Flight Operations and Training
© 2000, 2001 Flight Safety Foundation
CFIT and ALAR Task Forces
Flight Safety Foundation
Steering Committee
and
Working Groups
CFIT
ALAR
Flight Safety Foundation
ALAR Task Force Organization
Steering
Committee
Data Acquisition
and Analysis
Working Group
Operations and
Training Working
Group
FSF CFIT/ALAR
Action Group
(CAAG)
Air Traffic Control
Training and Procedures/
Airport Facilities
Working Group
Aircraft Equipment
Working Group
Approximately 125 aviation safety specialists are involved worldwide.
ALAR Objectives
•
To reduce the approach-and-landing accident
(ALA) rate by 50% within 5 years of issuing
final recommendations in 1999.
•
To identify equipment, operational, regulatory
and training measures that will improve safety
for aircraft from commencement of approach
through circling, landing or missed approach.
Statistics for
Approach-and-landing Accidents
(ALAs)
•
56% of Western-built large commercial jet accidents
are ALAs.
•
Approximately 50% of fatalities are the result of
Western-built large commercial jet ALAs.
•
By 2010, the task force estimates 23 Western-built large
commercial jet fatal accidents will occur annually.
•
Controlled-flight-into-terrain (CFIT) accidents are not
showing a downward trend.
ALAR Data-driven Strategy
•
High-level analyses of 287 accidents
•
In-depth study of 76 incidents and accidents
•
Line observations on 3,300 U.S. flights
•
All conclusions supported by data
Inadequate Situational
Awareness in ALAs
•
Inadequate situational awareness was a factor
in 51% of ALAs.
•
Currently available safety equipment was not
installed in 29% of the aircraft in ALAs.
Food for Thought:
The captain was the pilot flying in
74% of ALAs involving dual-pilot
operations.
From the Outer Marker
To the Landing
4% of flying time results in 45% of
hull-loss accidents involving
Western-built large commercial jets.
Most Common Types of
Approach-and-landing Accidents
•
CFIT
•
Loss of control
•
Landing overrun
•
Runway excursion
•
Unstabilized approach
These comprised 76 percent of the sample.
Missed Approach
• Failure to recognize the need for a missed
approach and to execute a missed approach is a
major cause of ALAs.
• Companies should declare and support no-fault
go-around policies.
Photo by Dr. David Powell
Factors in Unstabilized
Approaches and
Missed Approaches
•
42% involved “press-on-itis.”
•
36% were low and/or slow on approach.
•
30% were high and/or fast on approach.
•
Only 17% of crews initiated go-arounds.
Unstabilized Approaches
• Unstabilized approaches contribute to ALAs.
• Operators should define the parameters of a stabilized
approach in their flight operations manuals.
• Operator policy should state that a go-around is
required if the approach becomes unstabilized below
the minimum stabilization height.
• The implementation of certified constant-angle,
stabilized-approach procedures for nonprecision
approaches should be expedited globally.
Minimum Stabilization Height
The approach should be stabilized by 1,000
feet in IMC, 500 feet in VMC.
IMC = Instrument meteorological conditions
VMC = Visual meteorological conditions
Recommended Elements of a
Stabilized Approach
1. The aircraft is on the correct flight path;
2. Only small changes in heading/pitch are required to
maintain the correct flight path;
3. The aircraft speed is not more than VREF + 20 knots
indicated airspeed and not less than VREF;
4. The aircraft is in the correct landing configuration;
(continued)
Recommended Elements of a
Stabilized Approach (continued, #2)
5. Sink rate is no greater than 1,000 feet per minute; if
an approach requires a sink rate greater than 1,000
feet per minute, a special briefing should be
conducted;
6. Power setting is appropriate for the aircraft
configuration and is not below the minimum power
for approach as defined by the aircraft operating
manual;
7. All briefings and checklists have been conducted;
(continued)
Recommended Elements of a
Stabilized Approach (continued, #3)
8. Specific types of approaches are stabilized if they also
fulfill the following: instrument landing system (ILS)
approaches must be flown within one dot of the
glideslope and localizer; a Category II or Category III
ILS approach must be flown within the expanded
localizer band; during a circling approach, wings
should be level on final when the aircraft reaches 300
feet above airport elevation; and,
9. Unique approach procedures or abnormal conditions
requiring a deviation from the above elements of a
stabilized approach require a special briefing.
Photo by Jan Ovind
CRM, SOPs and Training
Factors Involved in ALAs
•
74% - Inadequate crew decision making
•
72% - Inadvertent nonadherence to procedures
•
63% - Failure in CRM (cross-check/coordination)
•
46% - Failures in company management
•
40% - Deliberate nonadherence to procedures
•
37% - Inadequate training
CRM = Crew resource management
SOPs = Standard operating procedures
Standard Operating Procedures
• Establishing and adhering to adequate SOPs and
flight crew decision-making processes improves
approach-and-landing safety.
• States should mandate, and operators should
develop and implement, SOPs for approach and
landing operations.
• Operators should implement routine and critical
evaluation of SOPs to determine the need for
change.
• Operators should provide education and training
that enhance flight crew decision making and
risk management.
Communication Factors
• 33% of the ALAs and serious incidents
involved incorrect or inadequate ATC
instruction/advice/service.
Pilot-Controller Communication
•
Improving communication and mutual
understanding between controllers and pilots
of each other’s operational environment will
improve approach-and-landing safety.
Terminal Area Infrastructure
• 21% of ALAs involved lack of ground aids.
• 12% of ALAs involved lack of ATC equipment (terminal
approach radar, minimum safe altitude warning).
• The risk of ALAs during nonprecision approaches is five
times greater than the risk of ALAs during precision
approaches.
• The risk of ALAs in the absence of terminal approach
radar is three times greater than the risk of ALAs with
terminal approach radar available.
(continued)
Terminal Area
Infrastructure (continued, #2)
• Precision approach capability and approach radar
reduce the risk of ALAs.
• Encourage crews to use more precise approach
guidance at all times such as ILS, GNSS, PAPI and
VASI.
• Develop precision approach capability to all runways
by application of technology (e.g., GNSS and LAAS).
• Implement MSAW or equivalent on all approach
radars for ATC terrain warning.
GNSS = Global navigation satellite system PAPI = Precision approach path indicator
VASI = Visual approach slope indicator LAAS = Low altitude alert system
MSAW = Minimum safe altitude warning system
Environment
•
59% of ALAs involved poor visibility.
•
21% of ALAs involved disorientation/visual
illusion.
•
18% of ALAs involved runway condition:
–
•
73% of ALAs involved overruns on
contaminated runways.
37% of ALAs involved precipitation/winds.
(continued)
Environment (continued, #2)
• The risk of ALAs is higher in operations conducted in
low light and poor visibility, on wet or otherwise
contaminated runways, and with the presence of visual
or physiological illusions.
• Flight crews should be trained in operations involving
these conditions before they are assigned line duties.
• Flight crews should make operational use of a riskassessment tool to identify approach and landing
hazards. Appropriate procedures should be
implemented to reduce the risks.
Safety Data
Monitoring Programs
• Through the collection and analysis of in-flight
parameters, FOQA programs identify performance trends
that can be used to improve approach-and-landing safety.
• FOQA should be implemented worldwide in concert with
information-sharing partnerships such as GAIN, BASIS
and ASAP.
• Provision should be made on aircraft for equipment to
support data collection and analysis.
FOQA = Flight operational quality assurance
GAIN = Global Aviation Information Network
BASIS = British Airways Safety Information Service
ASAP = U.S. Federal Aviation Administration Aviation Safety Action Program
Aviation Safety Information
• Global sharing of aviation information decreases the
risk of ALAs.
• FOQA data must be de-identified.
• Public awareness of the importance of information
sharing must be increased.
• Airlines and regions that share information have the
lowest accident rates.
• Crews that are aware of an accident and its causes are
less likely to repeat that type of accident.
FOQA = Flight operational quality assurance (program)
ALAR Tool Kit
•
•
•
•
•
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•
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•
•
•
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•
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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