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proficiency checks for simulated instrument failures (partial panel) are adequate. (112)
Airlines/operators should ensure that their training/standardization programs emphasize
the importance of adequate preflight planning. (113)
Airlines/operators should ensure that their training/standardization programs emphasize
the dangers of rushed approaches. (115)
Airlines/operators should establish procedures for flight crews to review/cross check
instructions, clearances, etc., to ensure consistency with expected procedures or practices.
(95)
Emphasize Safety in Business/Operational Practices (Airlines/Regulatory Agencies):
Airlines/operators should encourage a culture that emphasizes safe arrivals over timely
arrivals. (22)
Airlines/operators and regulatory agencies should emphasize that only published route
segments should be flown in non-radar environments. (50)
Airlines/operators should encourage flight crews to use precision approaches (glideslope
guidance) when available and appropriate. (125)
ATC should prioritize the use of precision approaches (glideslope guidance) when
available and appropriate. (126)
Implement flight operations quality assurance (FOQA):
Airlines/operators should implement a Flight Operations Quality Assurance (FOQA)
program to identify flight crew failure to respond to GPWS warnings. (55)
Page 12
Enhance Approach Plate Procedures/Standards:
Regulatory agencies should mandate that approach plates show color contours for terrain.
(5)
Regulatory agencies should establish standardized approach plate depiction/information
requirements for approach plate publishers. (6)
The aviation industry should establish worldwide standards for the presentation format of
instrument approach procedures. (8)
Enhance Communication:
Establish/enhance quality assurance checks/training to ensure that timely and accurate
communication between controllers and flight crews is occurring. (21)
Airlines/operators and air traffic service providers should implement a monitoring
program to ensure the consistent use of the ICAO phraseology. (42)
Develop additional ICAO phraseology for flight crew/air traffic service to address
communication regarding aircraft position, equipment status, and communication which
is not consistent with the situation or with expected responses. (83)
Airlines/operators and air traffic service providers should ensure fluency/proficiency in
the use of basic English language. (40)
Airlines/operators and air traffic service providers should train flight crews and
controllers to ICAO standards to ensure fluency/proficiency in the use of the ICAO
phraseology. (41)
Airlines/operators should train and monitor flight crew compliance with established
communication phraseology guidelines. (88)
Train and monitor ATC adherence to established communications procedures. (106)
Page 13
Ensure ATC awareness/training/procedures include CFIT prevention programs:
Air Traffic service providers should train Air Traffic Controllers to use all available tools
to establish aircraft position (example: don't fixate on just DME). (10)
Air Traffic service providers should emphasize in ATC training the controllers' potential
in assisting the flight crew in improving their situation awareness. (12)
Air Traffic service providers should enhance ATC training to emphasize the dangers of
rushed approaches and performance characteristics of modern jet transports. (13)
Expand availability and utilization of precision approach capability (glideslope or
constant angle vertical guidance):
Eliminate nonprecision approaches where possible. (77)
Others which were highly effective for at least one accident, but no worse than
moderately difficult to implement
Emphasize Safety in Business/Operational Practices (Airlines/Regulatory Agencies):
Airlines/operators and regulatory agencies should strictly enforce the regulations
pertaining to alcohol use/substance abuse. (2)
Airlines/operators and regulatory agencies should strictly enforce flight/duty time
limitations. (48)
Airlines/operators should establish a policy that supports the reporting of substance
abuse. (101)
Ensure CFIT prevention programs are developed, published, and implemented:
Airlines/operators should ensure that their training/standardization programs instruct that
ground proximity escape maneuvers are to be conducted with the aircraft properly
configured (e.g., speedbrakes retracted). (117)
Airlines/operators should implement procedures to avoid simultaneous maintenance on
redundant flight critical systems. (66)
Page 14
Enhance Approach Plate Procedures/Standards:
Regulatory agencies should review and where appropriate eliminate duplicate NAVAID
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