In primary, instrument, and commercial flight training, a student pilot is inundated with information and warnings on the great and varied dangers of aviation. In spite of all of this information, if one were to spend a few days loitering around a municipal or other small airport, there is no doubt they would hear the famous line, “The most dangerous part of any flight is the drive to the airport.” While this statement is undeniably true of air carrier operations, exact metrics for highway deaths per mile versus deaths per miles flown in general aviation, hereafter abbreviated as GA, are hard to find; the statistics available are approximate at best. However, it does seem that in respect to GA, flying is not generally safer than driving. The problem lies in translating airplane hours to miles or highway miles to hours. In any case, a well-informed pilot knows the dangers inherent in flying. It is the responsibility of individuals to keep themselves informed and the responsibility of the administrative and observational organizations to provide information on accidents and viable safety solutions. One of the leading causes of aviation fatalities that pilots must be aware of and trained to avoid is controlled flight into terrain.
While the term “controlled flight into terrain” seems self-explanatory, several definitions can be found for the phenomenon. One paper published by the Federal Aviation Administration defines CFIT this way, “CFIT occurs when an airworthy aircraft, under the control of a pilot, is flown into terrain (water or obstacles) with inadequate awareness on the part of the pilot of the impending disaster (FAA, 2000).” The same paper states the CFIT accidents account for 10% of all GA accidents (Shappell & Wiegmann). According to an NTSB presentation based on data from a five-year period, controlled flight into terrain accounted for 9.4% of fatal accidents in personal flying, 20.9% in business flying, and 7.4% in instructional flying. Metrics published by Boeing in accordance with the Commercial Aviation Safety Team and International Civil Aviation Organization state that from 2003 through 2012 the worldwide commercial jet fleet experienced 17 CFIT accidents resulting in 972 deaths with one attributed to a person on the ground (NTSB 2015). It is important to note that the leading cause of fatal accidents is loss of aircraft control, which outweighs all other causes greatly; CFIT is the second or third leading cause in all of the aforementioned categories. The most valuable information pertaining to CFIT accidents is much harder to quantify. What pilots, the administrator, businesses, and aviation organizations want to know is why CFIT accidents occur.
How does a pilot let this happen? In most cases, they don’t. By definition CFIT accidents only involve aircraft that are airworthy, they can simply gain altitude if they are in danger of hitting the ground. Therefore it goes without saying that when CFIT accidents happen, the pilot is either unaware of the danger entirely, or it is too late to prevent a crash when they realize it is imminent. CFIT can occur for a multitude or reasons, most which fall under the umbrella of loss of situational awareness defined as the ability to identify, process, and comprehend the critical elements of information about what is happening. Proper situational awareness includes properly preparing for a flight by gaining familiarity with an aircraft, all areas in which the flight will be conducted, weather reports and forecasts, departure procedures, arrival procedures, airport facilities and so on. Most CFIT accidents and aviation accidents in general are a result of deteriorated situational awareness.
The CFIT incidents that have been studied the most and on which the most information is available to the public are those involving airlines. Although airline crashes are investigated much more than GA incidents, there are data on both that this paper will examine. An incident that occurred in 1972 involving an L-1011-385-1 TriStar resulted in the deaths of 101 people. Two hours and twenty-two minutes after takeoff, the aircraft flew into the ground in the Florida everglades region, 18.7 miles from the end of the runway at their destination. The crash was a result of the entire flight crew allowing themselves to become preoccupied by a possible landing gear issue. After a gear-down indicator light burned out, the aircraft entered a hold to assess the problem. As the captain turned to send the flight engineer to the avionics compartment he inadvertently disarmed the altitude hold function of the autopilot. As the aircraft began to descend, a “leaving altitude” warning chime sounded at the flight engineer station, but the flight engineer was below deck to find out if the nose gear of the airplane was down or up and it is thought that the rest of the crew did not hear the warning. The NTSB report states that the cause of the crash is “The failure of the crew to monitor the flight instruments during the final four minutes of the flight,” (NTSB 1973). Something as small as an indicator bulb downed an airliner because the entire flight crew allowed it to tear a gaping hole in their situational awareness.
In this incident, the pilot and crew were absolutely at fault, however it is also notable that Miami ATC had the plane on radar and failed to properly inquire as what was going on with the aircraft. At the time Eastern Airlines Flight 401 was the second deadliest air disaster in U.S. History. The positive aspect of this disaster is that it led to sufficient research and new regulations to improve aviation safety.
Another accident where improper situational awareness led to a perfectly airworthy machine was flown into the earth is the famous New Hampshire Learjet 35A crash in 1996. In this event, an experience pilot and first officer flew an airplane into a mountain because they totally did not know where they were. It is apparent from the NTSB incident report that the crew, both of whom were ATP rated pilots, became disoriented in instrument meteorological conditions. The aircraft shot several approaches into the Lebanon airport and each time was unable to receive navaid signals appropriately. The aircraft did not make a single correct position report from the time it first switched to Lebanon tower communication frequency until it crashed. The pilot failed to recognize that he did not know where he was, instead assuming that the ground based navigational equipment was faulty for more than one approach at a single airport. The most alarming aspect of this flight is that the flight crew performed multiple missed approach procedure incorrectly and without ever really being on the approach.
This crash led to the longest aircraft search and rescue operation in New Hampshire state history. The plane was eventually found three years later in November of 1999. This crash also highlights ATC failure to properly locate an aircraft on radar, and led to legislation improving aviation safety. This crash specifically and directly led to the mandatory installation of emergency locator transmitters in aircraft available for charter.
Examples of CFIT accidents and loss of situational awareness are abundant; the final example that all pilots are familiar with and taught in school is the infamous JFK Jr. crash. There are a multitude of reasons that John Kennedy’s piper Saratoga crashed in 1999, but they all add up to a loss of situational awareness and a perfectly good plane being crashed. JFR Jr. got himself into instrument conditions that he was not certified to be in, but had he properly brought into his awareness all adverse conditions and recognized the poor decision chain he may not have embarked on his doomed flight.
Controlled flight into terrain is a hazard that must be assessed on all flights, often as planes get bigger, routes, longer and flights more routine; pilots become complacent. In these situations a pilot is personally responsible for less of the preflight action taken to ensure a safe trip. An action as simple as double-checking minimum safe altitudes for each quadrant a flight will cover on a sectional chart can save lives. It seems absurd that a perfectly good airplane would hit the ground with the levels of oversight involved in the modern aviation industry, and indeed CFIT accidents are declining. Today, airline standard operating procedures and FAA regulations are keep pilots and passengers safer than ever. The greatest advancement in CFIT prevention has been crew resource management training. The huge amount of emphasis placed on CRM training by both the airlines and the administrator has really made a difference. As radar technology get more precise CFIT should only become increasingly less common, though it may be impossible to totally eliminate as long as human factors are involved in flying.
A pilot’s greatest asset in CFIT risk mitigation is proper training. The constant emphasis on CRM can be annoying to a young pilot, exited to experience new challengers at the controls of different types of aircraft, but it is imperative. In this writer’s opinion, the single most important piece of CRM and flight safety training is humility. Pilots are notorious for having inflated egos. The FAA and flight schools teach about hazardous flight attitudes, most of which involve a pilot failing to see or admit that they could be wrong. One great example of pilot humility saving lives is in the famous Sioux City DC-10 crash, where the pilot invited an off duty United Airlines flight instructor to take his post, knowing that the man could do a better job. That crash result in over a one hundred deaths, but it had almost two hundred survivors.
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