CFIT Accident Review

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Ernest Richard
5 years ago
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1 PPL/IR Europe AGM CFIT Accident Review Coventry, 9 April 2011 Note: These slides were used as aids in a presentation and the content is not necessarily complete without the accompanying commentary. Published reports are not available for 2 of the accidents; the author has used informal internet sources which may be partially or wholly inaccurate.

2 Recent CFIT accidents Seneca, 2007, Enroute French Mountains Jet Prop, 2008, Approach Austria Piper Tomahawk, 2010, Enroute Welsh hills Cessna, 2011, Enroute Yorkshire Dales PA %20Tomahawk,%20G-TOMS% pdf 2

3 Common themes These accidents were not just the result of various holes in the cheese lining up They involved (with hindsight) high-risk scenarios in which all three of the factors below were present How? Why? Marginal or Partial (really, ) Ad-hoc, off-route, low-level IFR Terrain 3

4 A stating the obvious chart... VFR IFR 4

5 I don t believe that pilots intentionally do either of these things I shall continue VFR into VFR IFR I am in but I shall now descend below MSA 5

6 The / transition is not always obvious - night blackout, day whiteout - precipitation -layers of cloud - partial ground reference Whiteout between layers? Night, ground ahead obscured by fog, other ground features visible Snow showers 6

airport in? change Asked for IFR clearance shortly before impact.

7 Partial IFR can also give false comfort Incorrect position fix gave comfort descending into black area VFR IFR Made-up own approach to VFR airport in? change Asked for IFR clearance shortly before impact. Unaware that small Direct To track had placed aircraft onto flight path with 7000 terrain 7

8 Common theme?...pilots who think their flight is drifting in this direction... VFR IFR Conditions are marginal, or deteriorating but not quite really Flight is IFR enough, navigation gives comfort that it s OK to be in these marginal conditions 8

9 ...when, in reality, this is happening VFR IFR Conditions are not marginal or partial, they are whenever visual terrain clearance is not obvious and assured Flight is not IFR enough for such conditions, especially given navigation error risk. If it isn t 100% compliant IFR, it is VFR into 9

10 ...but I would never do this Air New Zealand Flight 901, Antarctic: DC10 crew of 3 highly regarded professionals Blue skies either side and sea visible below, but sector whiteout ahead meant Mt Erebus not perceived Mistook Lewis Bay (in front of 12,000 Mt Erebus) for McMurdo Sound (no terrain inland) 10

11 Lesson 1: In the scenario below, the holes are already lined up: you are one navigation or altimetry error away from CFIT Marginal or Partial (really, ) Ad-hoc, off-route, low-level IFR Terrain 11

12 Lesson 2: avoid the boundary, be aware how easy it is to misjudge inflight and drift across into the red box VFR Turn back and maintain real... IFR...or establish full IFR and then continue into But don t cut the corner 12

13 Lesson 3: Get Terrain Awareness Ideally TAWS-B......or a portable unit: 500 buys much more capability than airline GPWS in the 90s Only works if your immediate reaction to an alert is to initiate a full power Vx climb (maintain the scan!) and a course change if appropriate Alerts provide only a relatively small buffer, no time to work out why an unexpected alert has happened Doesn t work on a made up approach or IFR below MSA Be aware that our brains under stress can filter out even the most obvious alerts 13

OPERATIONS MANUAL PART A

OPERATIONS MANUAL PART A PAGE: 1 Table of Content A.GENERAL /CHAPTER 7 -....3 7.... 3 7.1 Minimum Flight Altitudes /Flight Levels VFR Flight... 3 7.2 Minimum Flight Altitudes /Flight Levels IFR Flight... 4 7.2.1 IFR flights non