Operation

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TABLE OF CONTENTS

TABLE OF CONTENT

DESCRIPTION PAGE

Table of Content 1

Chapter 1. GENERAL 2

Chapter 2. AIRCRAFT ACCIDENT STATISTICS 3

Chapter 3. LACK OF SITUATIONAL AWARENESS 9

Chapter 4. ATC – PILOT COMMUNICATION 11

Chapter 5. STANDARD OPERATING PROCEDURES 13

Chapter 6. APPROACH AND DEPARTURE PROCEDURES 15

Chapter 7. ALTIMETERS SETTING 17

Chapter 8. NAVIGATION ERROR 19

Chapter 9. AUTO PILOT 20

Chapter 10. BRIEFING AND CALL OUTS 22

Chapter 11. TRAINING 26

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CHAPTER 1. GENERAL

The overall goal of this CFIT Education and Training Aid is to reduce CFIT accidents and incidents
through appropriate education and training. The Example CFIT Training Program is an
example of the type of training that should be conducted to meet that goal. The program is prima-
rily directed toward two aspects of the CFIT problem: avoidance and escape.

The most important goal for any flight crew is maintain vertical and horizontal situational
awareness in relation to the ground, water, and obstacles. When this is not accomplished
and the potential for impact with the ground, water, or obstacles is imminent, the proper escape
maneu- ver must be used to improve the chance of surviving.

This CFIT training program is structured to stand alone, but it may be integrated into existing initial,
transition, and recurrent training and check pro- grams. The Academic Training Program is
designed to improve awareness by increasing the flight crew’s ability to recognize and avoid im-
pending CFIT situations. The Simulator Training Program is designed to apply this knowledge as
well as develop proficiency in an escape maneuver that must be used as a last resort for survival.

DEFINITION OF CFIT :
Controlled Flight Into Terrain occurs when an airworthy aircraft under the control of a pilot is
inadvertently flown into terrain, water, or an obstacle with inadequate awareness on the part of
the pilot of the impending disaster.

Since the beginning of commercial jet operations, more than 9,000 people have died worldwide
because of CFIT.
CFIT Task Force studied the causes of CFIT and made recommendations to reduce CFIT
accidents. The task force comprised representatives from aircraft manufacturers, airline operators,
government regulators, industry associations, pilots groups and others.
This industry effort resulted in the CFIT Education and Training Aid being produced in 1996. Since
that time, the FSF Approach-and-landing Accident Reduction Task Force was organized to study
approach-and-landing accidents (ALAs).

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CHAPTER 2. AIRCRAFT ACCIDENT STATISTICS

Global Perspective of Accident Rates

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FW Occurrence Categories
for Commercial Fixed-Wing Aircraft (2010 - 2020)

RW Occurrence Categories for Fatal Accidents

Only (2013-2020)

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Where does it happen ?

Two-thirds of the accidents occur within eight miles of the runway with the
majority of them occurring within three miles of the runway. Fifty accidents
in the ALA phase within eight nautical miles of the runway resulted in 2,293
fatalities.

January 2001

Two-thirds of the accidents occur within eight miles of the runway with the majority of them
occurring within three miles of the runway. Fifty accidents in the ALA phase within eight
nautical miles of the runway resulted in 2,293 fatalities.

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There was a lack of vertical situation awareness resulting in aircraft impacting short of
the runway. Note that many of these approaches appear to be stabilized and near a
three-degree profile — right into the ground.

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FACTORS THAT CONTRIBUTE

TO CFIT AWARENESS
CFIT AWARENESS

Why CFIT difficult to prevent ? One factor is Human Nature

• Lack of Situational Awareness

• Lack of Situational Awareness

• ATC – Pilot communication

• Standard Operating Procedures

• Approach and Departure Procedures

• Altimeter setting

• Navigation Error

• Auto pilot misuse

• Briefing and Callouts

• Trainings

There are many factors that lead to CFIT accidents. The pilot has the final responsibility for
preventing a CFIT accident.
Improved training, enhanced pilot awareness and modern equipment on the ground and in the
aircraft are among the methods to prevent CFIT accidents

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CHAPTER 3: LACK OF SITUATIONAL AWARENESS

SITUATIONAL
AWARENESS

Complacency can be defined as self-satisfaction, smugness or contentment. You can understand

why after years in the same flight deck, on the same route structure to the same destinations, a
pilot could become content, smug or self-satisfied. Add a modern flight deck with a well-functioning
autopilot, and you have the formula for complacency.
Flight crews may also have been exposed to false GPWS warnings perhaps because of a
particular terrain feature or a GPWS database that was not customized for the arrival. The flight
crew becomes conditioned to this situation, because they have flown the approach many times.
This can also lull the flight crew into complacency, and they may fail to react to an actual threat.
Note: Newer versions of GPWS can be programmed by the manufacturer for specific airfield
approach requirements so that these nuisance warnings are eliminated.
Strict adherence to standard operating procedures (SOPs) is a must if pilots are going to operate
airplanes safely. Deviations should not be tolerated or accepted by flight crews or airline
management.
Good crew resource management will ensure that SOPs are followed and that both pilots are fully
involved with the management of the flight. CRM should be one of the foundations of an airline’s
training program.

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Anytime there is a difference in the normal operation of the airplane, such as a minimum
equipment list (MEL) condition or weather situation, these differences should be included in the
briefing and operation in such a way that both pilots are aware of how these differences will be
handled and how they will affect the performance and operation of the airplane.
Flying transport aircraft is a profession: We must maintain a professional attitude. This includes
being prepared for all training sessions and flights.

SITUATIONAL AWARENESS

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CHAPTER 4 : ATC – PILOT COMMUNICATION

ATC is not always responsible for safe terrain clearance for the aircraft under its jurisdiction. Many
times ATC will issue en route clearances for pilots to proceed off airway direct to a point or allow a
flight to deviate around weather. When a pilot accepts this clearance, the pilot also accepts
responsibility for maintaining safe terrain clearance.

ATC controllers have a responsibility to use standard phraseology when communicating with
pilots. They must maintain adequate language skills to do this effectively.
If a pilot receives a clearance that he is unable to comply with, he must advise ATC of his inability
to comply with the clearance. Example: ATC instructs a pilot to cross a fix at an altitude and
airspeed. The pilot determines that he will not be able to make both the altitude and the airspeed,
and advises ATC accordingly.
If a pilot does not understand a clearance, he should request ATC to repeat it until he does
understand it. This may mean that ATC must get another controller to repeat the clearance or to
spell the clearance using the phonetic alphabet. The pilot must do whatever is necessary to
ensure that he understands the clearance.
Pilots must also use the autopilot in the mode that facilitates compliance with ATC instructions.
When in a terminal area, it is too late for one pilot to be “head-down” programming an approach
into the FMC. Instead, fly using heading select or VOR/LOC. This keeps both pilots in the loop
and allows both pilots to watch for traffic and monitor the airplane.

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It is essential that pilots read back all clearances and that ATC verifies that the readback is correct.
Both pilots listening to ATC clearances and practicing good CRM will help ensure that an accident
does not occur because of a misunderstood clearance.

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CHAPTER 5 : STANDARD OPERATING PROCEDURES

Studies show that operators with established, clear and well-implemented SOPs consistently have
safer operations. It is through these procedures that the operator sets the standards that all flight
crews are expected to follow.
CFIT accidents have occurred when flight crews did not know the procedures, did not understand
them or did not comply with them, or when there were no procedures established. In the absence
of SOPs, flight crews may invent their own SOPs. It is the responsibility of management to develop
the comprehensive procedures, train the flight crews and ensure quality control.
It is the responsibility of the flight crew to learn and to follow the procedures and provide feedback
to management when the procedures are incorrect, inappropriate or incomplete.

Standard
Operating
Procedures

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CHAPTER 6 : APPROACH AND DEPARTURE PROCEDURES

Unstabilized approaches contribute to many CFIT accidents or incidents. Unstabilized approaches

increase the possibility of diverting a pilot’s attention away from the approach procedure to regain
better control of the airplane.
These recommended parameters define a stabilized approach and should be met by 1,000 feet
above airport elevation in IMC or 500 feet in VMC:
1. The aircraft is on the correct flight path;
2. Only small changes in heading/pitch are required to maintain the correct flight path;
3. The aircraft speed is not more than VREF + 20 knots indicated airspeed and not less than
VREF;
4. The aircraft is in the correct landing configuration;
5. Sink rate is no greater than 1,000 feet per minute; if an approach requires a sink rate
greater than 1,000 feet per minute, a special briefing should be conducted;
6. Power setting is appropriate for the aircraft configuration and is not below the minimum
power for approach as defined by the aircraft operating manual;
7. All briefings and checklists have been conducted;
8. Specific types of approaches are stabilized if they also fulfill the following: instrument
landing system (ILS) approaches must be flown within one dot of the glideslope and
localizer; a Category II or Category III ILS approach must be flown within the expanded
localizer band; during a circling approach, wings should be level on final when the aircraft
reaches 300 feet above airport elevation; and,
9. Unique approach procedures or abnormal conditions requiring a deviation from the above
elements of a stabilized approach require a special briefing.

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To maintain safe operations, airlines must have a set of standard operating procedures (SOPs) for
the operation of the airplanes. Pilots must follow these SOPs to ensure flight safety.
Pilots must understand the procedures, restrictions and limitations that affect flying instrument
approaches, missed approaches and departure procedures. They must follow precisely the
procedures to ensure safety.
Use of all available aids can greatly reduce workload. It is much easier for a pilot to monitor an
autoflight system flying an instrument approach than it is to manually fly the approach. As with any
automatic system, the autoflight system must be closely monitored; if it is not performing as
expected, its use should be discontinued.
Good crew resource management requires that both pilots stay in the loop for all phases of flight.
Good communication among crewmembers, ATC, flight attendants, dispatch and maintenance will
go a long way to ensure safety. If the pilot not flying becomes aware of something he does not
understand or agree with, he must find out why.
Most approach-and-landing accidents are the result of pilots flying unstabilized approaches. Pilots
must understand what a stabilized approach is and always use this procedure when landing. If the
aircraft is not stabilized by 1,000 feet on an instrument approach or 500 feet on a visual approach,
go around.

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CHAPTER 7 : ALTIMETER SETTINGS

Accidents and incidents have occurred because of factors associated with aircraft altimeters.
These factors can be divided into two groups: altimeter units of measurement and altimeter
settings.
While there is an international standard for units of measurement recommended by the
International Civil Aviation Organization — hectopascals — it is not adhered to by all countries.
Settings may be given in inches of mercury (in. Hg), hectopascals (hPa), or millibars (mb).
Additionally, some air traffic systems use meters and some use feet for altitude reference. The unit
of measurement varies with the area of the world in which the flight crew is flying. A problem can
occur when the flight crew is accustomed to using one method of measurement but may be
required to use a different and less familiar method of measurement.
For example:
An ATC controller, who speaks English as a second language, hurriedly advises the crew to
“descend and maintain 9,000 feet” using an altimeter setting of “992.” The crew sets 29.92 in. Hg,
not 992 hPa that the controller intended. Throughout the approach, the airplane will be
approximately 600 feet below the altitude indicated on the altimeter. This can make the difference
between a normal landing or an accident.

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Set/cross-check radio altimeters. Ensure that both pilots know the radio altimeter settings and why
the altitude is selected (advisory, decision height, etc.).
An improvement to the terrain awareness and warning system (TAWS) is the addition of geometric
altitude (global positioning system [GPS] computed altitude augmented by radio altitude). Pilots
need to understand how the system uses geometric altitude.
A QFE altimeter setting results in the altimeter reading height above runway threshold or height
above airport elevation. The altimeter always reads “0” on landing. By using a QFE selectable
altimeter and autopilot, it is not necessary to convert the local altimeter to QFE.
Eliminating three-needle altimeters will help to eliminate altimeter errors by the pilots.
Standardizing the phraseology for altimeter setting by stating digits and units will help eliminate
errors. For example, “altimeter 992” could be interpreted as setting QNE pressure altitude (29.92
in. Hg) or it could be a low altimeter setting “992 hPa” or “992 mb.”

“Vertical awareness” implies that pilots know the relationship of the airplane altitude to the
surrounding terrain, obstacles and intended flight path. During instrument meteorological
conditions (IMC) and reduced-visibility flight conditions, it is necessary to rely on altitude
information provided by instruments, not outside visual cues.
To assist pilots, instrument flight rules en route charts and approach charts provide minimum safe
altitudes (MSAs), minimum obstruction clearance altitudes (MOCAs), minimum en route altitudes
(MEAs) and, in most terminal areas, actual heights of the terrain or obstacles.
Traditional charts, such as sectional charts or operational navigation charts, are available for more
detailed study. The potential for CFIT is greatest in the terminal areas.
Detailed altitude information is provided to assist the pilot in maintaining situational awareness.

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Just as pilots have to study systems and standard operating procedures, they also have to study
instrument procedures, terminologies and definitions.
With construction around airports and as new technology improves instrument approaches,
approach procedures change frequently.
These changes should be checked at the time the revisions are installed, and a more in-depth
review should be done during the approach briefing. New technology brings new terminologies and
definitions that must be learned, too.

Revisions should be entered on the due date, which could require that different approaches are
inserted in the manual at the same time. A system needs to be in place for determining when to
remove the old approach chart and when to begin using the new one.
Color contours on charts provide a quick and easy reference for terrain height changes. These
should also be reviewed by both pilots during the approach briefing.
Pilots are responsible for knowing, understanding and being able to perform the GPWS/TAWS
escape/pull-up maneuver. This should be taught and checked during simulator training.

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CHAPTER 8 : NAVIGATION ERROR

Most CFIT accidents occur during nonprecision approaches, specifically VOR/DME approaches.
Inaccurate or poorly designed approach procedures, coupled with different depictions of the same
approach, can be part of the problem.
This is an example of an approach procedure produced by different sources. The minimum terrain
clearances on some published approach charts have contributed to both accidents and incidents.
For more than a decade, a worldwide effort has been underway to both raise and standardize the
descent gradient of nonprecision approaches.
There are gradients as shallow as 0.7 degrees in some VOR approach procedures.
In addition to the shallow approach gradients, many approaches use multiple altitude step-down
procedures. This increases pilot workload and the potential for making errors.

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CHAPTER 9 : AUTO PILOT

Near-collisions with terrain occur each year because of autoflight systems. Not all incidents are
reported. The advancement of technology in modern airplanes includes flight directors, autopilots,
autothrottles and flight management systems. All of these devices are designed to reduce pilot
workload. They maintain altitude, heading, airspeed and the approach flight path, and they tune
navigation aids with unflagging accuracy.
When used properly, this technology contributes to flight safety. But technology can increase
complexity and also lead to unwarranted trust or complacency.
Autoflight systems can be misused, can contain database errors and can 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.
• Avoid complacency.
• Cross-check raw navigation information.
•
Imagine this situation: The aircraft is descending, and the autoflight system is engaged and
coupled to fly the FMC course. It is nighttime, and the FMC is flying an instrument arrival
procedure in mountainous terrain.
The FMC has been properly programmed and the airplane is on course, but ATC amends the
routing. In the process of reprogramming the FMC, an erroneous active waypoint is inserted. While
the flight crew is reconciling the error, the airplane begins a turn to the incorrect waypoint! It does
not take very long to stray from the terrain-altitude-protected routing corridor.

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Appropriate use of the autoflight system means that the system will help to reduce workload. If the
system is not set up correctly and you are close in on an approach, fly the airplane manually rather
than try to reprogram the autoflight system.
Systems that have the ability to display vertical paths to the runway, if programmed properly, can
be a great aid to flying a stabilized approach. As with any automatic system, this function must be
monitored and minimum descent altitude/height [MDA(H)] or decision altitude/height [DA(H)] must
be honored.
If flying a instrument approach with altitude step-down procedures, the autoflight system, if
programmed properly, can provide information to the crew to allow them to fly a constant-angle
nonprecision approach (CANPA) rather than having to level off at different altitudes during the
approach.
This function must be monitored during the approach to ensure that the airplane meets altitude
restrictions.

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CHAPTER 10 :
BRIEFING AND
CALL OUTS

The importance of takeoff and arrival briefings is stressed as a means to overcome some of the
factors associated with the departures and arrivals.
However, if the briefings
do not stress applicable
unique information,
provide usual and
routine information,
or are conducted at
the expense of normal
outside-the- cockpit
vigilance, their value is
lost and risks can be
increased.

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Use the following guidelines if other guidance is not provided by standard operating procedures or
the airplane manufacturer:
• Weather at the time of departure.
• Runway in use, usable length (full length or intersection takeoff).
• Flap setting to be used for takeoff.
• V speeds for takeoff.
• Expected departure routing.
• Airplane navigation aids setup.
• Minimum sector altitudes and significant terrain or obstacles relative to the
departure routing.
• Rejected takeoff procedures.
• Engine failure after V1 procedures.
. Emergency-return plan.

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Accident statistics
show that the vast
majority of accidents
occur during the
approach at the
destination airport. Is it
not logical then to
prepare carefully
and properly for
the arrival approach
and landing?
The approach
briefing sets the
professional tone for
your safe arrival at
the destination.
The pilot flying
should discuss
how he or she expects
to navigate and fly the
procedure.
This will not only solidify the plan for the approach, it will inform the pilot not flying of intentions,
which provides a basis for monitoring the approach.

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Deviations from the plan now can be more readily identified by the pilot not flying. The approach
briefing should be completed before arriving in the terminal area, so that both pilots can devote
their total attention to executing the plan.
Use the approach briefing guidelines shown above if other guidance is not provided by standard
operating procedures or the airplane manufacturer.

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Callouts are defined as verbal announcements, by flight crewmembers or by airplane

equipment, of significant information that could affect flight safety.

CHAPTER 11 : TRAINING

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Many CFIT
accidents have
occurred when the
crew was attempting to fly a procedure turn
outside of the defined procedure turn area.
Some of the reasons for being outside of the procedure turn area were: speed too fast, flying
procedure turn before reaching the fix and flying a “short cut” to where the crew perceived the
procedure turn area to be.

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The instructions for the approach designers are many and complex. They include definitions and
terrain/obstacle clearances for: primary area, secondary area, maneuvering zone, initial approach
segment, intermediate approach segment, final approach segment, and go-around segment with
climb requirements.
When the pilot reads his approach plate, these requirements have been predetermined so that all
he has to do is follow the procedure to assure proper terrain/obstacle clearance.

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For a straight-in nonprecision approach, the initial segment provides a primary area that is four
miles wide on either side of centerline and ensures 1,000 feet of terrain/obstacle clearance.
The secondary area is an additional two miles on either side with terrain/obstacle clearance
sloping to zero at the outer edge.
After the aircraft crosses the initial fix inbound and is in the intermediate approach segment area,
the width of both the primary and secondary areas is reduced until the aircraft crosses the final
approach fix.
Terrain/obstacle clearance in the intermediate approach segment area is 500 feet in the primary
area sloping to zero at the outer edge of the secondary area.
After crossing the final approach fix inbound, the width of the primary and secondary areas
remains fairly fixed with terrain/obstacle clearance in the primary area being 250 feet and sloping
to zero at the outer edge of the secondary area.
Naturally, if you see radar altitudes less than 250 feet while in IMC, something is wrong.
As pilots, we must fly our approaches accurately and if we observe a full-scale deflection of a
course-deviation indicator or glideslope indicator at any time during the approach, we must GO
AROUND because we will not be able to determine how close we are to having NO
terrain/obstacle clearance.

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With a straight missed approach, the width of the primary and secondary areas varies at the
missed approach point and widens to four miles either side of centerline for the primary area and
an additional two miles for the secondary area at 15 miles from the missed approach point. The
procedure also requires a 40:1 climb gradient.

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Any obstacle or terrain in the missed approach area that intersects the 40:1 climb gradient will
result in the landing weight being limited by go-around performance to ensure the 40:1 climb
gradient. This would require a takeoff weight adjustment to be able to meet the go-around
performance for landing.
A go around initiated below the missed approach altitude may not meet the obstacle climb
gradient.

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PANS OPS Volume I Part III Chapter 3

3.6.1.8 It is emphasized that a missed approach procedure which is based on the nominal climb
gradient of 2.5 percent cannot be used by all aeroplanes when operating at or near maximum
certificated gross mass and engine-out conditions.
The operation of such aeroplanes needs special consideration at aerodromes which are critical
due to obstacles on the missed approach area and may result in a special procedure being
established with a possible increase in the decision altitude/height or minimum descent
altitude/height.

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Flight crews must be adequately prepared for CFIT conditions, both en route and at the
destination. Flight crews must be provided with adequate means to become familiar with en route
and destination conditions for routes deemed CFIT-critical. The following methods are considered
acceptable for this purpose:

• When making first flights along routes or to destinations deemed

CFIT-critical, the captain should be accompanied by another pilot familiar with the
conditions; or,

• Suitable simulators can be used to familiarize flight crews with airport-critical

conditions when those simulators can realistically depict the procedural
requirements expected of flight crewmembers; or,

• Written guidance, dispatch briefing material and video familiarization using actual or
simulated representations of destination and alternatives should be provided and
reviewed by the flight crew.

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Most of the factors that have been identified in CFIT accidents are the result of deficiencies in flight
crew training programs. Therefore, training becomes a significant factor that contributes to CFIT.

Well-designed equipment, comprehensive operating procedures, extensive runway approach aids,

standardized charting, standardized altimeter setting procedures, and standardized units of
measurement will not prevent CFIT unless flight crews are properly trained and managed.
• Develop and implement effective initial and recurrent flight crew training programs
that consider CFIT.
. Implement flight operational quality assurance (FOQA) programs.

EGPWS Warning Escape Maneuver

The EGPWS warning is normally the flight crew’s last opportunity to avoid CFIT. Incidents and
acci- dents have occurred because flight crews have failed to make timely and correct
responses to the EGPWS warnings.

The available time has increased between initial warning and airplane impact since the first
version of the EGPWS; however, this time should not be used to analyze the situation. React
immediately. With the early versions, there was as little as 5 sec warning, and none at all if the
impact point was on a relatively steep slope of a mountain.
There may be as much as 30 sec for newer and future versions.
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In the absence of standard operating procedures or airplane manufacturer guidance,

execute the following maneuver in response to a EGPWS warning, except in clear daylight
VMC when the flight crew can immediately and unequivocally confirm that an impact
with the ground, water, or an obstacle will not take place:

• React immediately to a EGPWS warning.

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

Continue the escape maneuver until climbing to the sector emergency safe altitude or until
visual verification can be made that the airplane will clear the terrain or obstacle, even if
the EGPWS warning stops.

CFIT Traps
In the previous sections, the causes of CFIT and contributing factors are identified, along with rec-
ommendations and strategies that may be used to avoid CFIT accidents and incidents. It could be
misleading to the reader when causes and factors are discussed separately. Accidents and
incidents do not normally happen because of one decision, or one error.

They rarely happen because the flight crew knowingly disregarded a good safety prac- tice.
Accidents and incidents happen insidiously. Flight crews fall into traps—some of their own making
and some that are systemic. Let’s look at some examples of traps that could happen when a flight
crew employs one recommendation, but disregards another.

We have identified that nonprecision VOR instru- ment approaches are especially hazardous when
they include shallow approach paths and several altitude step-down points. We recommend that
the autoflight system be used, if available, to reduce the workload.
While this technique may mitigate the problem with the approach procedure, it can create another
trap if the flight crew becomes complacent and does not properly program the computer, monitor
the autoflight system, make the proper cockpit callouts, etc.

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All manufacturers publish recommended configurations and airspeeds for approaches.

Using these procedures will help to assure that you stay in the protected area during maneuvering
for the approach and are in a configuration and at a speed appropriate for a safe landing.

If at any time during the approach, you feel that you are out of position or configuration and the
safety of flight is compromised, GO AROUND.

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