FF LL II GG HH TT SS AA FF EE TT YY FF OO UU NN DD AA TT II OO NN AUGUST–NOVEMBER 2000 FLIGHT SAFETY D I G E S T S P E C I A L I S S U E ALAR Approach-and-landing Accident Reduction s e t o N g n i f e i r B FLIGHT SAFETY FOUNDATION Flight Safety Digest For Everyone Concerned With the Safety of Flight Officers and Staff Vol. 19 No. 8–11 August–November 2000 Stuart Matthews US$160.00 (members) US$300.00 (nonmembers) Chairman, President and CEO Board of Governors Robert H. Vandel Executive Vice President James S. Waugh Jr. In This Issue Treasurer Carl Vogt FSF ALAR (Approach-and-landing Accident 1 General Counsel and Secretary Board of Governors Reduction) Briefing Notes ADMINISTRATIVE One of several products included in the FSF ALAR Tool Kit, Ellen Plaugher these 34 briefing notes provide information and data-driven Executive Assistant recommendations to help prevent approach-and-landing Linda Crowley Horger accidents, including those involving controlled flight into Office Manager terrain. Each briefing note focuses on a specific topic identified during FSF ALAR Task Force analyses of accidents and FINANCIAL incidents from 1980 through 1997, and audits of flight Crystal N. Phillips Director of Finance and Administration operations. TECHNICAL Preliminary Data Show Downward 197 James Burin Director of Technical Programs Trend in Controlled-flight-into-terrain Joanne Anderson Accidents Among Large Western-built Technical Assistant Commercial Jets Louis A. Sorrentino III Managing Director of Internal Evaluation Programs These data also show that approach-and-landing accidents Robert Feeler remain a significant safety problem. Q-Star Program Administrator Robert Dodd, Ph.D. FAA Publishes Specifications for 208 Manager, Data Systems and Analysis Darol V. Holsman Portable Boarding Devices Manager of Aviation Safety Audits The publication includes recommendations for the design of MEMBERSHIP equipment used to help airline passengers whose mobility Ann Hill is impaired. Senior Manager, Membership and Development Kim Granados Uncommanded Engine Shutdowns 211 Membership Manager Ahlam Wahdan Prompt Emergency Landing Membership Services Coordinator Two of the DC-8’s engines flamed out as the airplane was PUBLICATIONS being flown over the Atlantic Ocean after departure from an Roger Rozelle airport in the Caribbean. Director of Publications Mark Lacagnina Senior Editor Wayne Rosenkrans Senior Editor Linda Werfelman Senior Editor Cover: Copyright © 2000 PhotoDisc Inc. Karen K. Ehrlich Production Coordinator Flight Safety Foundation is an international membership organization Ann L. Mullikin dedicated to the continuous improvement of aviation safety. Nonprofit and independent, the Foundation was launched officially in 1947 in response to Production Designer the aviation industry’s need for a neutral clearinghouse to disseminate objective Susan D. Reed safety information, and for a credible and knowledgeable body that would Production Specialist identify threats to safety, analyze the problems and recommend practical Patricia Setze solutions to them. Since its beginning, the Foundation has acted in the public Librarian, Jerry Lederer Aviation Safety Library interest to produce positive influence on aviation safety. Today, the Foundation provides leadership to more than 830 member organizations in more than 150 Jerome Lederer countries. President Emeritus Foreword This issue of Flight Safety Digest presents the Flight Safety Foundation (FSF) Approach-and-landing Accident Reduction (ALAR) Briefing Notes. This set of 34 unique documents is one product of the ongoing work of volunteers (see page vi) throughout the world who — with the support of their organizations — have addressed the primary causes of fatalities in commercial aviation. The Foundation-led controlled-flight-into-terrain (CFIT)/ALAR accident-reduction effort was begun in the early 1990s. The briefing notes are a follow-on to “Killers in Aviation: FSF Task Force Presents Facts About Approach- and-landing and Controlled-flight-into-terrain Accidents” published in Flight Safety Digest in early 1999. They are one product in the extraordinary FSF ALAR Tool Kit, which will be released officially by the Foundation in January 2001. The tool kit is published on a compact disc (compatible with Macintosh® and Windows® operating systems) and includes a variety of products, all aimed to help prevent ALAs, including those involving CFIT. Nearly all of the products can be viewed and printed from the CD, which includes the following: • Several Microsoft® PowerPoint® presentations review a variety of topics in the context of ALAs such as air traffic control (ATC), flight operations and training, aircraft and ground equipment, CFIT, and the economics of safety; • FSF Approach-and-landing Risk Assessment Tool raises flight crew awareness of hazards in that phase of flight; • FSF Approach-and-landing Risk Reduction Guide provides chief pilots, line pilots and dispatchers with a means to determine if training, standard operating procedures and equipment are adequate to cope with risks; • FSF CFIT Checklist is a risk-assessment tool that can be used to evaluate specific flight operations and enhance pilot awareness of CFIT; • A variety of posters (produced by Business & Commercial Aviation) illustrate important messages based on the recommendations of the task force; • FSF Standard Operating Procedures Template; • Nearly 100 selected FSF publications are linked to the briefing notes and provide additional facts and examples; • FSF Controlled Flight Into Terrain: An Encounter Avoided is a video that reviews a business aviation ALA involving CFIT; and, • A variety of other products. FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 i The following conclusions and recommendations, adapted from task force findings, provided the framework for the briefing notes: Conclusion No. 1: Establishing and adhering to adequate standard operating procedures (SOPs) and flight crew decision-making processes improve approach-and-landing safety. Recommendations • Nations should mandate, and operators should develop and implement, SOPs for approach-and-landing operations. The data showed that the absence of SOPs resulted in higher exposure to approach-and- landing incidents and accidents. • Operators should develop practical SOPs for a normal operating environment. The involvement of pilots is essential in the development and evaluation of SOPs; they will identify and will help eliminate inadequate procedures; and they will support adherence to SOPs that they helped to create. • Operators should conduct regular evaluations of SOPs to remove procedures that are obsolete or ineffective, and to include new ones as required. Pilot input should be a primary resource for such evaluations. • Operators should provide education and training that enhance flight crew decision making and risk management. Whether the training comprises a version of crew resource management (CRM) or other aids, the goal is to develop satisfactory flight crew decision making. Sufficient resources must be allocated to achieve this goal. • Operators should develop SOPs for the use of automation in approach-and-landing operations, and train flight crews accordingly. • All operators should have a written policy in their flight operations manuals (FOMs) for defining the role of the pilot-in-command in operationally demanding situations. The data show that task saturation and overload of the pilot flying are factors in ALAs. Company policy on the sharing of flight deck duties must recognize that the effective distribution of tasks and decision making among crewmembers is essential to avoid overloading the pilot flying. Training should provide SOPs for the practice of transferring pilot- flying duties during operationally demanding situations. Conclusion No. 2: Failure to recognize the need for a missed approach and to execute a missed approach is a major cause of ALAs. Recommendations • Company policy should specify a well-defined approach gate for approach-and-landing. Criteria for reaching the decision to conduct a go around should include: – Visibility minimums required before proceeding past the final approach fix (FAF) or the outer marker (OM); – Assessment at FAF or OM of crew and aircraft readiness for the approach; and, – Minimum altitude at which the aircraft must be stabilized. • Companies should implement and should support no-fault go-around policies. Training systems and company management should reinforce those policies. Conclusion No. 3: Unstabilized approaches cause ALAs. Recommendations • Operators should define the required elements of a stabilized approach in their FOMs, including at least the following: – Flight path; ii FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 – Airspeed; – Power setting; – Attitude; – Sink rate; – Configuration; and, – Crew readiness. • Company policy should state that a go-around is required if the aircraft becomes unstabilized during the approach. Training should reinforce this policy. • Pilots should “take time to make time” when the flight deck environment becomes task saturated or confusing. This means climbing, holding, requesting vectors for delaying purposes, or conducting a missed approach. “Rushing” approaches and “press-on-itis” (continuing toward the destination despite a lack of readiness of the airplane or flight crew) are factors in ALAs. • Nonprecision approaches are five-times more hazardous than precision approaches. The implementation of constant-angle nonprecision approach (CANPA) procedures should be expedited globally, and pilots should be trained to use them. • Pilots also should be educated on approach-design criteria and obstacle-clearance requirements. Conclusion No. 4: Improving communication and mutual understanding between controllers and pilots of each other’s operational environment will improve approach-and-landing safety. Recommendations ATC should: • Introduce joint training programs that involve controllers and pilots to: – Promote mutual understanding of each other’s procedures, instructions, operational requirements and limitations; – Improve controllers’ knowledge of the capabilities and limitations of advanced-technology flight decks; and, – Foster improved communication and task management by pilots and controllers during emergency situations. • Ensure that controllers are aware of the hazards of ambiguous communication, particularly during in- flight emergencies. The use of standard ICAO phraseology should be emphasized. • Implement procedures that require immediate clarification/verification by a controller if communication from a pilot indicates a possible emergency. • Implement procedures for ATC handling of aircraft in emergency situations to minimize pilot distractions. • In cooperation with airport authorities and rescue services, implement procedures for emergencies and implement standard phraseology. • Develop, jointly with airport authorities and local rescue services, training programs that are conducted on a regular basis. Pilots should: • Confirm each communication with the controller and request clarification/verification when necessary. • Report accurately abnormal/emergency situations, and use ICAO standard phraseology. FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 iii Conclusion No. 5: The risk of ALAs increases in operations conducted in low light and poor visibility, on wet runways, or runways contaminated by standing water, snow, slush or ice, and with the presence of visual/physiological illusions. Recommendations • Pilots should be trained to recognize these conditions before they are assigned line duties. • Pilots should use a risk assessment tool or a checklist to identify approach-and-landing hazards; appropriate SOPs should be implemented to reduce risk. • Operators should develop and should implement CANPA procedures to enable pilots to conduct stabilized approaches. • Operators should develop and should implement a policy for the use of appropriate levels of automation for the approach being flown. Conclusion No. 6: Using the radio altimeter effectively will help prevent ALAs. Recommendations Education is needed to improve pilot awareness of radio-altimeter operation and its benefits. • Operators should install radio altimeters in their aircraft and activate “smart call-outs” at 2,500 feet, 1,000 feet, 500 feet, the altitude set in the DH (decision height) window, 50 feet, 40 feet, 30 feet, 20 feet and 10 feet for terrain awareness. The smart-call-outs system recognizes when an ILS approach is being conducted, and some call-outs can be eliminated to prevent confusion. • Operators should and specify SOPs for radio altimeter and require that the radio altimeter be used during the approach. • Development and installation of advanced terrain awareness and warning systems (TAWS) should be continued; “enhanced ground-proximity warning system” and “ground collision avoidance system” are other terms used to describe TAWS equipment. TAWS is effective in reducing CFIT accidents. This recommendation, however, recognizes that time will be required to implement TAWS worldwide and to ensure that terrain-awareness tools are used correctly. Conclusion No. 7: Collection and analysis of in-flight data (e.g., flight operational quality assurance [FOQA] programs) can be used to identify trends that can be used to improve approach-and-landing safety. Recommendations • FOQA should be implemented worldwide in conjunction with information-sharing partnerships such as the Global Aviation Information Network (GAIN), British Airways Safety Information System (BASIS) and FAA Aviation Safety Action Program (ASAP). • Examples of FOQA benefits (safety improvements and cost reductions) should be publicized widely. • A process should be fostered to develop FOQA and information-sharing partnerships among regional airlines and business aviation operators. Conclusion No. 8: Global sharing of aviation information decreases the risk of ALAs. Recommendations • De-identification of data is essential in FOQA/information-sharing programs. • Pilots who are aware of an accident and its causes are likely to avoid repeating the events that would lead to a similar accident. Distribution of accident reports in the pilots’ native languages will enhance their understanding of safety information. iv FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 • Public awareness of the importance of FOQA/information sharing must be increased through a coordinated and responsible process. Optimum Use of Current Technology/Equipment • Operators should consider the immediate benefit of optimizing the use of current technology such as: – TAWS; – Quick access recorder (QARs) to support FOQA programs; – Radio altimeter with smart call-outs; – Precision approach guidance, whenever available, and visual approach slope indicator (VASI) or precision approach path indicator (PAPI) during the visual segment of the approach; – Global positioning system (GPS)-based lateral navigation and barometric vertical navigation (pending enhancements that will enable precision approaches with GPS); – Communication/navigation/surveillance (CNS) equipment, such as controller-pilot data-link communication; – Mechanical checklists or electronic checklists to improve checklist compliance (particularly amid interruptions/distractions); and, – Airport/approach familiarization programs based on: • Charts printed at high-resolution; • Video display; and/or, • Simulator visual presentations. Together, we continue to make a safe transportation system safer. Stuart Matthews President and CEO Flight Safety Foundation November 2000 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 v CFIT/ALAR Action Group (CAAG) In April 1998, the CFIT/ALAR Action Group (CAAG) was created to supersede the FSF ALAR Task Force. The CAAG is involved currently in implementing the task force’s recommendations. C. Don Bateman Honeywell Commercial Avionics Systems James M. Burin Flight Safety Foundation Dave Carbaugh The Boeing Co. Andres Fabre MasAir Cargo Airline Al Garin US Airways Dan Gurney BAE SYSTEMS Stuart Julian New Zealand Air Line Pilots Association Inc. Ratan Khatwa, Ph.D. Honeywell Flight Safety Systems John Long US Airways Stuart Matthews Flight Safety Foundation Dick McKinney American Airlines (retired) John O’Brien Air Line Pilots Association, International Brian L. Perry Airworthiness Consultant Erik Reed-Mohn SAS Flight Academy Ron Robinson Boeing Commercial Airplanes Group Roger Rozelle Flight Safety Foundation Richard Slatter International Civil Aviation Organization Doug Schwartz AT&T Michel Tremaud Airbus Industrie Robert Vandel Flight Safety Foundation Dick van Eck Air Traffic Control, Netherlands Rob Wayne Delta Air Lines Paul A. Woodburn International Air Transport Association Milton Wylie International Civil Aviation Organization FSF Approach-and-landing Accident Reduction Task Force Members Operations and Training Working Group Jim Anderson Delta Air Lines Pat Andrews Global Aircraft Services, Mobil Corp. Dayo Awobokun Mobil Producing, Nigeria Jaime Bahamon Avianca Don Bateman AllliedSignal Jim Bender Boeing Commercial Airplanes Group Ben Berman U.S. National Transportation Safety Board Philippe Burcier Airbus Industrie Ron Coleman Transport Canada and Canadian Air Force Kevin Comstock Air Line Pilots Association, International Suzanna Darcy Boeing Commercial Airplanes Group David Downey U.S. Federal Aviation Administration Juan Carlos Duque Avianca Dick van Eck Air Traffic Control, Netherlands Erik Eliel U.S. Air Force Advanced Instrument School Bob Francis U.S. National Transportation Safety Board Al Garin US Airways vi FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 Robert Helmreich, Ph.D. The University of Texas at Austin Doug Hill United Airlines Ratan Khatwa, Ph.D. Rockwell Collins Curt Lewis American Airlines John Lindsay British Airways John Long Air Line Pilots Association, International Kevin Lynch Hewlett-Packard Co. Lance McDonald American Eagle Airlines Dick McKinney American Airlines (retired), U.S. Air Force (retired) Erik Reed Mohn SAS Flight Academy Henri Mudigdo Garuda Airlines Luis Garcia Perez Mexicana Airlines Roger Rozelle Flight Safety Foundation Robert Ruiz American Airlines Paul Russell Boeing Commercial Airplanes Group Jim Sackreiter U.S. Air Force Advanced Instrument School Sergio Sales American Airlines Jim Savage U.S. Federal Aviation Administration Dick Slatter International Civil Aviation Organization Fernando Tafur U.S. Air Force School of Aerospace Medicine and Avianca Fabrice Tricoire Computed Air Services Robert Vandel Flight Safety Foundation Keith Yim KLM Cityhopper Tom Young Air Line Pilots Association, International Data Acquisition and Analysis Working Group Ron Ashford Aviation and safety consultant Jim Bender Boeing Commercial Airplanes Group Col. Ron Coleman Transportation Safety Board of Canada Kevin Comstock Air Line Pilots Association, International Peter Connelly The University of Texas at Austin Jim Danaher U.S. National Transportation Safety Board Sarah Doherty U.K. Civil Aviation Authority Dick van Eck Air Traffic Control, Netherlands Andres Fabre Aviacsa Aeroexo Airlines Robert Helmreich, Ph.D. The University of Texas at Austin Ratan Khatwa, Ph.D. Rockwell Collins Carl Kuwitzky Southwest Airlines Pilots Association Stuart Matthews Flight Safety Foundation Paul Mayes International Society of Air Safety Investigators Dick McKinney American Airlines (retired), U.S. Air Force (retired) Lou van Munster International Federation of Air Line Pilots’ Associations Robert de Muynck National Aerospace Laboratory, Netherlands Jerry Nickelsburg FlightSafety Boeing George Robinson British Aerospace Airbus Paul Russell Boeing Commercial Airplanes Group Adrian Sayce U.K. Civil Aviation Authority Richard Slatter International Civil Aviation Organization Jean-Jacques Speyer Airbus Industrie Frank Taylor Cranfield University Safety Centre FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000 vii Bruce Tesmer Continental Airlines Hal Thomas Honeywell Robert Vandel Flight Safety Foundation Vera van Wessum-Faust Amsterdam Schiphol Airport Dick Whidborne U.K. Air Accidents Investigation Branch John Wilhelm The University of Texas at Austin Jack Wilkes Air Line Pilots Association, International Keith Yim KLM Cityhopper Aircraft Equipment Working Group E.S. Bang Boeing Commercial Airplanes Group W. Bresley Boeing Commercial Airplanes Group R. Coleman National Defence Headquarters, Canada J.-P. Daniel Airbus Industrie P.G. Emmerson British Aerospace R. Khatwa, Ph.D. Rockwell Collins D. McKinney American Airlines (retired), U.S. Air Force (retired) G.R. Meiser Boeing Commercial Airplanes Group M. Patel British Airways B.L. Perry International Federation of Airworthiness J. Sciera Air Line Pilots Association, International J.L. Sicre Sextant Avionique J. Terpstra Jeppesen Sanderson A. Wargh Saab T. Yaddaw Bombardier Air Traffic Control Training and Procedures/Airport Facilities Working Group Don Bateman AlliedSignal Cay Boquist International Civil Aviation Organization Rob Bowen American Airlines Jerry Broker U.S. Air Force Bob Conyers Associated Aviation Underwriters Barry Cooper Air Line Pilots Association, International Darren Gaines U.S. Federal Aviation Administration Pat Gallagher Allied Pilots Association Norm LeBlanc Transport Canada Mike Maekawa All Nippon Airways Dick McKinney American Airlines (retired), U.S. Air Force (retired) Ben Rich Allied Pilots Association Paul Smith National Business Aviation Association Ed Stevens Raytheon Co. Ted Thompson Jeppesen Sanderson Simon Tyas Guild of Air Traffic Control Officers Shannon Uplinger Uplinger Translation Services Bob Vandel Flight Safety Foundation Paul Van Tulder Boeing Commercial Airplanes Group Tom Young Air Line Pilots Association, International (US Airways) Bendt Zinck Copenhagen Airports viii FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • AUGUST–NOVEMBER 2000