11 - CFIT Avoidance

CFIT avoidance
Training Course
21/10/08 1
1. DEFINITIONS
What is CFIT?
Controlled Flight Into Terrain (CFIT) is defined as an

event in which a mechanically normally functioning
airplane is inadvertently flown into the ground, water,
or an obstacle.
21/10/08 2
1. DEFINITIONS
B747-300 accident at Guam on the 6th of August 1997:
Circumstances: During a night (1:50 AM). Non Precision

ILS without Glide approach to runway 6L, the
airplane hit 3,5 nm short. Glide slope
inoperative.
Weather: S 800, B 1900, OVC 3500, rain, visibility 1 mile;
Configuration: Landing;
Other: Minimum Safe Altitude Warning System
(MSAW) gave no warning to the controller.
Fatalities: 229 of 254 on board.
21/10/08 3
CFIT avoidance Training Programme

1
2. THE SITUATION
Since the beginning of commercial jet

operations, more than 9,000 people have died
worldwide because of CFIT.
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2. THE SITUATION
21/10/08 5
2. THE SITUATION
21/10/08 6

2
3. CONTRIBUTING FACTORS
Flight crews make operational decisions that

are critical for flight safety;
The last line of defence in preventing CFIT
accidents;
The responsibility and influence associated
with higher levels of decisions making.
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Policies are made or at least influenced by

people or organisations:
o Political leaders;
o Aviation regulatory agencies;
o International aviation organizations;
o Airline management;
o Aircraft manufacturers;
o Aircraft lessors;
o Aircraft insurers;
o
21/10/08 8
Accident causation model

Adapted from Dr James Reason 1995 SYSTEM Accident
DEFENCES
PERFORMERS
Unsafe actions
RESSOURCES
Structural
Precursors
MANAGEMENT
Inadequate
Decisions
DECISION MAKER
Inadequate
Decisions
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3
Cost Considerations
Necessity of constant balancing act between:

The need to fulfil production goals;
vs.
Safety goals.
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Cost Considerations
Total Costs
Costs
Risk
Losses
Reduction
Protection
Safety vs. costs

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Cost Considerations
Balance between profits and safety,
management has to make rational decisions
Safety Production
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4
Management implication:
Airline management creates the safety

culture of the organisation;
This culture then affects everyone within the
organisation.
21/10/08 13
3. CFIT ACCIDENT STATISTICS
As far as the airplane was functioning

correctly such accident need never have
happened !
In the early days of Commercial Air transport,
half of all accidents were attributable to CFIT
6 CFIT accidents per year in the last 90s
In 2006, 3 CFIT accidents as an average.
But CFIT related accidents are still taking
place.
21/10/08 14
4. INSTALLATION OF GPWS
In 1973 the number of CFIT accidents

reached a historical high;
By the end of 1975, the FAA required large
transport airplanes to be equipped with
GPWS;
The International Civil Aviation Organization
(ICAO) established GPWS standards in
1979;
All of these actions resulted in the reduction
of the number of worldwide CFIT accidents.
21/10/08 15

5
4. INSTALLATION OF GPWS
Unfortunately the first GPWS model, the

Mark I, was plagued with false and nuisance
warnings;
The result was a loss of confidence in this
system;
Improvements have been adopted on latest
versions of GPWS (Mark V and VII) which
are tailored for terrain around specific
airports;
Nevertheless this lead to failure of flight
crews to respond properly to valid GPWS
warnings.
21/10/08 16
5. CAUSES OF CFIT ACCIDENTS
2 fundamental causes lie behind CFIT

accidents:
o Flight crews lack of vertical position awareness;
o Flight crews lack of horizontal position
awareness relative to ground, water or obstacle.
More than 2/3 of all CFIT accidents happen
due to altitude error or lack of vertical
awareness;
Flight crew need to know where they are and
the safe altitude for flight.
21/10/08 17
Altitude problems:
Error associated with the use of the
barometric altimeter and its setting added
with:
o Different languages;
o No standard phrases
o Varying units of measurement
An international standard does exist but not
all states adhere to it.
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6
Altitude problems (Cont.):
Altimeter settings are displayed in:
o Inches of mercury;
o HectoPascals;
Refer to altitude in Feet or Meters.
21/10/08 Inches of mercury HectoPascals 19

When flight crews are trained and normally

operate in one part of the world and only
periodically operate elsewhere problems can
arise.
Inches of
HectPascals
Mercury
Feet Meters
21/10/08 20

Be sure which altimeter units of

measurement are used in the region in which
you are flying;
If unsure, check whether the setting was
issued in Inches of Mercury or HectoPascals;
Be prepared for the conversion of meters in
feet.
21/10/08 21

7
The altitude settings are:

o QNH;
o QFE; and
o QNE or standard setting (1013 HectoPascals/
millibars or 29.92 inches of mercury).
Extreme atmospheric anomalies, such as low
temperature or low pressure can affect
altimeters and reduce altitude margins.
21/10/08 22

Know what altimeter units of measurement

are used for the area;
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; and
Operate at higher than minimum altitudes
during atmospheric anomalies.
21/10/08 23

Vertical awareness:
For flight crew to be vertically aware, the

must be familiar with the altitude relationship
of the aircraft to the surrounding terrain or
obstacle;
During IMC flight crew will need to rely on
altitude information gained from other
sources than visual.
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8
Vertical awareness (Cont.)

Altimeter setting
1013 mb or
29.92 hg
FL Transition Level
Transition Layer
ALT Transition Altitude

QNH
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Vertical awareness:
Make sure adequate charts are available;
Study the altitude information; and
Know and fly at or above the safe altitudes

for your area of operation.
21/10/08 26

ATC communication:
Lack of English language proficiency can

make understanding of instructions prone to
error;
Heavy workloads can lead to hurried
communications and the use of abbreviated
or non standard phraseology; and
Unreliable radio equipment still exist in some
areas of the world.
21/10/08 27

9
ATC responsibility:
ATC is not always responsible for safe terrain

clearance;
Very often ATC issue en-route clearances to
proceed off airways direct to a point;
When pilots accept this clearance, they also
accept responsibility for maintaining safe
terrain clearance.
21/10/08 28
Be aware of the height of the highest terrain

or obstacle in the operating area;
Be sure of your position relative to
surrounding elevated terrain;
Challenge or even refuse ATC instruction
when they are:
o Not really understood;
o When questionable;
o When they conflict with your assessment of
aircraft position relative to terrain .
21/10/08 29
Human resources:
Complacency can be defined as self
satisfaction, smugness or contentment;
Even if you fly on the same route structure to
the same destinations:
o Know that familiarity can lead to complacency;
o Do not assume that this flight will be like the last
flight; and
o Adhere to procedures.
21/10/08 30

10
Human resources (Cont.):

Flight crew may be exposed to continued
false GPWS warnings due to particular
terrain feature;
Such alerts can actually lull a flight crew into
complacency so that they fail to react to an
actual threat;
Never having heard a WHOOP WHOOP,
PULL UP previously, the flight crew is
unsure how to react.
21/10/08 31
Warning Modes (GPWS Mark III)

Mode 2A : Flaps non in landing configuration
25 2450 ft 250 kt
radio Altitude Speed
x 100 ft 20 4090 ft/mn extension
1650 ft 190 kt
Terrain Terrain 15
Then Warning
10
Whoop Whoop Zone
pull up 2038 ft/mn
5
30 ft
0
1 2 3 4 5 6 7
Closure rate x 1000 ft/mn

21/10/08 32
Example of inapropriate GPWS warning
Terrain Terrain
5000 ft
2418 ft
2582 ft
21/10/08 33

11
Standard Operations Procedures:

CFIT occurs when flight crew have been:
o Unfamiliar with procedures;
o Have not understood them;
o Have not followed them; or
o When no procedures were established.
21/10/08 34
Standard Operations Procedures (Cont.):

Do not invent your own procedures;
Management must provide satisfactory
standard operating procedures and provide
effective training to the flight crew; and
Comply with these procedures.
21/10/08 35
Standard Operations Procedures (Cont.):
Flight crew must provide the management

with feed back when SOP are found to be:
o Incorrect;
o Inappropriate or
o Incomplete.
21/10/08 36

12
Most of the CFIT accidents occur during descent,

approach and landing phases of flight
21/10/08 37
So as to decrease the number of CFIT accidents,

an important improvement has been made in term
of implementation of:
Runway approach aids; and
Additional ILS as well as;
Runway approach lightning systems
21/10/08 38
Most CFIT accidents occur during non-

precision approaches, specifically VOR/DME
approaches;
Inaccurate or poorly designed approach

procedures, coupled with a variety of
depictions, can be part of the problem.
21/10/08 39

13
Minimum terrain clearances on a number of

published approach charts;
Global effort to standardize the descent

gradient of a non-precision approaches;
Multiple altitude step-down procedures

increase flight crew work load and the
potential of error.
21/10/08 40
21/10/08 41
Be sure of which approach and runway aids

are available before initiating an approach;
Make certain to use all approach and runway

aids available; and
Make use of each aid to help you ascertain

your position and required altitude.
21/10/08 42

14
Be sure to study the approach procedures

before departure;
Identify unique gradient and step-down
requirements;
Check approach procedures once more during
approach briefing; and
Use auto-flight systems, when these are
available.
21/10/08 43
Different standards for approach procedures

exist around the world:
o Terminal Instrument Procedures (TERPS)
o Procedures for Air Navigation Services Aircraft
Operations (PAN-OPS);
o The Russian Federation uses yet another
standard.
Flight crew might be exposed to different
standards and different margins of terrain
clearance.
21/10/08 44
Unstable approaches:
o Constant rate of descent 3 degree;
o Stable airspeed (VRF);
o Power setting and trim;
o Plane configured for landing.
Fly stabilized approaches; and
Execute a missed approach if not stabilized by
500 feet above ground level or an altitude
specified by your SOP.
21/10/08 45

15
Flight guide system;
Using FPV/FPA enable a stabilized approach
along specified slope with automatic correction
of wind effect; but
Computed profile for a non-precision approach
provided by the Flight Management System
can be used if:
o Approach profile is stored in the database;
o Verified as regards obstacle clearance criteria;
o FMS navigation accuracy confirmed (HIGHT).
21/10/08 46

Flight guide system;
Crew workload is lessened when using
autoflight system thus providing a higher level
of safety ; but
Autoflight systems can be misused, contain
database errors, or be provided with faulty
inputs by the flight crew;
They will sometimes do things that the flight
crew did not intend for them to do.
21/10/08 47
Flight guide system (Cont.);
Monitor the autoflight system for desired

operation;
Avoid complacency;
Follow procedures; and
Cross-check raw navigation information.
21/10/08 48

16
Flight crew training;

Flight crew training is a significant factor that
contributes to CFIT but:
o Well-designed equipment,
o comprehensive operating procedures,
o extensive runway approach aids, and
o standardized charting or altimeter setting
procedures and units of measurement
will not prevent CFIT unless flight crews are
properly trained and disciplined.
21/10/08 49
Flight crew training (Cont.);
Proper training is vital;

Develop and implement effective initial and
recurrent flight crew training programs that
consider CFIT; and
Implement Flight Operations Quality
Assurance Programs.
21/10/08 50

Flight crew communication;
Many of the CFIT accidents show a lack of

flight crew communication;
One of the best ways to let the non-flying pilot
know what to expect is to conduct a briefing
before each takeoff and each approach;
Some briefing items may be more important
than others and some unique items may be
added, but there are some items that should
always be covered.
21/10/08 51

17
Flight crew communication (Cont.);
Flying pilot should discuss with colleagues
how they anticipate navigating and flying the
procedure;
This reinforce the plan for approach;
Let non-flying pilot know the flying pilots
intention and provide a basis for monitoring
the approach; and
Approach briefing should be over before
arriving in the terminal area.
21/10/08 52
Take-off briefing:
o Weather at the time of departure;
o Runway in use, usable length (full length or intersection
takeoff);
o Flap setting to be used for takeoff;
o V speeds for takeoff;
o Expected departure routing;
o Airplane navigation aids setup;
o Minimum sector altitudes and significant terrain or
obstacles relative to the departure routing;
o Rejected takeoff procedures;
o Engine failure after V1 procedures; and
o Emergency return plan.
21/10/08 53
Approach briefing:
Expected arrival procedure to include altitude and
airspeed restrictions;
Weather at destination and alternate airports;
Anticipated approach procedure to include:
o Minimum sector altitudes;
o Airplane navigation aids setup;
o Terrain in the terminal area relative to approach
routing;
o Altitude changes required for the procedure;
o Minimums for the approach DA/H or MDA/H;
o Missed approach procedure and intentions.
Communication radio setup;
Standard callouts to be made by the non-flying pilot.
21/10/08 54

18
Use of autoflight systems:

Proper use of the modern autoflight systems
reduces workloads and significantly improves
flight safety;
Flight crew must be trained in the use of
Autopilot and Auto-Throttle for:
o Non-precision approaches;
o Precisions approaches; and
o Missed approaches.
21/10/08 55

CFIT critical routes:
Flight crews must be provided with adequate
means to become familiar with en-route and
destination conditions for routes deemed CFIT
critical:
Accompanied when making first flight by pilot
familiar with the conditions;
Use of suitable simulators which can realistically
depict the procedural requirements expected;
Written guidance, dispatch briefing material, and
video familiarization using actual or simulated
representations of destination.
21/10/08 56

Altitude awareness:
Ascertain the applicable MSA reference point;

Know the applicable transition altitude or transition
level;
Use a checklist item to ensure that all altimeters are
correctly set in relation to the transition altitude/level;
Confirm altimeter setting units by repeating all digits
and altimeter units in clearance read backs and intra-
cockpit Communications.
21/10/08 57

19
Altitude awareness (Cont.):
Call out any significant deviation or trend away from

assigned clearances;
Include radio height in the pilot instrument scan;
Upon crossing the final approach fix, outer marker, or
equivalent position, the pilot not flying will cross-check
actual crossing altitude/height against altitude/height
as depicted on the approach chart;
Follow callout procedures.
21/10/08 58

A callout should be made at the following
times:
o Upon initial indication of radio altimeter height. At
this point altitude versus height above terrain
should be assessed and confirmed to be
reasonable;
o When the airplane is approaching from above or
below the assigned altitude;
o When the airplane is approaching relevant
approach procedure altitude restrictions and
minimums; and
o When the airplane is passing transition altitude/
level.
21/10/08 59

GPWS Warning (Cont.)
Except when the flight crew can immediately
and unequivocally confirm that an impact with
the terrain, water, or obstacle will not take
place:
o React immediately to a GPWS warning;
o Positively apply maximum thrust, and rotate to the
appropriate pitch attitude for your airplane;
o Pull up with wings level to ensure maximum
airplane performance; and
o Always respect stick shaker.
21/10/08 60

20
GPWS Warning (Cont.)
Even if the GPWS alert stops, continue the

escape manoeuvre until climbing to the sector
emergency safe altitude or until visual
verification confirms the airplane will clear the
terrain or obstacle.
21/10/08 61
Accidents and incidents happen deceptively;

Flight crews fall into traps some of their own
making and some systemic.
Be vigilant, the traps are there !
21/10/08 62
VIDEO FILM
16/11/08 63

21
Thank you for
your ATTENTION
21/10/08 64

22

11 - CFIT Avoidance

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CFIT avoidance

Controlled Flight Into Terrain (CFIT) is defined as an

B747-300 accident at Guam on the 6th of August 1997:

Circumstances: During a night (1:50 AM). Non Precision

CFIT avoidance Training Programme

Since the beginning of commercial jet

CFIT avoidance Training Programme

Flight crews make operational decisions that

Policies are made or at least influenced by

Accident causation model

CFIT avoidance Training Programme

Necessity of constant balancing act between:

Safety vs. costs

CFIT avoidance Training Programme

Airline management creates the safety

3. CFIT ACCIDENT STATISTICS

As far as the airplane was functioning

In 1973 the number of CFIT accidents

CFIT avoidance Training Programme

Unfortunately the first GPWS model, the

5. CAUSES OF CFIT ACCIDENTS

2 fundamental causes lie behind CFIT

5. CAUSES OF CFIT ACCIDENTS

CFIT avoidance Training Programme

21/10/08 Inches of mercury HectoPascals 19

5. CAUSES OF CFIT ACCIDENTS

When flight crews are trained and normally

5. CAUSES OF CFIT ACCIDENTS

Be sure which altimeter units of

CFIT avoidance Training Programme

The altitude settings are:

5. CAUSES OF CFIT ACCIDENTS

Know what altimeter units of measurement

5. CAUSES OF CFIT ACCIDENTS

For flight crew to be vertically aware, the

CFIT avoidance Training Programme

Vertical awareness (Cont.)

ALT Transition Altitude

5. CAUSES OF CFIT ACCIDENTS

Make sure adequate charts are available;

Study the altitude information; and

Know and fly at or above the safe altitudes

5. CAUSES OF CFIT ACCIDENTS

Lack of English language proficiency can

CFIT avoidance Training Programme

ATC is not always responsible for safe terrain

5. CAUSES OF CFIT ACCIDENTS

Be aware of the height of the highest terrain

5. CAUSES OF CFIT ACCIDENTS

CFIT avoidance Training Programme

Human resources (Cont.):

Warning Modes (GPWS Mark III)

Closure rate x 1000 ft/mn

5. CAUSES OF CFIT ACCIDENTS

Example of inapropriate GPWS warning

CFIT avoidance Training Programme

Standard Operations Procedures:

5. CAUSES OF CFIT ACCIDENTS

Standard Operations Procedures (Cont.):

5. CAUSES OF CFIT ACCIDENTS

Standard Operations Procedures (Cont.):

Flight crew must provide the management

CFIT avoidance Training Programme

Most of the CFIT accidents occur during descent,