CFIT Ooops ! Whoop!

1. CFIT Ooops! Whoop! AC No: 61-134 Definitions Some Data on CFIT The Administrator’s view VFR & IFR How to avoid CFIT Perspective in Alaska

2. Definitions FAA CFIT is defined as an event in which a mechanically normally functioning airplane is inadvertently flown into the ground, water, or an obstacle. FAA AC 61-134 Controlled Flight into Terrain (CFIT). CFIT occurs when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision. ICAO International Civil Aviation Organization Controlled flight into terrain (CFIT) accidents and incidents, are those in which an aircraft, under the control of the crew, is flown into terrain (or water) with no prior awareness on the part of the crew of the impending disaster (Wiener, 1977).

3. Definitions FAA CFIT is defined as an event in which a mechanically normally functioning airplane is inadvertently flown into the ground, water, or an obstacle. FAA AC 61-134 Controlled Flight into Terrain (CFIT). CFIT occurs when an airworthy aircraft is flown, under the control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending collision. ICAO International Civil Aviation Organization Controlled flight into terrain (CFIT) accidents and incidents, are those in which an aircraft, under the control of the crew, is flown into terrain (or water) with no prior awareness on the part of the crew of the impending disaster (Wiener, 1977).

4. Definitions as per AC61-134e • Loss of Control refers to emergency situations from which a pilot may have been able to recover but did not, such as problems with situation awareness, recovery from windshear, mishandling of an approach, and recovery from a stall. • Situational Awareness. As used in this AC, means the pilot is aware of what is happening around the pilot's aircraft at all times in both the vertical and horizontal planes. This includes the ability to project the near term status and position of the aircraft in relation to other aircraft, terrain, and other potential hazards. • Education Vs Training: • Education and training are term loosely used among operational personnel. • They are, however, quite distinct and certainly not interchangeable (ICJO, 1989). While familiar with training, operational personnel is seldom exposed to education, since it is assumed that it forms part of the basic individual baggage that everyone carries before being hired.

5. Definitions as per AC61-134e • Loss of Control refers to emergency situations from which a pilot may have been able to recover but did not, such as problems with situation awareness, recovery from windshear, mishandling of an approach, and recovery from a stall. • Situational Awareness. As used in this AC, means the pilot is aware of what is happening around the pilot's aircraft at all times in both the vertical and horizontal plane. This includes the ability to project the near term status and position of the aircraft in relation to other aircraft, terrain, and other potential hazards. • Education Vs Training: • Education and training are term loosely used among operational personnel. • They are, however, quite distinct and certainly not interchangeable (ICJO, 1989). While familiar with training, operational personnel is seldom exposed to education, since it is assumed that it forms part of the basic individual baggage that everyone carries before being hired. (remember the second part of this talk is SPIN awareness)

6. Some Statistics The worldwide accident rate (which includes CFIT), for the commercial jet fleet, decreased significantly in the 1960s and 1970s. This rate stabilized at that time and remains fairly stable today .

7. Some data The worldwide accident rate (which includes CFIT), for the commercial jet fleet, decreased significantly in the 1960s and 1970s. This rate stabilized at that time and remains fairly stable today . Us Jet Fleet Non-Us Jet Fleet GPWS Implementation

8. Worldwide Airline Accidents Classified by Type 1991Through 1995 1,000 Fatalities, from which 336 are due to CFIT The important thing to understand about these accidents is that they happened with normally functioning airplanes. These are, accidents, that operators could have prevented.

9. Worldwide Airline Accidents Classified by Type 1991Through 1995 1,000 Fatalities, from which 336 are due to CFIT The important thing to understand about these accidents is that they happened with normally functioning airplanes. These are, accidents, that operators could have prevented.

10. As an appetizer…. On how the administrator may think… ….. nearly philosophical

11. Aviation authorities' recognized CFIT • First in 1975: Concern over CFIT occurrences was first reflected in regulations after a B-727 struck a mountain during a non-precision approach to Dulles, Virginia: • A premature descent was attributed to ambiguous pilot-controller communications and unclear information in the approach chart (NTSB-AAR-75-16). • Therefore two solutions were proposed: • In Aircraft >>> Ground Proximity Warning System (GPWS) requirement for large, turbine-powered airplanes engaged in international operations, • And its ground counterpart, the Minimum Safe Altitude Warning (MSAW) as a feature of the automated radar terminal system (ARTS-3), Here we recognize a solution based “mainly” on: EQPT

12. Aviation authorities' recognized CFIT • Then During the 1980’s, enthusiasm for Human Factors led industry efforts to reduce CFIT occurrences through enhanced flight crew performance: • The trigger was a DC-8 crash during approach to Portland, Oregon, after running out of fuel. This CFIT was attributed to breakdowns in flight crew coordination & discipline. • Therefore two solutions (*) were proposed: • Crew resource management (CRM) • Line-Oriented Flight Training (LOFT) stressing the need for: • Improved intra-cockpit communication, • Exchange of relevant operational information and of course • Situational awareness.. Here we recognize a solution based “mainly” on: People. (*) This was accompanied by the inevitable exhortations about cockpit discipline and professional behavior, elusive terms which escape sound definition and only generate foggy solutions with rather dubious results

13. We need a CFIT Training Package? • The success of the Takeoff Training aid package (1992) and the Windshear Training package (1997) in reducing Take off windshear-induced accidents – has lured the industry in adopting similar approaches to other observed safety deficiencies… • Not surprisingly, many advocate for a training package to reduce CFIT occurrences. It is asserted, however, that neither technical nor Human Factors training are the solution to reduce CFIT statistics. • Any CFIT training package would be redundant with existing training curricula hence a waste of resources, Didn’t we leaned (all of us)? • Take off, Departure procedures, Navigation, altimeter setting, Standards approaches procedures…. And so forth… • So What to tackle? • The thinking “on something else” already started after the crash of a DC10 in an active volcano in Antarctica….

14. Aviation authorities' recognized CFIT • The study of the Crash of a DC10 in an active volcano in Antarctica - due to incorrect coordinates in its computer-generated flight plan - showed shortcomings of systemic nature. • Circumstances to be put forward: • Aviation since the 90 has become an incredibly complex system • leading to the safest mean of transportation of the world, • Any interference on such system can lead to catastrophic consequences. • We just showed that approach to reduce human error was mainly: • Technology driven i.e we modify eqpt to minimize Human Error, • Stopped at the Micro Level rather than the Macro Level of systems • Therefore some to think that we did not eliminate the error but merely displaced it because of the “de facto” piece meal approach.

15. Aviation authorities' recognized CFIT • Hence the new approach was to: • Answer to CFIT occurrences lies in looking at them from a systems perspective and act upon the Latent failures which have slipped into the system, • The latest combined with operational personnel active-failures and, further compounded by adverse environmental conditions, may combine to produce an accident. • And implemented via: • Systemic analysis of interactions between Human and Machines in a complex environment, • Consider Education versus training. Here we recognize Organizational Processes Issues (Systems) (*) leading to the safest mean of transportation of the world,

16. Do we hear frequently, Pilot Error? Not so fast!!!

17. Example of Latent Failures • Poor strategic planning of operations, • Failure to properly train personnel to achieve them, • Lack of strategic planning, or with incompatible goals, • Inconsistent with declared safety goals….. among others. • No clear channels of communication between mgt & operations,

18. Example of Latent Failures • Poor strategic planning of operations, • Failure to properly train personnel to achieve them, • Lack of strategic planning, or with incompatible goals, • Inconsistent with declared safety goals….. among others. • Absence of clear channels of communication between mgt and operational personnel: • a widely lamented but seldom acted upon, • Deficient SOP (Standard Operational Procedures) a direct consequence of the aforementioned, • Corporate objectives which are difficult or impossible to achieve with existing resources and corporate goals, • Failure to communicate corporate goals, • It is impossible to act upon a problem unless awareness about it is gained: • Or using a famous snapshot: • “What gets measured gets done”, • Hence management and ops people need education on how to recognize latency.

19. Fokker F-28 Mk 1000 Accident On 15 November 1975, a Fokker F-28 Mk l 000 with 6 crew members and 65 passengers crashed while attempting to land following a circling non-precision night approach in IMC at Concordia, Argentina. An honest analysis was directed inside the cockpit and the pilot was fined by the civil aviation authority and demoted by the airline. He was to be re-instated as another analysis showed an abundance of latent failures:

20. Fokker F-28 Mk 1000 Accident On 15 November 1975, a Fokker F-28 Mk l 000 with 6 crew members and 65 passengers crashed while attempting to land following a circling non-precision night approach in IMC at Concordia, Argentina. An honest analysis was directed inside the cockpit and the pilot was fined by the civil aviation authority and demoted by the airline. He was to be re-instated as another analysis showed an abundance of latent failures: • Lack of strategic planning with lack of resources to achieve goals: • This started with in-house training with no flight simulator manned with tng staff with doubtful qualifications and stability, • The Company operational procedures were rushed and not concise,

21. Fokker F-28 Mk 1000 Accident On 15 November 1975, a Fokker F-28 Mk l 000 with 6 crew members and 65 passengers crashed while attempting to land following a circling non-precision night approach in IMC at Concordia, Argentina. An honest analysis was directed inside the cockpit and the pilot was fined by the civil aviation authority and demoted by the airline. He was to be re-instated as another analysis showed an abundance of latent failures: • Lack of strategic planning with lack of resources to achieve goals: • This started with in-house training with no flight simulator manned with tng staff with doubtful qualifications and stability, • The Company operational procedures were rushed and not concise, • Faulty tactical planning like: • Mismatch in crew matching (the captain had no turbine time and the FO fresh from school just hired by the Airline) • Company dispatch overestimated the capability of the aircraft in considering weather limitations….

22. Conclusion Typical Latent failures like we just saw, generate working environments which foster human error. • Even more important, such environments oftentimes make violations inevitable if tasks are to be achieved. • Unless environments are corrected, they force crews to ignore warnings, thereby generating violations to fulfill the task. • Eventually environment or task conditions which generate errors and violations lead to system-induced accidents. Accident databases are replete with CFIT occurrences which support this contention.

23. Conclusion Allow me a question, How can you use - what we just saw (studied) - in your profession as Certified Flight Instructor? Typical Latent failures like we just saw, generate working environments which foster human error. • Even more important, such environments oftentimes make violations inevitable if tasks are to be achieved. • Unless revised, they force crews to ignore warnings, thereby generating violations to operational orders to fulfill such procedures. • Eventually environment or task conditions which generate errors and violations lead to system-induced accidents. Accident databases are replete with CFIT occurrences which support this contention.

24. HOW DO CFI PREVENT CFIT? • The most important goal for any flight crew is to maintain vertical and horizontal situational awareness in relation to the ground, water, and obstacles. Of course in VFR and IFR. • When this is not accomplished and the potential for impact with the ground, water, or obstacles is imminent, the proper escape maneuver must be used to improve the chance of surviving.

25. It is real…. Nall report 2008

26. VFR-ONLY PILOTS OPERATING IN MARGINAL VFR/IMC CONDITIONS. • Scud Running: • National Transportation Safety Board (NTSB) & FAA data, cite one of the leading causes of GA accidents is to continue VFR flight into IMC. • The result is often a CFIT accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. • Some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. • The accident may or may not be a result of a loss of control before the aircraft impacts the obstacle or surface. • Therefore the root cause can be: • The importance of complete weather information, to correlate the pilot's skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough.

27. VFR pilots in reduced visual conditions may develop spatial disorientation & lose control, Failure to understand the weather conditions that resulted in reduced conditions, and failure to turn around to avoid deteriorating conditions when first able. Will result in CFIT as: • Skills: • Inability of the pilot to operate the aircraft at its minimum controllable airspeed. • Loss of aircraft control. • Loss of situational awareness: • Getting lost or being off the preplanned flight path: • Increased risk of hitting one of many new low altitude towers (for cell –phones). This risk is especially great along major highways (VFR pilots trying to follow a highway when lost ). • Time: • Reduced reaction time to see and avoid rising terrain or obstacles. • Reduced pilot reaction time in the event of A/C problem because of a low or lowering altitude. • Processes: • Breakdown in good aeronautical decision making. • Failure to comply with appropriate regulations. • Failure to comply with minimum safe altitudes. People Environment Equipment Processes !

28. IFR PILOTS OPERATING IN IMC CONDITIONS. • Risks: • IMC operations pose special risks, whether it is : • Failure to follow safe takeoff and departure techniques, • Failure to follow recommended en route procedures ― which includes loss of situational awareness • Failure to maneuver safely to a landing, • People & Processes: • IFR operations can be dangerous for those not prepared to operate or not current and proficient in the IMC and IFR environments. • Equipment: • IFR operations can be dangerous with minimum, operational current equipment to operate in IMC and IFR environments. • Results: • Many of these accidents result in fatalities.

29. People (AC No: 61-134): • Knowing when not to fly. • In a crewed aircraft, both pilots have adequately briefed the flight and operation of the aircraft, including shared responsibilities. • Importance of maintaining situational awareness, both horizontal and vertical, throughout the flight to avoid flying into hazardous terrain or known obstacles. • Complete knowledge on how to operate all equipment onboard the aircraft. • Use Auto Pilot to reduce load is widely encouraged…(2.1.2 FAA Material)

30. Equipment: • Importance of the aircraft being properly equipped for the intended flight. • Environment: • Having complete weather data for the flight, including knowing where visual meteorological conditions exist or a safe alternative is since many GA aircraft flown IFR have limited range or speed to fly out of un-forecasted weather conditions. • Processes: • Knowledge of minimum safe or sector altitudes and of the highest terrain in the area. • Properly using an installed autopilot, if so equipped, to reduce pilot workload. • Proper use of checklists • The increased CFIT risk of non-precision approaches. • The increased CFIT risk of high descent rates near the ground. • The importance of flying a stabilized approach.

31. TOP 10 RECOMMENDED INTERVENTION STRATEGIES. • Education (AC No: 61-134 ): • Increase pilot awareness on accident causes, • Improve safety culture within the aviation community, • Develop and distribute mountain-flying technique advisory material. • People: • Improve pilot training (i.e., weather briefing, equipment, decision-making, wire and tower avoidance, and human factors • Equipment: • Promote dev/use of a low cost terrain clearance and/or a look ahead device. • Standardize and expand use of markings for towers and wires. • Use high visibility paint & other visibility enhancing features on obstructions. • Processes / Organization: • Improve the quality and substance of weather briefs. • Enhance the flight review and/or instrument competency check. • Eliminate the pressure to complete the flight where continuing may compromise safety.

32. Stall / Spin Awareness AC 61-67C Some Data on Stall/Spin Basics on Stall What to do

33. Some statistics Nall report 2008 56%

34. Some statistics Nall report 2008 56%

35. Basic on Stalls (1/4) • What say the administrator: • The FAA concentrates on STALL RECOGNITION & PREVENTION, • Only CFI have to have a SPIN endorsement (is this advanced training?), • We can teach Imminent stall in any aircraft but should teach fully achieved stall in an Aircraft which have known and safe spin characteristics. • The fact: • A STALL CAN OCCUR AT ANY AIRSPEED, IN ANY ATTITUDE AT ANY POWER SETTING. • Any given airplane will stall at the SAME Angle Of Attack, regardless of Weight, Load Factor, Airspeed, and Density Altitude.. This assumes that the wing is NOT Altered by damage or ice.. • Weight: • The Critical Angle of Attack (AOA) does not depend of the weight, but additional lift can be obtained by higher airspeed, therefore the aircraft will stall at higher Airspeed but at the same AOA. • Generally 20% increase in aircraft weight (Light GA A/C) will result in 10% increase in stall speed. • In absence of AOA indicator, the airspeed is a crutch to stay away from a stall.. The stall of the elevator is not exposed here

36. Basic on Stalls (2/4) • The fact: • A STALL CAN OCCUR AT ANY AIRSPEED, IN ANY ATTITUDE AT ANY POWER SETTING. • Any given airplane will stall at theSAME Angle Of Attack, regardless of Weight, Load Factor, Airspeed, and Density Altitude. This assumes that the wing is NOT altered by damage or ice. • Weight: • We just did it. • Load Factor: • The Critical Angle of Attack (AOA) does not depend of the Load Factor, but the centripetal Force is ADDED to the normal weight of the A/C. Therefore the aircraft will stall but at the same AOA. but at a MUCH higher Airspeed. • The Stall Speed increases as the square root as the load factor: • At 60º bank the wings are producing twice as much lift than in S&L Flight, referred as 2G, • For instance VSO = 60 Kts become 85 Kts • At 75º bank the wings are producing 3.86 as much lift than in S&L Flight, referred as 3.86G, • At 80º bank the wings faces 5.76G and at 81º bank the wings faces 6,25G • We all know the famous graph …

37. Basic on Stalls (3/4) • The fact: • A STALL CAN OCCUR AT ANY AIRSPEED, IN ANY ATTITUDE AT ANY POWER SETTING. • Any given airplane will stall at the SAME Angle Of Attack, regardless of Weight, Load Factor, Airspeed, and Density Altitude. This assumes that the wing is NOT Altered by damage or ice. • Airspeeds: • We just covered the airspeed, according to weight and Load Factor…. • Density Altitude (Altitude and Temperature): • Altitude as LITTLE or no effect on the stall speed, • Wing damage or Ice: • Like wing damage, ICE can result in loss of lift and increased weight… • Wing damage: yes I saw some… bird strike mainly.

38. Basic on Stalls (4/4) • The fact is that we fly with different payloads: • Yes the COG has an effect on the Stall Recovery: • A forward CG implies a higher stall speed at the Critical AOA, greater forces to stall, to recover, • An AFT (After) CG implies lighter forces to stall, but high load can be induces in recovery • An AFT CG can lead to flat spin…. GENERALLY IMPOSSIBLE TO RECOVER. • The fact is that we fly a multitude of aircrafts with different wings.. . • We cannot describe them all • But the common factor is: • The wings are designed to produce a gradual and symmetrical loss of lift, • This loss progresses from the root till the ailerons, leaving the ailerons virtually untouched at the Critical AOA. • The “root” stall produces a turbulent flow which affects the elevator, hence the “Buffet” that we feel .. This is much before the Critical AOA… • But watch: • Piper Cub, Stinson, Luscomb, and Areonca, the wing tip stalls at the same time as the root. • Another fact … but equally important: • The stall speed is affected by turbulent conditions • Any updraft current will modify the direction of the airflow relative to the wing hence creating a pseudo AOA, invisible to the pilot…

39. Where and which types of stall (6)? 1. P/Off Slow Flight 1600 RPM 1/3 Flap 1 .P/Off TURN Slow Flight 1600 RPM 2/3 Flap 1. P/Off 2. P.On 4. Elevator Trim 6. X.Control Stall 5. Accelerated Stall Approach 1600 RPM 3/3 Flap 3. Secondary Stall Full Power 1. P/off

40. Anatomy of a Spin…. (by Budd Davisson March 2006) 1/3 • In Budd’s eyes, it is not that people do not know to recover from a SPIN • The problem is that they do not know what they were doing wrong to cause a spin… • To SPIN two factors are needed: • A/C MUST BE stalled • A/C must have excess yaw. • But: • In today’s aircraft the student must go VERY SLOW (High AOA) with a LOT of yaw. • Slow >>>>> nose too high, versus horizon?: • Even the most poorly trained pilot will detect it. • So it must happen in a nearly normal looking condition……. • Ball totally off center: • Again a lot of rudder will be needed and the pilot will detect it. • So what is happening????

41. Anatomy of a Spin…. (by Budd Davisson March 2006) 2/3 • Well, it starts with AILERON and finishes with rudder • Showing the adverse yaw: • Slow down the A/C to approach speed or below, no rudder and apply aileron: • The ball moves in the direction of the ailerons, • The slower the airspeed, the worse is the adverse yaw. • Back to our case: The Pilot is slow & late to turn onto final, and he/she overshoots: • As he/she banks the aircraft too get back on a center line, • The pilot exceed his zone of comfort …. Too much bank… • So the pilot applies outside of the turn aileron…. Driving the ball off center and slowing down the turn.. • Now the pilot feeds more rudder in direction of turn, driving the ball even more off center…. • We are IN THE PERFECT CASE OF Crossed Control • The turn drives the stall speed UP, and the X-control lower again the Lift • We are good to go FOR SOMETHING BAD..

42. Anatomy of a Spin…. (by Budd Davisson March 2006) 3/3 • We are good to go FOR SOMETHING BAD.. • This is when the pilot becomes distracted, let say a traffic call: • The pilot lets the nose comes up…but not even closer that extreme attitude • So the pilot won’t see it: • With the flap down the stall is more abrupt, and starts to roll over the top. • At this time the instinct calls for opposite aileron of the roll, • This stall “even better” the inside wing.. • The spin occurs. • There is not enough time to do a full turn … • So what is the point to teach recovery from a fully developed spin? HENCE TEACH SPIN PREVENTION IS MORE ADAPTED TO REALITY The best would be recovery from a SPIN DEPARTURE…. But what type of airplane can you use for Spin Departure?

43. So it went bad and you have enough altitude: Remember: • P Power Idle • A Aileron Neutral • R Rudder Full Opposite • E Elevator, brisk mvt down (for AOA)

44. The end Thank You

45. Ace Check: • The quickest way to recover an airplane from a stall situation is to:     a.   Pull back (nose up) on the elevator control • Reduce engine power • Reduce the load on the wing by pushing forward (down) on the elevator control  • Teaching full stalls: a. Can be safely instructed in any airplane make and model b. Should be instructed only in airplanes which have known and safe spin characteristics  c. Is no different than teaching imminent stalls  • An airplane make and model will stall at the same indicated airspeed regardless of the airplane altitude : a.   True b.   False

46. Back Up Slides • OTHER DEFINITIONS

47. Other definitions • Organization: Is a social arrangement which pursues collective goals, controls its own performance, and has a boundary separating it from its environment. We can cite: • Organization – process-related: how an entity is being organized to complete a task. • Organization – functional: organization as a function of how entities like businesses or state .authorities are used (organization as a permanent structure). • Organization – institutional an entity is an organization (organization as an actual purposeful structure within a social context). The broader analysis of organizations is commonly referred to as or organizational studies / behavior or organization analysis. • Management: • in all business areas and organizational activities are the acts of getting people together to accomplish desired goals and objectives. • Management comprises planning, organizing, staffing, leading or directing, and controlling an organization (a group of one or more people or entities) or effort for the purpose of accomplishing a goal.

48. Other definitions • Systems: • Is a set of interacting or interdependent entities forming an integrated whole (*). • Most systems share common characteristics, and have: • Structure defined by parts and their composition; • Behavior which involves inputs, processing and outputs of material, levels of energy, • Interconnectivity, where the various parts of a system have functional as well as structural relationships between each other. • by themselves functions or groups of functions . • The scientific research field which is engaged in the study of the general properties of systems include: • Systems theory, • Dynamical systems and • Complex systems • These researches investigate the abstract properties of the matter and organization, searching concepts and principles which are independent of the specific domain, substance, type, or temporal scales of existence. (*)The concept of an 'integrated whole' can also be stated in terms of a system embodying a set of relationships which are differentiated from relationships of the set to other elements, and from relationships between an element of the set and elements not a part of the relational regime.

49. Back Up Slides • HOW TO AVOID CFIT WHILE ON IMC / IFR

50. People: • Knowing when not to fly. • Importance of the pilot in command (PIC) being qualified, current, and proficient for the intended flight. • In a crewed aircraft, both pilots have adequately briefed the flight and operation of the aircraft, including shared responsibilities. • Importance of maintaining situational awareness, both horizontal and vertical, throughout the flight to avoid flying into hazardous terrain or known obstacles. • Complete knowledge on how to operate all equipment onboard the aircraft. This includes the limitations and operations of new types of navigation equipment. • In a crewed aircraft, the crew is aware of and follows FAA and industry recommended crew resource management principles. If a single-piloted flight, the pilot knows to use all available resources including air traffic control to help ensure a safe flight as well as any onboard resource such as a passenger or onboard charts or manuals. • PIC is aware of the risks involved when transitioning from visual to instrument or from instrument to visual procedures on takeoff or landing.