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I lay awake most of the night, flying the approach over in my mind. I knew the aircraft was exactly where it should
have been on the entire approach. I thought back on how many approaches I had made in my career, approaches
such as NDBs that required the most skill of all approaches, and never having any problems. What went wrong?
Finally, at three o’clock in the morning, I told myself that I had flown the approach as published, and it was the
approach that had to be flawed.
A few days after I had given the FAA all the pertinent information it needed, I received a letter from the
Albany FSDO stating that while I would not be subject to any enforcement action, the incident gave the agency
reason to believe that re-examination of my airman competency was necessary under Title 49 United States
Code Section 44709, which would require me to take a check ride with an FAA examiner. I answered the letter
and followed up with a phone call to the FAA inspector who issued the letter, explaining that I had just completed
a check ride three months earlier, that I had flown the GPS approach to Runway 5 at Saratoga Springs precisely
as published, and that I was convinced the approach was flawed and should be checked. I also stated that by
agreeing to take the check ride I would be admitting pilot error. The inspector said, “You can work that out with
your local FSDO, and whatever they decide will be fine with me. I just have to clear my plate.”
Five days later, with temporary repairs completed and a ferry permit in hand, we were ready to fly the aircraft back
to Nashville. The weather on departure was severe clear, with not a cloud in the sky. We called Albany Approach
on departure and made a request to fly the GPS Runway 5 approach. They gave us vectors almost exactly like
those we had received on the night of the incident. We intercepted the inbound course outside the IAF and
continued the approach. I started the descent with reference to our glideslope indication, just as I had on the night
of the incident. I wanted to maintain the three degrees as published on the approach plate. When we were
approximately two miles from the runway it was clear we should no longer proceed: three degrees, if maintained,
was going to put us into the tops of the trees. I broke off the approach and initiated a climb. Albany Approach
cleared us on course and we departed.
After talking to some of my pilot friends back in Nashville–some of them instructors, one a certified engineer–I
became convinced the approach was flawed. One of my friends, the engineer, took all the data from the approach
plate and the data I had given him and came to this conclusion: a stabilized approach in a Learjet 45 at the weight
we were the night of the incident, maintaining Vref+10 on descent for an approach at a three-degree glideslope
with calm wind would make for a descent rate of 650 fpm and a descent gradient of 325 feet per nautical mile.
Continuing the approach from the VDP to the runway at this rate for 1.2 miles would put the aircraft at 43 feet
above the threshold. This was the profile we had flown on the night of the incident.

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With this data in hand, I talked to the FAA Flight Standards Office in Oklahoma City, filed a user report on
Saratoga Springs Airport and requested a Terps analysis and a flight check of the GPS Runway 5 approach. I
called the FAA Hotline in Washington, reported the incident and told them I thought the approach was flawed and
should be checked. I then took the data to the Nashville FSDO and met with two of their inspectors. After
checking that data, one of the inspectors said, “Jim, if this data is correct, have you thought about a takeoff on
Runway 23 having a problem?” (The Runway 23 departure was listed as a standard departure.) “No,” I replied. “I
have enough to do with the incident on Runway 5, let alone Runway 23.”
Later, I had my engineering friend run the data for departing on Runway 23 in the Learjet 45. Using
the FAA criteria for obstacle clearance, power failure on one engine after V1 and continuing the takeoff,
accelerating to rotation speed, rotating, climbing at V2, crossing the end of the runway at 35 feet and maintaining
a climb rate of 250 feet per nautical mile, the aircraft would hit the same tree, but at a much thicker part of its

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trunk, 84 feet lower than the height at which we had topped it. (The FAA will base a hazard decision on any
departure requiring a climb gradient of more than 200 feet per nautical mile.) The data showed that a climb
gradient of 350 feet per nautical mile would be required for the Learjet 45 to clear the tree 1,166 feet from the end
of Runway 23, and even then it would clear the timber by a mere two feet. Under the same conditions, if the
aircraft yawed by five degrees to the right it would hit much taller trees even at a climb gradient of 350 feet per
nautical mile.
The FAA swung into action, and things began to happen. On August 6, Notams were issued prohibiting any and
all approaches at Saratoga Springs Airport at night until further notice. On August 15, Notams were issued
prohibiting the GPS approaches to Runways 5 and 23 and the VOR DME A approach at night until further notice.
On September 4, a Notam was issued prohibiting the GPS approaches to Runways 5 and 23 at any time. On
September 9 I received information from the FAA that it intended to prohibit GPS approaches to Runways 5 and
23 until the procedure was changed. This Notam remained in effect for eight months. The agency also marked 15
trees that had to be removed before it could reinstate authorization for the approach procedures to be flown. On
September 10 an FAA inspector told me that the procedure for the GPSRunway 5 approach had been drawn
using a 1990 survey that contained a 500-foot error. The 47-foot threshold crossing height should have been 500
feet farther down the runway, and several trees on that approach penetrated the obstacle clear line, some by as
much as 80 feet. Three were more than 100 feet tall.
The insurance company carrying the policy for our aircraft conducted its own investigation, and its findings were
startling. The factual summary stated: “Mr. Huddleston, the captain of the flight in question, was guaranteed by
certification criteria a 20:1 obstacle clearance slope until the VDP (visual descent point) and a 34:1 obstacle
clearance slope from the VDP to the runway threshold. A pilot flying a GPSapproach with a VDP on the published
approach plate is assured this margin of obstacle clearance. The subsequent tree survey showed the tree [that
the aircraft struck] extended well into the 20:1 glideslope far in excess of the 34:1 required by this type of
approach. The VDP feature of this type of approach assures the pilot that a 34:1 slope from the VDP to the
runway threshold is free of obstructions.”
The insurance company’s consulting firm wrote a seven-page summary of its findings. The condensed version
stated, “The pilots met all requisite FARs for a legal and safe flight and executed a proper GPS approach that
contained a VDP terrain clearance component, and the airport authority did not maintain the requisite obstacle
clearance required by FARs and New York’s DOT, causing penetration of trees into the protected zone around
the airport property, which directly led to the incident.”
Documents provided by Saratoga County showed that every runway and every approach had trees penetrating
the Obstacle Clear Line, and documents proved that these discrepancies were known about as far back as 1999.
One document dated September 1999 stated, “Obstruction analysis study of Runway 5 identified ‘numerous
penetrations’ to the approach surfaces, both on and off airport, and determined that ‘to maintain a clear 20:1
approach surface, the Runway 5 threshold would have to be displaced 946.5 feet’ [almost twice the 500 feet
calculated initially].” Numerous documents and emails from the Saratoga County Department of Public Works and
New York’s DOT were written between September 1999 and (more than two months after our incident) October
2008 addressing the issues, but no action was taken.
Two years earlier, in April 2006, one email stated: “FAA flyover inspection shutdownVASI on Runway 05. Flight
Inspection Report states, ‘Obstacle clearance unsatisfactory due to trees near threshold.’” While no one took any
action, these trees were growing at a rate of three to five feet per year. From September 1999, when obstacle
issues were first identified, until the night of our incident on July 13, 2008, not a single tree on the approach to
Runway 5 was topped or removed. An August 2008 email from NY DOTabout the results of its inspection stated:
“RWY 05-Trees +89’, 1035’ from RWY end, 9:1 slope.”
My main objective in writing this article is that it will prevent anyone from flying under the false impression that as
long as you “fly the plate” you are protected. That might have been the case back in the good old days before we
became so automated. Back then, all instrument approaches were flight checked. I have instructed and typed
numerous pilots in Learjets, and for more years than I would like to admit I have preached to them, “Fly the plate
and you won’t get hurt.” I quit preaching that on the night of July 13, 2008.
I wanted to write this article immediately after the FAA had verified the approach was flawed and prohibited the
approaches because of tree penetrations, but ongoing litigation did not allow me to. I can only hope that similar
incidents have not occurred in the interim.

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Accident Precursors
Study of CFIT accidents has enabled a large number of accident precursors to be identified. These precursors are
not necessarily contributing factors, but they are warnings revealing that a weakness has been detected in
existing defence mechanisms. The identification of an accident precursor usually necessitates action to
strengthen these defences.
Examples of CFIT precursors that have been identified are listed below. By definition, this list cannot be
exhaustive and continuous efforts must be made to identify other precursors.

CFIT Precursors - Occurrences (Uneventful events)

 GPWS/TAWS alert/warning (genuine or false)
 Other cases of reduced terrain separation
 Prolonged loss of communication between pilot and controllers
 Low-energy state during approach
 Land short (runway undershoot) event
 Low altitude pattern following a go-around
 Inappropriate low altitude maneuvering

CFIT Precursors - Deviations (Procedural/Flight Path)

 Low pitch attitude/shallow flight path/altitude loss after lift-off
 Flight below desired profile path during climb
 Lateral deviation during climb (SID)
 Descent/flight below Minimum Safe Altitude
 Altimeter setting error
 Failure to check navigation accuracy before approach
 Lateral deviation during approach (STAR)
 Failure to revert to navaids raw data in case of doubts on automation
 Incorrect or inappropriate radar vectoring by ATC (i.e., below minimum vectoring altitude (MVA) and/or
toward high terrain)
 Premature descent to the next step-down altitude during a multiple-steps-down non-precision approach
 DME confusion (non-collocated DME versus ILS-DME), in identifying the final descent point
 Premature descent to DH before G/S intercept or premature descent to MDA before final descent-
point/FAF
 Premature descent below MDA before reaching the visual descent-point (VDP)
 Flight below desired flight path during initial and/or final approach
 Continued approach, when below DH or MDA after loss of visual references
 Late or inadequate response to GPWS/TAWS alert/warning
 Late or inadequate response to windshear warning
 Unstabilized approach (steep or shallow approach)
 Failure to go-around
 Lack of effective flight path control during go-around
 Failure to follow published missed-approach procedure
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CFIT Defences and Controls

Identification of accident precursors is only half the battle; it is also necessary to define and implement defences
and control strategies to address the threats involved.
Listed below are defence or control strategies that have been identified:
 Adherence to SOPs (task sharing, briefings, use of checklists, standard calls and excessive-deviation
callouts, mutual crosscheck and backup)
 Cross-check of takeoff data: mass and balance, fuel distribution, wind component, runway conditions,
flaps setting, V1/Vr speeds, etc.
 Adherence to sterile-cockpit rule
 Adopting the constant-angle non-precision approach (CANPA)/constant descent final-approach (CDFA)
concept
 Adequate use and supervision of automation
 Vertical and horizontal flight paths monitoring (situational and energy awareness)
 Altimeter setting cross-check
 Cross-checking cleared altitude versus minimum safe altitude
 Timely and adequate response to GPWS/TAWS alert or warning
 Timely and adequate response to windshear alert or warning
 Awareness of minimum vectoring altitudes
 Awareness of approach design criteria
 Awareness of relationship between track distance to runway threshold and height (300 ft/nm rule-of-
thumb)
 Awareness of Cold temperature corrections to be added to minimum approach altitudes
 Awareness of minimum safe radio-altimeter readings for each approach segment (IAF-IF, IF-FAF)
 Awareness of "black-hole" or other visual illusions for prevailing approach
 Timely go-around
 Adherence to published missed-approach procedure

GPWS, EGPWS & TAWS

A ground proximity warning system (GPWS) is a safety net that provides automatically a timely and distinctive
warning to the flight crew when the aeroplane is in potentially hazardous proximity to the earth’s surface.
GPWS was introduced in the 1970s as a means to combat the high incidence of CFIT accidents and near-
accidents.
Early GPWS used height above ground (measured by the radio altimeter) and rate of closure to determine when
the aircraft was in a potentially hazardous situation. Subsequent improvements incorporated aeroplane
configuration (e.g. landing gear status) and ILS glideslope deviation. This 'basic' GPWS was mandated in many
countries and was responsible for a worthwhile reduction in the number of accidents. However, basic GPWS
suffers from a serious limitation: because the radio altimeter does not look ahead, it is unable to predict a sudden
change in terrain, for example, when meeting steeply rising ground.
In 1991, Honeywell introduced their Enhanced Ground Proximity Warning System (EGPWS) which was
developed in order to overcome the above limitation. This system combines accurate positional knowledge
(normally determined from GPS) with a precise three dimensional map of the terrain, to look ahead of the aircraft
as well as downwards. This generates warnings to the pilot if certain parameters are breached. Subsequently,
other manufacturers produced similar systems, which are known collectively as Terrain Awareness and Warning
Systems (TAWS). The acronym 'TAWS' is used by FAA to refer to this equipment; however, ICAO still uses the

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generic term 'GPWS'. To avoid confusion, the terms 'basic GPWS' and 'TAWS' are used in this article to
distinguish between the earlier and later systems.

The EGPWS internal database consists of four subsets:

1. Terrain data of varying degrees of resolution (higher resolution grids for airport areas).
2. Cataloged obstacles 100 feet or greater in height located within North America (expanding as data is
obtained).
3. Airport runway data containing information on all runways 2000 feet or longer in length.
4. An Envelope Modulation database to support the Envelope Modulation feature

With the use of accurate GPS information, the EGPWS is provided present position, altitude, track and ground
speed. With this information, the EGPWS is able to present a graphical plan view of the aircraft relative to the
terrain and advise the flight crew of a potential conflict with the terrain or obstacle. Conflicts are recognized and
alerts provided when terrain or an obstacle violates specific computed envelope boundaries in the projected flight
path of the aircraft. Caution or warning alerts are provided in the form of visual light annunciation, audio
enunciation based on the type of conflict, and color enhanced visual display of the terrain or obstacle relative to
the forward look of the aircraft. The terrain display is provided on a Weather Radar Indicator, EFIS display, or
Multi Function Display.

Escape Manoeuvre Techniques

Practice recovery training in the simulator has paid great dividends in helping the pilot to recognize CFIT risks,
and helps reduce the reaction time and improve the recovery. The real world documented pilot response to a
GPWS warning varies, but pilots respond rather quickly. Most respond to a terrain alert within two seconds when
flying in instrument meteorological conditions (IMC) especially at night.
Execute the following manoeuvre in response to a GPWS warning, except in all but clear daylight VMC, when the
flight crew can immediately and unequivocally confirm that an impact with the terrain, water, or obstacle will not
take place:

1. React immediately to a GPWS warning.

2. Positively apply maximum thrust, and rotate to the appropriate pitch attitude for your airplane.
3. Pull up with wings level to ensure maximum airplane performance.
4. Always respect stick shaker.

Continue the escape manoeuvre until climbing to the minimum safe altitude or until visual verification can be
made that the airplane will clear the terrain or obstacle, even if the GPWS warning stops.

Situational Awareness
Many of the precursor events that were identified above relate to a loss of situational awareness.
We gain situational awareness by using the senses to scan the environment and compare the results with mental
models. Planning, communication and coordination for upcoming flight phases, goal setting and feedback are
essential ingredients of situational awareness and decision making. Inattention, distraction and high workload
threaten situational awareness.
The following framework can be used to build and maintain a high level of situational awareness.

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Build Situational Awareness

 Set specific objectives – Define flight targets and data gathering
 Set priorities – Follow standard operating procedures (SOPs)
 Prepare for anomalies – Consider visual illusions, missing information, etc.
 Make risk assessments – Ask “what if?”
 Manage workload – Shift tasks away from busy times, delegate, anticipate

Maintain Situational Awareness

 Communicate – Keep all crewmembers and external participants informed
 Manage attention – Set priorities, avoid distractions, adjust monitoring to the urgency of the flight
phase
 Seek Information – Use your senses
 Know WHAT is important, WHEN to seek it and WHERE to find it
 Validate your data
● Cross-check – Use multiple sources of information when available
● Use rules of thumb when data are not available
 Check Your Understanding
 Check for contradictory elements in the real world
 Apply experience and lessons learned
 Think Ahead
 Brief others on what you expect
 Compare projected situation with objectives
 Set markers for confirmation and information
 Compare actual situation with expectations and objectives
 Readjust your plan if required

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Detect a Loss of Situational Awareness

 Look for clues of degraded Situational Awareness
Ambiguity – Unclear flight plans or ATC instructions
Fixation – Focusing on one thing to the exclusion of all else
Confusion – Uncertainty about or misunderstanding a situation or information
Preoccupation – Everyone focusing on non-flying activities; no one flying the aircraft
Unresolved discrepancies – Contradictory data or personal conflicts
Expected checkpoints not met – Flight plan, profile, time, fuel burn
Poor communications – Vague or incomplete statements
Broken rules – Limitations, minimums, regulatory requirements, failure to follow SOPs
No time – Falling behind the aircraft

Recover Situational Awareness

 Go to the nearest SAFE, SIMPLE and STABLE situation
 Follow rules, procedures and SOPs
 Change automation level
 Buy time
 Communicate – Asking for help is not a sign of weakness
 Recover the big picture
 Go back to the last thing you were sure of
 Assess the situation from different perspectives, with different sources
 Expand your focus to avoid fixation and tunnel vision
 Manage stress and distraction
 Take time to think / Use that time / Be willing to delay flight progress

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