Go around? Nah, it'll be fine.

I think these happen more often than we like to admit, usually when the authority gradient is very steep. That is, when the captain is much senior in experience and flying time than the first officer. These captains usually get away with this breach in Crew Resource Management (CRM). But not always.

1 — Alitalia 404 in Zurich, Nov 14, 1990

2 — Air India Express Flight 812, 737, Mangalore, May 22, 2010

3 — Cessna 560XL, N46CF, 2021

4 — United Express 4339, 2025

Alitalia Flight 404 departed Milan - Linate on November 14, 1990, bound for Zurich-Kloten, Switzerland. After a problem-free flight, the crew was cleared by Zurich Approach to descend to 4,000 feet and for the ILS 14 approach. The aircraft captured the localizer about 14 NM from the runway threshold and then flew through the cleared altitude. The descent rate was constant until impacting the ground about 5 NM from the runway. Everyone on board were killed and the aircraft was destroyed. [AAIB 1990/57, para. 0.1]

Date: November 14, 1990

Time: 2011 L

Type: Douglas DC-9-32

Operator: Alitalia

Registration: I-ATJA

Fatalities: 6 / 6 crew, 40 / 40 passengers

Aircraft Fate: Destroyed

Phase: Landing

Airport (arrival): Zurich-Kloten, Switzerland

The Crew

The captain was a 47-year-old Italian national with 10,193 total flying hours of which 3,194 were in type. He was a military veteran and had been flying for Alitalia for twenty years. He had been a captain for just over two years. [AAIB 1990/57, para. 1.5.1.1]

The copilot had much less experience by any metric. He was a 28-year-old Italian national with only 831 total flying hours of which 621 were in type. He was hired by Alitalia just sixteen months before the accident flight, presumably with only 200 hours total flying time. [AAIB 1990/57, para. 1.5.1.2]

This would be their second day on duty, having flown two legs the day prior followed by a 15 hour, 20 minute rest period. [AAIB 1990/57, para. 1.5.1.3]

Setup for failure

The VOR/ILS receivers.

The aircraft arrived on its previous flight with two Technical Logbook entries, one for VHF NAV 2 not displaying a To-FROM indication and the other for the autopilot failing to maintain glide path during a Cat II ILS. After the next flight, with the accident crew, the captain informed maintenance that the “failure had now been observed in position RADIO 1.” The maintenance team replaced both VHF-NAV receivers and asked the crew to fly a CAT II approach into Zurich so the aircraft could regain its CAT II status. [AAIB 1990/57, para. 1.0]

The aircraft ended up with a King model KNR6030 VOR/ILS receiver in the Number 1 position and a Collins 51RV-2B in the Number 2 position. There was a known issue with the KNR6030:

There is, however, a NAV instrument comparator that compares deviation signals of the glide path and localizer between the VOR/ILS receivers, but it only does this if the radio selector is set to the APP positions, when both NAV receivers deliver valid GP and LOC signals. In position RADIO 1 or RADIO 2, the comparator is not active. [AAIB 1990/57, para. 1.16.1.5.1]

With a mix of King and Collins VOR/ILS receivers, flying in the RADIO APP position would alert the pilots if the King receiver failed with zero deviation. Flying in the RADIO 1 or RADIO 2 position removes that protection.

Alitalia Standard Operating Procedure requires the APP position. [AAIB 1990/57, para. 1.16.1.11.1]

The altimeters.

Headsets and microphones.

The weather.

The weather into Zurich was mainly in cloud but during the descent became clear between 4,400 and 3,900 ft AMSL. Other aircraft had the approach and runway lighting “almost continuously in sight,” however this may not have been the case “for an aircraft flying too low.” [AAIB 1990/57, para. 1.7.1]

The approach

The first officer (COPI) was the pilot flying and the captain (PIC) was the pilot monitoring. The crew was cleared for the ILS 14 approach and to descend to 4,000 ft. [AAIB 1990/57, para. 1.7.1]

At 19:07:25, the crew selected RADIO APP. The captain’s GP indication was centered due to the King VOR/ILS receiver fault. The first officer’s ADI GP indication, in this mode, is slaved to the captain’s HSI and was also centered. The first officer’s HSI GP indication, however, correctly showed the aircraft well below glide path with a full-scale deflection. [AAIB 1990/57, para. 2.3]

At 19:07:40, the GP Comparator warning came on due to the disparity between GP indications. The first officer asked, “Do you have the glide?” The captain responded, “On one.” The first officer said, “I don’t have it.” [AAIB 1990/57, para. 2.3]

At 19:08:00, the captain said, “Good, let’s do it on one.” The first officer ordered the switch. Now both ADIs and both HSIs were using the faulty King VOR/ILS receiver and showed centered GP indications. The NAV selector was switched to ILS and GP-CAP was annunciated. The flight path changed from about 1,150 fpm descent rate to 700 fpm. [AAIB 1990/57, para. 2.3]

At 19:08:57, as the aircraft passed 3,700 ft., the altitude alert sounded because the selected altitude of 4,000 ft. was exceeded. The captain canceled the alert and changed the altitude select to 5,000 ft., the missed approach altitude. [AAIB 1990/57, para. 2.3]

At 19:10:43, the captain remarked that the DME showed 7 NM and said, “That doesn’t make sense to me.” His thoughts were interrupted by a radio call from Zurich Approach, instructing a switch to tower frequency. [AAIB 1990/57, para. 2.3]

At 19:10:59, the first officer called out, “Pull, pull, pull, pull,” and disconnected the autopilot. The first officer apparently correctly read his altimeter showing a height of 300 ft. QFE, causing him to commence a missed approach and order, “Go around.” The captain apparently misread his altimeter to read 1,300 ft. QFE. [AAIB 1990/57, para. 2.3]

Standard Operating Procedures

Crew Resource Management

Investigators surmised that because “during the entire flight the conversation restricted itself to operational matters,” the PIC showed his “experience-based superiority.” [AAIB 1990/57, para. 2.3]

This may be what we today call a steep authority gradient.

About 40 seconds prior to impact, the first officer asked if the outer marker had been passed and the captain said that it had not. Then the captain noted that the DME didn’t make sense and a radio altimeter warning sounded ten seconds later. The first officer initiated the go around, but the captain overruled him. The first officer failed to challenge the captain’s decision. [AAIB 1990/57, para. 2.3.1.5]

Lessons Learned

There are several “micro” lessons from this crash, most of which could have been solved by the one “macro” lesson. First, the micro.

1. Know your aircraft’s limitations to include those of individual components. If the altimeter is easy to misread, learn to verbalize what you are seeing so you can subconsciously check yourself and to give your crew a chance to do the same. If a certain mode of the avionics can bite you, such as the RADIO APP mode in this aircraft, understand the risks and devise a mitigation strategy.

2. Adopt Standard Operating Procedures even if you have survived without them, realizing they are designed to protect you when circumstances, such as faulty equipment, conspire against you.

3. Fully brief stabilized approach criteria to include reasons to go around, agree that all it takes is either pilot to initiate the go around, and a go around call cannot be overruled.

The macro lesson is all about authority gradient; the lesson comes in two parts. First, for captains: understand that a wide gap in experience level puts the other pilot at a severe disadvantage that you, the captain, will have to address. A first officer who too easily agrees with your decisions or is reluctant to speak up robs you of a sanity check. No matter your experience level, you need that measure of quality control. Second, for first officers: realize that you will arrive at the scene of the accident the same time the captain does. If the captain makes a non-critical mistake, voice your opinion tactfully. If you think the mistake will be critical, then speak up tactfully at first, and then more forcefully as needed.

For the first 1 hour and 40 minutes of the Cockpit Voice Recorder (CVR), which recorded the last two hours of the flight, there was no conversation between the pilots because the captain was asleep and could be heard snoring. The flight was during the Window of Circadian Low (WOCL) but the crew did have the required rest period before the flight. Because a special qualification was needed to land on the “tabletop runway” at Mangalore, the captain would be required to carry out the landing. The crew didn’t plan the approach properly and was almost twice as high as the glide slope during the approach. The first officer made three go around calls, which the captain ignored. [Accident Report, pp. viii - ix]

The flight did not end well.

Date: May 22, 2010

Time: 0605 India Standard Time (IST)

Type: Boeing 737-8HG

Operator: Air India Express

Registration: VT-AXV

Fatalities: 6 / 6 crew, 152 / 160 passengers

Aircraft Fate: Destroyed

Phase: Landing

Airport (arrival): Mangalore-Bajpe Airport (IXE), India

The Crew

The captain was a 55-year-old Serbian who got his start in erstwhile Yugoslavia and flew for JAT airline in that country until Yugoslavia was dissolved. He then flew in several other countries, including Malta, Canada, and Australia. He had 10,215 flight hours as a PIC, 2,844 in type. He was hired by Air India Express as a captain in 2008. He appeared to be friendly and well liked, except some of the first officers who had flown with him said he was “assertive in his actions and tended to indicate that he was ‘ALWAYS RIGHT.’” [Accident Report, para. 1.5.1]

The first officer was a 40-year-old Indian national with 3,620 total flight hours of which 3,320 were in type. He was due for upgrade to captain. He was known for being meticulous in his adherence to procedure and for being “a man of few words.” He had previously complained about another foreign national captain for not following company SOPs and having poor CRM techniques. [Accident Report, para. 1.5.2]

Setup for failure

Five months before the accident flight, the captain was counseled by the airline’s Chief of Flight Safety for a hard landing incident. The captain was said to be upset about the counseling because it was the first officer’s landing and it was just over the company’s “Vg” limit,1.9 Vg, but still below the manufacturer’s limit of 2.1 Vg. [Accident Report, para. 1.5.1]

The captain was suffering from an upset stomach and a sore throat prior to the accident. The report says, “it is possible that the captain was not fully fit on the day of the flight.” [Accident Report, para. 2.14.3]

The regularly scheduled flight was slated to depart Mangalore at 21:35 IST, land in Dubai at 02:45 IST, and to return to Mangalore at 06:30 IST. Much of the flight duty is during the WOCL. [Accident Report, para. 1.1]

The approach

The accident flight was through the WOCL and both pilots exhibited signs of being tired. The captain was audibly snoring, and the first officer could be heard yawning several times. They began their descent late and were much higher than would be expected throughout the DME Arc approach. The captain apparently realized this and selected the landing gear with the speed brakes still deployed at an altitude of 8,500 ft. [Accident Report, para. 1.1]

The radiation pattern of an ILS glide slope antenna can result in more than one overlapping lobe, usually in multiples of the true glide slope angle. (The exact angles depend on the frequency, antenna installation geometry, and terrain.) In some cases, the 90 and 150 Hz signals can invert, giving pilots reverse sensing. The solution to avoid these false glideslopes is to capture the proper glideslope from below. You should crosscheck your descent rate; if you are descending much faster than predicted, you may be on a false glideslope. In the report’s example, shown on diagram 16, a false glideslope exists at 9° and shows a centered glideslope indicator.

The aircraft’s airspeed was 142 kt. when the first officer said the runway was “straight down.” The captain pushed the nose over, causing the airspeed to increase. When the speed reached 162 kt., the Flaps Load Relief System (FLRS) automatically retracted the flaps from Flaps 40 to Flaps 30. [Accident Report, para. 2.2.14]

The tower asked if they were established on ILS approach, to which the captain prompted the first officer to answer “Affirmative.” The Flight Data Recorder showed they crossed the runway threshold at 200 feet with an indicated speed of 164 kt, 20 knots higher than the computed speed for their landing weight. [Accident Report, para. 2.2.14]

The FLRS later automatically extended the flaps when the speed slowed below 158 kt. This extension during the flare caused the aircraft to float. [Accident Report, para. 2.2.14]

The captain continued the landing, and the final touchdown was about 5,200 ft. from the threshold of Runway 24, leaving approximately 2,800 ft of remaining paved surface. [Accident Report, para. 1.1]

The impact and subsequent fire destroyed the aircraft and killed all 6 crewmembers and 152 of 160 passengers. [Accident Report, para. 1.1]

Standard Operating Procedures

Air India Express had conventional stabilized approach rules, mandating the approach be stable by 1,000 feet altitude IFR and 500 feet if VFR. If the desired approach conditions were not met by these altitudes, the first officer was required to give a go around call, and the captain was required to do so. [Accident Report, para. 1.17.3.7]

Crew Resource Management

The first officer did speak up three times, starting with a question, “Go around?” He followed this with a directive statement and finally by transmitting the go around call on the radio. But he did not take any action to prevent the captain from landing, such as assuming control of the aircraft. This begs two questions: why was the captain so reluctant to go around and why was the first officer reluctant to take action? I think a clue exists with the captain’s earlier hard landing counseling.

While the aircraft manufacturer specifies that 2.1 Vg, with other factors, correlates to a hard landing, the Air India Express Flight Safety Department set a limit of 1.65 Vg and used 1.8 Vg or more to determine when verbal counseling was to be used.

As the report notes, these counseling sessions should be done with discretion, “so that a pilot does not feel embarrassed,” and “not to intimidate a pilot.” [Accident Report, para. 1.17.6.3]

Lessons Learned

As I started studying this accident, my first thought was the crew was set up by the schedule. But the pilots were given ample rest time prior to the WOCL flight. The captain had two nights off in a local hotel and the first officer lived in Mangalore and spent those nights at home. Flying early in the morning isn’t optimal, but it is the job.

I next wondered about the captain’s health. The captain’s family said he was suffering from an upset stomach and sore throat. The report says he may have been unfit to fly, and it is evident that the captain suffered from sleep inertia during the approach.

We cannot excuse the captain’s failure to plan and execute a stable approach or his failure to go around when the first officer called for it. We also cannot excuse the first officer’s failure to take the next step to prevent the crash by taking command of the aircraft. But we must also acknowledge that while these failures led to the accident, they were not the precipitating cause. I think it all began with airline management.

The report indicates an adversarial relationship between management and its pilots. The airline can say in writing that go arounds are required when approaches are unstable, but their actions requiring Operational Incident Reports following go arounds say otherwise. The report says the captain’s counseling over the earlier hard landing incident “cannot be considered as a contributing factor.” I disagree. The captain was indeed the reason this crash occurred. But I do think the airline’s pressure against go arounds was also a factor. It may also have been a factor pressuring the captain to fly when the wiser decision would have been to call in sick.

The technical lessons from this accident are fairly obvious and easy to learn. That isn’t true of the interpersonal lessons. First, the technical:

1) Brief the approach fully, including what it takes to descend into the approach environment, stable approach criteria, and the non-negotiable reasons to go around.

2) Monitor the descent in terms of track miles to go and target altitudes.

3) Intercept the glideslope from below, if possible, crosscheck the descent rate. A good rule of thumb for a descent rate on a 3° glide path is to take half your ground speed and add a zero. (120 kts groundspeed on a 3° glideslope should give you 600 ft/min.)

As for the interpersonal lessons:

1) When directing a go around, starting in a form of a question leaves open the possibility of a refusal. The go around call needs to be a command.

2) If the pilot flying refuses the go around call, transmitting the call on the radio is an excellent way to prompt the correct response.

3) When faced with a pilot who has “tunnel vision” or “target fixation” to salvage an unsalvageable landing, the next step becomes very hard to accomplish. If you feel certain the results will hurt the airplane and its occupants, you make the call “Go Around now or I’ve got the aircraft,” then execute the go around. I’ve never had to do this but have rehearsed the scenario in my head. My thought process includes: I’d rather be fired from the airline and live, than honored by the airline posthumously for being a team player.

4) When in doubt and you have the fuel to go around, then go around. If the airline makes you report that, do so. If the airline counsels you verbally or in writing, so be it. Once again: I’d rather be fired from the airline and live, than honored by the airline for having died on duty.

5) If the airline publicizes the fact you’ve been chastised, approach the guilty parties privately. If they persist, seek union protection. If that fails, seek another employer.

If you ever find yourself crossing the runway threshold with an extra 50 knots, it might be a little late to think, “I can salvage this approach.” That was this captain’s thought, even after the first officer called for a go around four times. The captain’s response? “No, we are landing.”

Date: July 21, 2021

Time: 1604 L

Type: Cessna 560XL

Operator: PV Transport Inc

Registration: N46CF

Fatalities: 0 / 2 crew, 0 / 4 passengers

Aircraft Fate: Substantially damaged

Phase: Landing

Airport (arrival): Reading Regional Airport / Spaatz Field, PA (KRDG)

The NTSB couldn’t be bothered to visit the accident site and devoted a scant six pages to the final report. I guess you can’t blame them: nobody was injured, except the airplane. As for the airplane, a 20-year-old Citation XL wasn’t worth much more than $ 2 million at the time. So, there aren’t a lot of details available and the most important point was left out by the investigators entirely. But more on that later.

The Crew

The captain was 49 years old at the time and had 5,412 total flight hours of which 412 were in type. He had type ratings in the LR-JET, G-200, CE-560XL, and MD-11. [ERA21LA296 docket]

The first officer was 24 years old at the time and had 1,929 total flight hours of which 396 were in type. He had type ratings in the BE-300 and CE-560XL, as well as an SIC type in the CE-500. [ERA21LA296 docket]

Setup for failure

The conditions were ideal: day, 10 miles visibility, few clouds at 1,800 feet, light winds, dry runway. [ERA21LA296 Final Report]

Reading “between the lines,” however, there was a potential for problems. The captain had more than double the first officer’s experience in terms of age and flight hours. The first officer did speak up during the approach but didn’t follow through.

The approach

Standard Operating Procedures

The accident docket includes an excerpt from Image Air LLC Standard Operating Procedures, so we can assume the crew had SOPs, but we don’t know how well they were trained or checked.

Crew Resource Management

In a conversation with the captain, the investigator noted the captain “takes responsibility for the breakdown in CRM.”

It’s easy enough to “be trained” in CRM, but it is incumbent on those being trained to take the lessons to heart. If the environment doesn’t allow feedback, a pilot with a blindness to CRM will never know. About that . . .

Another EMAS Save

What the report leaves out . . .

As far as I can tell after plotting the Runway 13 extended centerline, the terrain drops about 400 feet after the EMAS, ending 90 feet lower at the Schuylkill River. (The river name comes from early Dutch settlers and means “hidden river.”)

I think that without the EMAS, the outcome would have been tragic. The two pilots and four passengers are lucky to be alive.

Lessons Learned

There are obvious lessons in this accident but stating the obvious will be of no use to those who need the lessons the most. The worst part of that is that those who need the lessons the most are the least likely to realize that. So, let’s address this as if we are talking to all pilots, even those who are certain they would never make the same mistakes.

As the Pilot Flying: the only way you can benefit from the safety of a stable approach is to take every approach seriously. Evaluate your progress:

- At the final approach fix or glide slope intercept during an instrument approach

- At 1,000 feet on a visual straight-in

- On base-to-final during a circling approach

If you don’t have the numbers “wired” by these points, verbalize the disparities and announce you will go around if you don’t have them solved by 500 feet VMC / 1,000 feet IMC. This becomes a promise to the Pilot Monitoring. And then follow through.

As the PM: your integrity is on the line as much as the PF’s. Becoming “just a passenger,” as the accident first officer stated, is a cop out. There are graduated responses to an unresponsive PF:

- Announce the problems without the phrase “Go Around” to give the PF the chance to make the call.

- Make the go around call authoritatively, not as a suggestion. “Unstable, go around.”

- If you have time for a second attempt, include a threat, “If you don’t go around, I will take control of the aircraft and execute the go around myself.”

- If the PF continues, toggle TO/GA, push the throttles forward, say, “I’ve got it.”

If you are thinking that last bit was a bridge too far, consider in our earlier case studies the PMs died while “just a passenger.” In the case of this accident, the first officer’s hope for a successful career must surely be over. I would never hire him.

In another case of becoming fixated on landing and being saved by the EMAS, this United Express landed in heavy rain and failed to stop in the confines of the runway. The crew computed that with a Runway Condition Code of 5, (less than 1/8-inch depth of water), they would have a margin of only 200 feet. When it became apparent they had a problem, the first officer called for a go around twice. The captain continued and the results were predictable.

Date: September 24, 2025

Time: 2117 L

Type: Embraer EMB-145XR

Operator: CommuteAir (dba United Express)

Registration: N21129

Fatalities: 0 / 3 crew, 0 / 50 passengers

Aircraft Fate: Minor damage

Phase: Landing

Airport (arrival): Roanoke-Blacksburg Regional Airport (KROA), Roanoke, VA

The final report is still pending and as of this writing, the NTSB docket isn’t available. So, all of what follows is from the preliminary report. I offer it only as the most recent example to illustrate that the ignored go around call is still with us.

The Crew

The captain was the Pilot Flying and the first officer was the Pilot Monitoring.

Setup for failure

It was a night flight with the weather forecast of clouds at 3,200 ft. AGL, a ceiling at 4,900 ft. AGL, 1.75 miles visibility. En route, the ATIS reported calm winds, no precipitation, a cloud ceiling of 15,000 ft., and that Runway 6 was in use. The first officer suggested reviewing landing performance for a wet runway, but the captain declined because of the ATIS report. Checking in with approach control, they were informed about precipitation along the approach path to Runway 6 and that other aircraft were using Runway 34. The crew set up for an ILS to Runway 34. [Preliminary Report, DCA25LA339, p. 1]

The approach

Lessons Learned

I will not speculate about problems with CRM or SOPs and will wait for the final report to be issued. The lessons of the previous three case studies, however, apply.

Way back in 1990, perhaps before these two pilots were even alive, the crew of Alitalia learned that following SOPs can be critical when the unexpected happens.

Twenty years later, the captain of Air India Express 812 refused the first officer’s go around calls until it was too late. The first officer verbalized the go around but failed to intervene when it became obvious failing to do so would be a fatal mistake.

Five years ago, the crew of a business jet was lucky to survive because the runway’s EMAS prevented them from careening down a hill into a river. The first officer said he felt like a passenger and that was apt, he essentially became a passenger when the captain refused to go around.

The obvious lessons you will read from these accident reports is that captains need to go around when the first officer calls for it. But nowhere will you find what needs to happen after the captain refuses to go around. If the alternative is probable loss of life, the answer is to toggle TO/GA, push the throttles forward, and say, “I have control of the aircraft.”

Aviation Investigation Final Report, Accident Number ERA21LA296, Cessna 560XL, N46CF, Reading, PA, July 21, 2021, 1604 Local.

Aviation Investigation Preliminary Report, DCA25LA339, Embraer EMB-145XR, N21129, Roanoke, VA, September 24, 2025.

Final Report of the Federal Aircraft Accidents Inquiry Board (AAIB) concerning the Accident of the aircraft DC-9-32, ALITALIA, Flight No AZ 404, I-ATJA on the Stadlerberg, Weiach/ZH, of November 1990, Nr. 1990/57 (Translation of the German original context).

National Transportation Safety Board (NTSB) Safety Recommendation, February 4, 1992, Refer to A-92-8 and -9.

Report on Accident to Air India Express Boeing 737-800 Aircraft VT-AXV on 22nd May 2010 at Mangalore, Government of India Ministry of Civil Aviation, New Delhi, 31st October 2010