Safety Alert: Pilots... Manage Risks to Ensure Safety


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  • Good Morning.Thank you all for taking your time from the numerous Sun n Fun activities to attend my presentation today. I’d also like to thank the FAA for opportunity to speak at their Safety Seminar and Workshop program.On March 12, 2013, the NTSB conducted a Board Meeting on General Aviation Safety and issued 5 safety alerts. One of those alerts, Pilots: Manage Risks to Ensure Safety, I will be discussing with you today. This safety alertaddresses fatal accidents involving ineffective risk management or poor aeronautical decision-making. Although few pilots knowingly accept severe risks, accidents can result when several risks of marginal severity are not identified or are ineffectively managed by the pilot and compound into a dangerous situation. This important issue can be associated with almost any type of fatal accident across all GA sectors.[CLICK]
  • As a background to the rational behind the GA Safety Alerts . . .Each year, NTSB regional investigators investigate about 1,500 accidents, averaging about 4 every day, in which about 475 people are killed.
  • The most common accident occurrence categories are noted here. In-flight loss of control, although due to various underlying reasons, accounts for the overwhelming majority of GA accidents. This presentation will be considering risk management. Unfortunately, not properly managing risk can lead to an accident in virtually any of these occurrence categories.[CLICK]
  • Becauseof the need for improvement in the decade-long plateau in the GA accident rate, the NTSB has placed GA safety on its Most Wanted List.Education, training and risk management skills can assist pilots, mechanics, and members of the aviation community in reducing this accident rate.
  • Each safety alert defines a GA safety problem, identifiesstatistics related to the issue, and provides accident case studies. Finally, the alerts highlight practical remedies to mitigate the problem and enhance safety of flight.[CLICK]
  • Overall, the Safety Alert topics include: aerodynamic stalls at low altitude in daylight visual weather conditions (which is a type of loss of control accident); reduced visual reference accidents (which we will be discussing in this presentation); accidents involving pilot inattention or inappropriate responses to aircraft mechanical problems;risk management strategies for pilots because effective risk management is essential for preventing all types of GA accidents; and, finally, risk management strategies for mechanics because aviation maintenance technicians play a critical role in GA safety.[CLICK]
  • It should be noted that the accident case studies I will discuss today are for educational purposes. They are not intended to admonish the accident pilots. Rather, they are intended to help other pilots learn and apply the lessons learned to your flying and your decision-making process.
  • The first accident case study involved improper aeronautical decision making that resulted in an in-flight collision with mountainous terrain. It occurred near Lander, Wyoming, on October 25, 2010.[CLICK]
  • The airplane involved was a Mooney M-20, which was a non turbo-charged, single-engine airplaneThe accident flight was the pilot’s attempt to return to his home in Minnesota after a vacation.The accident occurred while the airplane was operating on an instrument flight plan, in winter weather which included icing conditions, over mountainous terrain in Wyoming.The pilot and his 3 sons were on board – All four were fatally injured [CLICK]BACKGROUNDA/C mfgd 1977
  • The pilot had a total flight time of about 940 hours.He obtained his IFR rating about 1 year before accident, and had logged about 23 hours of actual instrument time, mostly over the relative lowlands of MNFor the accident flight, the pilot was instrument current in accordance with the regulations, but his instrument requalification checkout was conducted over the course of 6 hours and 2 sessions in the airplane, the week prior to the trip[CLICK]BACKGROUNDEarned Pvt Pilot Cert about 8 yrs before accident
  • A review of the sequence of events reveals that initially, the pilot utilized good risk management, but his backup plan was foiled by circumstances beyond his control.His original return trip was planned for a Sunday, the day before the accident, but he cancelled that flight due to adverse weather.He then purchased commercial airline tickets for a Monday return.However, that commercial flight was cancelled on Monday morning due to mechanical problems.The pilot then opted to fly his airplane home later that same day.[CLICK]
  • On the day of the accident, the pilot’s initial risk management efforts were manifested by his multiple weather briefings and filed route changes. Those changes were due to the dynamic weather situation at the departure airport, and over the mountainous terrain along his route of flight.When the pilot was finally ready to depart and was assigned his final ATC clearance, he accepted a route/altitude combination that was not in compliance with ATC requirements, and an altitude which was near the airplane’s published altitude performance limit.[CLICK]BACKGROUNDLMFSS 0918LMFSS & F/P 1037 (1130 liftoff) MEA 14000 filed 9000Internet F/P 1237 (1247 liftoff) MEA 14000 filed 9000Invalid b/c: thru Class G (not rqstd by pilot), and below off route obstruction clearance altitudeA/C at/near MTOGW. Svc ceiling 18,400 (35 year old airplane- mfgd 1977)
  • After departure, the pilot reported that he was having difficulty reaching his assigned altitude of 16,000 feet. Radar data indicated that the airplane achieved a maximum altitude of about 14,500 feet.The pilot also reported that he was encountering some icing.For undetermined reasons, the airplane subsequently entered an uncontrolled descent, which continued until ground impact.[CLICK]BACKGROUNDSvc ceiling (at MTOGW) 18,700Assigned 16000Conditions conducive to icing and he reported samePossibilities included icing, turbulence, and spatial disorientation
  • Here is a graphic to illustrate the routes and situationThis is a Low Altitude IFR Chart[CLICK]The origination point,Jackson, Wyoming, (JAC) is shown in blue; the first filed route, via the Dunoir (DNW) and Boysen (BOY) navigation facilities, isshown in green [CLICK]The second filed route, via the Dunoir (DNW) and Riverton (RIW) navigation facilities, is also shown in green Both these filed routes were on established airways [CLICK]The green circles show the minimum enroute altitudes, or MEAs, for the airways, in this case 14,000 feet [CLICK]The red line depicts the assigned route from ATC, via the via KICNE intersection direct to Riverton (RIW) – note that this is an off-airway route[CLICK]The red dashed circle highlights the Off Route Obstruction Clearance Altitude (known as OROCA) for the brown-shaded area that the assigned clearance route traversed The OROCA was 16,100 feet, a significant increase over the requested altitude for the non-turbocharged, fully loaded airplane[CLICK]The red star depicts the approximate accident locationCLICK TO NEXT SLIDEBACKGROUND1037 JAC-DNW- BOY: MEA 14,000 (wanted to go VFR over mtns, then pick up IFR)1130 JAC- DNW-RIW: MEA 14,000 MEA (PIC filed 9,000)1258 Assigned JAC-KICNE-RIW: OROCA 16,100. 9,000 unable, ATC said 16k, PIC rqstd & was granted 14k (500 blo Class E ctlled airspace; 14k was class GM20 nav capability: Had Garmin 430 and XM wx
  • To provide a sense of the terrain the pilot was attempting to cross, this photograph depicts the view from the accident location. The wreckage is shown in the inset.The NTSB determined that the probable cause of this accident was the pilot’s decision to depart into known adverse weather conditions over mountainous terrain, which required operation near the limits of the airplane's performance capability.Contributing to the accident was an improper clearance issued by the air traffic controller and the pilot's acceptance of that clearance. [CLICK]BACKGROUNDAlso contributing to the accident was the extended loss of radar data from the Rock Springs Air Route Surveillance Radar, which caused loss of radar contact and consequent loss of minimum safe altitude warning protection for the flight.
  • The primary missed opportunity was that the pilot did not adhere to his initial risk management strategy.The pilot’s initially conservative decision-making was overtaken by external pressures, which then adversely affected his conduct.In this case, it was the building time pressure to return home and his subsequent decision to attempt the flight.[CLICK]BACKGROUNDBy determining the opportunities that were missed in this sequence of events, others should be able to learn and avoid pursuing a similar course of action, with a similar undesired outcomeOnce decision to go was made, appears all risk mitigation strategizing was abandoned (a side effect of ‘get-home-it is’?)Biggest pressure- Get home it is (time/space, $, other committments??) Biases risk assessment and therefore mitigations
  • On the day of the accident, pilot did not avail himself to postponement or cancellation alternatives, although he did so the day before the accident.The pilot did not question the routing or altitude assigned by ATC – he accepted a clearance that was not in accordance with FAA requirements, and he accepted a flight altitude that minimized his altitude performance margin.Once he departed Jackson (JAC), the pilot failed to exercise any turnback or diversion options, and he did not explicitly ask ATC for assistance.[CLICK]BACKGROUNDInitially the pilot exhibited good risk mitigation strategies, but after cancellation of the commercial airline flight, those processes were subjugated his primary goal- getting home on time“tunnel-vision like” decision options- focused on end goal (flight) i/o on bigger picture of risk mgmnt
  • Other lessons that can be drawn from this accident include the following:FAA legal does not necessarily equate to ‘safe’ – while the pilot was legal to conduct the instrument flight, he stacked the odds against a successful flight;The combination of the pilot’s limited instrument experience, his recent instrument requalification, the weather, the terrain elevations, and the airplane capabilities presented a very challenging set of circumstances, which significantly increased the risk level;Pilots mustaccurately evaluate their skill level and equipment capability, and then follow through by aligning their options and actions with those evaluation results.[CLICK]BACKGROUNDOnce decision to go was made, appears all risk mitigation strategizing was abandoned (a side effect of ‘get-home-it is’?)Biggest pressure- Get home it is (time/space, $, other commitments??) Biases risk assessment and therefore mitigations
  • Many accidents are repeat events, which in retrospect, were easily avoidable.As an air safety investigator, I frequently find myself asking the question “what were they thinking?” about the persons involved, and particularly, their decision-making.With alarming regularity, the best answer seems to be that at least for that particular flight, the decision making process was far from rigorous. If every pilot could spend a few months as an air safety investigator; I believe that their decision-making process improve dramatically.It seems clear that the rigorous application of basic risk management strategies to every flight would significantly reduce the number of GA accidents.[CLICK]BACKGROUNDOnce decision to go was made, appears all risk mitigation strategizing was abandoned (a side effect of ‘get-home-it is’?)Biggest pressure- Get home it is (time/space, $, other commitments??) Biases risk assessment and therefore mitigations
  • The second accident case study also involved improper aeronautical decision making. It occurred on December 12, 2009, in Alva, Oklahoma.[CLICK]
  • About midnight, during a return cross-country flight, a twin-engine Cessna 310 impacted terrain during instrument meteorological conditions just short of the destination airport.The intended trip was about an 85 mile return flight to the pilot’s home airfield; the area surrounding the airfield was open, flat terrain. Thecommercial pilot was fatally injured.The pilot had flown to Oklahoma City for business and wasn’t expected to stay overnight.[CLICK]
  • Pilot was well qualified, holding commercial pilot and flight instructor certificates, with about 4,300 flight hours.Toxicology testing during the autopsy revealed 10 medications in the pilot’s system, 4 of which were prescription medicines for anti-seizure and pain and would have disqualified him for a medical certificate.A review of personal medical records, noted a history of severe migraines, including a doctor visit about a week prior to the accident flight. The records also revealed a variety of potentially impairing medications that had been prescribed by his personal doctor’s visit’s.There was no record of the pilot’s condition or treatments with the FAA. The pilot received his second class flight medical about 7 months prior to the accident flight. [CLICK]
  • During the day the pilot had been in contact family and friends, and they had told him the visibility was poor.Prior to the flight, the pilot contacted flight service and obtained a weather briefing. Again, the weather was night instrument conditions. During a conversation with a weather briefer, the pilot stated his concern with the potential for fog.Complicating the weather briefing was that fact that the closest weather reporting station was about 45 miles away from his home (or destination) airfield . The automated weather station was temporality out of service at his destination airfield. [CLICK]
  • The pilot conducted an instrument approach to the airport, however was not able to land on the first approach.Radar data tracked the airplane’s approach and showed the airplane executing the missed approach after descending to an altitude of 1,700 feet.The pilot stated to air traffic control that he’d try a second approach and that he wasn’t sure that a successful approach could be accomplished, adding that the heavy ground fog was present.[CLICK]
  • This slide represents the a profile view of the second approach to the airport.The lines and altitudes noted in black are information from the published approach procedureThe information annotated in red is the airplane’s track and altitudes taken from radar data.The airplane came to rest at an elevation of 1,440 feet, about a quarter mile form the end of the runway.The NTSB probable cause was: The pilot’s impairment due to medication use, a migraine headache or both, and his decision to continue the approach below minimum without the proper visual reference resulting in the subsequent collision with terrain. Contributing to the accident was the pilot’s falsification of medical information to the FAA.[CLICK]
  • In looking at this accident, the pilot had both the information and experience to make the flight.The pilot had received weather information about fog conditions at night. He still elected to depart on the accident flight and flew below the prescribed minimum altitude on the approach.Finally, the pilot had a potentially disqualifying medication condition that was not declared and was on several medications that could have impaired his decision-making ability. [CLICK]
  • In aviation we often have acronyms that remind pilot’s of various procedures.The Manage Risk Safety Alert mentions the “IM SAFE” acronym and it certainly applies in this case:Issues of Illness, Medication, Stress, Fatigue, are easily identified in this particular case, add poor weather conditions, and this flight would have been better accomplished another day. [CLICK]
  • The third case study involved spatial disorientation in daylight IMC. It occurred on November 26, 2011, near Crystal Lake, Illinois. [CLICK]
  • The accident involved a Cirrus SR-20 airplane that collided with trees and terrain in daylight IMC near Crystal Lake, Illinois. The intended destination was the DuPage Airport, located about 30 miles west of Chicago. The accident site was located about 22 miles north of the DuPage Airport.No flight plan had been filed.Thepilot and three passengers were fatally injured.Daylight VMC prevailed at the departure airport and throughout the initial portion of the flight. However, the flight encountered deteriorating weather and the destination airport was under IFR at the time of the accident.The pilot expressed concerns to air traffic controllers about getting trapped by IFR conditions after landing.[CLICK]
  • The accident pilot held a private pilot certificate; however, he did not hold an instrument rating.He had accumulated about 207 total flight hours and had recent experience in the accident airplane.When queried during the flight, the pilot informed air traffic controllers that he had been receiving instrument flight training. However, discrepancies with the pilot’s logbook entries shed some doubt on the validity of his instrument flight training.[CLICK]
  • There was no record that the pilot obtained an official weather briefing. Before departing on the accident flight, the pilot told a line service representative at the FBO that he was aware of the weather west of Chicago and that conditions were forecast to be VFR at their estimated time of arrival.The departure airport and initial portion of the flight were conducted under VFR.At the time of the flight’s arrival, the intended destination airport operating under IFR.At the time of the accident, local airports were reporting marginal VFR conditions. Incidentally, as the flight entered the Chicago terminal area, the airplane passed southwest of Midway Airport, which was reporting marginal VFR conditions.[CLICK]
  • Air traffic control radar data provided information about the accident airplane’s route of flight. This map shows the flight path in blue overlaid onto an aeronautical chart. The flight entered the Chicago terminal area south of Midway Airport . . .[CLICK]. . . and proceeded on a northwest course to a point about 5 miles south of DuPage Airport, where the pilot turned north.[CLICK]The pilot inquired about landing at DuPage, but was advised that the airport was under instrument flight rules. After the pilot inadvertently overflew the airport, the controller issued a landing clearance to the pilot. The pilot ultimately elected not to land at DuPage citing his concerns about getting trapped by the weather.[CLICK]
  • This slide depicts the meandering path of the accident flight subsequent to his contact with the DuPage tower controller. The pilot flew north from DuPage Airport and was handed off to Chicago Approach Control. The approach controller provided weather conditions at local airports and the pilot indicated that he would proceed to an airport where VFR conditions were reported. However, the pilot later decided against that plan, informing the controller that he “didn’t want to mess with the weather” and he didn’t “want to get stuck.”[CLICK]
  • The radar data depicted the accident airplane subsequently entering a right-hand descending spiral.[CLICK]
  • A witness reported hearing an airplane that sounded like the pilot was doing aerobatics, but he was not able to see it because of the cloud cover. Shortly afterward, he observed the airplane below the clouds in a 70-degree nose down attitude before it struck the ground. A second witness also described the sound of an airplane in aerobatic flight. She then observed the accident airplane exit the clouds in a nose down attitude. A postaccident examination determined that the airframe parachute likely deployed as a result of the impact.[CLICK]
  • The NTSB determined that the probable cause of this accident was the noninstrument-rated pilot’s decision to continue flight in IMC, which resulted in the pilot’s spatial disorientation and loss of control of the airplane.[CLICK]
  • There are a number of lessons that other pilots can learn in order to prevent accidents due to continued flight into IMC.There was no record that the pilot obtained an official weather briefing. Although, he was reportedly aware of adverse weather in the vicinity of the destination airport, the investigation was unable to confirm the scope or adequacy of any weather information he may have obtained before the flight. Based on his indecision exhibited during the flight, it seems likely that he did not consider alternatives in the event the flight could not be completed as planned.The pilot repeatedly expressed a concern about getting stuck by the weather. It seems clear that the pilot’s schedule did not allow for a delay in the planned itinerary. Possibly because of this, the pilot failed to deviate to any of several airports in the area that were reporting VFR conditions. In addition, he had the option of returning along the initial flight path where weather conditions were better. Finally, the pilot did not seem aware that weather conditions were not conducive to VFR operations at the destination airport. Although the pilot could have requested a special VFR clearance in order to land and takeoff, for some reason, he did not do so.[CLICK]
  • This accident illustrates that marginal weather conditions require more detailed preflight planning, which should include:Obtaining an official weather briefing;Identifying specific alternatives to the flight itinerary in the event that the flight cannot be completed as initially planned;Identifying specific alternatives to personal plans in the event of a flight deviation;Finally, pilot’s must have the discipline to deviate to an alternate airport based solely on safety of flight considerations and not any personal constraints.[CLICK]
  • NTSB accident reports, such as these presented here, provide pilots with a selection of “lessons learned” from which to hone their decision-making skills. Consider reviewing accident reports on a regular basis.In addition, the safety alert provides links to educational resources.It also provides some risk mitigation strategies . . .[CLICK]
  • Understand that effective risk management take practice. It is a decision-making process by which you can systematically identify hazards, assess the degree of risk, and determine the best course of action.Understand the safety hazards associated with human fatigue, and strive to eliminate fatigue contributors in your life.[CLICK]
  • Be honest with yourself and the FAA about your medical condition. If you have a medical condition or are taking any medication, do not fly until your fitness for flight has been thoroughly evaluated.Develop good decision-making practices that will allow you to identify personal attitudes that are hazardous to safe flying, apply behavior modification techniques, recognize and cope with stress, and effectively use all resources.[CLICK]
  • Be honest with yourself and your passengers about your skill level and proficiency. Refuse to allow external pressures, such as the desire to save time or money or the fear of disappointing passengers, to influence you to attempt or continue a flight in conditions in which you are not comfortable.Plan ahead with flight diversion or cancellation alternatives, and brief your passengers about the alternatives before the flight.This concludes my presentation and I’d be happy to answer your questions at this time.[CLICK]
  • Safety Alert: Pilots... Manage Risks to Ensure Safety

    1. 1. Safety Alert:Pilots: Manage Risks toEnsure Safety1
    2. 2. 1,500aviation accidents per year2
    3. 3. Top Occurrence Categories3Fatal accidents in GA personal flying sector, 2000-2011
    4. 4. Safety Alerts• General Aviation on NTSB MostWanted List• Need to reduce GA accident rate• Education, training, and riskmanagement skills4
    5. 5. Safety Alerts• Define a GA safety problem• Provide statistics on the problem• Provide examples of accidents• Provide ways to prevent accidents5
    6. 6. Safety Alert Topics• Aerodynamic stalls at low altitude• Reduced-visual references• Aircraft mechanical problems• Pilots’ risk management• Mechanics’ risk management6
    7. 7. Discussion of Accident Cases• Completed cases: commoncauses, factors, and scenarios• Used as educational tools• Not intended to admonish accidentpilots• Intended to help other pilots learn7
    8. 8. AeronauticalDecision Making8WPR11FA032Lander, Wyoming
    9. 9. Accident Synopsis• Mooney M-20 (non-turbocharged,single engine)• Attempting to return home• IFR flight plan, winter weather,icing, mountainous terrain• 4 POB (father and 3 sons, all fatal)9
    10. 10. Pilot• About 940 total flight hours• Instrument rated• About 23 hours actual instrument• Experience in Minnesota• IFR current per FARs - checkout:• 6 hours in accident airplane• In the week prior to accident10
    11. 11. Sequence of Events• Sunday (day before accident)cancelled flight due to weather• Purchased commercial airlinetickets for Monday morning• Airline flight cancelled (mechanical)• Then decided to conduct flight11
    12. 12. Sequence of Events• Multiple weather briefings andflight routes/plans (dynamicweather situation)• Accepted invalid IFR route• Accepted altitude near airplaneperformance limit12
    13. 13. Sequence of Events• Difficulty reaching assignedaltitude (14,500 feet versus16,000 feet)• Icing encountered• Uncontrolled descent, groundimpact13
    14. 14. 14DNWBOYRIWKICNEJACMEA = 14,000OROCA = 16,100
    15. 15. 15
    16. 16. Missed Opportunities• Adhere to risk managementstrategy• Prevent external pressures fromadversely influencing conduct• Time pressure Decision to fly16
    17. 17. Missed Opportunities• Postpone or cancel flight• Question ATC assignments• Flight route• Flight altitude• Turn back or divert• Request ATC assistance17
    18. 18. ASI Perspectives• “Legal” may not equate to “safe”• Accurately assess skill level andequipment capability• Align options and actions withskills and equipment18
    19. 19. ASI Perspectives• Too many repeat, avoidableaccidents• Decision-making: “What werethey thinking?”• Reduce accidents by riskmanagement19
    20. 20. AeronauticalDecision Making20CEN10FA071Alva, Oklahoma
    21. 21. Accident Flight• Cessna 310,night IMC• IFR flight plan tohome airport(open, flat terrain)• Returning homefrom work trip21
    22. 22. Pilot• Commercial certificate, single- andmulti-engine airplanes• 4,300 flight hours• Toxicology: 10 medications (4 ofwhich were disqualifying)• History of severe migraines notreported to FAA• Class 2 medical22
    23. 23. Weather• Received weather briefings fromFSS, concerned with fog• Reporting station at destinationairfield was out of service(closest was 45 miles away)23
    24. 24. Airport approach• First instrument approachunsuccessful• Radar data showed descent to1,700 feet• Pilot told ATC he would try asecond approach24
    25. 25. Accident Flight25
    26. 26. Missed Opportunities• Resist external pressures tocomplete flight• Adhere to weather informationwith regard to minimums• Report medical conditions,assess potential for impairment26
    27. 27. ASI Perspectives• Acronym “IM SAFE” for pilots• Illness (any illnesses)• Medication (prescription or over-the-counter)• Stress (job, health, finances, family)• Alcohol (consumption within the last 8hours and 24 hours)• Fatigue (not well-rested)• Emotion (emotionally upset)27
    28. 28. Spatial Disorientation:VFR into IMCCEN12FA083Crystal Lake, Illinois28
    29. 29. Accident Flight• Cirrus SR-20• Part 91, no flight plan• Pilot and 3 passengers were killed• Daylight, VMC into IMC• Deteriorating weather, intendeddestination airport was IFR• Pilot concerned about gettingtrapped by weather29
    30. 30. Pilot• Private pilot, no instrument rating• 207 total flight hours• 114 hours in accident airplane• Pilot reportedly receiving instrumenttraining• Discrepancies with logbookendorsements30
    31. 31. Weather• No record of a weather briefing• Departure airport and initial portionof flight conducted under VFR• Destination airport under IFR• Overcast clouds at 900 feet agl• Visibility 3 miles in light rain/mist• Airports east and south remainedunder VFR31
    32. 32. Accident Flight32Midway AirportDuPage Airport
    33. 33. Accident Flight33
    34. 34. Accident Flight34
    35. 35. Accident Site35
    36. 36. Accident Site36
    37. 37. Missed Opportunities• Obtain an official weather briefing• Resist pressures to completeflight as planned• Deviate to alternate airport• Be familiar with regulations37
    38. 38. ASI PerspectiveMarginal weather conditions requiredetailed preflight planning, including:• Obtain an official weather briefing• Identify flight itinerary alternatives• Identify alternate personal plans• Primary concern is safety of flight38
    39. 39. SummarySafety Alert – “Pilots: ManageRisks to Ensure Safety”• Accident summaries• Links to educational resources• “What can pilots do?”39
    40. 40. What can pilots do?• Understand that effective riskmanagement takes practice• Systematically identify hazards,assess degree of risk, anddetermine best course of action• Eliminate fatigue contributors40
    41. 41. What can pilots do?• Be honest with yourself and FAAabout medical fitness for flight• Develop good decision-making• Identify hazardous attitudes• Apply behavior modification• Recognize cope with stress41
    42. 42. What can pilots do?• Be honest about skill level andproficiency• Resist external pressures• Plan ahead with alternatives,brief passengers aboutalternatives42