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This was to be accomplished through a focused application of industry and FAA
resources, and a Joint Safety Analysis Team (JSAT) was chartered to analyze safety data
and recommend intervention strategies to address the problems identified in that data.
The accident category of Controlled Flight into Terrain (CFIT) was chosen for the first
JSAT, as CFIT is the leading cause of world-wide transport-category airplane fatalities.
The presence of many other CFIT studies also allowed comparison of the team’s results
with those of existing analyses. This latter point is important, as this first JSAT’s
primary aim was to develop the JSAT process, not to accomplish the definitive CFIT
study. A comparative review of the recommendations from existing CFIT studies is
provided in Section VIII.
The JSAT process has been documented in a companion report, entitled “Process for
Conducting Joint Safety Analysis Teams (JSAT’s).” The purpose of this report is to
document the results of the JSAT’s technical analysis, and to recommend intervention
strategies to minimize the occurrence of CFIT accidents.
A copy of the CFIT Joint Safety Analysis Team (JSAT) charter is provided in Appendix
A.
Page 2
VI. CONTROLLED FLIGHT INTO TERRAIN (CFIT) ANALYSIS
Note: The analytical process outlined in this section is discussed in greater detail in the
document entitled “Process for Conducting Joint Safety Analysis Teams (JSAT’s).”
Twelve CFIT accidents were selected to provide the data set for analysis. Both old and
new generation transport airplanes, inside and outside the United States, were included.
A critical factor turned out to be finding accidents that had sufficiently detailed reports to
support the analytical effort. While twelve accidents were selected, one of the reports
had not been released at the time of the JSAT inception, and one did not have adequate
detail. Both of these reports were thus removed from the data set. The accident data set
is provided in Appendix B.
Due to scheduling constraints and team size, the decision was made to perform the initial
accident review via two subteams - an East Team and a West Team (the names reflect the
general split in the home locations of team members). Several individuals were members
of both teams to provide continuity between the analysis process techniques used.
Figure 1
Most Common Problems
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9
Number
of
accidents
where
problems
occur
5 5 5 5 5
7 7
9
10
ATC/Flight
Crew
Inadequate
Communications
ATC Failure
to Follow
Procedures
Flight Crew
Failure to
Follow
Procedures
(SOP)
Flight Crew
Inadequate
Situation
Awareness
(Vertical)
Aircraft
Equipment
Failure
Flight Crew
Lack of Basic
Piloting Skills
or Knowledge
Flight Crew
PNF duties
Not
Performed
Flight Crew
Inadequate
Situation
Awareness
(Horizontal)
Flight Crew
“Presson-
itus”
Page 3
At the subteam meetings, an event sequence, consisting of time marks with
corresponding events and/or problems, was developed for each accident. The event
sequences were then used for assistance in identifying problems and possible
interventions. Within the event sequence, there was no requirement that each problem be
associated with a particular event or time mark, or that each event have a corresponding
problem statement.
At the next full team meeting, the standard problem statements were developed from the
individual problem lists for each accident. Appendix C contains a matrix of standard
problem statements versus their occurrence within each of the reviewed accidents.
Figure 1 illustrates the most common problems recorded by the JSAT evaluation of CFIT
events.
Similarly, a standardized intervention strategy list was developed The team recognized
that many of the intervention strategies had already been implemented by various
segments of the industry and government. In reviewing the interventions, organizations
which have already implemented a recommendation should consider this a validation of
the need for continuation of that portion of their program.
The team used the following effectiveness scale to evaluate the effectiveness of the
interventions (note that this scale is slightly different than the one recommended in the
JSAT process report):
Not applicable or unknown N/A
None (little or no potential for preventing the accident) 0
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