17th Flight Safety Conference

Rome, 21-24 March 2011

Go-around related human factors

Presented by Dr. Claire Pelegrin / Director Human Factors & Safety Management System

17th Flight Safety Conference

Rome, 21-24 March 2011

Content
Introduction
Before Go-around : anticipation and decision Effects of Go-around on perception : mechanisms of disorientation Factors leading to disorientation Prevention

Page 2
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17th Flight Safety Conference

Rome, 21-24 March 2011

Introduction
In normal go-around situations Flaps and gear are retracted Full thrust is applied at landing weight The aircraft pitches to a nose-up attitude

Frequently the aircraft accelerates quite quickly (low weight)

Significant aircraft acceleration might be wrongly interpreted as a developing
pitch-up This is believed to be a contributing factor to serious incident/accident

This presentation focuses on the potential confusion between significant

acceleration and pitch-up

Page 3
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17th Flight Safety Conference

Rome, 21-24 March 2011

Content
Introduction Before Go-around : anticipation and decision Effects of Go-around on perception : mechanisms of disorientation Factors leading to disorientation

Prevention

Page 4
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Before go-around: Pressures on landing commitment

Economic pressure Delays and extra-fuel represents extra-costs for the airlines Cultural pressure Justification of the reason : most of the time, performing a go-around
is not insignificant

The flight crew has to justify it towards the airline The airline has to justify it towards the airport ground logistics

Peer pressure he just did it I should do it...

Page 5
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17th Flight Safety Conference

Rome, 21-24 March 2011

Before go-around: Pressures on landing commitment

Personal feeling Pride and professionalism Go-around even officially accepted may be seen as a sign of
failure or weakness Feeling that everybody will know what has happened to us

Task pressure Added workload and time management.. New flight plan and reorganisation of approach Passenger communication Last segment of the flight especially for long-haul flights Accumulation of fatigue
Night flight/ jet lag Back home syndrome
Page 6
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Content
Introduction
Before Go-around : anticipation, decision and context Effects of Go-around on perception : mechanisms of disorientation Factors leading to disorientation Prevention

Page 7
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Spatial disorientation and go-around

Man has the ability to perceive orientation in 3-D space
based on his/her interpretation of the continuous input of signals from many sensory receptors 1) Eyes The brain compares visual inputs transmitted from the retina to the brains model of outside world 2) Pressure sensors in skin, muscles, joints - They are sensors for gravity

Page 8
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Spatial disorientation and go-around

3) Semicircular canals Are sensors of positive and negative accelerations They sense roll, pitch and yaw acceleration motion of the head They detect rotational acceleration They do not detect linear acceleration or constant angular velocity

4) Otolith (utricule & saccule) are sensors for linear acceleration and tilt

Page 9
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Effect of acceleration on vestibular system

Sense hairs bent

Pilot sensation = pitching up

Page 10
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Spatial disorientation and go-around

There is a mismatch between different signals Balance & orientation is performed automatically and unconsciously Attention which includes vision, reasoning and decision making is
performed consciously Unconscious processing is faster than conscious processing it is why balance and orientation could be felt more quickly

People require conscious clues to make a distinction between linear

acceleration and pitch

Page 11
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Spatial Disorientation and go-around

Pilot sensation

Actual

Possible pilot reaction based on sensation

Pitch-up illusion Application of go-around power coupled to a slow/low selection of pitch gives rise to an unexpected acceleration leading to the sensation of pitch up This may lead to an inappropriate pitch down command

Page 12
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Content
Introduction
Before Go-around : anticipation, decision and context Effects of Go-around on perception : mechanisms of disorientation Factors leading to disorientation Prevention

Page 13
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

External factors contributing to disorientation

Acceleration due to full thrust applied at low weight

Combined angular and linear accelerations

Night-ground/sky confusion IMC/VMC transition No external visual clues Visual illusions
Page 14
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Internal factors leading to disorientation

High workload reduces the ability to resolve perceptual conflict Too much head movement Alternating between external visual and instrument cues Fatigue End of the flight (especially long range flight) Night flight and jetlag Sick This may increase illusions Flight experience Training, experience and proficiency in instrument flight In particular opposite roll indicators - Knowing the tendency
to revert to previous habits
Page 15
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Content
Introduction
Before Go-around : anticipation, decision and context Effects of go-around on perception : mechanisms of disorientation Factors leading to disorientation Prevention

Page 16
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Recovering from spatial disorientation

Trust your instruments Flight conditions & procedures permitting
bring aircraft to straight and level flight and hold for at least 60 sec or until disorienting sensations disappear

Apply CRM principle

Coordination, mutual monitoring and call-outs Apply task sharing: I am disorientated, you have control

Page 17
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

Summary

Be aware of these effects and understand that all

crewmembers could experience the same disorientation

Ensure correct task allocation

PF should concentrate on flight instruments and defer non essential
tasks

Trust instruments rather than unconscious body sensations

Consider the use of automation

Page 18
AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.

17th Flight Safety Conference

Rome, 21-24 March 2011

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AIRBUS S.A.S. All rights reserved. Confidential and proprietary document.