Controlled Flight Into Terrain Education and Training Aid

919 Pages·2013·39.89 MB·English

by  Federal Aviation Administration

Controlled Flight Into Terrain
Education and Training Aid
U.S. Department
Flight Safety Foundation
of Transportation
Federal Aviation
Administration
Introduction Message from the Disclaimer
President of ICAO
Volume 1 Volume 2
Section 1 - 4 Section 5
Index
Welcome to the Controlled Flight Into Terrain (CFIT)
Education and Training Aid
Preventing CFIT accidents is the major goal of this training aid. The training aid includes a document (two volumes)
and a video. They are stored on this CD-ROM to provide a readily available source of information and to easily
enable the user to develop a program to prevent CFIT accidents. This training aid was developed by an international
CFIT Task Force composed of representatives from organizations that possess extensive aviation expertise: airplane
manufacturers, aviation training organizations, airplane equipment manufacturers, airlines, pilot groups and
government and regulatory agencies.
The document includes five sections. Section One provides top-level management with a concise, broad view of
the document. Section Two identifies areas where those people who govern, regulate, and run the industry can best
put their efforts to prevent CFIT. Section Three provides the history of CFIT, along with causal factors, traps and
solutions. This section is specifically aimed at the operator end of the scale. Section Four provides specific academic
and simulator training programs aimed at informing the flight crews of their responsibilities and duties in preventing
CFIT. Appendices include ground briefings, video script, and airplane-specific examples of the CFIT escape
maneuver. Section Five contains selected readings, including the latest CFIT accident/incident information. The
video “CFIT: An Encounter Avoided” addresses the CFIT problem in its entirety.
Management is encouraged to take appropriate steps to ensure that a viable, effective CFIT training program is in
place within its organization.
MESSAGE FROM THE PRESIDENT OF THE COUNCIL
OF THE INTERNATIONAL CIVIL AVIATION ORGANIZATION (ICAO)
I wish to express my sincere appreciation for the work completed in the preparation of the controlled
flight into terrain (CFIT) prevention material by the International Civil Aviation Organization (ICAO)
and the Industry Controlled Flight Into Terrain (CFIT) Task Force. It has always been by conviction
that all personnel involved in civil aviation must understand the CFIT problem and must be aware of
the risk of such accidents. The training aid will provide a major contribution to the prevention of
CFIT. I strongly recommend that those in positions of responsibility in civil aviation apply the
recommendations of the CFIT Task Force and make the best use of this education and training aid.
ICAO will continue to assist States in their efforts and provide, through its Annexes, the regulatory
framework which will permit the improvement of the use of ground proximity warning system (GPWS)
in operations worldwide.
Notice
This document is disseminated under the sponsorship of the Department of Trans-
portation in the interest of information exchange. The United States Government
assumes no liability for its contents or use thereof.
The United States Government does not endorse products or manufacturers. Trade
or manufacturers’ names appear herein solely because they are considered essen-
tial to the object of this report.
Controlled Flight Into Terrain
Education and Training Aid
Table of Contents
Section Page
Reference..........................................................................................................................................v
Units of Measurement........................................................................................................v
Acronyms...........................................................................................................................v
Glossary .............................................................................................................................vii
1 Overview for Management................................................................................................1.i
1.0 Introduction........................................................................................................................1.1
1.1 General Goals and Objectives...........................................................................................1.2
1.2 Documentation Overview..................................................................................................1.2
1.3 Industry Consensus............................................................................................................1.2
1.4 Resource Utilization ..........................................................................................................1.3
1.5 Conclusion.........................................................................................................................1.3
2 Decision Makers Guide .....................................................................................................2.i
2.0 Introduction........................................................................................................................2.1
2.1 Recommendations to Decision Makers.............................................................................2.2
2.1.1 Measurement and Evaluation of System Performance .....................................................2.2
2.1.2 Use of Autopilots...............................................................................................................2.2
2.1.3 Acceptance of ATC Clearances.........................................................................................2.2
2.1.4 Chart Supply......................................................................................................................2.3
2.1.5 Use of Checklists...............................................................................................................2.3
2.1.6 Allocation of Flight Crew Duties, Use of Monitored Approach Procedures ...................2.3
2.1.7 Rate of Descent Policy.......................................................................................................2.3
2.1.8 Route and Destination Familiarization..............................................................................2.3
2.1.9 Stabilized Approaches.......................................................................................................2.3
2.1.10 Crew Resource Management.............................................................................................2.4
2.1.11 Standard Operating Procedures.........................................................................................2.4
2.2 Communication..................................................................................................................2.4
2.3 Short-Term Goals ..............................................................................................................2.4
2.3.1 ATC Issues.........................................................................................................................2.5
2.3.2 Sharing Information...........................................................................................................2.5
2.3.3 Standard Operating Procedures.........................................................................................2.5
2.3.4 Ground Proximity Warning System Installation and Modification Updates....................2.5
2.3.5 CFIT Accident Prevention Training Program...................................................................2.5
2.3.6 Approach Procedure Design and Specifications...............................................................2.6
2.3.7 Barometric Altimetry.........................................................................................................2.6
2.4 Long-Term Solutions.........................................................................................................2.6
3 Operators Guide.................................................................................................................3.i
3.0 Introduction........................................................................................................................3.1
3.0.1 Operators Guide Objectives...............................................................................................3.2
3.1 CFIT Accidents..................................................................................................................3.2
3.1.1 The Positive Results of the GPWS....................................................................................3.4
3.1.2 GPWS Initial Reliability and Follow-On Improvements..................................................3.5
3.1.3 Industry Support Required for GPWS...............................................................................3.7
i
Section Page
3 Operators Guide (continued)
3.2 CFIT and the Flight Crew..................................................................................................3.8
3.2.1 Causes for CFIT Accidents................................................................................................3.8
3.2.2 Factors That Contribute to CFIT.......................................................................................3.8
3.2.2.1 Altimeter Setting Units of Measurement Factors..............................................................3.9
3.2.2.2 Altimeter Settings Factors.................................................................................................3.9
3.2.2.3 Safe Altitudes.....................................................................................................................3.10
3.2.2.4 Air Traffic Control Factors................................................................................................3.10
3.2.2.5 Flight Crew Complacency.................................................................................................3.11
3.2.2.6 Procedural Factors Associated With CFIT........................................................................3.12
3.2.2.7 Descent, Approach, and Landing Factors .........................................................................3.13
3.2.2.8 Autoflight System Factors.................................................................................................3.16
3.2.2.9 Training Factors.................................................................................................................3.17
3.3 CFIT Prevention ................................................................................................................3.18
3.3.1 Minimum Safe Altitude Warning System (MSAWS).......................................................3.18
3.3.2 Crew Briefings...................................................................................................................3.19
3.3.3 Autoflight Systems ............................................................................................................3.20
3.3.4 Route and Destination Familiarization..............................................................................3.20
3.3.5 Altitude Awareness............................................................................................................3.20
3.3.6 The Use of Callouts...........................................................................................................3.20
3.3.7 GPWS Warning Escape Maneuver....................................................................................3.21
3.3.8 Charts.................................................................................................................................3.21
3.3.9 Training..............................................................................................................................3.21
3.4 CFIT Traps.........................................................................................................................3.21
4 Example CFIT Training Program......................................................................................4.i
4.0 Introduction........................................................................................................................4.1
4.1 Academic Training Program .............................................................................................4.1
4.1.1 Academic Training Objectives..........................................................................................4.1
4.1.2 Academic Training Program Modules..............................................................................4.1
4.1.3 Academic Training Syllabus .............................................................................................4.2
4.1.4 Additional Academic Training Resources ........................................................................4.2
4.2 CFIT Simulator Training Program....................................................................................4.2
4.2.1 Simulator Training Objectives ..........................................................................................4.3
4.2.2 Simulator Training Syllabus..............................................................................................4.3
4.2.3 Pilot Simulator Briefing.....................................................................................................4.3
4.2.3.1 Generic GPWS Warning Escape Maneuver......................................................................4.4
4.2.4 Simulator Exercises...........................................................................................................4.4
4.2.4.1 Exercise 1: VMC Initial Introduction of Potential CFIT..................................................4.4
4.2.4.2 Exercise 2: IMC Potential CFIT Encounter......................................................................4.5
4.2.5 Pilot Requirements.............................................................................................................4.5
4.3 Simulator Implementation.................................................................................................4.6
4.3.1 Simulator Fidelity Check...................................................................................................4.6
4.3.2 Computer Analysis/Simulator Study Data Requirements.................................................4.6
Appendix 4-A Instructor Pilot Syllabus Briefing Supplement........................................4-A.1
Appendix 4-B Operators Guide to CFIT Questions.........................................................4-B.1
Appendix 4-C CFIT Safety Briefing................................................................................4-C.1
Appendix 4-D Escape Maneuvers....................................................................................4-D.1
Appendix 4-E Video Script: “CFIT: An Encounter Avoided”........................................4-E.1
ii
Section Page
5 CFIT Background Material ...............................................................................................5.i
5.0 Introduction........................................................................................................................5.1
5.1 General Goals and Objectives...........................................................................................5.1
5.2 Overview of Background Information..............................................................................5.1
Human Factors Issues in CFIT Accidents 1984-1994 ......................................................5.3
Human Factors and Training Issues in CFIT Accidents and Incidents ............................5.4
The Real World of Human Factors: Where Are We Going?............................................5.5
Chart Revision Could Enhance Non-Precision Operations ..............................................5.6
Managing Automation in the Cockpit...............................................................................5.7
Flight Safety Foundation CFIT Checklist.........................................................................5.8
Flight Safety Foundation Safety Alert...............................................................................5.9
The Dollars and Sense of Risk Management and Airline Safety......................................5.10
FSF CFIT Task Force Aircraft Equipment Team Final Report........................................5.11
FSF CFIT Task Force Flight Crew Training and Procedures Working Group: A Report5.12
5.3 Flight Into Terrain Update by Don Bateman
List of CFIT Accidents/Incidents Examples in this Report
Appendix
iii

REFERENCE
Units of Measurement
(cid:176) degree (temperature)
deg degree (angle)
deg/s degrees per second
ft feet
ft/min feet per minute
ft/s feet per second
hPa hectoPascal
hr hour
in inch
inHg inches of mercury
kt knot
m meter
mbar millibar
mi mile
min minute
nm nautical mile
sec second
Acronyms
ADF automatic direction finding MEA Minimum Enroute Altitude
AGL above ground level MIA Minimum IFR Altitude
ASRS Aviation Safety Reporting System MOCA Minimum Obstruction Clearance
ATC air traffic control Altitude
ATCRBS Air Traffic Control Radar Beacon MRA Minimum Reception Altitude
System MSA Minimum Safe Altitude
ATIS automatic terminal information MSAWS Minimum Safe Altitude Warning
service System
CFIT Controlled Flight Into Terrain MSL mean sea level
CRM Crew Resource Management MVA Minimum Vectoring Altitude
DA/H decision altitude/height NOTAM Notice To Airmen
EAS Emergency Safe Altitude PANS-OPS Procedures for Air Navigation
FAA Federal Aviation Administration Services - Aircraft Operations
FAF final approach fix PAPI precision approach path indicator
FMC flight management computer PAR precision approach radar
FMS flight management system PT procedure turn
GPS Global Positioning System RVV runway visibility point
GPWS Ground Proximity Warning SID standard instrument departure
System SOP standard operating procedure
HAA Height Above Airport STAR standard terminal arrival
HAT Height Above Touchdown TCAS Traffic Alert and Collision
IAF initial approach fix Avoidance System
ICAO International Civil Aviation TCH threshold crossing height
Organization TERPS Terminal Instrument Procedures
IFR instrument flight rules VASI Visual Approach Slope Indicator
ILS Instrument Landing System VDP visual descent point
IMC instrument meteorological VFR visual flight rules
conditions VMC visual meteorological conditions
INS Inertial Navigation System VOR VHF Omnidirectional Radio
MAP Missed Approach Point Station
MCA Minimum Crossing Altitude VOR/DME VOR Distance Measuring
MDA/H minimum descent altitude/height Equipment
v