ALAR

Approach and Landing Accident Reduction

Pilot Guide to Preventing CFIT

 CFIT Defined
Controlled flight into terrain (CFIT) occurs when an airworthy
aircraft under the control of the flight crew is flown
unintentionally into terrain, obstacles or water, usually with no
prior awareness by the crew.

This type of accident can occur during most phases of flight, but
CFIT is more common during the approach-and-landing phases,
which typically comprise about 16 percent of the average flight
duration of a large commercial jet.
CFIT and ALAR
Introduction
 Fatalities by Accident Categories
Fatal Accidents, Worldwide Commercial Jet Fleet
(1990-1999)
 Approach-and-landing Accidents
Distance from runway threshold
Accidents during a 5-year period

80
• 75 accidents/incidents
70 (25 greater than 8 nm) Middle marker
• 2293 total fatalities
60 (approach/landing only) Two-thirds of
Cumulative
number of 50
the accidents
undershoots
Average outer
happened within
40 marker, 5 nm 8 miles of the
30 runway
20
9 8 7 6 5 4 3 2 1 0
Distance to runway threshold (nm)
 CFIT ALAs
Map location of CFIT accidents/incidents
From runway threshold, 40 accidents/incidents

Runway
threshold
5

Tracks where a map

10
display would have
probably helped pilot(s)
identify and correct
15 problem

Fatal accident track

Incident track

In most of the CFIT accidents, the airplane was

lined up with the runway.
(continued)
 CFIT ALAs (continued, #2)
Vertical profile of some recent CFIT
accidents/incidents
3000
3º Outer marker, 5nm

2000
Altitude
(feet)

1000

0
10 9 8 7 6 5 4 3 2 1 0
Distance to runway threshold (nm)

200 180 160 140 120 100 80 60 40 20 0

Average time (seconds) There was a lack of vertical situation
awareness.
CFIT and ALAR
Accidents
 CFIT and ALAR
Contributing Factors
 Factors That Contribute to
CFIT Awareness
• Altimeters • Training
• Safe altitude - Terminal instrument procedures
• Air traffic control - Simulator

• Flight crew alertness • Briefings and callouts

• Standard operating
procedures
• Auto-flight system
 Altimeters

• Know what altimeter units of measurement are used for the area.
• Be vigilant during radio transmission. Verify if in doubt.
• Be prepared to convert feet and meters.
• Know the phase of flight to apply the appropriate altimeter setting.
• Use altimeter setting cross-check and readback cockpit procedure.
• Cross-check radio altimeter and barometric altimeter readings.
• Operate at higher than minimum altitudes during atmospheric anomalies.
Altimeter Recommendations

• Set/cross-check radio altimeters

• Geometric altitude – EGPWS improvement
• QFE selectable altimeters and autopilots
• Eliminate three-needle altimeters
• Standardize phraseology for altimeter settings
- Pilots and ATC
- Units/digits
Safe
Altitude
 Safe Altitude Recommendations
• Study terminal instrument procedures and
definitions.
• Ensure that charts are up-to-date and use
the color terrain contours when available.
• Study GPWS/TAWS procedures.
 ATC

• Challenge or refuse ATC instructions when they are not clearly understood,
are questionable or conflict with your assessment of aircraft position relative
to the terrain.
• Exercise good radio communication discipline.
• Know the height of the highest terrain or obstacle in the operating area.
• Know your aircraft’s position in relation to the surrounding high terrain .
 ATC Recommendations
• Use standard phraseology.
• Do not accept unreasonable clearances.
– You are responsible for altitude clearances.
• Demand clear understanding of clearances.
– Operate autopilot using the mode that facilitates
compliance with ATC instructions.
• Readback of clearances is essential to assure that
everyone agrees with the clearance content.
 Flight Crew
Complacency

• Know that familiarity can lead to complacency.

• Do not assume that this flight will be like the last flight.
• Adherence to procedures helps to eliminate crew
complacency.
 Flight Crew Complacency
Recommendations
• Strict adherence to standard operating
procedures.
• Good crew resource management practices.
• Emphasis on the operational differences in
briefings and in conducting the flight.
• Maintain a professional attitude towards flying .
 Procedures

• Do not invent your own procedures.

• Follow company standard operating procedures.
• Know what approach and runway aids are available before initiating
an approach.
• Use all available approach and runway aids.
• Use every aid to assist you in knowing your position and knowing
the required altitudes at that position.
Attempting to modify approach
procedures using the electronic flight
instrument system (EFIS) map display
resulted in this accident.

Fly the published approach

procedure. Do not improvise.
 Understand Approach Charts

• Identify unique gradient and step-down requirements.

• Review approach procedures during approach briefing
(preferably before top of descent).
• Use autoflight systems, when available.
 Stabilized Approaches
“I’m not stabilized.
I’m going around!”

• Fly stabilized approaches.

• Execute a missed approach if not stabilized by 500 feet above
airport elevation in VMC or 1,000 feet above airport elevation in IMC.
 Procedural Recommendations
• Follow standard operating procedures.
• Understand approach/missed approach and
departure procedures, and comply with them.
• Use all available aids (autopilot, autothrottles,
navaids, etc.) to assist in complying with
procedures.
• Practice good crew resource management.
• Fly stabilized approaches — if not stabilized,
GO AROUND.
 Autoflight
System

• Monitor the autoflight system for desired operation.

• Use the best available mode for current flight conditions.
• Follow procedures.
• Monitor navigation performance.
 Autoflight System
Recommendations
• Appropriately use the autoflight system to reduce crew
workload.
• Use autoflight capabilities to fly stabilized approaches.
• If available and if the crew has been trained, use the autoflight
system to fly constant-angle nonprecision approaches.
 Training

Terminal Instrument Procedures (TERPS)/Procedures for

Air Navigation Services – Aircraft Operations (PANS
OPS) Volume II

• Crews should enhance their knowledge of horizontal

and vertical terrain clearance.
• Crews need to understand why they must adhere to
standard operating procedures while flying in IMC.
Skilled work is behind instrument approach procedures.
All the pilot has to do is accurately fly the procedure.

Procedure
Turn Areas
(TERPS)
Protected Areas
(TERPS)
Protected Areas
(PANS OPS)
Procedure Turn
Initial
Approach Area
(TERPS)
Straight Missed Approach Area (TERPS)
Straight Missed Approach
Obstacle Clearance (TERPS)

Go-around climb performance could determine MDA altitude

and MAP position.
Missed Approach Area (PANS OPS)

Note: The 2.5% climb gradient PANS OPS requires is exactly the same as the 40:1
climb gradient TERPS requires.
Turning
Missed
Approach
Area
(TERPS)
(180-degree turn)
 Turning Missed Approach
Radii (miles) (TERPS)

Approach Obstacle Clearance Flight Path

Category Radius Radius
Max Speed

A (90) 2.6 1.30

B (120) 2.8 1.40
C (140) 3.0 1.50
D (165) 3.5 1.75
E (Military) 5.0 2.50
Simulator
 Briefings
and
Callouts

• Crews should adhere to company SOPs.

• Terrain awareness is a primary reason why we conduct
briefings and callouts.
• Both pilots should promote a common understanding of what
is to be expected.
 Typical Takeoff Briefing
• 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.
 Typical Approach Briefing
• Expected arrival procedure, including altitude and airspeed
restrictions.
• Weather at destination and alternate airports.
• Anticipated approach procedure, including:
- Minimum sector altitudes;
- Airplane navigation aids setup;
- Terrain in the terminal area relative to approach routing;
- Altitude changes required for the procedure;
- Minimums for the approach DA(H) or MDA(H); and,
- Missed approach procedure and intentions.
• Communication radio setup.
• Standard callouts to be made by the pilot not flying.
 CFIT-related Callouts
• Upon initial indication of radio altimeter height, appropriate
altitude vs. height above terrain should be assessed and
confirmed.
• When the airplane is approaching from above or below the
assigned altitude (adjusted as required to reflect specific airplane
performance).
• When the airplane is approaching relevant approach procedure
altitude restrictions and minimums.
• When the airplane is passing the transition altitude/level.
 Training
Recommendations

• Be prepared for initial and recurrent flight crew training programs

considering CFIT and including terminal instrument procedures.

• LOFT (line-oriented flight training) to promote route and destination

familiarization programs emphasizing terrain.

• Practice proper briefings and callouts to promote terrain awareness.

 Conclusion

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!!!.
 CFIT and ALAR
Avoidance & Training
 CFIT and ALAR
Accident Movies; DHC-5 Buffalo
 CFIT and ALAR
Accident Movies; MD-80
 CFIT and ALAR
Accident Movies; B-52H
 ALAR Tool Kit
• Flight Safety Digest: “ALAR Briefing Notes”
• Flight Safety Digest: “Killers in Aviation: FSF Task Force Presents Facts About Approach-and-
landing and Controlled-flight-into-terrain Accidents”
• FSF ALAR Task Force Conclusions and Recommendations
• FSF ALAR Task Force Members
• Selected FSF Publications
• Approach-and-landing Risk Awareness Tool
• Approach-and-landing Risk Reduction Guide
• Standard Operating Procedures Template
• ALAR Information Posters
• CFIT Checklist
• CFIT Alert
• Flight Operations and Training
• Equipment for Aircraft and Air Traffic Control
• Air Traffic Control Communication
• Pilot Guide to Preventing CFIT
• Approach-and-landing Accident Data Overview
• An Approach and Landing Accident: It Could Happen to You
• CFIT Awareness and Prevention
• Links to Aviation Statistics on the Internet