When a Go Around Goes Bad 18th Human Factors Symposium New York, October 2003 Presented by Dick McKinney Captain AAL Ret When a Go Around Goes Bad

When A Go-around Goes Bad! Captain Dick McKinney Title of the presentation 18th Human Factors Symposium New York, October 2003

FSF ALAR Statistics ALAR study showed that 78 % of the accidents were preventable by a timely go-around 17 % did go-around but some crashed! The ALAR Team found it puzzling because all Pilots are trained and checked on the maneuver There is little difference in the task elements for a G/A and those required for a normal take off Title of the presentation 18th Human Factors Symposium New York, October 2003

8 G/A Accidents/Incidents 4 fatal crashes and 4 serious upset incidents occurred to mechanically sound aircraft 3 AB-300s; at Nagoya, Taipei & Berlin 2 B-757s; at Seattle and Oslo 1 AB-320; at Bahrain 1 B-737; at San Francisco 1 HS-748; at Sandy Lake Canada Title of the presentation 18th Human Factors Symposium New York, October 2003

Common Factors in 8 Accidents/Incidents 7 second generation automation, 1 third generation 7 twin engine with under-wing mounting High thrust to weight & fast acceleration with maximum power at landing weights Generally poor visibility, night or IMC All had several different ways to conduct a G/A Title of the presentation 18th Human Factors Symposium New York, October 2003

Oslo Serious Upset Incident ATIS winds variable 010 at 3 kts, visibility 3000 meters in light freezing drizzle, few clouds at 200 feet, broken at 300 feet. Temperature & dew point -4C, QNH 985 hPa. Visibility temporarily down to 1000 meters, vertical visibility 200 feet, tail wind down to 200 feet Captain flying, briefed for CAT II R/W 01R As the flight neared Gardermoen Airport, ATC change R/W to 01L due to snowplowing on 01R Title of the presentation 18th Human Factors Symposium New York, October 2003

Behind in the Approach Phase Captain re-briefed for ILS 01L CAT I minimums 40 kt tailwind component, high on profile Late turn on, overshoot, intercept from right side Attempted to capture GS from above A/C leveled at 2500 feet, last setting on MCP A/P, A/T off, gear down, speed brakes, flaps 20 800 AGL 150 kts CA ILS indications disappeared Stowed S/B, power up, discussed ILS indications 500 AGL Captain called for go-around, hit TOGA Title of the presentation 18th Human Factors Symposium New York, October 2003

152 500 500 AGL Captain called for go-around, hits TOGA 2500 Title of the presentation 18th Human Factors Symposium New York, October 2003

Things get Confusing A/C accelerates rapidly in level flight Near flap limit, CA pulls up abruptly, 1.7 G’s Behind the A/C, climbs 800 feet before “Gear up” M/A Alt 4000 MSL, MCP set at 2500 feet FD ALT CAP, A/T to Speed Bug, set at 150 Kts Deck angle 23 degrees, F/O calls “Bug Up” CA directs attn. to MCP, releases throttles Engines go from maximum power to idle CA dials up the speed and selects FL CHG CA leans forward and pushes nose down Title of the presentation 18th Human Factors Symposium New York, October 2003

163 Deck angle 23 degrees, CA leans forward and pushes nose down GS 168 1800 163 EPR GA ALT ARM CMD LOC HDG HOLD Title of the presentation 18th Human Factors Symposium New York, October 2003

Really Confusing! Deck angle drops from +20 to -20 in 5 seconds CA thinks A/C stalled, pushes full down elevator Manuals, papers, dust all over the cockpit Attitude indicator display was all brown CA releases yoke from full down to slightly down Nose continues to drop, CA pushes nose down F/O “What are you doing?” “Pull up! Pull up!” CA begins abrupt pull up, joined by F/O Title of the presentation 18th Human Factors Symposium New York, October 2003

150 Deck angle drops from +20 to -20 in 5 seconds Nose continues to drop CA begins abrupt pull up, joined by F/O 150 Title of the presentation 18th Human Factors Symposium New York, October 2003

IMC Dive Recovery Pitch change from -50 to + 38 degrees G loads went from - .7 to + 3.6 Power went from idle to maximum Airspeed went from 255 to 132 Kts in recovery Nose high/low speed recovery with 0 G, Max pwr G/A announced and a new approach commenced F/O lands aircraft after CA’s ILS errors reappear Title of the presentation 18th Human Factors Symposium New York, October 2003

175 Pitch change from - 50 to + 38 degrees G loads went from - .7G to + 3.6G GS 175 2100 EPR ALT HOLD CMD HDG HOLD 175 Title of the presentation 18th Human Factors Symposium New York, October 2003

Normal Acceleration ‘G’ IMC Dive Recovery +38 deg +20 deg Pitch Attitude deg -50 deg +3.6G Normal Acceleration ‘G’ -0.7g Title of the presentation 18th Human Factors Symposium New York, October 2003

Aircraft Limits Exceeded Flaps 20 limits of 195 kts exceeded by 60 Kts Flap 20 G limit of -0 +2 exceeded -.7 and 1.6 Gs Ultimate design limit with flaps exceeded .6 Gs Normal pitch maneuver limits of +25 -10 degrees exceeded by +13 and -40 degrees Title of the presentation 18th Human Factors Symposium New York, October 2003

75 Pax and 7 Crew Very Shaken Cabin Crew reported a very uncomfortable and terrifying experience Loose articles were flung from pockets, seat backs Liquid from the lavatories flew all over Items from in front of the wing went to aft galley Passengers were praying, crying and shouting Fortunately there were no physical injuries, only one passenger had a seat belt unfastened Title of the presentation 18th Human Factors Symposium New York, October 2003

A Very Near Thing Vertical velocity was 272 FPS, with an acceleration rate of 23 FPS PS just prior to pull up Delay of the pull up for more than another second would have probably been fatal RA minimum reading of 321 feet above terrain F/O increasing G load to 3.6 G very necessary Title of the presentation 18th Human Factors Symposium New York, October 2003

Design Philosophy Fighter Pilot saying about G’s They were lucky Boeing builds them strong! They were lucky the Boeing design allows the Pilots to exceed the limits to survive The A/C had a C check and a special structural check recommended by Boeing The aircraft suffered no damage, but flap track bolts and engine fuse plugs were replaced Title of the presentation 18th Human Factors Symposium New York, October 2003

Incident Analysis CA was automation dependent CA is a “single cue scanner” Very poor instrument scan with inputs 8 -10 seconds late Very abrupt control inputs, hand flying skills rusty Poor crew coordination F/O was just along for the ride until the critical moment when the 50 degree dive was recognized Title of the presentation 18th Human Factors Symposium New York, October 2003

Instrument Scan & Crew Coordination 7 of the 8 accidents/incidents studied had similar lapses in instrument scan and CRM breakdowns 7 of the 8 occurred in poor visibility, night or IMC 2 are attributed to “somatogravic illusion” Many twins have fighter aircraft acceleration rates at Max power and low gross weights In 7 cases the Pilots failed to scan and believe the instruments allowing extreme pitch excursions Title of the presentation 18th Human Factors Symposium New York, October 2003

Recommendations Train more for G/A because ALAR study showed 78% of approach accidents could have been prevented by a properly executed go-around Initiate G/A from various places in the pattern Pick 1 way, 2 at most to do G/As from the 7 ways on B-757 Choose 1 method close to normal T/O procedure Employ the KISS principle SOP, a G/A brief to be given for every approach A clearance to land is also a clearance to G/A Title of the presentation 18th Human Factors Symposium New York, October 2003

Recommendations CFIT, ALAR, LOC studies stress Back to Basics Train the 3 Ps; Pitch, Power & Performance “Advanced Aircraft Maneuvering Program” All Pilots should know: How to recover from a nose high/low speed condition & nose low/high speed condition The A/C won’t stall at 0 G, but bad things happen at negative G loads & you should know you are pushing too hard on the yoke if your tie is stuck to your face Title of the presentation 18th Human Factors Symposium New York, October 2003

Summary The airline allowed me to present this in the hope that others may benefit from their experience No one will live long enough to discover all the aviation lessons personally. Learn from this! Don’t believe it couldn’t happen at your airline These 2 Pilots were very experienced and had no previous flying problems until this incident The B-737 upset at SFO was flown by Test Pilots Title of the presentation 18th Human Factors Symposium New York, October 2003

Practice G/A from various places in the pattern A clearance to land is also a clearance to G/A G/A brief to be given for every approach Train for G/A KISS Back to Basics Pitch, Power & Performance “Advanced Aircraft Maneuvering Program” All Pilots should know how to recover from upset conditions Title of the presentation 18th Human Factors Symposium New York, October 2003