Pilot Guide to Preventing CFIT

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Pilot Guide to Preventing CFIT
© 2000, 2001 Flight Safety Foundation
CFIT Defined
Controlled flight into terrain (CFIT) occurs when an airworthy
aircraft under the control of the flight crew is flown
unintentionally into terrain, obstacles or water, usually with no
prior awareness by the crew. This type of accident can occur
during most phases of flight, but CFIT is more common during
the approach-and-landing phases, which typically comprise
about 16 percent of the average flight duration of a large
commercial jet.
Fatalities by Accident Categories
Fatal Accidents, Worldwide Commercial Jet Fleet
(1990-1999)
Approach-and-landing Accidents
Distance from runway threshold
Accidents during a 5-year period
80
70
• 75 accidents/incidents
(25 greater than 8 nm)
60
• 2293 total fatalities
(approach/landing only)
Cumulative
number of 50
undershoots
Middle marker
Two-thirds of
the accidents
happened within
8 miles of the
runway
Average outer
marker, 5 nm
40
30
20
9
8
7
6
5
4
3
2
Distance to runway threshold (nm)
1
0
CFIT ALAs
Map location of CFIT accidents/incidents
From runway threshold, 40 accidents/incidents
Runway
threshold
5
10
15
Tracks where a map
display would have
probably helped
pilot(s) identify and
correct problem
In most of
the CFIT
accidents,
the
airplane
was lined
up with the
runway.
Fatal accident track
Incident track
(continued)
CFIT ALAs (continued, #2)
Vertical profile of some recent CFIT
accidents/incidents
3000
3º
There was a
lack of vertical
situation
awareness.
Outer marker, 5nm
2000
Altitude
(feet)
1000
0
10
9
200
180
8
7
6
5
4
3
2
Distance to runway threshold (nm)
160
140 120 100 80
60
Average time (seconds)
40
1
0
20
0
Factors That Contribute to
CFIT Awareness
•
•
•
•
Altimeters
Safe altitude
Air traffic control
Flight crew alertness
• Standard operating procedures
• Autoflight system
• Training
– Terminal instrument procedures
– Simulator
• Briefings and callouts
Altimeters
Inches of Mercury
•
•
•
•
•
•
•
Hectopascals
Millibars
Know what altimeter units of measurement are used for the area.
Be vigilant during radio transmission. Verify if in doubt.
Be prepared to convert feet and meters.
Know the phase of flight to apply the appropriate altimeter setting.
Use altimeter setting cross-check and readback cockpit procedure.
Cross-check radio altimeter and barometric altimeter readings.
Operate at higher than minimum altitudes during atmospheric anomalies.
Altimeter Recommendations
• Set/cross-check radio altimeters
• Geometric altitude – EGPWS improvement
• QFE selectable altimeters and autopilots
• Eliminate three-needle altimeters
• Standardize phraseology for altimeter settings
– Pilots and ATC
– Units/digits
“Mountain range off to left—
check. MSA—check. Minimums—
check.”
Safe
Altitude
• Make sure adequate charts are available.
• Study the altitude information.
• Know and fly at or above the safe altitudes for your area
of operation.
• Understand terrain clearance limitations for approaches.
Safe Altitude Recommendations
• Study terminal instrument procedures and
definitions.
• Ensure that charts are up-to-date and use the
color terrain contours when available.
• Study GPWS/TAWS procedures.
“Proceed direct to
airport.”
“Roger that…I better
check my altitude
requirement.”
ATC
• Challenge or refuse ATC instructions when they are not clearly
understood, are questionable or conflict with your assessment
of aircraft position relative to the terrain.
• Exercise good radio communication discipline.
• Know the height of the highest terrain or obstacle in the
operating area.
• Know your aircraft’s position in relation to the surrounding
high terrain.
ATC Recommendations
• Use standard phraseology.
• Do not accept unreasonable clearances.
– You are responsible for altitude clearances.
• Demand clear understanding of clearances.
– Operate autopilot using the mode that facilitates
compliance with ATC instructions.
• Readback of clearances is essential to assure that
everyone agrees with the clearance content.
Flight Crew
Complacency
• Know that familiarity can lead to complacency.
• Do not assume that this flight will be like the last flight.
• Adherence to procedures helps to eliminate crew complacency.
Flight Crew Complacency
Recommendations
• Strict adherence to standard operating procedures.
• Good crew resource management practices.
• Emphasis on the operational differences in
briefings and in conducting the flight.
• Maintain a professional attitude towards flying .
Procedures
• Do not invent your own procedures.
• Follow company standard operating procedures.
• Know what approach and runway aids are available before
initiating an approach.
• Use all available approach and runway aids.
• Use every aid to assist you in knowing your position and knowing
the required altitudes at that position.
Attempting to modify approach
procedures using the electronic
flight instrument system (EFIS)
map display resulted in this
accident.
Fly the published approach
procedure. Do not improvise.
Understand Approach Charts
• Identify unique gradient and step-down requirements.
• Review approach procedures during approach briefing
(preferably before top of descent).
• Use autoflight systems, when available.
Stabilized Approaches
“I’m not stabilized.
I’m going around!”
• Fly stabilized approaches.
• Execute a missed approach if not stabilized by 500 feet above airport
elevation in VMC or 1,000 feet above airport elevation in IMC.
Procedural Recommendations
• Follow standard operating procedures.
• Understand approach/missed approach and departure
procedures, and comply with them.
• Use all available aids (autopilot, autothrottles, navaids,
etc.) to assist in complying with procedures.
• Practice good crew resource management.
• Fly stabilized approaches — if not stabilized,
GO AROUND.
Autoflight
System
•
•
•
•
Monitor the autoflight system for desired operation.
Use the best available mode for current flight conditions.
Follow procedures.
Monitor navigation performance.
Autoflight System
Recommendations
• Appropriately use the autoflight system to
reduce crew workload.
• Use autoflight capabilities to fly stabilized
approaches.
• If available and if the crew has been trained,
use the autoflight system to fly constant-angle
nonprecision approaches.
Training
Terminal Instrument Procedures (TERPS)/Procedures
for Air Navigation Services – Aircraft Operations (PANS
OPS) Volume II
• Crews should enhance their knowledge of horizontal
and vertical terrain clearance.
• Crews need to understand why they must adhere to
standard operating procedures while flying in IMC.
Skilled work is behind instrument approach procedures.
All the pilot has to do is accurately fly the procedure.
Procedure
Turn
Areas
(TERPS)
Protected Areas
(TERPS)
Protected Areas
(PANS OPS)
Procedure Turn Initial
Approach Area (TERPS)
Understand Terrain Clearance for
Each Segment and Type of
Approach (TERPS)
Straight-in nonprecision approach
Straight Missed Approach Area
(TERPS)
2 nm
MAP
Primary Area
4 nm
Missed Approach Course
Final
40:1
15 nm from MAP
4 nm
Width of Area Varies
at the MAP
2 nm
Straight Missed Approach
Obstacle Clearance (TERPS)
MAP
Min Obstn
Clnc on Final
15 nm
Runway
Go-around climb performance could determine MDA altitude
and MAP position.
Missed Approach Area (PANS OPS)
Note: The 2.5% climb gradient PANS OPS requires is exactly the same as the 40:1
climb gradient TERPS requires.
Turning
Missed
Approach
Area
MAP
MAP
(TERPS)
(180-degree turn)
2 nm
4 4nm
nm
4 nm
2
2 nm
nm
Turning Missed Approach
Radii (miles) (TERPS)
Approach
Category
Obstacle Clearance
Radius
Flight Path
Radius
2.6
2.8
3.0
3.5
5.0
1.30
1.40
1.50
1.75
2.50
Max Speed
A
B
C
D
E
(90)
(120)
(140)
(165)
(Military)
Simulator
• Be prepared to demonstrate GPWS/TAWS escape maneuver.
• Practice CFIT knowledge during approach, missed approach and
departure procedures.
• Practice altitude awareness (instructors should promote this).
• Demonstrate good crew resource management techniques.
Briefings
and
Callouts
• Crews should adhere to company SOPs.
• Terrain awareness is a primary reason why we conduct briefings
and callouts.
• Both pilots should promote a common understanding of what is to
be expected.
Typical Takeoff Briefing
• Weather at the time of departure.
• Runway in use, usable length (full length or intersection takeoff).
• Flap setting to be used for takeoff.
• V speeds for takeoff.
• Expected departure routing.
• Airplane navigation aids setup.
• Minimum sector altitudes and significant terrain or obstacles
relative to the departure routing.
• Rejected takeoff procedures.
• Engine failure after V1 procedures.
• Emergency-return plan.
Typical Approach Briefing
• Expected arrival procedure, including altitude and
airspeed restrictions.
• Weather at destination and alternate airports.
• Anticipated approach procedure, including:
–
–
–
–
Minimum sector altitudes;
Airplane navigation aids setup;
Terrain in the terminal area relative to approach routing;
Altitude changes required for the procedure;
– Minimums for the approach DA(H) or MDA(H); and,
– Missed approach procedure and intentions.
• Communication radio setup.
• Standard callouts to be made by the pilot not flying.
CFIT-related Callouts
• Upon initial indication of radio altimeter height, appropriate
altitude vs. height above terrain should be assessed and
confirmed.
• When the airplane is approaching from above or below the
assigned altitude (adjusted as required to reflect specific
airplane performance).
• When the airplane is approaching relevant approach
procedure altitude restrictions and minimums.
• When the airplane is passing the transition altitude/level.
Training
Recommendations
• Be prepared for initial and recurrent flight crew training programs
considering CFIT and including terminal instrument procedures.
• LOFT (line-oriented flight training) to promote route and destination
familiarization programs emphasizing terrain.
• Practice proper briefings and callouts to promote terrain awareness.
Conclusion
If at any time during the approach, you feel that you are out of position
or configuration and the safety of flight is compromised, GO AROUND.
ALAR Tool Kit
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Flight Safety Digest: “ALAR Briefing Notes”
Flight Safety Digest: “Killers in Aviation: FSF Task Force Presents Facts
About Approach-and-landing and Controlled-flight-into-terrain
Accidents”
FSF ALAR Task Force Conclusions and Recommendations
FSF ALAR Task Force Members
Selected FSF Publications
Approach-and-landing Risk Awareness Tool
Approach-and-landing Risk Reduction Guide
Standard Operating Procedures Template
ALAR Information Posters
CFIT Checklist
CFIT Alert
Flight Operations and Training
Equipment for Aircraft and Air Traffic Control
Air Traffic Control Communication
Pilot Guide to Preventing CFIT
Approach-and-landing Accident Data Overview
An Approach and Landing Accident: It Could Happen to You
CFIT Awareness and Prevention
Links to Aviation Statistics on the Internet
More information?
Flight Safety Foundation
Suite 300, 601 Madison Street
Alexandria, VA 22314-1756 U.S.
Telephone: +1 (703) 739-6700
Fax: +1 (703) 739-6708
www.flightsafety.org
This is a self-contained product of the Flight Safety Foundation Approach-and-landing Accident Reduction (ALAR) Task Force and includes a
variety of information to help prevent approach-and-landing accidents, including those involving controlled flight into terrain (CFIT).
This information is not intended to supersede operators’/manufacturers’ policies, practices or requirements,
or to supersede government regulations.
In the interest of aviation safety, the contents of the FSF ALAR Tool Kit may be displayed, printed, photocopied and/or
distributed on paper for noncommercial use. Except as specifically permitted above, the contents must not be offered for sale
directly or indirectly, used commercially, distributed on the Internet and/or on any other electronic media without
the prior written permission of Flight Safety Foundation. All uses of the FSF ALAR Tool Kit must credit Flight Safety Foundation.
Contact Roger Rozelle, director of publications, for more information.
© 2000, 2001 Flight Safety Foundation (official release v. 3.0)
Flight Safety Foundation
Suite 300, 601 Madison Street, Alexandria, Virginia 22314-1756 U.S.
Telephone: +1 (703) 739-6700; Fax: +1 (703) 739-6708
http://www.flightsafety.org
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