CONTROLLED FLIGHT

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• CONTROLLED FLIGHT
• INTO TERRAIN
• C F I T

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C F I T

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

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OVERVIEW FOR MANAGEMENT
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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

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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

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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

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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

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C F I T ACCIDENTS
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HULL-LOSS ACCIDENTS FOR WORLDWIDE COMMERCIAL JET
FLEET
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CFIT HULL-LOSS ACCIDENTS FOR WORLDWIDE COMMERCIAL
JET FLEET
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WORLDWIDE AIRLINE ACCIDENTS CLASSIFIED BY TYPE
- 1991 THROUGH 1995
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WORLDWIDE AIRLINE FATALITIES CLASSIFIED BY TYPE
OF ACCIDENT-1991 THROUGH 1995
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POSITIVE RESULTS OF GROUND WARNING SYSTEMS (GPWS)
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CFIT ACCIDENT PER YEAR-USA AND WORLD CARRIERS
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GPWS INITIAL RELIABILITY AND FOLLOW- ON
IMPROVEMENTS
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FLIGHT PATH PROFILE 707-300, Santa Maria,
Azores, February 8, 1989
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INDUSTRY SUPPORT REQUIRED FOR GPWS
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WORLD AIRLINE JET FLEET EQUIPPED WITH GPWS
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COMMERCIAL JET CFIT ACCIDENTS 7-YEAR PERIOD-1989
THROUGH 1995
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CFIT AND FLIGHT CREW
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CAUSES FOR CFIT ACCIDENTS
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PRIMARY CAUSE FACTORS FOR HULL-LOSS ACCIDENTS FOR
WORLDWIDE COMMERCIAL JET FLEET
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FACTORS THAT CONTRIBUTE TO CFIT

• ALTIMETER SETTING UNITS OF MEASUREMENT
• ALTIMETER SETTING
• SAFE ALTITUDES
• AIR TRAFFIC CONTROL
• FLIGHT CREW COMPLACENCY
• PROCEDURAL
• Contd.

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PERCENTAGE OF ALL ACCIDENTS BY PHASE OF FLIGHT
AND THE PERCENTAGE OF FLIGHT TIME THAT THE FLIGHT
CREW IS EXPOSED DURING THAT PHASE
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MAP LOCATION OF CFIT ACCIDENTS/INCIDENTS
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FACTORS THAT CONTRIBUTE TO CFIT

• DESCENT, APPROACH AND LANDING

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PRIMARY CAUSE FACTORS FOR HULL-LOSS ACCIDENTS FOR
WORLDWIDE COMMERCIAL JET FLEET
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GEOGRAPHICAL LOCATION OF CFIT ACCIDENTS
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FACTORS THAT CONTRIBUTE TO C F I T

• AUTOFLIGHT SYSTEM
• TRAINING

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C F I T PREVENTION

• MINIMUM SAFE ALTITUDE WARNING SYSTEM (MSAWS)

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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

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EXAMPLE CFITTRAINING PROGRAM
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ACADEMIC TRAINING PROGRAM
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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

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CFIT SIMULATOR TRAINING PROGRAM
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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

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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

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GENERIC GPWS WARNING ESCAPE 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

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GROUND PROXIMITY WARNING MODES (MARK VI)
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GPWS MODE 1
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GPWS MODE 1
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GPWS MODE 2
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GPWS MODE 3
Fig.4
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GPWS MODE 4
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GPWS MODE 4
Fig. 4
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GPWS MODE 5
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GPWS MODE 6
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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)

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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