Turbine Pilot

Task force report yields useful insights into what causes accidents

Big airplanes and little airplanes experience different types of accidents. On the surface this may not sound terribly strange, but once you delve into the subject some interesting facts emerge.

Big airplanes involved in either fatal or serious accidents generally fall victim to a controlled flight into terrain (CFIT) scenario or a hazard associated with some phase of landing. Light aircraft have greater difficulty in negotiating marginal or severe weather conditions and maneuvering at low altitude. While light aircraft have a high number of accidents associated with takeoff and landing, the takeoff phase proves to be a more significant source of fatal or serious accidents than the landing phase; landing accidents tend to be fender benders.

Not so in larger airplanes. Therefore, business and corporate turbine-powered aircraft operators have become increasingly aware of the approach and landing phases of flight as containing potentially the most hazardous flight regime.

ALARm

Most remarkable about approach and landing accidents is that while they represent more than half of the total number of accidents, they occur during a phase that lasts roughly 5 percent of the total flight. To better understand the phenomenon, a group led by the Flight Safety Foundation (FSF) conducted a thorough investigation of worldwide turbine-powered fatal accidents involving aircraft weighing more than 12,500 pounds maximum takeoff weight and occurring from 1980 through 1996. The Approach and Landing Accident Reduction (ALAR) Task Force's 1998 report yielded useful insights into what was causing the accidents and provided a number of recommendations to rectify the situation. Since the study included business and corporate aviation, the report findings are also germane to this community, not just airlines. While the report concentrates primarily on fatal accidents a number of serious nonfatal accidents were also considered. The goal of the FSF ALAR Task Force was to reduce by 50 percent the worldwide fatal approach and landing accident (ALA) rate by 2004.

While business and corporate aviation accidents were included in the sample, no definition of these operations was offered. Business aviation is generally considered to be the use of an aircraft in support of a business activity and not flight conducted for compensation or hire. Corporate operations use this as a base but also specify that the aircraft be flown by a professional flight crew, specifically compensated for their efforts as pilots.

Findings

The majority of the aircraft involved in the 287 fatal accidents studied were airliners operating in scheduled service. This speaks well for business aviation but it does skew the results somewhat; the majority of airline accidents occur during the approach phase while the majority of business accidents occur during the landing phase. Yet, all the conclusions and recommendations fit the business community quite well.

Lack of positional awareness in the air and omission of action or inappropriate action were found to be the most frequent causal factors (in 47 and 43 percent of the accidents, respectively). The former usually resulted in a CFIT accident, the latter in the crew's continuing descent below decision height or minimum descent altitude without adequate visual reference. A major factor in the omission scenario was the intentional or unintentional deviation from a standard operating procedure (SOP).

Among the circumstances surrounding accidents, lack of safety equipment (ground proximity warning system [GPWS], traffic alert and collision avoidance system [TCAS], wind shear warning), failure in crew resource management (CRM), poor visibility, and lack of ground aids topped the list. Although most of the accidents occurred during daylight hours the rate for ALAs at night was calculated to be nearly three times that for daytime. Since some of the accident data were less than complete or lacked detail, the type of approach used was unknown in more than half of the accidents; however, the study concluded from data available that there is a fivefold increase in accident risk for aircraft flying nonprecision approaches compared to those flying precision approaches. Interestingly, the study calculated that for freight, ferry, or positioning flights the accident rate was eight times higher than for passenger-carrying operations.

A second phase of the study involved a detailed analysis of 76 serious ALAs that did not result in fatalities. A third phase examined thousands of airline line audits, specially designed to evaluate the skills required for flight management. Both of these sub-studies supported and amplified the main body of data collected from the fatal accidents.

A number of working groups contributed individual reports to the main study, including reports on data acquisition, operations and training, aircraft equipment, and air traffic control training, procedures, and facilities. While each of these reports contains interesting and useful information, we will concentrate on the conclusions and recommendations provided by the operations and training working group, shown in the accompanying sidebar "ALAR Operations and Training Conclusions and Recommendations" on page 109. Because of the implications for pilots and space limitations, only the first three items will be examined. More information about the report and related recommendations is available online ( www.flightsafety.org/cfit5.html).

By the book

"States [countries] should mandate and operators should develop and implement SOPs for approach and landing operation. Although all factors cannot be anticipated, the data clearly showed that the absence of good, practical SOPs (recommended techniques) resulted in higher exposure to approach and landing problems." This strong statement opens the number-one recommendation of the operations section and sets the tone for subsequent recommendations. Among these are a call for the development of practical procedures, the need to evaluate them regularly, and the need for procedures regarding the use of automation. Perhaps most telling of all, the recommendations focuses on the workload of the pilot flying: "The data clearly show that task saturation and overload of the pilot flying are significant contributors to ALAs." The report goes on to call for the effective distribution of tasks and decision making among crewmembers. A report appendix provides examples of good SOPs.

Since many business aircraft are flown single-pilot or by pilots who do not fly as their primary duty, SOPs are even more important. The discipline involved in accomplishing operational tasks the same way every time provides a safety buffer to all types of operations. Inherent in this is the SOP that states, "Thou shall use the checklist, every time." Importantly, if you don't use the same procedures every time you can't measure cockpit performance.

It has been my experience in evaluating flight departments and observing flight crews from the jump seat that those using well-conceived, mature procedures as a matter of routine consistently perform the best.

What goes around comes around

"Companies should declare and support no-fault go-around and missed approach policies. Training and company performance management systems should reinforce those policies." We all know that this is the thought process that should prevail as we contemplate our next arrival, but ego, sadly, interferes.

We are led to believe from our early days of flight training that, through good planning, superior airmanship, and following the prescribed procedures, we can get it down, every time. In fact, if we do all the right things and something goes wrong at the last minute we feel cheated and resentful. An aircraft on the runway or failure to acquire the runway environment at the end of an instrument approach both qualify as last-minute disappointments that should not be ignored. My patient and saintly instrument instructor many years ago advised me to be a pessimist when it came to instrument approaches: "When you call, 'Commencing approach,' always say to yourself, 'I probably won't break out on this one.'"

Visual approaches may contain pitfalls, too. Runway changes, distractions in the cockpit, potentially conflicting air traffic, and just plain getting rushed in close can chip away at a comfortable, measured, and well-ordered culmination to an otherwise uneventful flight. If you feel uncomfortable or rushed, beware. For two-pilot operations, crew resource management can save the day in close; having another attuned to the task at hand can prove an invaluable aid.

Whether you're flying for a living or just for yourself, resolve to establish the "what goes around comes around" policy and let all concerned know what it means to them.

Conditional stability

"Company policy should state that a go-around is required if the aircraft becomes destabilized during the approach. Training should reinforce this policy." Obviously, this issue is closely related to the above section but the subtleties separating the two are important. The go-around/missed approach section offers a general prudential rule designed to protect us from a variety of unanticipated situations. The unstabilized approach describes a single operating parameter that mandates a go-around.

A large number of business and corporate aviation accidents involve a land-long or overshoot situation that results in an ungraceful and untimely departure from the runway surface. While most of these events do not involve significant injuries (except to pride and career prospects) they usually stem from some version of an unstabilized approach (see the accompanying sidebar " Stabilized Approach" on page 110).

Consider the following scenarios:

• You see the runway late in a nonprecision approach and dive for it.
• Low-level wind shear creates a severe low-and-slow situation — inevitably this leaves you high and fast.
• An unexpected tail wind leaves you high (and probably fast) in close.
• ATC starts you down late, leaving you "up there."
• The crosswind is greater than anticipated, taking you far off centerline.

We've all been there. But there is at least a bit of the "I can salvage this terrible approach" mentality in all of us. Thus, the need for well-defined limits.

The most important item listed is: "If approach becomes unstabilized below 1,000 feet agl in IMC or below 500 feet in VMC, a go-around is mandatory" — emphasis on mandatory.

Risky business

One of the tools the ALAR study provides is an Approach-and-Landing Risk Awareness Tool, essentially a checklist to be used in assessing your chances of having difficulty in any flight regime. The tool lists a variety of factors that have been shown to affect the safe outcome of a flight and ranks them according to their potential for increased risk.

Risks are assigned from one to three exclamation marks according to the severity. For instance, risks awarded three exclamation marks include:

• No approach radar service or airport tower service.
• Nonprecision approach, especially with stepdown or circling procedures.
• No GPWS/EGPWS.
• No radio altimeter.

While pilots don't have to read this checklist along with the cockpit procedures checklists, reviewing it prior to flight and prior to descent will provide an alert frame of mind attuned to potential hazards. More important, it will promote the concept of risk awareness and avoidance.

Knowing where hazards lurk is more than half the battle. Knowing that night visual approaches to strange airports or nonprecision approaches to short runways contain above-average risks gives you an edge. And, if your pucker factor gets too high, just say no — go somewhere else or insist on a procedure that doesn't raise the hairs on the back of your neck.

Big picture

The level of detail and number of recommendations contained in the ALAR report is extensive. Most of the world's major airlines and business and corporate training vendors have adopted many of the recommendations into their training programs. The FAA has recognized the study as significant and published a flight standards information bulletin (FSAT 01-12) on the subject. The International Civil Aviation Organization (ICAO) purchased 10,000 copies of the ALAR Tool Kit CD and is providing them free of charge to its 188 states. In short, ALAR is considered to be a landmark effort in reducing accidents at the upper end of the civil aviation spectrum. While it is too early to see if the effort has improved the accident rate, preliminary estimates are that its recommendations have had a positive effect.

The essential elements include:

• Half the accidents occur during one-twentieth of the flight time.
• Night and IMC conditions, and nonprecision approaches increase the risk.
• Situational awareness and taking the appropriate action are important.
• Be prepared to go around.
• Having and using SOPs may be the key element bringing all of this together.

As ALARming as the study's findings are, the recommendations are reasonable, relatively easy, and don't cost much. Why not try them?

John J. Sheehan is president of Professional Aviation Inc., a company assisting corporate flight departments with safety, management, and training issues. He holds an ATP certificate. He also serves as secretary general of the International Council of Aircraft Owner and Pilot Associations.

ALAR Operations and Training Conclusions and Recommendations

• Establishing and adhering to adequate standard operating procedures and flight crew decision-making processes improve approach-and-landing safety.
• Failure to recognize the need for and to execute a missed approach when appropriate is a major cause of ALAs.
• Unstabilized and rushed approaches contribute to ALAs.
• Improving communication and mutual understanding between air traffic control services and flight crews of each other's operational environments will improve approach-and-landing safety.
• The risk of ALAs is higher in operations conducted in low light and poor visibility, on wet or otherwise contaminated runways, and with the presence of optical illusions or physiological illusions.
• Using the radio altimeter as an effective tool will help prevent ALAs.
• Collection and analysis of in-flight parameters (for example, flight operational quality assurance programs) identify performance trends that can be used to improve approach-and-landing safety.
• Global sharing of aviation information decreases the risk of ALAs.

Stabilized Approach

• On correct flight path.
• Only small heading and pitch changes required to maintain path.
• Speed between V _REF +20 and V _REF.
• In landing configuration.
• Sink rate not more than 1,000 fpm.
• Appropriate power setting.
• Briefings and checklists complete.
• Within one dot of glideslope and localizer deflection. For visual approach, wings level below 300 ft agl.
• Unique approaches or conditions require special briefings.
• If approach becomes unstabilized below 1,000 ft agl in IMC or below 500 ft in VMC, a go-around is mandatory.

The takeoff and landing phases continue to be primary causes of GA accidents. To help address those accidents, the AOPA Air Safety Foundation has developed a free seminar called "The Ups and Downs of Takeoffs and Landings." The entertaining and informative seminar is playing all over the United States. For details of the seminars and a schedule of locations, see AOPA Online ( www.aopa.org/asf/seminars/).