Controlled Flight Into Terrain
Another insightful post from Helena1320
Whenever an
airworthy aircraft, with all mechanical, electrical, hydraulic, electronic,
flight control and automation systems operating normally, wings level, or in a
coordinated controlled bank and all crew members at their stations, but is at
an altitude where the aircraft encounters ground level, it is called controlled
flight into terrain. If all systems are operating normally and within set
parameters, there is no possible opportunity for an airplane to crash. Any unscheduled
event that leads to an airplane crash is the result of one or more system
failures.
Controlled
Flight Into Terrain (CFIT) exists only in a virtual world of perfectionism.
CFIT definition of airplane accidents is removing a system from total flight
operational systems required to complete the flight, which is the Human
Performance System.
As early as
the late 50’s Human Performance System analysis were in a beginning stage and
included in behavioral studies. Over the years since then, human behavior, or
human factors developed into a science of management of the Human Performance
System. This system does not only include the last link of events, but is
viewed in a Safety Management System as organizational accountability of zero
tolerance to compromise aviation safety. During the early days of aviation,
human behavior, or Human Performance System, were often assigned to be the
cause of accidents and defined as pilot error. Pilot error is not a system
failure, but a procedure failure during a specific and last segment of the
flight just prior to the crash. As data of accidents and unscheduled events
were collected and analyzed over years, the industry realized that human job
performance factors are manageable factors of a functional Human Performance
System. By the 1990’s human factors in flight was widely accepted as system
factors of a safe flight.
On November
28, 1979 a passenger jet crashed into a mountain and the cause was identified
as Controlled Flight Into Terrain, since all known technical systems were
operating normally. At some point during the flight an unplanned event happened
and the airplane crashed.
On July 19, 1989 there was a system failure in a passenger
jet, which again caused a complete flight control system malfunction. Pilots,
or automation were unable to produce yaw, roll and pitch control for a safe
flight. During the flight an unplanned event disabled required systems for a
safe flight, except for the Human Performance System. Pilots and flight crew
were in essence the only viable operational system available to continue the
flight.
These two flights produced the end
result of an airplane crash. The first one was identified as pilot error, or
CFIT,
while the
second as a technical system failure. Both accidents have one common
denominator, which is the Human Performance System. In one accident there was a
system breakdown, while with the second accident human performance raised to
the challenge in management of technical system failures and went above and
beyond expected job performance. Human Performance System is as much as a
requirement for a safe flight as operational technical systems. However, when
Controlled Flight Into Terrain becomes the cause of accidents, Human
Performance Systems are ignored as a requirement system for the completion of a
safe flight.
Helena1320
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