CONTROLLED FLIGHT

INTO TERRAIN

C F I T

C F I T

DEFINITION

AN EVENT WHERE A MECHANICALLY NORMALLY FUNCTIONING AIRPLANE IS INADVERTENTLY FLOWN INTO THE GROUND, WATER, OR AN OBSTACLE

OVERVIEW FOR MANAGEMENT

INTRODUCTION• CFIT CONTINUES TO BE THE DOMINANT REASON FOR

ACCIDENTS INVOLVING HULL LOSSES AND FATALITIES

• 9000 PEOPLE HAVE DIED WORLD WIDE BECAUSE OF CFIT

• AT CURRENT RATE CFIT COULD CAUSE ONE MAJOR AIRLINE HULL LOSS, AND ASSOCIATED FATALITIES, PER WEEK BY YEAR 2010

• IT IS IMPERATIVE THAT CFIT ACCIDENT RATE BE LOWERED

• OPERATORS MUST BE MADE AWARE OF THE CFIT PROBLEM AS WELL AS TRAINED TO AVOID THESE ACCIDENTS

GENERAL GOALS & OBJECTIVES

• EDUCATE BOTH OPERATIONAL & MANAGEMENT PERSONNEL

• PROVIDE SPECIFIC, APPROPRIATE EDUCATIONAL MATERIAL

• PROPOSE AN EXAMPLE TRAINING PROGRAM

• PROVIDE MANAGERS WITH AN EFFECTIVE CFIT AVOIDANCE STRATEGY

RESOURCE UTILIZATION

• OPERATORS SHOULD USE BOTH THE ACADEMIC AND SIMULATOR TRAINING PROGRAM TO ACHIEVE A WELL-BALANCED, EFFECTIVE CFIT TRAINING PROGRAM

• ALLOCATION OF TRAINING TIME FOR CFIT WITHIN BOTH RECURRENT AND TRANSITION PROGRAM WILL VARY WITH EACH OPERATOR

DECISION MAKERS GUIDE

• AIRLINE MANAGEMENT CREATES THE SAFETY CULTURE OF THE ORGANIZATION. THIS CULTURE THEN AFFECTS EVERYONE WITHIN THE ORGANIZATION

• ACCIDENTS AND INCIDENTS ARE PREVENTABLE THROUGH EFFECTIVE MANAGEMENT: DOING SO IS COST EFFECTIVE

C F I T ACCIDENTS

HULL-LOSS ACCIDENTS FOR WORLDWIDE COMMERCIAL JET FLEET

CFIT HULL-LOSS ACCIDENTS FOR WORLDWIDE COMMERCIAL JET FLEET

WORLDWIDE AIRLINE ACCIDENTS CLASSIFIED BY TYPE - 1991 THROUGH 1995

WORLDWIDE AIRLINE FATALITIES CLASSIFIED BY TYPE OF ACCIDENT-1991 THROUGH 1995

POSITIVE RESULTS OF GROUND WARNING

SYSTEMS (GPWS)

CFIT ACCIDENT PER YEAR-USA AND WORLD CARRIERS

GPWS INITIAL RELIABILITY AND FOLLOW- ON IMPROVEMENTS

FLIGHT PATH PROFILE: 707-300, Santa Maria, Azores, February 8, 1989

INDUSTRY SUPPORT REQUIRED FOR GPWS

WORLD AIRLINE JET FLEET EQUIPPED WITH GPWS

COMMERCIAL JET CFIT ACCIDENTS; 7-YEAR PERIOD-1989 THROUGH 1995

CFIT AND FLIGHT CREW

CAUSES FOR CFIT ACCIDENTS

PRIMARY CAUSE FACTORS FOR HULL-LOSS ACCIDENTS FOR WORLDWIDE COMMERCIAL JET FLEET

FACTORS THAT CONTRIBUTE TO CFIT

• ALTIMETER SETTING UNITS OF MEASUREMENT

• ALTIMETER SETTING

• SAFE ALTITUDES

• AIR TRAFFIC CONTROL

• FLIGHT CREW COMPLACENCY

• PROCEDURAL

Contd.

PERCENTAGE OF ALL ACCIDENTS BY PHASE OF FLIGHT AND THE PERCENTAGE OF FLIGHT TIME THAT THE FLIGHT CREW IS

EXPOSED DURING THAT PHASE

MAP LOCATION OF CFIT ACCIDENTS/INCIDENTS

FACTORS THAT CONTRIBUTE TO CFIT

• DESCENT, APPROACH AND LANDING

PRIMARY CAUSE FACTORS FOR HULL-LOSS ACCIDENTS FOR WORLDWIDE COMMERCIAL JET FLEET

GEOGRAPHICAL LOCATION OF CFIT ACCIDENTS

FACTORS THAT CONTRIBUTE TO C F I T

• AUTOFLIGHT SYSTEM

• TRAINING

C F I T PREVENTION

• MINIMUM SAFE ALTITUDE WARNING SYSTEM (MSAWS)

C F I T PREVENTION• MSAWS

• CREW BRIEFING

• AUTOFLIGHT SYSTEMS

• ROUTE & DESTINATION FAMILIARIZATION

• ALTITUDE AWARENESS

• USE OF CALL OUTS

• GPWS WARNING ESCAPE MANEUVER

• CHARTS

• TRAINING

EXAMPLE CFITTRAINING PROGRAM

ACADEMIC TRAINING PROGRAM

ACADEMIC TRAINING PROGRAM

• RECOGNIZE FACTORS THAT LEAD TO CFIT ACCIDENTS AND INCIDENTS

• KNOW PREVENTION STRATEGIES THAT WILL ENSURE SAFE FLIGHT

• IMPROVE SITUATIONAL AWARENESS TO AVOID CFIT

• LEARN ESCAPE MANEUVER AND TECHNIQUES TO ENHANCE POSSIBILITY OF SURVIVAL

CFIT SIMULATOR TRAINING PROGRAM

SIMULATOR TRAINING OBJECTIVES

• RECOGNIZE CONTRIBUTING FACTORS THAT CAN LEAD TO A CFIT INCIDENT

• MAINTAIN PROPER HORIZONTAL AND VERTICAL SITUATIONAL AWARENESS

• COMMUNICATE & COORDINATE ON FLIGHT DECK DURING CRITICAL PHASES OF FLIGHT

• RECOGNIZE A POTENTIAL CFIT SITUATION AND TAKE APPROPRIATE ACTION

• GAIN CONFIDENCE IN THE GPWS

• PERFORM A SUCCESSFUL CFIT ESCAPE MANEUVER

PILOT SIMULATOR BRIEFING

• REVIEW CONTRIBUTING FACTORS AND CAUSES

• EXPLAIN NEED FOR GOOD FLIGHT CREW COORDINATION

• DISCUSS GPWS OPERATING MODES• REVIEW AIRPLANE ESCAPE MANEUVER /

PROCEDURE AND PILOT TECHNIQUES• DISCUSS COMMON FLIGHT CREW ERRORS

GENERIC GPWS WARNING ESCAPE MANEUVER

IF YOUR AIRPLANE MANUFACTURER OROPERATIONS MANUAL DOES NOT PROVIDE A GPWSWARNING ESCAPE MANEUVER OR PROCEDURE, USETHE FOLLOWING MANEUVER

• REACT IMMEDIATELY TO A GPWS WARNING

• POSITIVELY APPLY MAXIMUM THRUST AND ROTATE TO THE APPROPRIATE PITCH FOR YOUR AEROPLANE

• PULL UP WITH WINGS LEVEL TO ENSURE MAXIMUM PERFORMANCE

• ALWAYS RESPECT STICK SHAKER

GROUND PROXIMITY WARNING MODES

(MARK VI)

GPWS MODE 1

GPWS MODE 1

GPWS MODE 2

GPWS MODE 3

Fig.4

GPWS MODE 4

GPWS MODE 4Fig. 4

GPWS MODE 5

GPWS MODE 6

ICAO ACTION ON CFIT PREVENTION

• EXPANDED GPWS CARRIAGE REQUIREMENTS (31 DECEMBER 1998)

• MINIMUM GPWS MODE REQUIREMENTS (31 DECEMBER 1998)

• NON-PRECISION APPROACH PROCEDURE DESIGN

• SPECIFICATIONS FOR INSTRUMENT APPROACH CHARTS AND OTHER CHARTS (SID, STAR, AND TERMINAL AREA)

ICAO ACTION ON CFIT PREVENTION (2)

• FUTURE PUBLICATION OF THE CFIT PREVENTION PROGRAMME

• FUTURE MAJOR EFFORT TO ENSURE IMPLEMENTATION OF THE PROGRAMME IN INTERNATIONAL AND IN DOMESTIC OPERATIONS