CONTROLLED FLIGHT INTO TERRAIN (CFIT)
JOINT SAFETY ANALYSIS TEAM (JSAT)
Results and Analysis
September 1, 1998
Revision A, November 20, 1998
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REVISIONS
Revision A: November 20, 1998
Modified report for clarification and simplification. Clarified document purpose and
recommendations. Revised prioritization category definitions and method description.
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CONDUCTED BY THE
CONTROLLED FLIGHT INTO TERRAIN JOINT SAFETY ANALYSIS
TEAM (CFIT JSAT)
THE SUBJECT JSAT WAS COMPOSED OF REPRESENTATIVES OF THE
FOLLOWING ORGANIZATIONS:
1. Federal Aviation Administration:
* Engine & Propeller Directorate, Aircraft Certification Service (ANE)
* Transport Airplane Directorate, Aircraft Certification Service (ANM)
* Flight Standards Service (AFS)
* Office of Accident Investigation (AAI)
* Air Traffic Service (AAT)
* Aviation Systems Standards (AVN)
2. The Boeing Company
3. Air Line Pilots Association (ALPA)
4. National Aeronautics and Space Administration (NASA)
5. Airbus Industrie
6. Air Transport Association (ATA)
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TABLE OF CONTENTS
I. Executive Summary
II Team Members
III Acronyms
IV. Definitions
V. Introduction
VI. Controlled Flight Into Terrain (CFIT) Analysis
VII. Prioritized List of Interventions
VIII. Comparison with Results from Prior CFIT Studies
IX. Conclusion
X. Recommendations
XI. Footnotes
XII. Appendices
A: CFIT Joint Safety Analysis Team (JSAT) Charter
B. Data Set
C. Problem Statement by Accident Summary
D. CFIT Intervention Effectiveness and Feasibility Ratings
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FIGURES
Figure 1
Most Common Problems
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I. EXECUTIVE SUMMARY
During the fall of 1997, the Commercial Aviation Safety Team (CAST), a combined
organization of the Federal Aviation Administration (FAA), National Aeronautics and
Space Administration (NASA), Air Line Pilots Association (ALPA), Air Transport
Association (ATA), and airplane and engine manufacturers dedicated to working together
to improve aviation safety, chartered a Joint Safety Analysis Team (JSAT). The JSAT
was tasked to develop, document, and utilize an analytical process to recommend safety
intervention strategies. The team was further tasked to validate the concept of a joint
industry/government task force, and to validate the developed process by review of
Controlled Flight into Terrain (CFIT) data.
The JSAT reviewed 9 previously completed studies of CFIT accidents. The team also
performed a detailed analysis of 10 commercial CFIT accidents utilizing the JSAT
process found in the document entitled “Process for Conducting Joint Safety Analysis
Teams (JSAT’s)”. This process develops intervention strategies and a recommended
priority for implementation. The priority is based on the effectiveness of a proposed
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