Safety Note

Flight Safety Bureau

N°01
Février.2022

MISMANAGED GO-AROUND

Introduction
Failure to recognize the need to execute a go-around and missed-approach when
appropriate is a major cause of approach and landing accidents.
Therefore, the importance of being go-around-prepared and minded must be
emphasized.
To be go-around-prepared and minded the flight crew should:
 Have a clear mental image of applicable briefings, sequences of actions, task
sharing, standard calls and excessive-deviation callouts
 Be ready to abandon the approach, if:
• Visibility (RVR) is below the required weather minimums, and/or
• Criteria for a stabilized approach are not (or no longer) achieved, and/or
• Doubt exists about the aircraft position, and/or
• Confusion exists about the use of automation, and/or
• Appropriate visual references are not obtained at MDA(MDH) or DA(DH),
and/or
• Appropriate visual references are lost below MDA (MDH) or DA (DH).
 Be fully committed to fly the published missed-approach procedure, after the
go-around is initiated.

This Safety Note provides an overview of operational and safety

recommendations starting from the descent preparation and approach briefing to
go-around execution.

Operational threat
In operations, various go-around situations may happen:
 Go-around from intermediate approach altitude: High energy, rushed or
non-stabilized approaches, Loss of required traffic separation (called by
ATC).
 Go-around below minimums not called by ATC: Destabilization of the
approach, Loss of appropriate visual references or Runway incursion.
 Missed approach during circling: Visual references lost while circling to
land from an instrument approach.

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Flight Safety Bureau
For example, unlike a go-around at DA (DH), there are various go-around
situations from intermediate approach altitude, and all these situations may not
be reviewed during the approach briefing.
Pilots should be aware that go-around situations may vary with various aircraft
configurations, speeds, unprepared horizontal trajectories, altitude close to the
go around altitude target, and/or TOGA thrust may not be required.
According to Flight Safety Foundation, Common errors related to go-around from
intermediate approach altitude are:
 Go-around not properly announced and initiated, and/or
 Forgetting to retract the flaps and/or the landing gear, and/or
 Initiating the turn before the MAP or required turning point, and/or
 Thrust levers (throttle) mismanaged after levelling off, and/or
 Exceeding the go-around altitude target, and/or
 Exceeding the flaps speed limitations.

Mismanaged go-around safety issue

Failing to abandon a risky approach when necessary can be disastrous, but
several times in recent years, go-arounds, formerly considered a simple
maneuver, have themselves ended in disasters. Go-arounds occurs between one
and three times every 1000 flights (Flight International 29th July 2014).
Air Algerie data study from 2019 to 2021 has shown a slight increase in go-
arounds rate per 1000 flights post-covid lockdown during 2021, but still remains
within industry standard rate varying between 1 and 3 go-arounds per 1000
flight.

Go-around rate per 1000 flight / all sectors

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Flight Safety Bureau
During 2021, a total of 47 missed
approach have been achieved, 16 on
the ATR72-212A, 29 on the Boeing
737 and 2 on the Airbus 332. The
major cause of those go-arounds is
instable approaches, followed by
weather conditions (excessive
tailwind/crosswind, no visual contact
upon minima, windshear…etc.),
other causes recorded were due to
failures (mainly FLAPS and LANDING
GEAR related issues), ATC called or
runway lighting failure.

Go-around maneuvers are often

performed at low altitude, low
speed, and sometimes very close to
the ground. A significant number of
actions must be performed in a
short period of time, and all of them
are related to important changes of
attitude, thrust, flight path, airplane
configuration (i.e., flaps and gear),
and pitch trim.
83% of go-arounds were executed
below 1000ft AFE and 58% below
500ft, furthermore, nearly the third
of all go-arounds were performed
below 200ft, in a state of low
altitude and low energy also called
rejected/balked landing.
Aircraft energy states that are too
high or too low make the safe
execution of go-arounds less likely,
and this situation can be
exacerbated by a failure to
understand how to manage aircraft
pitch attitude.
Each action must be carefully
monitored and cross-checked. Automation has brought additional checks related
to autopilot, flight director, and auto throttle modes, all of which need to be read,
checked, and announced by pilots during the go-around.
During 2021 nearly the quarter, of all go-arounds have not been performed
correctly.

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Flight Safety Bureau
In 55% of mismanaged go-around,
errors and deviations from standard
operations have occurred, crew
failed in some cases to select the
correct (AP/FD) modes or pilot flying
did push on go-around switch not
engaging the go around mode. In
other cases, the crew mismanaged
power/speed that resulted in
Landing Gear or Flaps speed limits
exceedances.
Even though mismanaging a missed
approach is an undesired event, Go-arounds, although considered a normal flight
maneuver, are rare. Therefore, lack of pilots practice in real life environment can
explain some deviations that remain overall acceptable if energy is managed
correctly, path remains under control and any exceedance is reported on the
ATL.
However, 45% of mismanaged go-around, or in in other words, nearly one in 10
go-arounds has a potentially hazardous outcomes, most common are incorrect
flaps selection, failure to retract the landing gear, losing altitude after leveling off
or busting the published missed approach altitude.
In a situation where unprepared pilot execute a go-around, ATC can add to the
flight crew’s workload by requesting information about the cause of the go-
around, crew intentions, and sometimes issuing frequency changes. Even without
being asked by ATC, a pilot may feel the need to communicate immediately with
ATC.
The capacities of both the pilot flying (PF) and pilot monitoring (PM) to manage
priorities during this phase follow the safety adage of “Aviate, Navigate,
Communicate, in that order.” All of these factors explain why the go-around
maneuver needs to be approached with care.
During a significant pitch reduction, the indicated airspeed increases quickly
toward the maximum speed. This has a powerful attraction effect and could
capture the attention of both pilots to the point that the instrument scan is
slowed down or even suspended.
Simultaneously, somatogravic effects, due to longitudinal acceleration, remove
the perception of descent while maintaining the feeling of a climb or a level flight
path. As a consequence, a nose-down attitude could develop without being
noticed, causing the pilots to lose situational awareness.
Similarly, flight management annunciation (FMA) information must be read
through central vision. An unexpected FMA display during a go-around maneuver
could capture attention and distract pilots from the basic instrument scan long
enough to lead to the same consequences. The PM may be distracted from tasks

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during the go-around by getting involved with ATC communications at a critical
moment. This could happen when the PM feels obliged to call or answer ATC at
the precise time that the PF is deviating from the correct course.

Operational Recommendations
Task Sharing
Strict adherence to the PF-PM task-sharing is the most important factor to
conduct a safe go-around. Manufacturer’s operational documentations and
operators SOP provides expanded information on PF-PM task sharing
Approach/Go-around Briefing
To be go-around prepared, the flight crew should include a detailed go-around
briefing in the descent and approach briefing, highlighting the key points of the
go-around maneuver and missed-approach, and the task-sharing under normal
or abnormal/emergency conditions.
The go-around briefing should recall briefly the following key aspects:
 Go-around callout (i.e. a loud and clear go-around/flaps call)
 PF-PM task sharing (i.e. flow of respective actions including use of AP,
speed restrictions, go-around altitude, parameter-excessive-deviation
callouts)
 Intended use of automation (i.e. automatic or manual go-around, use
of FMS lateral navigation or use of selected modes for the missed-
approach)
 Missed-approach lateral navigation and vertical profile (e.g. speed
limitations, airspace restrictions, highlighting obstacles and terrain
features, low level-off altitude, immediate turn after missed approach…
etc.)
 Intentions (i.e. second approach, or diversion); In the case of a second
approach, discuss the type of approach (i.e. if a different runway
and/or type of approach is envisaged) and Confirm the minimum
diversion fuel.
It is recommended to briefly recall the main points of the go-around and missed
approach when established on the final approach course, or after completing the
landing checklist (as deemed practical).
Concept of Next Target and Descent Monitoring
Throughout the entire flight, the flight crew should define a next target at all
times to stay ahead of the aircraft. If the flight crew anticipates that one or more
elements of the next target will not be met, they should perform the required
corrective action(s) without delay.
Final Approach
When flying with the AP engaged, the flight crew should consider the following
aspects, to be ready to take over manually:

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Flight Safety Bureau
 Seat and armrest adjustment (this is of primary importance for an
effective handling of the aircraft in a dynamic phase of flight)
 Flying with one hand on the control wheel (or side stick, as applicable),
and one hand on the thrust levers (power levers as applicable).
Transition from Visual References back to Instrument Flying
Once the PF has acquired appropriate visual references, the PM must maintain
instrument references and be ready to announce the appropriate callouts if one
flight parameter deviates from the normal and safe value. If a go-around is
initiated, an immediate transition back to instrument flying must take place.
Instrument flying prevents illusions, which can lead to crew corrections that
cause the aircraft to deviate from vertical or horizontal flight paths. These
illusions originate in:
 A sudden linear acceleration: Illusion that the aircraft is pitching too
much up and can lead the pilot to pitch down (Somatogravic illusion).
 An angular acceleration: In a case of sustained movement in one
direction, there is a sensation of moving in the opposite direction
(Somatogyral illusion). For example, in right bank the pilot may
continue to turn right.
Go-Around below the Minimums
When the need for go-around is identified, the decision should not be delayed.
Go-around can be decided until the selection of the reverse thrust. If the go-
around has been initiated, it must be completed. Reversing a go-around decision
can be hazardous (e.g. F/O initiating a late go-around; Captain overriding and
trying to land the aircraft).

Safety Recommendations
A flight crew can successfully avoid the hazards that may be present in a go-
around maneuver in a number of ways:
 Both pilots should keep an efficient instrument eye-scan pattern for the
duration of the go-around maneuver until the end of the level-off phase.
 Both pilots should be aware of the consequences of failing to closely
monitor the pitch indication of the ADI. At night or in instrument
meteorological conditions, an extreme nose-down attitude could develop in
less than 10 seconds without being felt by the pilots
 Flying the pitch and monitoring the pitch during attitude changes have
priority over any other tasks, including communication with ATC. The PM
could answer “Stand by, I will call you back” while monitoring and
coordinating the maneuver with the PF.
 Pilots should understand automation and mode changes that occur during
go-arounds. Many of these features are designed to aid pilot performance.
 Pilots should understand the issues involved in go-arounds conducted at
other than minimum approach altitudes.

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