Killers in Aviation: FSF Task Force Presents Facts About Approach-And-Landing and Controlled-Flight-Into-Terrain Accidents
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FLIGHT SAFETY FOUNDATION NOVEMBER–DECEMBER 1998 JANUARY–FEBRUARY 1999 FLIGHT SAFETY DIGEST Killers in Aviation: FSF Task Force Presents Facts About Approach-and-landing and Controlled-flight-into-terrain Accidents Special FSF Report FLIGHT SAFETY FOUNDATION For Everyone Concerned Flight Safety Digest With the Safety of Flight Vol. 17 No. 11–12 November–December 1998 Officers and Staff Vol. 18 No. 1–2 January–February 1999 Stuart Matthews US$80.00 (members) US$120.00 (nonmembers) Chairman, President and CEO Board of Governors James S. Waugh Jr. Treasurer In This Issue Carl Vogt General Counsel and Secretary Killers in Aviation: FSF Task Force Presents Board of Governors Facts about Approach-and-landing and 1 ADMINISTRATIVE Controlled-flight-into-terrain Accidents Nancy Richards This special report includes the most recent versions of working- Executive Secretary group reports from the FSF Approach-and-landing Accident Ellen Plaugher Reduction (ALAR) Task Force, as well as previously published Executive Support–Corporate Services reports that also include data about controlled -flight-into-terrain (CFIT) accidents. These combined reports present a unique and FINANCIAL comprehensive review of ALAs and CFIT. Elizabeth Kirby Controller 1997 Fatal-accident Rates among Aircraft in TECHNICAL Scheduled Services Increased, but 257 Robert H. Vandel Director of Technical Projects Passenger-fatality Rate Decreased Jim Burin The International Civil Aviation Organization said that the 1997 Deputy Director of Technical Projects passenger-fatality rate for turbojet aircraft was substantially Robert H. Gould lower than the passenger-fatality rates for propeller-driven Managing Director of Aviation Safety Audits aircraft. and Internal Evaluation Programs Robert Feeler Standards for Engineered-materials Manager of Aviation Safety Audits Arresting Systems Aim to Provide 260 Robert Dodd, Ph.D. Runway-overrun Safety Area Manager, Data Systems and Analysis MEMBERSHIP U.S. Federal Aviation Administration addresses planning, design, and installation of safety measure. Joan Perrin Director of Marketing and Development Ann Hill Ignition-switch Malfunction Causes Membership Services Manager DC-9 Cockpit Fire 263 Ahlam Wahdan Assistant to the Director of Marketing Flight Safety Foundation Boards, and Development Committees and Members 267 David A. Grzelecki Librarian, Jerry Lederer Aviation Safety Library PUBLICATIONS Roger Rozelle Cover: Wreckage of Korean Airlines Flight 801, a Boeing 747-300, lies near Director of Publications the top of Nimitz Hill, three miles from Guam International Airport in Agana, Mark Lacagnina Guam, on Aug.6, 1997. The flight crew was conducting a localizer approach Senior Editor to Runway 6L in instrument meteorological conditions when the aircraft, in a wings-level and slightly nose-high attitude, struck terrain and trees, and came Wayne Rosenkrans to rest 2,100 feet (641 meters) from the initial impact point. Twenty-nine of the Senior Editor 254 people aboard the aircraft survived the accident. John D. Green Copyeditor Photo: U.S. National Transportation Safety Board Rick Darby Editorial Consultant Flight Safety Foundation (FSF) is an international membership organization Karen K. Ehrlich dedicated to the continuous improvement of flight safety. Nonprofit and Production Coordinator independent, FSF was launched in 1945 in response to the aviation industry’s Ann L. Mullikin need for a neutral clearinghouse to disseminate objective safety information, Production Designer and for a credible and knowledgeable body that would identify threats to Susan D. Reed safety, analyze the problems and recommend practical solutions to them. Production Specialist Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides leadership Jerome Lederer to more than 700 member organizations in 76 countries. President Emeritus Contents Preface ................................................................................................................................................................................. iii FSF Approach-and-landing Accident Reduction Task Force Members ............................................................................. iv Flight Safety Foundation Approach-and-landing Accident Reduction Task Force Final Reports Data Acquisition and Analysis Working Group Final Report Ratan Khatwa, Ph.D, Rockwell Collins and Robert L. Hemreich, Ph.D., The University of Texas at Austin..... 1 Operations and Training Working Group Final Report Capt. Dick McKinney, American Airlines (retired), U.S. Air Force (retired) .................................................... 78 Aircraft Equipment Working Group Final Report Jean-Pierre Daniel, Airbus Industrie ................................................................................................................. 93 Air Traffic Control Training and Procedures/Airport Facilities Working Group Final Report Robert Vandel, Flight Safety Foundation.......................................................................................................... 112 A Study of Fatal Approach-and-landing Accidents Worldwide, 1980–1996 Ronald Ashford, Aviation and Safety Consultant, Accident Analysis Group, U.K. Civil Aviation Authority .......... 122 An Analysis of Controlled-flight-into-terrain Accidents of Commercial Operators, 1988 through 1994 R. Khatwa and A.L.C. Roelen, National Aerospace Laboratory (NLR)–Netherlands ............................................. 163 Airport Safety: A Study of Accidents and Available Approach-and-landing Aids John H. Enders, Enders Associates; Robert Dodd and Rick Tarrel, Records Management Systems; Ratan Khatwa, A.L.C. Roelen and Arun K. Karwal, National Aerospace Laboratory (NLR)–Netherlands ........... 213 International Air Carrier Establishes Guidelines for Preventing CFIT Accidents British Airways Flight Crew Information Bulletin No. 42 ....................................................................................... 249 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • NOVEMBER 1998–FEBRUARY 1999 i ii FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • NOVEMBER 1998–FEBRUARY 1999 Preface This special issue of Flight Safety Digest (FSD) presents several unique reports about approach-and-landing accidents (ALAs) and controlled-flight-into-terrain (CFIT) accidents — the primary causes of fatalities in aviation. The reports, some new and some previously published by the Foundation, combine to present a powerful image of two killers that remain at large in the international aviation community, despite their worldwide recognition. Flight Safety Foundation (FSF) has targeted these two causes of accidents, as well as accidents caused by airplane upset and human factors, as the foremost challenges in commercial aviation safety. The Foundation is not alone in its recognition of these accident causes, or in its efforts to gather and disseminate information to help prevent them. The International Air Transport Association (IATA) and the International Civil Aviation Organization (ICAO) are but two among many organizations and other FSF members that have worked earnestly with the Foundation in supporting two FSF-led international task forces that have focused, respectively, on the reduction and prevention of CFIT and ALAs. Moreover, the difficult and time-consuming work of these task forces has involved a wide variety of volunteers who not only have presented factual data to further substantiate the seriousness of the issues, but have also recommended actions that could prevent accidents. (See “International Air Carrier Establishes Guidelines for Preventing CFIT Accidents” beginning on page 249 of this issue.) The FSF Approach-and-landing Accident Reduction (ALAR) Task Force, created in 1996 as another phase of CFIT accident reduction launched in the early 1990s, presented its final working-group reports in November 1998; the reports were highlighted at the joint meeting of the FSF 51st International Air Safety Seminar, International Federation of Airworthiness 25th International Conference and IATA, at Cape Town, South Africa. Further refined since that meeting, the reports are reprinted in this FSD and provide compelling data. None of this extraordinary work by the FSF ALAR Task Force could have been produced without the unselfish efforts of volunteers (listed on the following pages) and the support of their respective organizations, and we — all of us in the aviation community — owe them a heartfelt “Thank you!” Together, we are making a safe transportation system even safer. Stuart Matthews Chairman, President and CEO Flight Safety Foundation January 1999 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • NOVEMBER 1998–FEBRUARY 1999 iii FSF Approach-and-landing Accident Reduction Task Force Members The success of this international effort was made possible by the volunteers who comprised the following working groups: Operations and Training Working Group Jim Anderson Delta Air Lines Capt. Pat Andrews Global Aircraft Services, Mobil Corp. Capt. Dayo Awobokun Mobil Producing, Nigeria Capt. Jaime Bahamon Avianca Don Bateman AllliedSignal Jim Bender Boeing Commercial Airplanes Group Ben Berman U.S. National Transportation Safety Board Philippe Burcier Airbus Industrie Ron Coleman Transport Canada and Canadian Air Force Kevin Comstock Air Line Pilots Association, International Suzanna Darcy Boeing Commercial Airplanes Group David Downey U.S. Federal Aviation Administration