Controlled Flight Into Terrain

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

Situational Awareness Are Emotions And Decisions

Situational Awareness Are Emotions And Decisions

Another insightful post from Helena1320

After severe accidents involving major air carriers, new technology and automation were developed and implemented into aircraft systems to make flying safer for the public. All these safety improvements to safety came at the ultimate price, but were justified for future safety improvement and for accidents never to happen again.

Over years there have been midair collisions, controlled flights into terrain and airplanes on approach to occupied runways. Loss of situational awareness was assigned as root causes for several of these accidents. With loss of situational awareness as the determining point of failure, the solutions became to help pilots to always know where they were by installing more automated systems. Without a clear definition and collected data about loss of situational awareness, the cause of accident was assigned to pilot error as the last link in the chain of events leading up to these catastrophic accidents.  

Situational awareness is more than just knowing where you are at point in space over the surface of the earth. Situational awareness is to understand where in the process the automated system is, it is to understand what is coming next in the process, it is to understand the effect of flight control inputs, including long-term effect, it is to understand power plants, it is to understand human factors, it is to understand the environment, 

it is to understand topography, it is to understand law of physics, it is to understand aircraft systems, it is to understand navigation aid inputs, it is to understand display outputs, including visual navigation, it is to understand positions as to point in space, it is to understand air traffic controller communication and intent, it is to understand outside visual clues, it is to understand airport environment and it is to overlay all these situational awareness clues in correct order onto visual cockpit displays and instrument communication, with a mental picture of what effect it will have on continuing the flight. In addition, when in visual meteorological conditions, or on a visual approach, situational awareness is to transfer this virtual information onto the visual view ahead.

When there is an overload of information driving a vehicle, the driver can stop, rest, review and catch up. When there is an overload in an airplane the pilots are behind the airplane and the task becomes to move out of being behind by having situational awareness of what is current relevant information and then discharge all irrelevant information and clues.

The only available option to discharge all information and start over again is to initiate an overshoot, climb to an obstacle free altitude and level off. At that point, when the pilot has regained control of situational awareness, the pilot may request further clearances to proceed to destination. When data from loss of situational awareness reports are analyzed with defined root cause, then there are data and tools available to make changes to reduce, or eliminate loss of situational awareness in flight. 

Situational awareness can be trained for and learned within a just culture of a safety management system where there is organizational accountability to incidents. When pilots are experiencing momentarily loss of situational awareness, it may not be reported due to fear of job performance punishment. Without incident reports there are no information available to justify that loss of situational ever occurred and therefore initiate awareness training, or operational corrective actions. Since it is not reported, loss of situational awareness is not analyzed as a regular occurrence but as an extremely remote operational risk and possibility.

Training for situational awareness is more than learning what situational awareness is. It is to understand the emotions of loss of control when a pilot is behind the airplane, how to overcome these emotions, to make interpretations and decisions, do a quality assurance check of interpretations and to discard all non-required information. When it is determined that continuing the flight could cause harm, or that the short term outcome of continuing the flight is unknown, then the pilot must go to ground zero and start over again from that point.

Training for situational awareness can be summarized as training to recognize emotions, training for analyzing data under stress, training of an ongoing operational quality assurance test, decision making training and training to implement corrective action. Restoring situational awareness training is not only for the pilot to be situational awareness confident, but also for co-pilot and all other flight crew members.

Confirmation of situational awareness is the most critical step of training. In the process of navigation, a human mind has a tendency to manipulate the facts to match wishes and assumption. This is learned early on in flight training with the cross country training exercises.

A brand new student pilot navigating an aircraft for the first time with visual reference to the ground, following roads, rivers, lakes, towns, or dead reckoning by time and estimated distance, learns quickly that assumptions of situational awareness are not always facts. A lake on the ground may look identical to the lake on the map if the map is rotated, a valley in the mountains appears to be the valley to fly if the compass had been set correctly and the duration flown must be right because the timing that was off.  In hindsight, all these clues of not being on flight planned path make sense. However, at the time of emotional inputs, distress and refusal of accepting to be lost, all incorrect information seems right. In their own mind, the pilots had situational awareness at the time just prior to the accidents. There are many examples of loss of situational awareness, but one that stands out in history is Flight 571 in 1972.

In an organization operating within a just culture and with an operational non-punitive incident reporting policy, there is a much greater chance that incidents are reported. These incidents then become available as a tool to analyze, track, categorize and address in training and operational management. In aviation, the hazard that is not known eventually becomes the unknown risk that will cause harm.

Loss of situational awareness is when information of collected data is rejected and overpowered by emotional decisions. Automation and human factors are integrated functional areas adding to safer operations of flights. However, when automation become the default fail-safe recovery system, then human errors are transferred from pilots into the hands of automation analysts and software programmers. The most valuable resource available for recovery from errors and malfunctions, is human resilience and for pilots to collect data, analyze, take actions, bounce back and start over again.

Helena1320