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go-around study
Registrations for these events can be completed
Le Bureau d’Enquêtes et d’Analyses (BEA) pour la sécurité de l’aviation through the Members Area of the IFALPA
civile, the French authority for safety investigations in civil aviation, website:
released in August a study of “aeroplane state awareness during
go-around” (ASAGA), otherwise described as a loss of control of AAP Committee Meeting HUPER Committee Meeting
the flight path during or at the end of a go-around maneuver. November 6-8, 2013 November 16-18, 2013
The BEA believes such events revealed “inadequate management Hong Kong Auckland, New Zealand
by the flight crew of the relationship between pitch attitude and
thrust, with go-around mode not engaged, but with the aircraft ATS Committee Meeting NAM Regional Meeting
close to the ground and with the crew attempting to climb. Moreover, November 12-14, 2013 December 5, 2013 (tentative)
these events seemed to have some common features, such as startle Algiers, Algeria Ottawa, Canada
effect, the phenomenon of excessive preoccupation by at least one
member of the crew, poor communication between crew members, ADO Committee Meeting CAR/SAM Regional Meeting
and difficulties in managing the automatic systems.” November 12-14, 2013 December 12-14, 2013
A study was initiated with a view to listing and analyzing the Sydney, Australia Playa del Carmen, Mexico
factors common to such go-around events, as well as suggesting
strategies to prevent their recurrence.
Organizations which participated in or contributed data to
the study included airlines, safety directorates, national aviation
authorities, aircraft manufacturers, universities, human factors
specialists, pilots, the International Civil Aviation Organization,
and the US National Transportation Safety Board.
The BEA focused on 16 accidents and serious incidents from
the various databases searched.
The study concluded that ASAGA-type events are due to a
combination of factors, such as:
l Time pressure and a high workload.
l The inadequate monitoring of primary flight parameters during
go-arounds, especially with a startle effect.
l The difficulty in applying CRM principles in a startle effect situation.
l Inadequate monitoring by the pilot not flying (PNF).
l Somatogravic illusions related to excessive thrust on airplanes
(the misperception of being in a nose-up or nose-down attitude,
caused by a rapid acceleration or deceleration while in flight
situations that lack visual reference).
The BEA made 34 recommendations, including:
l Ensure that go-around training integrates instruction explaining
the methodology for monitoring primary flight parameters, in
particular pitch, thrust, then speed.
l Ensure pilots have practical knowledge of the conduct required
during a go-around at low speed with pitch trim in an unusual
nose-up position, and that they make a competence assessment.
l Aircraft manufacturers add devices to limit thrust during a
go-around and to adapt it to the flight conditions.
l Define standards and recommended practices so that air traffic
controllers, except where necessary for safety reasons, do not give
instructions that are in contradiction with the published missed-
approach procedure.
The Safety and Technical Journal of IFALPA | InterPilot Vol 1 | No 3 | October 2013
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