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autopilot, autothrottle, flight management system, and fly-by-wire flight control
systems);
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· Position awareness with respect to the intended flight path and proximity to terrain,
obstacles, or traffic; and
· Potential causes, flightcrew detection, and recovery from hazardous pitch or bank
angle upsets while under autopilot control (e.g., wake vortex, subtle autopilot failures,
engine failure in cruise, atmospheric turbulence).
Situation Awareness-5 The FAA should encourage the exploration, development, and
testing of new ideas and approaches for providing effective feedback to the flightcrew to
support error detection and improved situation awareness.
Haase, D., ALPA Ground Proximity Warning System Survey, November 2, 1992.
This survey was a compilation of several CFIT and GPWS papers, NTSB accident
recommendations, ALPA questionnaire summaries and the ICAO ANC Task No. OPS-
9103: Review of the Provision On Ground Proximity Warning Systems in Annex 6, Parts
I and II (Haase’s attachment 6).
In the ICAO review, 206 CFIT accidents were tabulated. The report states:
“The GPWS was known to have provided a warning in 43 of the 206 accidents.
However, information available shows that in 3 of these cases, there was
insufficient time to react, in 17 the warning was disregarded or canceled, in 16 the
response was either too little or too late.”1
The review indicates that “CFIT accidents result from any of a number of factors,
including:
· non-observance of minimum safe altitude;
· characteristics of the flight director system;
· characteristics of the autopilot;
· navigation error;
· misinterpretation of approach procedures;
· misunderstanding or misinterpretation of ATC instructions;
· ATC vectoring error;
· non-compliance with approach procedures;
· non-compliance with departure procedures;
· attempt at visual flight in non-visual conditions;
· altimeter setting error;
· temperature or pressure widely different from the standard atmosphere;
· increasing and unchecked or unappreciated bank angle;
· lack of flight crew cross-checking.”2
Further, the ICAO paper goes on to say: “The ability of the GPWS to affect the outcome
of a potential accident may itself be compromised by any of the following:
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· piecemeal introduction of GPWS without proper awareness of its use, characteristics
and benefits;
· no operator policy on the use of the GPWS;
· inadequate training of flight crew;
· GPWS provided but totally disabled;
· GPWS provided but partially disabled;
· GPWS disabled by the flight crew prior to approach;
· warning canceled or disregarded by the flight crew;
· too many false warning in the flight crew’s previous experience;
· too many unwanted warnings in the flight crew’s previous experience;
· warning too late;
· flight crew response too late and/or too little to a warning.”3
A spreadsheet was developed to tabulate the ICAO report factors against the JAST CFIT
problem statements. The ICAO review validates the recommendations for TAWSEGPWS
installation, for flightcrew training, for airline/operator policies to be
implemented, standardized and monitored, and for instrument approach/departure
procedures to be improved. In total, the ICAO review identified 13 factors that are
contained in the JSAT analysis.
It is worth noting that the ICAO review was international in scope.
ICAO, Safety Study, Human Factors Issues in Controlled Flight into Terrain (CFIT)
Accidents, 1984-1994 (draft), September, 1994.
The referenced report dealt with human factors and organizational issues. The report
cites a dual pathway to a CFIT event:
“The analysis thus discloses a dual pathway leading to CFIT accidents: an ‘active’
pathway, generated by actions or inactions of front-line operational personnel
(i.e., pilots, controllers, mechanics, and so forth) ; and a ‘latent’ pathway,
generated by deficiencies in various aspects of the aviation system, for which
managers and decision-makers are responsible.”4
Twenty-four accidents were reviewed in the subject report. The analysis classifies the
deficiencies as Organizational Process (27.8%), Active Failures (12.2%), Latent Failures
(19.6%), Local Working Conditions (20.9%) and Defensces (19.6). Each of these
categories includes sub-level classifications. Of the 36 standard problem statements
identified in the JSAT analysis, the ICAO HF report showed strong agreement in 26 areas
　
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