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Enhance Terrain Awareness and Warning System (TAWS):
Avionics manufacturers should improve GPWS capability to reduce GPWS false
warnings. (60)
Install/Enhance Aircraft Maintenance & Health Monitoring Systems:
Manufacturers should develop and implement system failure annunciation capabilities to
alert flight crews of pending failures (e.g., HUMS). (103)
Manufacturers should implement a system to identify the recommended implementation
schedule and priority of aircraft and operational changes. (68)
Regulatory agencies should establish criteria for, and manufacturers should evaluate and
improve, the reliability and failure tolerance of flight systems. (49)
Airlines/operators and regulatory agencies should review procedures to ensure that
design changes (service bulletins) to flight critical systems are incorporated in a timely
manner. (98)
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Emphasize Safety in Business/Operational Practices (Airlines/Regulatory Agencies):
Regulatory agencies should discontinue on-time arrival tracking for airlines. (37)
Airlines/operators and regulatory agencies should strictly enforce the regulations
pertaining to flight crew use of prescription and non-prescription medication. (70)
Airlines/operators and regulatory agencies should improve the availability, clarity, and
prioritization of NOTAM information. (78)
Airlines/operators should ensure, and regulatory agencies should check, that operators
who create their own AOM's include all procedures prescribed by original equipment
manufacturers Airplane Flight Manual (AFM). (80)
Airlines/operators should implement a culture that encourages flight crew voluntary
removal from flight status due to illness. (63)
Implement System Wide Information Sharing:
Airlines/operators, regulatory agencies, and manufacturers should implement a program
designed for sharing of safety related information within the aviation community. (57)
Enhance Communication:
Improve the real time radio communication of critical airport and weather information.
(93)
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Interventions not applicable to or already widely
implemented in the United States
Maximize the effectiveness of MSAW:
Install MSAW-like capabilities world-wide with emphasis on high-risk airports. (72)
Ensure ATC awareness/training/procedures include CFIT prevention programs:
Implement worldwide surveillance radar (example: ADS/B). (121)
Upgrade/Install Flight Deck Equipment:
Airlines/operators should ensure that the aircraft is equipped with all expected NAVAID
frequencies. (73)
Emphasize Safety in Business/Operational Practices (Airlines/Regulatory Agencies):
Airlines/operators and regulatory agencies should prohibit engineering flight tests during
revenue flights following maintenance of critical systems. (90)
Airlines/operators and regulatory agencies should standardize on usage of QNH altimeter
settings. (91)
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VIII. COMPARISON WITH RESULTS FROM PRIOR CFIT
STUDIES
Several members of the JSAT reviewed prior CFIT studies performed by various industry
and government organizations. The findings of these studies were compared, for
validation purposes, to the recommendations developed by the JSAT. In general, this
comparison with previous CFIT studies indicates that the problems and interventions of
the JSAT have been identified by other groups. Specifics are documented in the
following paragraphs.
Bateman, D., Flight Into Terrain and the Ground Proximity Warning System,
Engineering Report 070-4251, Sundstrand Data Control, Redmond, WA, revised
May, 1995 (continually updated).
The referenced report advocates the installation of EGPWS. A second conclusion notes
that 40% of all CFIT losses occur during nonprecision approaches, specifically, VORDME/
LOC-DME approaches (page 3.8). These two findings from the Bateman paper
validate the JSAT top prioritization interventions recommending installation of TAWSEGPWS
and the elimination of nonprecision approaches.
FAA Human Factors Team, The Interfaces Between Flightcrews and Modern Flight
Deck Systems, Federal Aviation Administration, June 18, 1996.
The JSAT analysis produced 36 accident problem statements and over 100 intervention
strategies which were compared to the 51 Human Factors Team Report
recommendations. Direct comparison is not appropriate, as the two reports had different
purposes and products. The JSAT report specifically addressed CFIT accidents, whereas
the Human Factors Team report addressed the overall aviation system, concentrating on
modern flight decks. Despite these different approaches and purposes, there are
similarities in the problem statements, intervention strategies and recommendations.
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