loss of control in flight - the go around manoeuvre - how to make it safer? by bertrand de courville

8/3/2019 Loss of Control in Flight - The Go Around Manoeuvre - How to make it safer? By Bertrand de Courville

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Capt. B. de Courville Air France FSF EASS - Istanbul Mars 2011

Loss of Control in FlightThe Go Around Manoeuvre

How to make it safer ?

Staying in Control Loss of Control Prevention and RecoveryEASA Safety Conference Cologne 4/5 October 2011Capt. Bertrand de Courville

ECAST Co-Chair


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CEO & COO BriefIATA Safety Report 2010 2

Western-built Jet Hull Losses


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Go around: facts and data

Between 1 and 2 go around per 1000 arrivals

1 every year for short range pilots 1 every 5 to 10 years for long range pilots

Go Around figures: major European airport, all runways


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Capt. B. de Courville FSF IASS - Milan Novembre 2010

Go around manoeuvre: the context

Operational aspects Low altitude, low speed sometimes very close to the ground

Reduced margin, little time to react in case of deviation

Simultaneous changes of: attitude, thrust, flight path,

aircraft configuration, trim balance, ATC clearance

Very low level off altitude frequently published Human performance aspects (threats)

Sudden and total change of action plan

Multiple actions to be performed, monitored and checked

Automation mode changes to be read, checked and called

Cockpit communications limited to standard call outs ATC expectation and intervention during GA

Somatogravic illusions/disorientation


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Go Around level offheight at JFKILS runway 31L

Easy to fly with a DC3.not any more witha B777or a A380


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Aircraft flight path flown by PF and monitored by PM (PNF) Possible ATC instructions to be answered and followed

Attitude

Thrust

FlapsSpeed

AutomationModes

Gear UpVertical speed


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Go around manoeuvreFMA checking and reading


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Immediatemandatory ATC callin case of Go around


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Basic IFR T type instruments scan pattern


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Go around manoeuvreInitial phase context and incident

Aircraft handling Rarely performed in real Mostly trained from DA/MDA with one engine out Implicit pilot concern about cabin confort/perception Thrust/Speed/Trim combinations to be controlled

Automation Cockpit instrument scan including FMA reading/checking Awareness of automation modes changes through central

vision with high cognitive cost of reading FMA messages Weaker cockpit instrument scan of today's pilots due to

Follow the FD effect (flying the FD iso Attitude)


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See Bournemouth AAIB investigation reportShared issue with wing mounted engines

Initial go around phase occurrenceThrust/Trim/Speed unsafe combination


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Throttle to Flex (should be TOGA)GA not activatedAP/FD still in Land modeDetection/correction ?The ATC factor

Safety case: Go Around AP ONFailure to detect an initial error by both PF & PM,Eyes instrument scan, ATC call factor


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Final phase ofgo around maneuver

Level off phaseImportance of a robust instrument scan pattern

Somatogravic illusion


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The level off phaseBreak down of instrument scan pattern

A320 Accident - 2000After initiating a go around at night over the sea, at 1000 ft the pilotflying kept a prolonged pitch down input resulting in a dive which wasnot recovered. The amplitude and duration of the initial reaction to aGPWS pull up warning was insufficient (a full back stick input wasneeded).

B757 Incident - 2002

After initiating a go around in IMC, 2500 ft the pilot flying kept aprolonged pitch down input resulting in a dive until an extreme negativeattitude (-40) which was recovered. () And when we suddenly gotthe altitude capture commands from our FDS, when both of us weremindset for a go-around, we became confused and later on theunbelievable nose down pitch attitude, we became even more confused.

A330 Incident 2007After initiating a go around at night over the sea, the altitude capture

mode activated, the pilot flying pitched down to level off. The IASincreased towards VFE. Instead of keeping a leveled flight path, thepilot flying kept a prolonged pitch down input. Attitude reached 9,vertical speed 4000ft/mn. The GPWS activated and the climb wasresumed. The minimum altitude was 600 ft over the sea. The totalduration: about 15 seconds


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VFEFlaps Speed

Limit

Safety cases: Level off phase> Break down of eyes scan pattern> VFE fear factor


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VFEFlaps SpeedLimit



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VFEFlaps SpeedLimit



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Cockpit Scan and Loss of Situational Awarenessby Capt. John Ford and Cdr. Andy Bellenkes

This error [cockpit scan breakdown] has caused () spatialdisorientation and numerous problems associated with loss ofsituation awareness.

Considering how critical an effective scan is, it is surprisingthat the development of a good set of scan patterns is notgiven high priority during training; especially since one of themost commonly cited forms of visual problems associated with

mishaps is the breakdown in cockpit scan; ()

Go around maneuverSpatial disorientation in IMC or at night


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Long. acceleration and perceived pitchPerceived attitude

Actual attitude

Vertical flight path profile

Go around maneuverSpatial disorientation in IMC or at night

Poor instrument scanning PF and PM is an opened door tosomatogravic illusion, disorientation and important pitch down input.

At Night/IMC, whenever the instrument scan is inefficient, any significantlongitudinal acceleration create a wrong and powerful perception of climb attitude forboth pilots with a high probability of hazardous flight control input. When close to the ground, it could become impossible to recover.


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Go around maneuverWays of improvement

Instrument scan break down Identify the source of scan breakdownup Set prevention strategy from the conclusions

Training Train to managed critical thrust/trim/speed combination Train to execute go-around satisfactorily from various and

power and altitude difference from altitude capture

Operational Monitoring FDM (FOQA): how far go around are performed as expected Take action from the result

ATC/Airport/Airspace design

Simplify go around profile vertical and lateral Reduce ATC communication during go around


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Go around manoeuvre

We can make it safer

loss of control in flight - the go around manoeuvre - how to make it safer? by bertrand de courville

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