The purpose of this workshop is to stimulate discussion on what we can do as instructors to improve upon the way we are teaching. Your job as the presenter is to guide the discussion to get the instructors and examiners involved in sharing methods, techniques, and what examiners are seeing as shortcomings of applicants from their perspective as examiners. THIS IS NOT a ground school.
2012/5/21-009 (E) As always, we want this to be a discussion; we want attendees to share! For the presenter, there should be included in the folder the following: two articles by Hobie Tomlinson on CFIT; the NTSB final report on the Ted Stevens crash; if available at time of release, the probable cause report on the Superstition Mountain accident; AC 61- 134. Presenters are highly encouraged to read these documents prior to presenting.
Here are the three main areas we will discuss. 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. In essence there are two main reasons this happens: 1. The terrain can’t be seen; 2. There is a lack of performance from either the aircraft or the pilot. In many instances a lack of pilot discipline is an underlying cause. The main issues still go back to training, culture, and cockpit discipline! How do we teach cockpit discipline to an undisciplined culture?
“ I ’m convinced that the first item on any Emergency Checklist is something like “Aawwh Shucks!” I’m also convinced that pilots don’t get up in the morning and say to themselves, “Shall I have my eggs over easy or scrambled - or should I go crash my plane?” So what happens between the eggs and the “Aawwh Shucks!!!”? Perhaps it was decision making done - or not done - days prior to the eggs. ” - BC.
Note that Private Pilot and Commercial pilots have almost the same percentages. This would indicate that susceptibility is not reduced with higher certification.
Have the discussion center around ways to teach/test best practices to mitigate these six basic causes. The ensuing slides come back to these causes as potential factors in CFIT accidents.
The Human Factors Analysis and Classification System (HFACS) has been applied to CFIT accidents. More fatal than non-fatal accidents were associated with violations. Decision errors were more often associated with non-fatal CFIT accidents. When weather was a factor, more CFIT accidents were associated with violations and decision errors. Note that the HFACS data shows 50% of CFIT accidents were due to pilot judgment errors, thus we need to improve pilot decision making ( education, practical test standards, written exam questions). Analysis also shows 30% skill based errors (feedback to CFIs, designated flight examiners, FBOs). With 30% of CFIT accidents due to violations, we have existing FAA responses to violations, but we also need to educate pilots that violations during conditions conducive to CFIT risk are major contributors to death. Finally, with 20% of CFIT accidents due to perceptual associations, we must continue to emphasize the illusions and hazards of flight due to spatial disorientation and visual illusions.
A little bit of dark humor… But once again it boils down to self-discipline! What are some of the violations? Things like: duck unders; flying below minimum safe altitudes; buzzing; flying “below” airspace minimums for visibility and ceiling; etc.
When we say controlled, what do we mean? If the PIC was in “ control ” of the aircraft - and not suicidal - then it follows that either the terrain was not seen or the performance of the aircraft or pilot was not available. Does this mean that there was inadequate awareness on the part of the pilot of the impending collision? What part could “ hazardous attitudes ” (anti-authority; macho; invulnerability; impulsivity and / or resignation) play in this? In the next two slides we’ll look at two rather prominent recent CFIT accidents. The Thanksgiving accident in Phoenix and the Ted Stevens accident in Alaska
With first picture you could ask: “How could someone NOT miss this mountain? If it’s night! What other factors were involved with this accident? Overlying airspace with a floor of 5000’ MSL (Phoenix Class B), ATC vectors? It is possible that the NTSB will release Probable Cause prior to presentation of this seminar. If so it is suggested that it be reviewed.
This was the Ted Stevens crash in Alaska. Many factors involved here: MVFR; a route frequently flown by pilot; although terrain avoidance equipment on board there is the question of whether it was in use or operational; there is also an unanswered question as to possible pilot impairment. Full NTSB accident report should be included in “required reading” folder. Was the terrain not seen, or seen too late when performance was no longer available. (There is potential evidence showing that the pilot might have been in a banked climbing turn when impact with terrain occurred.)
Discuss question. When discussion is exhausted click for “checklist” of items. Of course there is night and obstructions to visibility - what else? This could be a good place for a discussion on VMC into IMC. It is not uncommon for VFR pilots to develop spatial disorientation and lose control, possibly going into a graveyard spiral or descending to an unsafe altitude while trying to maintain visual contact with the surface. The pilot then impacts terrain, the surface or an obstacle while trying to maneuver.
Discuss question. When discussion is exhausted click for “checklist” of items. Other elements include: loss of aircraft control (LOC); Inability of pilot to operate aircraft at minimum controllable airspeed; Reduced reaction time due to maintenance problem compounded by low or lowering altitude (heads down); Failure to understand the WX that resulted in the reduced conditions; breakdown of good ADM; Failure to comply with appropriate regulations; failure to comply with MSAs; Increased risk of hitting many new low altitude towers (i.e. cell phone towers). This risk is especially along major highways when VFR pilots attempt to follow a highway when lost or trying to stay under a lowering ceiling; Failure so see things like tower guy wires, “snags” (dead trees) above a forest canopy; Flying between hills or over rivers below hill tops if a power line or cable is strung between hills; Failure to 180 and avoid deteriorating conditions when first able; Failure to check an area from a safe altitude before descending into it;
Discuss question. When discussion is exhausted click for “checklist” of items. Obviously when flying IMC the terrain will be unseen. In addition to threats and errors enumerated above are: 1. Importance of aircraft being properly equipped for the flight; 2. Although not required VFR sectionals provide important terrain data; 3. Being familiar enough with a planned procedure to know when NOT to accept an unsafe clearance; 4. Having complete WX data for flight; 5. Maintaining sufficient SA both horizontal and vertical to avoid flying into hazardous terrain or known obstacles; 6. Knowing not only how to use onboard equipment for terrain avoidance but the limitations of the equipment; 7. Proper and timely use of autopilot; 8. Increased risks involved with non-precision approaches, high rates of descent near the ground, and circling approaches; 9. Importance of clarification of clearance whenever doubt exists; 10. Importance of not accepting a clearance intended for another aircraft;
Equipment can certainly minimize the possibility of CFIT. However it’s proper use is critical to longevity. It is important to understand the limitations as well as the potential pitfalls in their use. If the equipment is installed it is imperative to maintain a current database!
We need to teach: 1. Sound ADM; 2. Proper pre-flight planning; 3. The use of decision making “tools” such as the DECIDE ( D etect- E stimate- C hoose- I dentify- D o- E valuate) or 3P ( P erceive- P rocess- P erform) models; 4. Skills based maneuvers, particularly minimum controllable airspeed and angle of attack awareness; 5. The use of charts and publications to determine obstacles, MEAs, MSAa, MEFs for each stage of flight from takeoff through initial climb, enroute, terminal, descent and landing; 6. An accurate assessment of weather and lighting conditions for each phase of flight.
“ I suggest that weather should almost never be a surprise from the strategic standpoint of “good” or “doubtful”. Consider a 7-day planning tool such as this. For the first 4 days, the best you can do is something like the Weather Channel, but that includes enough information - such as frontal activity - to help keep you from getting a BIG surprise on the “day of.” All of this is to say that there is good information out there so use it for strategic planning and thinking of and developing options when appropriate. ” BC
Discuss question. When discussion is exhausted click for “checklist” of items. Others include: 1. Windshear and loss of flying speed / taking off with a tailwind; 2. Failure to operate aircraft within operating limitations; 3. Flying up a box canyon and not being able to fly up and out of it prior to impacting terrain; Modern laminar flow airfoils are quite intolerant of contamination (icing) and develop rather nasty stall characteristics when contaminated.
Discuss question. When discussion is exhausted click for “checklist” of items. Lack of pilot skills includes: maneuvering at minimum controllable airspeed; failure to maintain control when taking off and landing (i.e. crosswinds, PIOs, bounce recoveries, etc.); failure to maintain directional control / loss of control; trying to force performance which simply is not there leading to stall/spin and an impending CFIT in the recovery. Also consider: "Drift Down" single engine altitude capability in AME aircraft. (i.e. when below MEA, select routes that allow reaching lower MEAs during the drift down”; Routing which allows lower MEAs in ASE aircraft in the event of performance degradation (i.e. ice, engine power loss, etc.)
More emphasis on: 1. the proper use of performance charts; 2. the effects of increased density altitude; 3. thorough preflight aircraft inspections; 4. Skills based maneuvers, particularly minimum controllable airspeed and angle of attack awareness; 5. Awareness of aircraft’s performance margin (i.e. additional performance which is available but not currently needed.); 6. Comparison of performance required vs. performance available (per POH) for each phase of flight from Takeoff through initial climb, enroute terminal, descent and landing; 7. Awareness of wind on base leg of pattern; 8. Awareness of any restrictions to maneuvering in pattern, i.e. antennas, hills, etc.
Let ’s consider a CFIT accident with many teaching points. The pilot was a 45 year old very successful nurse who had spent several days at Chinle, AZ, a small Indian town with a hospital. Her home field was Henderson, NV, near Las Vegas. She was clearly a very focused woman: she went from Student Pilot to Private-Instrument in 10 1/2 months. She got her instrument rating on Oct 31, 2006 and crashed 6 weeks later. In her SR-22 it would be an easy 2 hour flight from E91 to HND. She departed in the early afternoon of Monday, Dec 18, 2006, one week before Christmas. She should have been landing at home before sundown. However, she seems to have been surprised by the weather and diverted to Winslow, AZ. What do you think of the decision making so far?
The weather is moving in from the west; the MEAs are 10K and above; it is winter and icing could be expected in clouds at IFR altitudes. The decision to launch from E91 in VMC was probably reasonable. Certainly, Winslow is a nicer town than Chinle for a RON. What do you think about the decision making so far?
She gets the airplane secured and checks into the motel and then confers with her husband. They talk about him driving out from Henderson - 5 hours - to get her and the plane home - probably the next day. Then he makes another weather check and it looks like she can swing south around the weather and remain VMC and get home that night with a 2 hr flight. Night, marginal weather, mountains. Discuss this decision. What do you think happens next? Why?
30 minutes after twilight ends, after flying a very circuitous route for an hour and 15 minutes to make 20 minutes of straight line progress, the flight ends in disaster. Think for a moment about the wide spread sadness this event caused to family, friends, associates. The lost opportunities for happiness.
In what ways is this CFIT common to others you know of? In what ways is it unique? Hold those thoughts and . . .
A matrix of exponential factors involved in above accident. A good place for a discussion of where to draw the line. Most folks would agree that any factor above level 4 should be a no-go!
How many training/testing factors can you think of that would help pilots avoid CFIT? Six basic causes of CFIT accidents: Loss of Situational Awareness Cockpit Distractions Complacency Lack of Technical or Operational Experience Lack of Adequate Preparation Confusion
CFIT seems to come in two main categories: can ’ t see to avoid and can ’ t perform to avoid. If we avoid those scenarios there will be a reduction of CFIT accidents. If we can train pilots to exercise self-discipline to avoid those situations there will be a significant reduction in CFIT accidents. “ As I said in the beginning, I do indeed believe that the information is there and available for the PIC before the drive to the airport, before the bacon and eggs, to know if there is going to be a challenge with respect to CFIT, either "unseen" or "performance" related. A really thoughtful consideration of the weather, obstacles, and performance available vs that required for the whole flight would, in my view, greatly enhance the PIC's go, no-go decisions, both before takeoff and enroute. This kind of pre-flight would also prompt logical considerations of alternative plans, like wait until tomorrow, drive, or take Delta.” BC
The discussion should lead fairly quickly to ….. What possibility could distraction have played in this accident?
What Are SomeEnvironmental Factors ThatWould Make Terrain“Unseen”?What about:Night; Visibility;Obscurations; Others?
What Factors Other ThanEnvironmental Could MakeTerrain “Unseen”?• Spatial Disorientation• Loss of situational awareness• Reduced reaction time to see & avoid• Optical illusions• Getting lost or off flight plannedroute• Head down in the cockpit• Scud running
What Factors Exist When FlyingIFR / IMC?• Currency / Proficiency• Current charts / plates / GPS database• Knowing when to say “Unable”• Knowing how & when to use equipment• Following MAP procedures• Knowing MSA & OROCAs• Improperly set altimeter• Unstable approach• Complacency
What Are SomeEnvironmental Factors ThatWould Make PerformanceUnavailable?What About:Density Altitude;Horsepower; Ice; MountainWave;
What Factors other thanEnvironmental Would MakePerformance Unavailable?• Mechanical• Lack of Pilot Skills• Failure to fly within OperatingLimitations• Distraction / diversion of attention• Buzzing
How Do We Train/TestFor CFIT AvoidanceWhen Performance NotAvailable?
23Consider: An Easy 2 Hr Flt FromChinle (E91) to Henderson(HND) Las VegasDiverted to Winslow
24Then Throw in WeatherMST Event1400 Departed Chinle, AZ (E91), Monday, Dec 181445 Enroute Between Layers; Diverts to Winslow(INW)~1515 Lands @ INW; Decides To RON; Spouse toDrive out (~5 Hrs)~1615 Pilot Decides to Go South Around Wx~1645 Returned to INW & Preflighted1715 Departed INW1724 Sunset; Twilight Ends 1754~1830 Crash; 1+15 In The Air; 20 min Straight Line
25Then Plan B - Also 2 Hr - AndThrow In Night VFR into IMC
26A Timeline to DisasterMST Event1400 Departed Chinle, AZ (E91)1445 Enroute Between Layers; Diverts to Winslow(INW)~1515 Lands @ INW; Decides To RON; Spouse toDrive out (~5 Hrs)~1615 Pilot Decides to Go South Around Wx~1645 Returned to INW & Preflighted1715 Departed INW1724 Sunset; Twilight Ends 1754~1830 Crash; 1+15 In The Air; 20 min Straight Line
Discuss This CFITAccident:In What Ways is ItCommon to Other CFITs?In What Ways is ItUnique?
Total Risk Increases asSquare of Factors InvolvedMountains = risk level 1Mountains + Weather = risk level 4Mountains + WX + Night = risk level 9Mountains + WX + Night + ExternalPressure = risk level 16Mts. + WX + Night + EP + Unfamiliar route= Risk Level 252528
How Do YOU Train/Test toAvoid CFIT?PreFlight Preparation especiallyWXTerrain to Be OverflownMountain Area Wind EffectsOther?
Summary:CFIT Comes in Two MainCategories:1. Can’t See to Avoid2. Can’t Perform to AvoidPilot DisciplinePilot Discipline CANCAN HelpHelpto Avoid CFIT Accidents!to Avoid CFIT Accidents!
WWW.SAFEPILOTS.ORGWWW.FAASAFETY.GOVThanks to:Gold Seal FlightWWW.GOLDSEALFLIGHT.COMWritten by: Bill Castlen, Hobie Tomlinson,Doug Stewart