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FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • SEPTEMBER 1991

Head-Up Display (HUD) Technology — Potential for Accident Prevention

Executive Summary

Head-up Guidance SystemTechnology (HGST) — A

Powerful Tool forAccident Prevention

This project report (FSF/SP-91/01), “Head-upGuidance System Technology (HGST) — APowerful Tool for Accident Prevention,” is basedupon a contracted study completed by FlightSafety Foundation in late 1990. In that study,the Foundation concludes that civil jet trans-port aircraft equipped with properly functioninghead-up guidance system technology (HGST),that provides critical aircraft flight guidanceand performance information to a correctlytrained flight crew, will result in significantlyfewer aircraft accidents, which will reduce lossof life. FSF advocates the use of this technol-ogy, which has only become available in re-cent years, because it offers aircraft operatorsan excellent tool to substantially reduce crewerror, to which approximately 70 percent offatal civil jet transport aircraft accidents is at-tributed.

The Foundation study of historic accident datasuggests a substantial number of the civil jettransport accidents that occurred between 1959

and 1989 might have been prevented or posi-tively influenced, if HGST had been availableand properly utilized. A total of 543 total lossaccidents and 536 major partial loss accidentsare analyzed in the study to determine thepotential of HGST to improve civil jet trans-port safety in takeoff/departure, descent/ap-proach/landing, and en route phases of flight.

Specifically, the Foundation concludes that HGSTmight have prevented or positively influencedthe outcome of 31 percent of the accidents. Italso determines that HGST could probably nothave prevented 56 percent of them. Insuffi-cient information is available to reach a rea-sonable conclusion about the influence HGSTmight have had in the remaining 13 percent ofthe accidents.

These conclusions are presented not as abso-lute certainties, but as reasonable estimatesbased upon a subjective analysis of the avail-able information.

Head-Up Display (HUD) Technology — Potential for Accident Prevention

Introduction

lized by some civil airlines. However, untilnow, its potential to improve safety has notbeen analyzed in depth.

HGST [see Appendix A for detailed descrip-tion of technology presumed in the study] al-lows the pilot, while looking through the wind-shield, to view simultaneously critical flightinformation, other traffic and the flight envi-ronment. HGST offers a decided advantagewhen compared to looking at panel-mountedflight instruments below the windshield, whichcalls for a downward movement of the headand a shift in eye focus during the transitionfrom the panel-mounted instruments to visualcontact through the windshield, especially inthe demanding phases of flight addressed inthe study.

In addition to providing pilots with enhancedsituational awareness through a single pre-sentation of information critical to safe flight,HGST provides the potential for maintenanceof instrument flying skills, because they canbe exercised regularly on each approach, landingand departure even in visual meteorologicalconditions.

FSF undertook the study with the knowledgethat accident causal factors show a persistentpattern. Based upon accident statistics, crewerror is associated with approximately 70 per-cent of worldwide civil jet transport accidents;sometimes these errors occur in combinationwith other factors, such as poor weather ormalfunctioning equipment.

Crew decision-making is influenced by the in-formation available at any given time. Safetyimprovements are possible in many areas, butthe greatest leverage, in terms of improvingcivil jet transport safety, lies in reducing thelikelihood of crew error. Additional resourcesmust be provided to aid crew responses tounexpected or difficult circumstances duringthose phases of flight where the flight situa-tion changes rapidly, and therefore, where therisk is greatest, i.e., takeoff/climb and descent/approach/landing.

Today, HGST represents more than three de-cades of development beginning with the ba-sic head-up display (HUD). HGST can pro-vide direct economic benefit by permitting land-ing and takeoff in low visibility and in poorweather, and the technology is currently uti-

Head-up Guidance System Technology (HGST) — A Powerful Tool for Accident Prevention

ing data from the two categories could haveled to misleading conclusions.

Each primary category is divided into threesubcategories:

• Takeoff/Climb Accidents

• Descent/Approach/Landing Accidents

• Other/En Route Accidents

The subcategories are in accordance with acci-dent statistics that confirm air transport acci-dents occur much more frequently during theTakeoff/Climb and Descent/Approach/Landingphases of flight, than while aircraft are en routeat cruise altitudes. Consequently, passengersand crew are exposed to much greater riskduring these relatively short and critical peri-ods when rapid and frequent changes in flightperformance and conditions often occur.

The study was performed using accident cat-egorization forms for each subcategory [Ap-

Each civil jet transport total loss accident andmajor partial loss accident, that occurred be-tween 1959 and 1989 for which data were avail-able, was reviewed to determine whether HGSTmight have altered the outcome of the flight.Some accidents were eliminated from detailedconsideration because insufficient informationon causal factors was not readily available forthe study.

In-house resources and readily available out-side resources were used for the accident re-views. Information was provided by govern-ment, industry and insurers.

The accident reviews are divided into two pri-mary categories:

• Total Loss Accidents

• Major Partial Loss Accidents

This is done both for ease of analysis and be-cause, as the results indicate, the causes ofthese accidents can be very different; combin-

Methodology

pendix B]. These forms allowed for sufficientinformation to justify the conclusions, but in-formation was brief enough to expedite analy-sis.

After each accident was reviewed and ana-lyzed, it was subjectively rated whether HGSTmight have aided the pilot to have preventedor positively influenced the accident outcome.The rating system is defined as follows:

Yes: It is nearly certain that HGST mighthave aided the pilot.

Yes(?): It is probable that HGST might haveaided the pilot.

No(?): It is not probable that HGST couldhave aided the pilot, but not enoughinformation is known to be nearlycertain.

No: It is nearly certain that HGST couldnot have aided the pilot.

Insufficient information is avail-able to reach a reasonable conclu-sion about the influence HGSTmight have had in this accident.

The ratings are combined into three groups toclassify data in the “Analysis and Results”section. The groups are defined as follows:

Yes/Yes(?) There is a reasonable certainty thatHGST might have prevented or posi-tively influenced the outcome ofthese accidents.

No/No(?) There is a reasonable certainty thatHGST could not have preventedor positively influenced the out-come of these accidents.

Insufficient information is avail-able to reach a reasonable conclu-sion about the influence HGSTmight have had in these accidents.

Takeoff/Climb Accidents

The specific data entered on the Takeoff/ClimbAccident Categorization Form include: typeof landing aid(s) available; windshear; icing;wet runway; snow or rain; low visibility ordarkness; control surface configuration; con-trol surface inoperative; over- or under-rota-tion; weight or balance problem; engine fail-ure; tire failure; brake failure; electrical powerloss or instrument loss; rejected takeoff (RTO);controlled flight into terrain (CFIT); other/notes; and a box for subjective rating.

The following factors in Takeoff/Climb Acci-dents might have been positively influencedby HGST:

• Rejected takeoff, with engine power losswell before V1

• Windshear, wind gust, heavy rain, engineor airframe icing, wake vortex

• Engine power loss (but not power loss onall engines)

• Over- or under-rotation; flap configuration

• Pilot loses control of aircraft while airborne,but aircraft, in principle, is flyable

• Electrical power or instrument loss

Descent/Approach/LandingAccidents

The specific data entered on the Descent/Ap-proach/Landing Accident Categorization Forminclude: type of landing aid(s) available; flightphase (approach, final approach, go-aroundor landing); CFIT; land long; land short or off-center; land hard; landing roll problems; wind-shear; high wind/crosswinds/gusting; wetrunway; low visibility; snow or rain; dark-ness; type of approach (precision or non-pre-cision); mechanical problem; navigational er-ror or disorientation; midair collision or run-way collision; emergency landing; other/notes;

and a box for subjective rating.

The following factors in Descent/Approach/Landing Accidents might have been positivelyinfluenced by HGST:

• CFIT after instrument landing system (ILS)is acquired or could have been acquired

• CFIT with airport visible, even without ILS(e.g., “black-hole” approaches)

• Windshear on final approach

• Electrical power loss or instrument loss

• Emergency landing

• Landing short, long, offside or hard

Other/En Route Accidents

The specific data entered on the Other/En RouteAccident Categorization Form include: mid-air collision; radar environment; non-radar en-vironment; CFIT; mechanical; weather; on-boardfire; system failure; flight management sys-tem (FMS); other/notes; and a box for subjec-tive rating.

Analysis and Results

All Total Loss Accidents

The results summary of all Total Loss Acci-dents in the Takeoff/Climb, Descent/Approach/Landing and Other/En Route subcategories ispresented in Figure 3-1.

Of 543 Total Loss Accidents, there is a reason-able certainty that HGST might have preventedor positively influenced the outcome in 33 percentof them; and a reasonable certainty that HGSTcould not have prevented or positively influ-enced 50 percent of them. Insufficient infor-mation is available to reach a reasonable con-clusion in the remaining 17 percent. The dataare further refined by examining each subcat-egory and those results are presented in Fig-ure 3-2.

Takeoff/Climb Total Loss Accidents

The results of the analysis of Takeoff/Climb

Total Loss Accidents by Occurrences

Yes (13%)

Yes(?) (20%)

No(?) (7%)No (43%)

InsufficientInformation (17%)

Figure 3-1

HGST might have prevented or positively influenced the outcome in 33 percent of All Total Loss Accidents.

Occurrences

Total Loss Accidents are presented in Figure3-3.

Of 164 Takeoff/Climb Accidents, there is areasonable certainty that HGST might haveprevented or positively influenced the out-come in 33 percent of them; a reasonable cer-tainty that HGST could not have prevented 48percent of them; and insufficient informationis available to reach a reasonable conclusionin the remaining 19 percent.

After completion of the analysis of this sub-category, several factors are identified that oc-cur more frequently than others. These fac-tors determine how the accidents are rated;they also suggest areas where HGST may bemost beneficial.

Of the 54 Yes/Yes(?) accidents, 30 percent oc-cur in conditions of low visibility or darkness.Engine failure or simulated engine failure playsa role in 24 percent of them. A minimum of 41percent of them involve crew error. Frequentfactors include recoverable engine failure andtraining error.

Of the 78 No(?)/No accidents, 19 percent oc-cur during low visibility or darkness. Enginefailure or simulated engine failure plays a rolein 26 percent of them. A minimum of 17 per-cent of them involve crew error. Frequentfactors include midair collision, runway colli-sion, tire failure, bird strike, irrecoverable en-gine failure, mechanical problem, control sur-face problem, sabotage, and training.

Insufficient information is available to reach areasonable conclusion in 32 accidents.

Descent/Approach/Landing Total LossAccidents

The results of the analysis of Descent/Approach/Landing Total Loss Accidents are presented inFigure 3-4.

Of 336 Descent/Approach/Landing Accidents,there is a reasonable certainty that HGST mighthave prevented or positively influenced theoutcome in 37 percent of them; a reasonablecertainty that HGST could not have prevented47 percent of them; and insufficient informa-tion is available to reach a reasonable conclu-sion in 16 percent of them.

After completion of the analysis of this sub-category, several factors are identified that oc-cur more frequently than others. These fac-tors determine how the accidents are rated;they also suggest areas where HGST might bemost beneficial.

Of the 125 Yes/Yes(?) accidents, 58 percentoccur during Landing and 35 percent occurduring Approach and Final Approach. Lowvisibility or darkness is present in 56 percentof the accidents. Short landing is a factor in 34percent; long landing or off-center landing is

Yes/Yes(?) (33%)

No(?)/No (48%)

Figure 3-3

HGST might have prevented or positively affected the outcome in 33 percent of the Takeoff/Climb Total Loss Accidents.

Occurrences

Total Loss Accidents by SubcategoryInsufficient

Yes Yes(?) No(?) No Information

Takeoff/Climb 16 38 13 65 32

Descent/Approach/Landing 56 69 21 138 52

Other/En Route 0 2 3 31 7

543 Total Loss Accidents are divided into three subcategories for rating.

Figure 3-2

Occurrences

reasonable certainty that HGST might haveprevented or positively influenced the out-come in five percent of the accidents; a rea-sonable certainty that HGST could not haveprevented 79 percent of them; and insufficientinformation is available to reach a reasonableconclusion in 16 percent of them.

After completion of the analysis of this sub-category, few factors are identified that couldbe subject to the positive influences of HGST;the outcome of the majority of the accidents inthis group could not have been influenced byHGST. The two Yes/Yes(?) accidents involvesevere turbulence and both are scored Yes(?).

Of the 34 No(?)/No accidents, there are nofactors collected on the categorization formsthat suggest a discernible pattern, but somefactors that are not collected on the categori-zation form did recur. Sabotage is a key ele-ment in 35 percent of the accidents. Violence,such as being forced to land or being shotdown, is a factor in 18 percent of the acci-dents. Nine percent of the accidents occur asthe result of major structural failure.

Insufficient information is available to reach areasonable conclusion in seven accidents.

a factor in 21 percent; and hard landing is afactor in 16 percent. Rain or snow is presentin 34 percent of the accidents. Frequent fac-tors are nose gear failure or main gear failurecaused by hard landing, altitude misjudgment,descent below minimums, low visibility andimproper airspeed control.

Of the 159 No(?)/No accidents, 36 percent oc-cur during Landing and 31 percent occur dur-ing Approach and Final Approach. Low vis-ibility or darkness is present in 38 percent ofthe accidents. Short landing is a factor in 14percent; long landing or off-center landing isa factor in 10 percent; and hard landing is nota factor in this subcategory. Rain or snow ispresent in 16 percent of the accidents. CFIToccurs in 21 percent of the accidents. Fre-quent factors are structural failure, runwaycollision, improper procedure and CFIT.

Other/En Route Total Loss Accidents

The results of the analysis of Other/En RouteTotal Loss Accidents are presented in Figure 3-5.

Of 43 Other/En Route Accidents, there is a

Yes/Yes(?) (37%)

No(?)/No (47%)

Descent/Approach/Landing Total Loss Accidents

Figure 3-4

HGST might have prevented or positively influenced the outcome in 37 percent of the Descent/Approach/Landing Total Loss Accidents.

Occurrences

Yes/Yes(?) (5%)

No(?)/No (79%)

Insufficient Information (16%)

Figure 3-5

HGST might have prevented or positively influenced the outcome in five percent of the Other/En Route Total Loss Accidents.

Occurrences

An analysis of the number of fatalities thatoccur in these accidents is made to estimatehow many fatalities might havebeen prevented by the use of HGST.The combined totals of all fatali-ties in the Takeoff/Climb, Descent/Approach/Landing and Other/EnRoute subcategories are presentedin Figure 3-6.

There is a reasonable certainty thatHGST might have prevented orpositively influenced the outcomeof the accidents which cause 25percent of the fatalities; a reason-

able certainty that HGST could not have pre-vented the accidents which cause 59 percentof the fatalities; and insufficient informationis available to reach a reasonable conclusionabout the accidents which cause 16 percent ofthe fatalities (Figure 3-7).

The results of the review of fatalities in this

Total Loss Accidents by Fatalities

subcategory are presented in Figure 3-8.

Of 6,938 fatalities, there is a reasonable certaintythat HGST might have prevented or positively

influenced the outcome of the accidents whichcause 28 percent of the fatalities; a reasonablecertainty that HGST could not have preventedthe accidents which cause 46 percent of the fa-talities; and insufficient information is availableto reach a reasonable conclusion in the acci-dents which cause 26 percent of the fatalities.Accidents with more than 150 fatalities are noted

Yes Yes(?) No(?) No InsufficientInformation

10,000

12,000

14,000

Figure 3-6

(10%)2,302

(15%)3,451

(8%)1,698

(51%)11,414

(16%)3,510

HGST might have prevented or positively influenced the outcome in 5,753 (25 percent) of the 22,375 fatalities that occurred in All Total Loss Accidents.

Fatalities

All Total Loss Accidents by SubcategoryInsufficient

Takeoff/Climb 961 952 651 2,554 1,820

Descent/Approach/Landing 1,341 2,333 611 6,014 1,392

Other/En Route 0 166 436 2,846 298

The 22,375 fatalities that occurred in the accidents are rated by subcategory.

Figure 3-7

Fatalities

Figure 3-8

(14%)961

(14%)952

(9%)651

(37%)2,554

(26%)1,820

1 - One accident with 155 fatalities, another with 213 fatalities.2 - One accident with 271 fatalities, another with 155 fatalities.3 - One accident with 520 fatalities.4 - One accident with 301 fatalities, others with 156, 248, 346, 156.5 - One accident with 256 fatalities, another with 163 fatalities.

HGST might have prevented or positively influenced the outcome in 28 percent of the fatalities in the Takeoff/Climb Total Loss Accidents.

Fatalities

Accidents with More Than 150 Fatalities

Fatalities

in Figure 3-8.

All these fatalities occur in 116 acci-dents, but the 12 accidents with morethan 150 fatalities each account for42 percent of the fatalities.

Descent/Approach/Landing TotalLoss Accidents

Results of the review of fatalities inthis subcategory are presented in Fig-ure 3-9.

Of 11,691 fatalities, there is a reason-able certainty that HGST might haveprevented or positively influenced theoutcome in the accidents which caused31 percent of the fatalities; there is areasonable certainty that HGST couldnot have prevented the accidents whichcaused 57 percent of the fatalities; andinsufficient information is available toreach a reasonable conclusion in theaccidents which caused 12 percent ofthe fatalities. Accidents with more than150 fatalities are noted in Figure 3-9.

All these fatalities occur in 221 accidents,but the 11 accidents with more than 150fatalities each account for 16 percent ofthe fatalities.

Results of the review of fatalities in thissubcategory are presented in Figure 3-10.

Of 3,746 fatalities, there is a reasonablecertainty that HGST might have preventedor positively influenced the outcome inthe accidents which cause four percentof the fatalities; a reasonable certaintythat HGST could not have prevented theaccidents which cause 88 percent of thefatalities; and insufficient information isavailable to reach a reasonable conclu-sion in the accidents which cause eightpercent of the fatalities. There are fa-talities in each of these 43 accidents, and

there are several with more than 150 fatalitieseach.

Figure 3-10

(4%)166

(12%)436

(76%)2,846

(8%)298

1 - One accident with 257 fatalities, another with 162.2 - One accident with 170 fatalities, others with 261, 290, 167, 329, 269.3 - One accident with 173 fatalities.

HGST might have prevented or positively influenced the outcome in four percent of the fatalities that occur during Other/En Route Total Loss Accidents.

Fatalities

Accidents with More Than 150 Fatalities

Yes Yes(?) No(?) No Insufficient Information

Figure 3-9

(11%)1,341

(20%)2,333

(5%)611

(52%)6,014

(12%)1,392

1 - One accident with 175 fatalities, others with 181, 180, 183.2 - One accident with 159 fatalities, others with 183, 154, 188, 191, 171.3 - One accident with 174 fatalities.

HGST might have prevented or positively influenced the outcome in 31 percent of the fatalities that occur during Descent/Approach/Landing Total Loss Accidents.

Fatalities

Accidents witn More Than 150 Fatalities

Total Loss Accidents by Region presentsthe potential influence of HGST by subcat-egories in specific regions of the world. Totalresults of all regions are presented in Fig-ure 3-11. [See Appendix C for explanationof how regions are defined for the purposeof this report.]

There is reason to believe that several re-gions of the world, including the U.S.S.R.,Eastern Europe and the People’s Republicof China have not reported all civil jet trans-port accidents that occurred during the 1959-1989 period. Therefore, the results of thisanalysis are skewed.

The results of the review and analysis ofthis subcategory are presented in Figure 3-12.

Total Loss Accidents by Region

The majority of the accident reports fromthe U.S.S.R. provide insufficient informa-tion to reach a reasonable conclusion inthis subcategory. North America reportsthe greatest number of Takeoff/Climb To-tal Loss Accidents.

Descent/Approach/Landing Total LossAccidents

The results of the review and analysis ofthis category are presented in Figure 3-13.North America reports the greatest num-ber of accidents.

The results of the review and analysis ofthis subcategory are presented in Figure3-14. The majority of the accidents in ev-ery region were rated in the No column.

Figure 3-12

Takeoff/Climb Total Loss AccidentsInsufficient

North America 6 14 4 23 2

Central America & Caribbean 1 0 0 2 3

South America 1 2 4 9 4

Western Europe 0 7 1 12 4

Scandinavia 0 2 0 1 0

Eastern Europe 0 1 1 1 1

Middle East 2 2 2 3 1

Africa 3 4 0 6 2

U.S.S.R. 0 3 0 1 10

Indian subcontinent 2 1 0 2 2

Southeast Asia 0 0 0 1 0

Asia 1 1 0 3 1

Pacific 0 1 1 0 2

Antarctica/Australia/New Zealand 0 0 0 1 0

Region

Figure 3-11

All Total Loss AccidentsInsufficient

Africa 8 14 2 31 12

U.S.S.R. 0 3 1 11 18

Asia 2 6 2 8 1

Pacific 6 8 2 13 4

Region

Figure 3-13

InsufficientYes Yes(?) No(?) No Information

Africa 5 10 2 22 9

U.S.S.R. 0 0 1 7 7

Asia 1 5 1 3 0

Pacific 6 6 1 11 1

Region

Figure 3-14

Other/En Route Total Loss Accidents Insufficient

Africa 0 0 0 3 1

U.S.S.R. 0 0 0 3 1

Asia 0 0 1 2 0

Pacific 0 1 0 2 1

Region

(* There is no Figure 3-15)

All Major Partial Loss Accidents

The results summary of all Major Partial LossAccidents in the subcategories of Takeoff/Climb,Descent/Approach/Landing and Other/EnRoute are presented in Figure 3-16.

Of 536 Major Partial Loss Accidents, there is areasonable certainty that HGST might haveprevented or positively influenced the outcomein 29 percent of them; a reasonable certainty

Major Partial Loss Accidents by Occurrences

Figure 3-17

Major Partial Loss Accidents by SubcategoryInsufficient

Takeoff/Climb 2 0 8 84 9

Descent/Approach/Landing 56 95 31 178 40

Other/En Route 0 2 1 29 1

536 Major Partial Loss Accidents are rated by subcategories.

Occurrences

that HGST could not have prevented 62 percentof them; and insufficient information is availableto reach a reasonable conclusion in nine percentof them. Major Partial Loss Accidents are ratedby subcategory in Figure 3-17.

Takeoff/Climb Major Partial Loss Accidents

The results of the review and analysis of thissubcategory are presented in Figure 3-18.

Of 103 accidents, there is a reasonable cer-

tainty that HGST might haveprevented or positively influ-enced the outcome in two per-cent of them; a reasonable cer-tainty that HGST could nothave prevented 89 percent ofthem; and insufficient infor-mation is available to reacha reasonable conclusion in ninepercent of them.

After completion of the analy-

Yes (11%)

Yes(?) (18%)

No(?) (7%)

No (55%)

Major Partial Loss Accidents

Figure 3-16

HGST might have prevented or positively influenced the outcome in 29 percent of all Major Partial Loss Accidents.

Occurrences

Yes /Yes(?) (2%)

No(?)/No (89%)

Figure 3-18

HGST might have prevented or positively influenced the outcome in two percent of the Takeoff/Climb Major Partial Loss Accidents.

Occurrences

sis of this subcategory, several factors are iden-tified that occur more frequently than others.These factors determine how the accidents arerated; they also suggest areas where HGSTmight be most beneficial.

Of the Yes/Yes(?) accidents, there are too few(two) accidents to reach a reasonable conclu-sion.

Of the 92 No(?)/No accidents, 43 percent oc-cur during conditions of engine failure or simu-lated engine failure; tire failure is a factor in11 percent of the them; and landing gear fail-ure is a factor in eight percent of them. Fre-quent accident factors include engine failure,premature retraction of landing gear and struc-tural failure of landing gear or airframe.

Insufficient information is available to reach areasonable conclusion in nine accidents.

Descent/Approach/Landing Major PartialLoss Accidents

The results of the analysis of accidents in thissubcategory are presented in Figure 3-19.

Of 400 accidents, there is a reasonable cer-tainty that HGST might have prevented or posi-

tively influenced the outcome in 38 percent ofthem; a reasonable certainty that HGS couldnot have prevented 52 percent of them; andinsufficient information is available to reach areasonable conclusion in 10 percent of them.

After completion of the analysis of this sub-category, several factors are identified that oc-cur more frequently than others. These fac-tors determine how the accidents are rated;they also suggest areas where HGST might bemost beneficial.

Of the 151 Yes/Yes(?) accidents, 83 percentoccur during Landing. Low visibility or dark-ness is present in 33 percent of the accidents.Short landing is involved in 25 percent of theaccidents; long landing or off-center landingis involved in 28 percent of them; and hardlanding is involved in 30 percent of them. Rainor snow is present in 35 percent of the acci-dents. Frequent factors include fast landingwhich causes runway overrun; hard landingwhich damages landing gear or airframe; andvisibility problems.

Of the 209 No(?)/No accidents, 83 percent oc-cur during Landing. Mechanical problems areinvolved in 45 percent of the accidents. Land-ing gear failure (mechanical or crew error),accounts for 49 percent of the accidents. Fre-quent accident factors include engine failure,landing gear or airframe failure, and crew er-ror related to landing gear.

Other/En Route Major Partial LossAccidents

The results of the analysis of accidents in thissubcategory are presented in Figure 3-20.

Of 33 accidents, there is a reasonable certaintythat HGST might have prevented or positivelyinfluenced the outcome in six percent of theaccidents; a reasonable certainty that HGS couldnot have prevented 91 percent of them; andinsufficient information is available to reach a

Yes /Yes(?) (38%)

No(?)/No (52%)

Descent/Approach/Landing Major Partial Loss Accidents

Figure 3-19

HGST might have prevented or positively influenced the outcome in 38 percent of the Descent/Approach/Landing Major Partial Loss Accidents.

Occurrences

reasonable conclusion in three percent of them.

After the analysis of this subcategory, few fac-tors are identified that would be subject to thepositive influences of HGST and the outcome

Yes/Yes(?) (6%)

No(?)/No (91%)

Other/En Route Major Partial Loss Accidents

Figure 3-20

HGST might have prevented or positively Influenced the outcome in six percent of the Other/En Route Major Partial Loss Accidents.

Occurrences of the majority of the accidents in this groupcould not have been influenced by HGST.

The two Yes/Yes(?) accidents are too few toreach a reasonable conclusion.

Of the 30 No(?)/No accidents, there are nofactors on the Accident Categorization Formwhich fall into a discernible pattern, althoughsome factors do recur. Engine failure plays arole in 33 percent of the accidents. Crew erroris present in a minimum of 15 percent of theaccidents. Frequent accident factors includestructural damage, exploding engine, volca-nic ash and weather.

Insufficient information is available to reach areasonable conclusion in one accident.

Major Partial Loss AccidentsBy Fatalities

All Major Partial Loss Accidents

There are too few fatalities in this category toallow a significant analysis.

The majority of the accidents in all regions arerated No. There are significantly greater num-bers of accidents in North America and West-ern Europe, which probably reflect a greaternumber of flights in those regions.

Descent/Approach/Landing Major PartialLoss Accidents

Results of the review and analysis of this sub-category are presented in Figure 3-23.

Major Partial Loss Accidents

All Major Partial Loss Accidents are rated byregion. Results are presented in Figure 3-21;they are skewed, because some regions of theworld report their accidents with less detailand accuracy than others.

Results of the review and analysis of this sub-category are presented in Figure 3-22.

Major Partial Loss Accidents by Region

Figure 3-21

All Major Partial Loss AccidentsInsufficient

Africa 1 10 0 16 3

U.S.S.R. 0 0 0 1 0

Asia 0 0 1 10 2

Pacific 3 6 5 20 5

Region

Figure 3-22

Takeoff/Climb Major Partial Loss AccidentsInsufficient

Africa 0 0 0 6 0

U.S.S.R. 0 0 0 0 0

Asia 0 0 1 1 0

Pacific 0 0 1 7 2

Region

Figure 3-23

Descent/Approach/Landing Major Partial Loss

AccidentsInsufficient

Africa 1 10 0 10 3

U.S.S.R. 0 0 0 1 0

Asia 0 0 0 7 2

Pacific 3 6 3 6 3

Region

Figure 3-24

Other/En Route Major Partial Loss Accidents Insufficient

Africa 0 0 0 0 0

U.S.S.R. 0 0 0 0 0

Asia 0 0 0 0 0

Pacific 0 0 1 7 0

Region

Other/En Route Major Partial LossAccidents

The results of the review of Other/En RouteMajor Partial Loss Accidents are shown in Figure3-24.

The majority of the accidents in all regions arerated No.

Narratives of 12 incidents which might havebeen prevented by HGST are presented in re-verse chronological order.

1. On August 22, 1979, a Boeing 727 encoun-tered a heavy rainshower with associatedwindshear during f inal approach toHartsfield International Airport in Atlanta,Georgia, U.S. The aircraft descended toless than 375 feet above ground level (agl)before it exited the shower and initiated asuccessful missed approach. The U.S. Na-tional Transportation Safety Board (NTSB)determined that the incident’s probable causewas the unavailability to the crew of timelyinformation concerning a rapidly chang-ing weather environment along the instru-ment landing system (ILS) final approachcourse. The unavailability of this data re-sulted in an inadvertent encounter with alocalized rainshower and associatedwindshears which required the crew to useextreme recovery procedures to avoid anaccident. A contributing factor was a lackof equipment for the airport terminal areathat could have detected, monitored andprovided quantitative measurements ofwindshear both above and outside theairport’s boundaries. There was no dam-age to the aircraft; there were no injuriesto passengers or crew.

2. On July 11, 1976, during an ILS approachto Sendai, Japan, a Boeing 727 descendedout of clouds at an altitude of 250 feet agland subsequently touched down on the rightmain landing gear. The right wing tip,right leading edge slat, outboard trailingflap and fairings were damaged. The flightcrew was unaware that the aircraft hadbeen damaged during the landing; therewere no injuries to passengers or crew.

3. On March 16, 1976, the pilot-in-commandof a Boeing 727 lost visibility after touch-down due to heavy rain. The aircraft ranoff the side of the runway, but the pilottaxied the aircraft to the terminal. Theaircraft sustained minor damage to the land-ing gear and the trailing edge flaps, and

there were no injuries to passengers or crew.

4. On March 4, 1976, during an ILS approachto runway 13 at New York/La Guardia, aBoeing 727 descended from clouds to theleft of the runway, at an altitude of 250 feetagl. The pilot-in-command banked the air-craft to the right and then to the left toalign the aircraft with the runway. Theaircraft touched down on the left main land-ing gear. The left wing tip, left leadingedge flap, outboard trailing flap and fair-ings were damaged. The flight crew wasunaware that the aircraft had been dam-aged during the landing; there were noinjuries to passengers or crew.

5. On September 3, 1974, during a coupledILS approach in instrument meteorologi-cal conditions to Nairobi Airport (eleva-tion 5,327 feet) in Kenya, the altitude se-lector was set to 5,000 feet; a descent tocapture this altitude was initiated. TheBoeing 747 aircraft descended through thecleared altitude (7,500 feet) just before itbecame established on the localizer. Al-though the aircraft was below the glide-slope, the descent was continued until theground was sighted at 200 feet agl. Duringthe subsequent overshoot maneuver, theaircraft flew within 70 feet of the groundat a distance of approximately 6.75 nauti-cal miles (nm) from the airport.

The incident was caused by the pilots’ ac-ceptance of an altitude to which they mis-takenly believed the aircraft had been clearedto descend, which was below the level ofthe surrounding terrain. Contributing fac-tors were the failure of the air traffic con-troller to challenge the incorrect readbackof the descent clearance; inadequate crewmonitoring; the relatively high speed ofthe aircraft’s approach; and crew sickness.There was no damage to the aircraft; therewere no injuries to passengers or crew.

6. On July 31, 1973, a DC-9 was executing abackcourse localizer approach to runway02 at Chattanooga/Lovell Field Airport in

Tennessee, U.S. The aircraft was still air-borne approximately 4,000 feet past thethreshold of the runway, which is 7,400feet in length. The aircraft landed approxi-mately 1,200 feet before the end of the run-way. The aircraft continued off the end ofthe runway in a right turn, executed by thepilot-in-command in an attempt to avoidapproach lights. The aircraft slid throughthe mud sideways for 420 feet and the leftmain landing gear collapsed. The aircraftcame to rest on the left wing, right maingear and nose gear. There were no injuriesto passengers and crew, and there was onlyminor damage to the aircraft. The weatherwas 400 feet scattered, 4,700 feet overcast,visibility one mile in light rain, fog andsmoke. The minimum visibility requiredfor the approach was one mile.

7. On May 9, 1973, tower personnel observeda DC-10 in an extreme nose-high attitudeas it contacted the runway. Following contactwith the ground, parts were observed tofall from the tail section, followed by thetail cone separating from the airframe atthe two lower hinge attach points. Investi-gation disclosed that the two hinges weredragged on the runway for 86 feet. Bothhinges were abraded sufficiently so thatthe tail cone became separated at the lowersection and struck the two inboard eleva-tors. Investigation disclosed this modelaircraft did not have a tail skid. Damagerequired replacement of the tail section andtwo elevators. The crew was unaware ofthe damage until the tower advised themof the incident. There were no injuries topassengers or crew.

8. On April 10, 1973, a Boeing 727 struck treeswhile executing an instrument approachto runway 25 at the Toledo Express Air-port in Toledo, Ohio, U.S. The incidentoccurred as the aircraft passed through asnow shower near the approach path tothe airport. The instrument approach wasabandoned and a second approach and land-ing were accomplished without further in-cident. Damage was limited to the leading

edge and trailing edge flaps of the rightwing. There were no injuries to passen-gers or crew. It was determined that theprobable cause of the incident was the fail-ure of the crew to adhere to establishedprocedures, which resulted in a descentbelow the authorized minimum descentaltitude and an impact with the trees.

9. On August 19, 1972, a Boeing 707 took offfrom Cologne, Germany, at 0115 hours boundfor Istanbul. In the vicinity of Zabreb,Yugoslavia, at flight level 330, there was afailure of the number three engine. Afterclearance from Belgrade air traffic control(ATC), the aircraft descended to flight level290. The flight requested permission toland at Sofia Airport due to the enginefailure and fuel depletion.

The aircraft descended for landing, madea left turn about 15 kilometers southwestof the Sofia outer marker and the crewreported that the aircraft was establishedon the ILS. The crew then discovered afire in the number four engine.

Sofia radar gave three course correctionsto the pilot-in-command to return the air-craft to the centerline. The flight reactedslowly to the corrections. About two kilo-meters before touchdown, the pilot-in-com-mand saw that the aircraft was well off theglide path and the runway was to the left.He elected to land, because the aircraftlacked sufficient fuel to go around, andtwo engines were inoperative.

The aircraft contacted the runway 101 metersfrom the threshhold, with its right wing tipand the number four engine. An additional75 meters farther, the right landing gear con-tacted the runway; 130 meters farther theleft landing gear contacted the runway. Tracksleft on the runway by the aircraft’s tires wereat 235 degrees magnetic, i.e., a deviation about40 degrees from the axis of the runway. Af-ter sliding about 150 meters, the aircraft leftthe runway, then started turning to the rightto return to the center of the runway. There

was minor damage to the aircraft and therewere no injuries to passengers or crew.

10. On December 21, 1971, a Boeing 727 wasflying from Charlotte, North Carolina, U.S.to Hartsfield International Airport, Atlanta,Georgia. An ILS approach to runway 9Rto Category II minima was initiated withthe automatic pilot and approach couplerengaged. The landing flaps were extendedto the 30 degrees position when the air-craft passed over the outer marker. Duringflap extension, the aircraft deviated fromthe glideslope centerline and did not be-come established again on the glideslope,until it was approximately 800 feet agl. At225 feet agl, the aircraft deviated again fromthe glideslope, and it began a descent thatcontinued until the landing gear struck theapproach lights. The aircraft was landedon the runway. There was minor damageto the aircraft; there were no injuries topassengers or crew.

It was determined that the probable causeof the accident was an unexpected and un-detected divergence of the aircraft fromthe glideslope centerline induced by a mal-function of the automatic pilot. This di-vergence occurred at an altitude from whicha safe recovery could have been made.However, both the pilot and first officerwere preoccupied with establishing out-side visual reference under visibility con-ditions which precluded adequate altitudeassessment from external clues. Conse-quently, the pilot did not recognize thedivergence from the glideslope in time toavoid contact with the approach lights.

11. On June 22, 1971, a DC-9 was on a flightfrom New Bedford, Massachusetts, U.S.,to Martha’s Vineyard, Massachusetts. Whileon a very high frequency omnidirectional

range station (VOR) final approach to theairport, in instrument meteorological con-ditions, the aircraft struck the water, butremained airborne. The captain then flewthe aircraft to Boston’s Logan InternationalAirport, where he made a normal landing.

The incident occurred at 0830 approximatelythree miles from the end of runway 24 atMartha’s Vineyard. There was minor damageto the aircraft and there were no injuries topassengers or crew. It was determined thatthe probable cause of the incident was lackof crew coordination in monitoring the alti-tude during performance of a non-preci-sion instrument approach, misreading ofthe altimeter by the captain and lack ofaltitude awareness by both pilots.

12. On December 13, 1969, a Boeing 747 wasbeing ferried from Boeing Field in Seattle,Washington, U.S. During the approach tolanding at Renton Airport, also in Washing-ton, the aircraft struck an embankment ap-proximately 20 feet short of the threshold ofrunway 15. The contact point was 30 inchesbelow the top of the bank. The aircraft cameto a stop on the centerline of the runway and3,500 feet from the threshold. There wassubstantial damage to the aircraft; there wereno injuries to passengers or crew.

Weather was scattered clouds at 4,500 feetand broken clouds at 6,500 feet. Visibilitywas 13 miles and the wind velocity was 20knots from 120 degrees true. It was deter-mined the probable cause of the incidentwas premature touchdown of the aircraftduring a visual approach to a relatively shortrunway, induced by the pilots not estab-lishing a glidepath, which would assurerunway threshold passage with an adequatesafety margin under somewhat unusual en-vironmental and perceptual conditions.

Conclusions

Flight Safety Foundation concludes that HGSTmight have prevented or positively influenceda significant number of the civil jet transportaccidents that occurred between 1959 and 1989,if the involved aircraft had been equipped withproperly functioning HGST that was operatedby a correctly trained crew. Such equipmentpresumed in this study, however, has becomeavailable only in recent years.

The greatest number of accidents occur dur-ing Descent/Approach/Landing and Takeoff/Climb, the two most critical phases of flightwhere HGST is most beneficial.

Thirty-three percent of All Total Loss Acci-dents might have been prevented or positivelyinfluenced by HGST. Analysis of Takeoff/ClimbTotal Loss Accidents indicates that 33 percent

of them might have been prevented or posi-tively influenced by HGST. Analysis of De-scent/Approach/Landing Total Loss Accidentsindicates that 37 percent of them might havebeen prevented or positively influenced by HGST.Analysis of Other/En Route Total Loss Acci-dents indicates that five percent of the acci-dents might have been prevented or positivelyinfluenced by HGST. (Refer to Figures 3-1through 3-5.)

Twenty-nine percent of All Major Partial LossAccidents might have been prevented or posi-tively influenced by HGST. Analysis of Take-off/Climb Major Partial Loss Accidents indi-cates that two percent of them might havebeen prevented or positively influenced by HGST.Analysis of Descent/Approach/Landing Ma-jor Partial Loss Accidents category indicates

that 38 percent of them might have been pre-vented or positively influenced by HGST. Analy-sis of Other/En Route Major Partial Loss Ac-cidents indicates that six percent of them mighthave been prevented or positively influencedby HGST. (Refer to Figures 3-16 through 3-20.)

Other technologies, applied in concert with HGST,such as ground proximity warning systems(GPWS) and image-enhancing radar, are likelyto further reduce human error in Descent/Ap-

proach/Landing and Takeoff/Climb phases offlight, as well as in ground operations.

Implementation of any new technology can beaccompanied by unforseen effects that, in somesituations, can introduce new opportunitiesfor error. Modern simulation capabilities, ap-plied to new technologies, offer an additionalresource to solve unforeseen problems, andreal-world experiences are likely to contributeto further refinements of HGST.

Appendix A — Head-upGuidance System Technology

The contracted study completed by Flight SafetyFoundation in late 1990, evaluates whether head-up guidance system technology might haveprevented or positively influenced the out-come of civil jet transport accidents that oc-curred between 1959 and 1989.

The study considers what might have beenthe likely outcome of the reviewed accidentsif properly operating head-up guidance equip-ment, correctly operated by a crew trained touse such equipment, had been in use aboardeach aircraft.

Head-up guidance equipment projects a holo-graphic display on a glass combiner attachedto the windshield. The display presents situa-tion and guidance data. Symbology data arefocused at infinity and more than 90 percentof the available light passes through the dis-play from the windshield. The operating fea-tures of the head-up guidance equipment pre-sumed for this study, were based upon cur-rent commercially available equipment for civiltransport category aircraft and included thefollowing:

• windshear detection and recoveryguidance

• roll index• indicated airspeed

• ground speed• radio altimeter• barometric altitude• vertical speed• DME (distance measuring equipment) data• navigation and course guidance

information• localizer and glideslope data• warnings and other information displayed

against a horizon line marked in five-de-gree magnetic heading tick-marks and apitch ladder marked in five-degree steps.

Also, flightpath vector data, which depicts wherethe aircraft is going based on its currentflightpath, and inertial acceleration data, whichdepicts acceleration or deceleration of the air-craft, were also included as operating features.

In the instrument landing system (ILS) mode,the system is presumed to track the ILS andguide the pilot through a precision approach,flare and landing. In a visual approach andlanding to an airport where ILS is not avail-able, the aircraft’s true inertial flight path isdisplayed and a head-up precision approachto a precise touchdown is made possible by anelectronically constructed glideslope. Run-way guidance is optimized to provide aircraftguidance information on the runway duringtakeoff roll and after touchdown.

Flight Safety Foundation FSF/SP-90/10

Appendix B — AccidentCategorization Forms

ff/Clim

rizatio

landing aid

windshear

wet runway

snow or rain

night orlow visibility

control surfaceconfiguration

control surfaceinoperative

over or underrotation

weight andbalance

enginefailure

tirefailure

brakefailure

electrical poweror instrumentloss

rejectedtakeoff

landing aid

flightphase

landlong

land short oroff-center

landhard

rolloutproblems

windshear

high, gusty orcrosswinds

wetrunway

lowvisibility

snow, sleetrain

darkness

type ofapproach

mechanicalproblems

navigation errorlost

midair orcollision onrunway

emergencylanding

rizatio

preventable byH

midair

radarenvironment

non-radarenvironment

mechanical

weather

systemfailure

Appendix C — Region Key

The following is a key to the regional indexingused in this report. The divisions are madegeographically, not politically.

North America: Canada, continental UnitedStates (including Alaska)

Central America: Costa Rica, Guatemala, Hon-duras, Mexico, Panama

Caribbean: Antigua, Barbados, Bermuda, Cuba,Dominican Republic, Guadeloupe, Haiti,Montserrat, St. Lucia, U.S. Virgin Islands

South America: Argentina, Bolivia, Brazil, Chile,Colombia, Ecuador, Paraguay, Peru, Surinam,Venezuela

Western Europe: Austria, the Azores, theBalearics, Belgium, Denmark, England, France,

Ireland, Italy, Luxembourg, Malta, The Neth-erlands, Portugal, Scotland, Spain, Switzerland,West Germany

Scandinavia: Norway, Sweden

Eastern Europe: Bulgaria, Czechoslovakia, EastGermany, Greece, Poland, Romania, Yugosla-via

Middle East: Afghanistan, Bahrain, Cyprus,Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Qatar,Saudi Arabia, Syria, Turkey, United Arab Emir-ates (UAE), Yemen

Africa: Algeria, Angola, Cameroon, CanaryIslands, Egypt, Equatorial Guinea, Ethiopia,Gabon, Ghana, Guinea, Ivory Coast, Kenya,Liberia, Libya, Madagascar, Madeira Islands,Mauritania, Mauritius, Morocco, Mozambique,

Namibia, Niger, Nigeria, South Africa, Sudan,Tangier, Tunisia, Zaire, Zambia

U.S.S.R.

Indian Subcontinent: India, Nepal, Pakistan,Sri Lanka

Southeast Asia: Burma, Cambodia, Malaysia,Singapore, Thailand, Vietnam

Asia: Hong Kong, Mongolia, People’s Repub-lic of China (PRC), South Korea, Taiwan

Pacific: American Samoa, Caroline Islands,Chejin Islands, Guam, Hawaii, Indonesia, Ja-pan, Palau Islands, Philippines, Tahiti

Antarctica/Australia/New Zealand

Appendix D — Personnel

The personnel listed below performed the contracted study.

• Capt. Edward Arbon (retired, Trans World Airlines)

• Leonard Wojcik, Ph.D.

This project report (FSF/SP-91/01), “Head-up Guidance System Technology (HGST) — A Pow-erful Tool for Accident Prevention,” based upon the contracted study, was produced by thefollowing personnel:

• Roger Rozelle, FSF director of publications

• Ashton Alvis, FSF production coordinator

• Allen Mears

• Tania Calhoun

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