flight safety digest november 1998-february 1999

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  • FLIGHT SAFETY

    F L I G H T S A F E T Y F O U N D A T I O N

    NOVEMBERDECEMBER 1998JANUARYFEBRUARY 1999

    D I G E S T

    Killers in Aviation:FSF Task Force Presents Facts

    About Approach-and-landing andControlled-flight-into-terrain Accidents

    Spec

    ial F

    SF R

    epor

    t

  • Flight Safety DigestVol. 17 No. 1112 NovemberDecember 1998Vol. 18 No. 12 JanuaryFebruary 1999

    US$80.00 (members) US$120.00 (nonmembers)

    FLIGHT SAFETY FOUNDATIONFor Everyone ConcernedWith the Safety of Flight

    Officers and StaffStuart Matthews

    Chairman, President and CEOBoard of Governors

    James S. Waugh Jr.Treasurer

    Carl VogtGeneral Counsel and Secretary

    Board of Governors

    ADMINISTRATIVE

    Nancy RichardsExecutive Secretary

    Ellen PlaugherExecutive SupportCorporate Services

    FINANCIAL

    Elizabeth KirbyController

    TECHNICAL

    Robert H. VandelDirector of Technical Projects

    Jim BurinDeputy Director of Technical Projects

    Robert H. GouldManaging Director of Aviation Safety Audits

    and Internal Evaluation Programs

    Robert FeelerManager of Aviation Safety Audits

    Robert Dodd, Ph.D.Manager, Data Systems and Analysis

    MEMBERSHIP

    Joan PerrinDirector of Marketing and Development

    Ann HillMembership Services Manager

    Ahlam WahdanAssistant to the Director of Marketing

    and Development

    David A. GrzeleckiLibrarian, Jerry Lederer Aviation Safety Library

    PUBLICATIONS

    Roger RozelleDirector of Publications

    Mark LacagninaSenior Editor

    Wayne RosenkransSenior Editor

    John D. GreenCopyeditor

    Rick DarbyEditorial Consultant

    Karen K. EhrlichProduction Coordinator

    Ann L. MullikinProduction Designer

    Susan D. ReedProduction Specialist

    Jerome LedererPresident Emeritus

    In This Issue

    Flight Safety Foundation (FSF) is an international membership organizationdedicated to the continuous improvement of flight safety. Nonprofit andindependent, FSF was launched in 1945 in response to the aviation industrysneed for a neutral clearinghouse to disseminate objective safety information,and for a credible and knowledgeable body that would identify threats tosafety, analyze the problems and recommend practical solutions to them.Since its beginning, the Foundation has acted in the public interest to producepositive influence on aviation safety. Today, the Foundation provides leadershipto more than 700 member organizations in 76 countries.

    Killers in Aviation: FSF Task Force PresentsFacts about Approach-and-landing andControlled-flight-into-terrain AccidentsThis special report includes the most recent versions of working-group reports from the FSF Approach-and-landing AccidentReduction (ALAR) Task Force, as well as previously publishedreports that also include data about controlled -flight-into-terrain(CFIT) accidents. These combined reports present a unique andcomprehensive review of ALAs and CFIT.

    1997 Fatal-accident Rates among Aircraft inScheduled Services Increased, butPassenger-fatality Rate DecreasedThe International Civil Aviation Organization said that the 1997passenger-fatality rate for turbojet aircraft was substantiallylower than the passenger-fatality rates for propeller-drivenaircraft.

    Standards for Engineered-materialsArresting Systems Aim to ProvideRunway-overrun Safety AreaU.S. Federal Aviation Administration addresses planning,design, and installation of safety measure.

    Ignition-switch Malfunction CausesDC-9 Cockpit Fire

    Flight Safety Foundation Boards,Committees and Members

    1

    257

    260

    263

    267

    Cover: Wreckage of Korean Airlines Flight 801, a Boeing 747-300, lies nearthe top of Nimitz Hill, three miles from Guam International Airport in Agana,Guam, on Aug.6, 1997. The flight crew was conducting a localizer approachto Runway 6L in instrument meteorological conditions when the aircraft, in awings-level and slightly nose-high attitude, struck terrain and trees, and cameto rest 2,100 feet (641 meters) from the initial impact point. Twenty-nine of the254 people aboard the aircraft survived the accident.

    Photo: U.S. National Transportation Safety Board

  • FLIGHT SAFETY FOUNDATION FLIGHT SAFETY DIGEST NOVEMBER 1998FEBRUARY 1999 i

    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 ReportRatan Khatwa, Ph.D, Rockwell Collins and Robert L. Hemreich, Ph.D., The University of Texas at Austin ..... 1

    Operations and Training Working Group Final ReportCapt. Dick McKinney, American Airlines (retired), U.S. Air Force (retired) .................................................... 78

    Aircraft Equipment Working Group Final ReportJean-Pierre Daniel, Airbus Industrie ................................................................................................................. 93

    Air Traffic Control Training and Procedures/Airport Facilities Working Group Final ReportRobert Vandel, Flight Safety Foundation .......................................................................................................... 112

    A Study of Fatal Approach-and-landing Accidents Worldwide, 19801996Ronald 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 1994R. Khatwa and A.L.C. Roelen, National Aerospace Laboratory (NLR)Netherlands ............................................. 163

    Airport Safety: A Study of Accidents and Available Approach-and-landing AidsJohn 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 AccidentsBritish Airways Flight Crew Information Bulletin No. 42 ....................................................................................... 249

  • i i FLIGHT SAFETY FOUNDATION FLIGHT SAFETY DIGEST NOVEMBER 1998FEBRUARY 1999

  • FLIGHT SAFETY FOUNDATION FLIGHT SAFETY DIGEST NOVEMBER 1998FEBRUARY 1999 i i i

    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 andsome previously published by the Foundation, combine to present a powerful image of two killers that remain at large in theinternational 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 andhuman 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 tohelp 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 supportingtwo 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 onlyhave presented factual data to further substantiate the seriousness of the issues, but have also recommended actions that couldprevent accidents. (See International Air Carrier Establishes Guidelines for Preventing CFIT Accidents beginning on page249 of this issue.)

    The FSF Approach-and-landing Accident Reduction (ALAR) Task Force, created in 1996 as another phase of CFIT accidentreduction launched in the early 1990s, presented its final working-group reports in November 1998; the reports were highlightedat the joint meeting of the FSF 51st International Air Safety Seminar, International Federation of Airworthiness 25th InternationalConference and IATA, at Cape Town, South Africa. Further refined since that meeting, the reports are reprinted in this FSD andprovide compelling data.

    None of this extraordinary work by the FSF ALAR Task Force could have been produced without the unselfish efforts ofvolunteers (listed on the following pages) and the support of their respective organizations, and we all of us in the aviationcommunity owe them a heartfelt Thank you!

    Together, we are making a safe transportation system even safer.

    Stuart MatthewsChairman, President and CEOFlight Safety Foundation

    January 1999

  • i v FLIGHT SAFETY FOUNDATION FLIGHT SAFETY DIGEST NOVEMBER 1998FEBRUARY 1999

    FSF Approach-and-landingAccident 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

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