(Note: This article was originally published on October 29, 2020).
I was recently reviewing the NTSB’s Accident Report from the Cessna Citation crash involving Dale Earnhardt Jr. and my immediate reaction was, “Not again. Here’s another catastrophic unstable approach that may have been prevented with an effective Flight Data Monitoring program. Why didn’t they go around?” If you are interested in reading the full NTSB report, you can find it here.
As I was reading the report, it did not surprise me that the cause of the accident was, “The pilot’s continuation of an unstabilized approach despite recognizing associated cues and the flight crew’s decision not to initiate a go around before touchdown.”
I am not sure I can count how many times I have seen a similar conclusion in an accident report.
Unstable approaches are a huge concern of the aviation industry, so it will probably come as no surprise that we spend a lot of time and effort monitoring for and analyzing unstable approaches in our Flight Data Monitoring/FOQA programs. Operators are continuously trying to reduce the rate at which unstable approaches occur, and for good reason, but I raise the question, “Why are we not going around?”
As pilots and aviation safety professionals, we KNOW that unstable approaches are a leading cause of incidents and accidents. It is in all of our best interests to reduce the rate of unstable approaches. So it is definitely a good thing that we are putting considerable effort into our Flight Data Monitoring programs to get our unstable approach numbers down.
But why do we seem to not take it a step further and improve our rates of go arounds?
After reviewing this accident report, I decided to take a look at the data to see how some of our operators were doing. The numbers were disappointing. They were so poor, in fact, that I thought we had a bug with our reporting. On average, only roughly 1 to 2% of unstable approaches were resulting in a go around.
Now, the picture is not quite as bleak as these numbers might suggest. I am not suggesting that every unstable approach (as defined in a Flight Data Monitoring program) should result in a go around. Many of these approaches were just minor deviations that were easily correctable, but some were certainly much more “interesting”. After reviewing the data, though, I could definitely draw at least one conclusion: we just do not like doing go arounds.
Go Arounds Are Not Bad!
In a typical Flight Data Monitoring program, the go around is a normal event to monitor. It is a staple of any Flight Data Monitoring program. As such, we put the typical “severities” on the event such as High, Medium, and Low. By doing so, maybe we are already putting a negative connotation on this phase of flight and this really should not be the case.
I would argue that, if we think go arounds are bad, then perhaps we need to change our way of thinking. Instead of monitoring how many “go arounds” we had last month, let’s look at how many unstable approaches ended with a go around and ask ourselves if, maybe, we should actually try to get that number UP (while still getting our rates of unstable approaches down, of course).
So why do we not like to go around? Even when we KNOW that we are in the middle of a horrible and potentially hazardous, unstable approach?
Are we complacent or over-confident? Is it a case where we have rushed approaches before without issue and everything was fine, so why should this be any different?
Are we under some external (or internal) pressure? Is “management” so concerned with costs and schedule that we could be reprimanded for the costs and delays associated with executing a go around? (If that’s the case, I would just counter that argument with a cost comparison of going around vs. going off the end of the runway).
Or is it scheduling pressure? Or weather? Or…
We are definitely doing the right thing by continuing to monitor unstable approaches in our Flight Data Monitoring program, but we may need to turn our program up a notch by also reviewing how many of those unstable approaches end in a go around.
A great place to start would be within our SMS program. Take a look at your unstable approaches in your Flight Data Monitoring program and see how many of those should have resulted in a go around according to your SMS criteria. If there is a disconnect, it may be a good time to examine the organization as a whole to find out why.
I can almost guarantee that it is not a problem with a particular crew, or even a problem strictly with flight ops, but rather a systemic issue that can be effectively addressed, once identified.
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