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FAILURE TO
EXERCISE
COMMAND
(CAPTAIN)
RESPONSIBILITY
ü ü 2
35 AIRLINE
OPERATIONS -
INADEQUATE
SAFETY DATA
SHARING
ü ü 2
36 AIRLINE
OPERATIONS -
IMPROPER
MAINTENANCE OF
CRITICAL SYSTEMS
ü 1
Page 47
Appendix D
CFIT Intervention Effectiveness and Feasibility Ratings
# Intervention Number of
accidents
in which
highly
effective
Overall
Effectiveness
U.S.
Feasibility
Issues
1 Airlines/operators should
implement an Airline Safety
Incident Reporting System
(e.g., BASIS, ASAP).
0 0.99 3 Process
2 Airlines/operators and
regulatory agencies should
strictly enforce the regulations
pertaining to alcohol
use/substance abuse.
1 0.33 3
3 Ensure that failure of the
aircraft system to capture
glideslope (or VNAV) is
adequately annunciated to the
flight crew.
2 0.70 2 Cost
4 Ensure FMS depiction is
consistent with approach plate
presentation.
0 0.48 2 Cost
Process
5 Regulatory agencies should
mandate that approach plates
show color contours for
terrain.
0 1.20 3
6 Regulatory agencies should
establish standardized
approach plate
depiction/information
requirements for approach
plate publishers.
1 0.93 3
7 Airlines/operators should
ensure that their
training/standardization
programs emphasize review of
approach and missed
approach procedures.
0 1.90 3
8 The aviation industry should
establish world-wide
standards for the presentation
format of instrument approach
procedures.
1 1.20 2 Process
Page 48
# Intervention Number of
accidents
in which
highly
effective
Overall
Effectiveness
U.S.
Feasibility
Issues
10 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).
0 1.00 2.5 Process
11 Air Traffic service providers
should implement procedures
that ensure that ATC trainees
are always supervised.
0 0.19 3
12 Air Traffic service providers
should emphasize in ATC
training the controllers'
potential in assisting the flight
crew in improving their
situation awareness.
0 1.19 3
13 Air Traffic service providers
should enhance ATC training
to emphasize the dangers of
rushed approaches and
performance characteristics of
modern jet transports.
1 0.86 2.5 Process
14 Install aural warning devices
on aircraft to alert flightcrew of
arrival at MDA/DH.
0 0.73 1.5 Cost
15 Airlines/operators should
ensure that their
training/standardization
programs instruct when to
disengage automated systems
and fly manually.
0 0.69 3
16 Manufacturers should ensure
that automated systems
provide the flight crew with
sufficient information
(automation feedback) to
prevent mode confusion.
0 0.61 1.5 Process
Cost
Technology
17 Airlines/operators should
ensure that their
training/standardization
programs emphasize the
importance of all flight related
briefings.
1 1.64 3
Page 49
# Intervention Number of
accidents
in which
highly
effective
Overall
Effectiveness
U.S.
Feasibility
Issues
19 Airlines/operators should
implement a procedure to
climb to a minimum safe
altitude when position
uncertainty exists by at least
one crew member. Flight
crew must advise ATC of
intentions.
3 1.89 2.5 Process
20 Airlines/operators should
ensure that command
oversight training for captains
is provided during the upgrade
process and in recurrent
training.
0 1.18 3
21 Establish/enhance quality
assurance checks/training to
ensure that timely and
accurate communication
between controllers and flight
crews is occurring.
0 1.32 2 Process
22 Airlines/operators should
encourage a culture that
emphasizes safe arrivals over
timely arrivals.
0 1.06 3
23 Airlines/operators should
ensure that regularly
scheduled recurrent training
(e.g., LOFT) emphasizes crew
cooperation and working
together to maximize safe
operations.
0 1.50 3
24 Airlines/operators should
implement procedures to
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