience as an active instructor.

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