CFIT Prevention: The Role of the Crew

According to Randy Gawenda, Business Development Manager at Frasca, one of the most significant things flight crew can do to aid with Controlled Flight into Terrain prevention is to refresh their knowledge of their Terrain Awareness and Warning Systems, assuming they have one.

“Effective pre-flight briefings can also play a very large role in maintaining situational awareness during a flight – especially when a distraction, or deviation causes a momentary breakdown in communication and loss of situational awareness,” he adds.

According to Gawenda, the Flight Safety Foundation (FSF) made a very thorough CFIT checklist that flight crews can study. In fact, they can actually generate a risk assessment number, based on the factors that are pertinent to a particular flight. This might include the number of time-zones crossed, runway lighting (or lack thereof), aircraft equipage, Standard Operating Procedures (SOP), and callouts.

“There is a multitude of factors that can have an effect on the flight, either increasing or decreasing the safety factors associated with CFIT,” Gawenda adds.

Improved Self-Awareness

It is important to establish that many CFIT-related accidents have related human factors as a cause; errors that the flight crew made, and which directly contributed to the accident.

“While we are all familiar with the Swiss cheese analogy of accident causation, or the accident chain example, the fact is that we are human, and we do make mistakes," Gawenda highlights. “At some point, we have to acknowledge this and strive for improved self- awareness.

For example, “Non-standard phraseology can cause confusion and breakdown in communication, both between the flight crew themselves, and between the flight crew and air traffic control (ATC).”

While admittedly slightly dated, the human factors issues discussed in ‘The Naked Pilot’, written by former Royal Air Force (RAF) pilot David Beaty, are still very relevant today, providing some excellent examples from which to learn, according to Gawenda.

Studying past CFIT accidents is also a good way to learn vicariously the ‘hows’ and ‘whys’ of what happened, and analyse what tools are available today to more effectively combat those risks or breakdowns that led to a CFIT accident.

“KAL 801, AA 965, Flying Tiger 66, EAL 401 are all classic studies in CFIT,” Gawenda highlights. “While many changes and improvements resulted from these accidents, there were fundamental breakdowns in communication that created confusion.

“And even in some cases, one has to know not only the advantages of using technology like Traffic Collision Avoidance Systems (TCAS) and TAWS, but also its limitations,” he adds. “Rescue 116 is a very notable CFIT accident where the terrain was not in the avionics database. Therefore, one must look at the specific operations, area of operation, type of mission, and take time to perform risk assessment before the flight.

“And flying at night or in IMC inherently adds more risk,” he continues. “We do not drive the same speed [on the road] when it is foggy, yet we do not have much choice about the appropriate flying speed in an aircraft – so we usually do not contemplate the situation as fully. We become complacent about the added risk because we routinely accept it as part of the job.”

Maximizing Training Effectiveness

According to Gawenda, everyone is ‘spring-loaded’ in training because they know that they are going to have to contend with emergencies and problems in the training session.

“The hard part is to create an atmosphere that is closest to the normal psychological state of the crew during normal operations,” he notes. “While everyone complains about the 2.00am or 3.00am simulator session, in many cases training during a degraded state of self may allow for a more realistic response or decision to occur.

“We’re generally going to be more tired at the end of a long day where we have had to delay, or re-route, due to weather or numerous other things beyond our control. If there is a way to manufacture some of that real-world state into training, it may give us a more accurate picture into why things do not always go as smoothly in the real world.

“It would be an objective worth striving for if we are truly seeking to understand and prevent these types of accidents from occurring.”

In addition, the focus needs to be on the common areas where errors are made, or where the safety of operations is compromised.

“We all know instances of false TCAS or Helicopter Terrain Avoidance and Warning Systems (TAWS) alerts in certain areas and around certain airports,” Gawanda highlights. “We know there are areas where the flight crew either turns off the system, or becomes complacent due to numerous false alerts. They become conditioned to not respond to them.

“While that works to a vast extent, we know it is not the proper way to operate, and that it only works if flight crews know exactly where they are.”

Emphasizing terrain awareness and conducting approach briefings should also help to reinforce the proper SOPs created to help counter risk, Gawenda says. Conducting training in mountainous areas can foster awareness and emphasize the importance of ensuring standard phraseology and communications, briefing approaches properly, and maintaining situational awareness.

“We used to have one scenario we would do regularly in the simulator, and it was fairly simple,” Gawenda shares. “We would be giving someone vectors for the ILS35L at Colorado Springs (KCOS). We would clear them to descend to intermediate altitude (around 8,000ft). We would give them a base vector heading of 270 degrees, and then simply initiate a comm failure.

“You would be surprised at the number of pilots who would miss the localizer go clear through. Depending on the approach speed, they would have roughly 90 to 150 seconds to realize it and turn away from terrain that exceeds 10,000ft rather quickly. It was eye-opening for a lot of pilots.”

The Role of Simulation

Simulation of Enhanced Ground Proximity Warning Systems (EGPWS), TAWS, and HTAWS has improved substantially over the years, often using the same hardware used in the aircraft to ensure that accuracy and fidelity are the same.

“Enhanced terrain resolution and postings can help recreate a scenario’s potential accident area more exactly, which is important when – in several cases – only a few feet may make the difference between clearing terrain in an emergency manoeuvre or not,” Gawenda says.

“I also think that proper training to follow resolution advisories and TAWS alerts continues to reinforce that procedures and manoeuvres be executed promptly. As the information and equipment is getting better and better, it is critical to replicate those systems accurately so pilots can be properly trained on how the system works.”

Moreover, it’s fundamental to understand how the technology in the cockpit operates, what information it provides and, what information is not provided. “This is also true when we purposely inhibit the equipment due to low altitude or VFR conditions in and around mountainous airports,” Gawenda notes.

“One always wants to strive for the training outcome to produce the correct response or action so that positive transfer of training from the simulator to the aircraft is maintained. The more ‘real’ we can make simulator training, the more value that training will have.

Making TAWS and EGPWS work accurately in the simulator is critical and allows repeatable training to be done in a cost-effective manner without undue risk.”

Regarding the design of simulation scenarios to train for CFIT prevention, Gawenda reckons it’s logical to draw from past CFIT accidents, re-creating a good scenario to incorporate some of the specific issues that caused it, while also incorporating modern technology.

“The goal is always to make it realistic and avoid the temptation to overload a crew in order to help facilitate any desired outcome. One needs to create the overall guidelines of the story, but allow the crew to assess, communicate, and make decisions,” he argues.

However, while there is a need to be students of aviation history, there’s also the need to be creative as new technology creates new situations that have yet to be experienced, points out Gawenda.

“We have always had accidents in aviation because we failed to fully understand the limitations of new technology,” he concludes. “We compound that by being human and making mistakes which adds some more holes to the block of Swiss cheese.

“If we continue to learn from mistakes of the past, apply them to today’s environment, and extrapolate them to incorporate advancements in our aviation technology for tomorrow, that would be a lofty, but achievable, goal.”

More information from www.frasca.com

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