XI. FOOTNOTES
1 Captain Dave Haase, ALPA Ground Proximity Warning System Survey, Attachment 6
(ANC Task No. OPS-9013: Review of the provisions on ground proximity warning
systems in Annex 6, Parts I and II, ICAO, Air Navigation Commission). November 2,
1992, Attachment 6, Appendix C, p. F-6.
2 Ibid., p. F-6.
3 Ibid., p. F-7.
4 Safety Study, Human Factors Issues in Controlled Flight into Terrain (CFIT) Accidents,
1984-1994 (draft). ICAO, September, 1994, unpaginated.
5 R. Khatwa and A. L. C. Roelen, An Analysis of Controlled Flight into Terrain (CFIT)
Accidents of Commercial Operators 1988 Through 1994. National Aerospace
Laboratory NLR, The Netherlands, February, 1996, p. 46.
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XII. APPENDICES
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Appendix A
CFIT Joint Safety Analysis Team (JSAT) Charter
I Purpose: To review and analyze data and make coordinated recommendations to
enhance commercial aviation safety.
II Background: Industry (ISST) and FAA have agreed to work together to identify
and implement a data driven, benefit focused, safety enhancement program designed
to continuously improve our safe commercial aviation system. The FAA and ISST
have further agreed that cooperatively and selectively pursuing the critical few high
leveraged safety intervention strategies will maximize the safety benefit to the flying
public through a focused application of industry and FAA resources. To achieve
this goal, the FAA and ISST have agreed to charter a working group.
III Task:
A. The team shall acquire publicly available data, including prior studies and
analyses. This will constitute the beginning point for review and analysis.
B. The team shall develop, document, and utilize an analytical process to develop
recommended safety intervention strategies. The process developed by the team
should include “appropriate levels” of causal analysis to substantiate the
effectiveness of recommended data driven intervention strategies. In addition to
documenting its safety analysis process, analysis results, and recommended
intervention strategies, the team shall define its assumptions regarding the
amount and extent of data considered (fleet size, time frame, etc.).
IV Products: The deliverables include reports to the FAA and industry documenting
the team’s process, recommended safety intervention strategies and assumptions
used in the analysis.
V Membership: The initial team will include representatives with the appropriate
technical background provided by industry and the FAA.
VI Proof of Concept: To validate the partnership process, the team will review
Controlled Flight Into Terrain (CFIT) data and present its findings and a
recommendation on continuing joint analysis at an executive meeting of the ISST
and FAA. Interim briefings to the ISST and FAA may be required to facilitate
business planning.
VII Resources: The signatories agree to provide the financial, logistic and personnel
resources to carry out this charter.
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Appendix B
Data Set
The following is a synopsis of the accidents that were used by the JSAT:
1. Buffalo Airways, Inc., Boeing 707-351C, April 13, 1987, Kansas City, Missouri
Aircraft crashed approximately 3 nautical miles short of Runway 1 while
conducting an Instrument Landing System (ILS) approach to that runway. All
4 occupants onboard the aircraft sustained fatal injuries.
2. Flying Tiger Line, Inc., Boeing 747-200, February 18, 1989, Kuala Lumpur
Aircraft crashed while executing a Non-Directional Beacon (NDB) approach
to Runway 33 at Subang Airport. The wreckage was located approximately 9
nautical miles southeast of Subang International Airport. All 4 occupants
onboard the aircraft sustained fatal injuries.
3. Markair, Inc., Boeing 737-200, June 2, 1990, Unalakleet, Alaska
Aircraft crashed approximately 7.5 nautical miles short of Runway 14 while
executing a Localizer approach to that runway. Several minor injuries and
one serious injury were sustained.
4. Alitalia AZ 404, Douglas DC-9-32, November 14, 1990, Zurich, Switzerland
Aircraft crashed while executing an approach to Runway 14 at Zurich. The
aircraft first impacted trees approximately 5.2 nautical miles from the runway
threshold. The aircraft then impacted the surface of the wooded north face of
the Stadlerbert. All 40 passengers and 6 crewmembers sustained fatal
injuries.
5. Air Inter, Airbus A320, January 20, 1992, Strasbourg, France (Dropped due to
lack of a published report)
Aircraft crashed while executing a Variable Omni-range Radar (VOR)
procedure approach to Runway 5 into Strasbourg. The wreckage was located
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