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of the reviewed accidents (greater than or equal to 2.5) but no
worse than moderately difficult to implement (greater than or
equal to 2 on the feasibility scale)
3rd choice: “Bottom” overall effectiveness scores (less than .75)
or:
“midrange” overall effectiveness scores (between .75 and 1.5)
and difficult to implement (less than 2 on the feasibility scale)
It should be understood that individual differences in ratings cannot be interpreted for
statistical significance. Broad categories were used for effectiveness and feasibility
assessments, therefore only broad categories for prioritization can be obtained from the
results.
Page 6
VII. PRIORITIZED LIST OF INTERVENTIONS
TAWS-EGPWS clearly stood out on the basis of its overall effectiveness rating compared
to the other interventions. Its overall effectiveness score was 2.9; the next closest overall
effectiveness score was 2.3. The reason TAWS-EGPWS was judged so high in overall
effectiveness is that it was seen to be a last line of defense in all of the reviewed
accidents. The specifics of each CFIT accident prior to the point of impact mean that
interventions aimed at addressing problems further up the chain of events may not apply
in all cases. This is not to indicate that these interventions are of lesser importance; only
that they are not a possible intervention in all cases.
In addition to its high effectiveness score, TAWS-EGPWS was judged to be moderately
feasible to implement (due to retrofit issues), and so was placed in the top prioritization
category (“Recommended - highest priority”). An additional 20 interventions were
placed in this category due to their having the highest overall effectiveness scores in the
JSAT assessments (at least 1.5 in overall effectiveness), and at least moderate feasibility
(2 or greater in feasibility), giving a total of 21 in the top category.
Two interventions had top overall effectiveness scores, but low feasibility; these were
placed in the second category for prioritization (“2nd choice”). An additional 31
interventions that had midrange overall effectiveness scores, and 10 interventions that
had high effectiveness for at least one accident, were placed in this category. This gives a
total of 43 in the secondary prioritization group.
Five interventions were determined to be either not applicable within the United States,
or already widely implemented. The remaining 37 interventions, which did not meet the
criteria for the first two prioritization categories, were placed in the third category for
prioritization (“3rd choice”).
The interventions have been arranged by topic within each of the prioritization
categories. No ranking within the prioritization categories is intended, nor should any be
attempted based on the data in this report.
The same method of prioritization could be performed for other regions of the world by
those familiar with capabilities and infrastructure within those regions. It is expected that
specific interventions would fall within different prioritization categories for different
regions.
It should be noted that only slight differences in wording between certain interventions
give the appearance of duplication. However, these interventions did have somewhat
different intended meanings, and were therefore maintained separately through the JSAT
analysis process.
Page 7
Recommended - Highest priority for implementation
These interventions had “top” overall effectiveness scores and were judged no worse than
moderately difficult to implement
Overall highest priority recommendation
Install TAWS-EGPWS:
Manufacturers should install TAWS-EGPWS in all new aircraft, airlines/operators should
retrofit TAWS-EGPWS into the existing fleet and international regulators should require
the installation of TAWS-EGPWS. (Intervention number 35)
Others
Ensure CFIT prevention programs are developed, published, and implemented:
Airlines/operators should ensure that their training/standardization programs emphasize
review of approach and missed approach procedures. (7)
Airlines/operators should ensure that their training/standardization programs emphasize
the importance of all flight related briefings. (17)
Airlines/operators should ensure that regularly scheduled recurrent training (e.g., LOFT)
emphasizes crew cooperation and working together to maximize safe operations. (23)
Airlines/operators should establish a CRM training program. (25)
.
Airlines/operators should ensure that their training/standardization programs direct the
flight crews to use all available tools (charts) to establish aircraft position. (47)
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