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Stabilized Landings A Runway Excursion Prevention Tool

NBAA Safety Committee – 2011 Runway Excursion Prevention Project

Safety Focus Project

• Raise awareness of the issue

• Promote the FSF Runway Safety Initiative (2009)

– http://flightsafety.org/current-safety-initiatives/runway-safety-initiative-rsi

• Develop, communicate safe landing guidelines

Runway Excursion Prevention

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Introduction

• Stabilized Approach Criteria has successfully elevated the in-cockpit awareness of risky approaches

• Data reveals, though, runway accidents is still the leading cause of accidents

• This presentation investigates the threat and presents strategies to prevent runway excursions

Presenter

Presentation Notes

This presentation investigates and proposes the concept of Stabilized Landing criteria. Conceptually, stabilized landing criteria establish the performance requirements for landings from the threshold to the end of the landing roll out. The stabilized landing concept serves to reinforce the requirement for pilots to perform landings in accordance with aircraft performance certification, FAA guidelines and industry standard best practices, similarly as with the stabilized approach criteria. The purpose of this presentation is to define and present the elements of a stabilized landing. Additionally, to propose that pilots seek to achieve successful landings by combining the elements of stabilized approach and stabilized landing criteria.

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Runway Excursion

• According to the Flight Safety Foundation, a runway excursion occurs when an aircraft on a runway surface departs the end or the side of that runway surface.

• Runway excursions can occur on takeoff or landing – Veer Off – Depart the side of the runway – Overrun – Depart the end of the runway

Presenter

Presentation Notes

(FSF.ALAR Briefing Note 8.1, p.159).

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Approach and Landing Accidents, by Year

93

89 90

81 81

65

76

64

76

61

78 81

72

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Num

ber o

f acc

iden

ts

Year

1995–2007 (1,007 accidents)

Presenter

Presentation Notes

The trend line, calculated using least squares linear regression, indicates that the absolute number of approach and landing accidents gradually decreased during the study period.

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Runway Excursion Accidents

Figure 2: Proportion of Fatal and Non Fatal Accidents (FSF, 2009, RSI Report, p. 5)

Presenter

Presentation Notes

The FSF Report of the Runway Safety Initiative (RSI) published May, 2009 documented alarming evidence that from 1995-2008, runway related accidents accounted for a full 30% of all commercial transport category aircraft; furthermore, runway excursion accidents represented 97% of those accidents.

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Most Common Types of Approach and Landing Accidents

1995–2007

These comprise 77 percent of the total approach and landing accidents.

• Landing veer-off • Landing overrun • Unstabilized approach • Controlled flight into terrain (CFIT) • Collision with terrain, non-CFIT • Runway undershoot

Presenter

Presentation Notes

These were the most common types of approach and landing accidents (ALAs) found in the 2009 study. Runway excursions, comprising veer-offs and overruns, account for approximately 45 percent of all ALAs. Some accidents can be categorized as more than one type.

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FSF Data: All Approach and Landing Accidents 1995-2007

Figure 1: FSF ALAR Update - Killers in Aviation Update Pg. 5

Approach Final approach Landing Other Unknown

Flight phase

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Runway Excursion Accidents Runway Excursions 1995-2008

05

1015202530354045

1995

1997

1999

2001

2003

2005

2007

Number ofAccidents

Trend

Figure 3: Runway Excursions 1995-2008 (FSF, 2009, RSI Report, p. 6)

Presenter

Presentation Notes

Considering the last 14 years, it appears that the trend has bottomed overall;

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Runway Excursions 2004-2008

0

10

20

30

40

50

2004 2005 2006 2007 2008

Number ofAccidents

Trend

Figure 4: Runway Excursions 2004-2008 (FSF, 2009, RSI Report, p. 6)

Presenter

Presentation Notes

However, a closer look at the last 5 years, 2004-2008, reveals that the trend is climbing (FSF, 2009, RSI Report, p. 6). In 2009, the year over year results show an 18% reduction in the number of accidents; although, the overall percentage of runway excursion accidents still accounted for some 26% of all accidents, repeating the 2008 results. (IATA.ORG, Feb. 2010, Press Release No. 5).

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Runway Excursions - 1995-2008

0

100

200

300

400

500

Takeoff Landing

21% 79%

Figure 5: Runway Excursion by Type (FSF, 2009, RSI Brief)

Presenter

Presentation Notes

According to the FSF the majority (79%) of runway excursion accidents occur in the landing phase with a near balance of overruns and veer offs.

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Runway Excursion Factors

• The FSF cites the major risk factors in landing excursions were:

– go-around not conducted, – long landings, – ineffective braking (contaminated runways), – gear malfunctions, and – fast approaches and landings.

Presenter

Presentation Notes

The FSF cites the major risk factors in landing excursions were: go-around not conducted, long landings, ineffective braking (contaminated runways), gear malfunctions and fast approaches and landings. IATA has determined that un-stabilized approaches, failure to conduct a go-around, abnormal touchdowns, and contaminated runways were the major contributors to landing excursions (IATA.ORG – Fact Sheet). Clearly, the risk factors have been well documented and published by the ALAR and RERR Toolkits.

Presentation Outline Jim Burin – Director of Technical Programs

2010 – 2011 Runway Excursion Accident Review focus on three related accidents: Hawker – Owatonna Airbus – Toronto Boeing - Mangalore

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Presentation Outline Steve Charbonneau – Sr. Manager Training and Standards

Landing Certification Concepts Consider the threats to safe landings Introduce the Safe Landing Guidelines

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Landing Certification

• FAR Section 25.125 specifies the requirement to provide landing distances, defined as the horizontal distance necessary to land from a point 50 feet above a dry hard surface and come to a complete stop.

• The aircraft must be in the landing configuration, having flown a stabilized approach at a speed of not less than VREF down to the 50 foot height, amongst other requirements.

• The Flight Test Guide for the Certification of Transport Category Airplanes, Advisory Circular 25-7A, provides manufacturers with guidance to ensure compliance with the regulations.

Presenter

Presentation Notes

It states that the landing must be made without excessive vertical acceleration and the pressures on the wheel braking systems may not exceed those specified by the brake manufacturer. The landing distance data must also include correction factors for not more than 50 percent of head wind components and not less than 150 percent of the tail wind component.

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• Distances are treated in two parts:

– the airborne distance from 50 feet to touchdown, and

– the ground distance from touchdown to stop

Airborne Ground

Presenter

Presentation Notes

The guide details the test and demonstration requirements for manufacturers during certification. It is interesting to note that for landing performance, distances are treated in two parts: the airborne distance from 50 feet to touchdown, and the ground distance from touchdown to stop (AC 25-7A, Chap. 2, p. 98).

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• Airborne Distance

– 3 or 3½ degree approach path – Sink rates as much as 8 feet per second at

touchdown (480 fpm)

Presenter

Presentation Notes

The test guide allows for airborne distances to be calculated at 3 or 3½ degrees, given appropriate requirements are met, with sink rates at touchdown as much as 8 feet per second. For example, the Gulfstream G-550 aircraft has been certified with a 3½º and 8 feet per second descent giving the shortest possible airborne distance (G-550, AFM Rev 29, Chap. 5, p. 05-120).

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• Ground Distance

• Transition within 2 secs

• Based on FULL Braking

Figure 6 Landing Time Delays (AC 25-7a, p. 103)

Presenter

Presentation Notes

In the ground distance calculation, the test guide allows for the use of transition distances, which is the distance from the point of touchdown to the full braking configuration, and stopping distances; or, a combination of the two, whichever is preferred by the applicant (AC 25-7a, p. 101). In either case, it is critical to note that the ground distance is based upon the aircraft decelerating with maximum allowable brake pressure and other aerodynamic devices deployed within two seconds or less after touchdown, as the test guide permits for manufacturers to reduce the two second delay by expanding the AFM data when seeking credit for automatic deceleration devices. Figure 4 Landing Time Delays (AC 25-7a, p. 103)

“Landing distances determined

during certification are aimed at

demonstrating the shortest landing

distances… Therefore, the landing

distances determined under FAR

23.75 and 25.125 are much shorter

than the landing distances achieved

in normal operations”.

(AC 91-79, App. 1, p. 8)

Presenter

Presentation Notes

They further amplify that “The importance of adhering to the landing procedures outlined in the AFM cannot be overemphasized… The AFM assumes that the deceleration devices will be fully deployed by 2 seconds after touchdown… The maximum braking condition is assumed to be maintained until the airplane reaches a full stop (AC 91-79, 11/06/07, App. 3, p. 3)”.

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Threats to Safe Landings

According to AC 91-79: • Un-stabilized Approach • Excess Airspeed • Excess Threshold Crossing Height • Landing Long (Beyond the touchdown zone) • Adverse wind conditions • Failure to assess required landing distance

RERR provides an excellent Threat Analysis presentation

Presenter

Presentation Notes

FAA AC 91-79 identified the major risks to runway excursions. Specifically it highlighted: a non-stabilized approach, excess airspeed, landing beyond the intended touchdown point, and failure to assess the required landing distance to account for contamination or the landing environment (AC 91-79, p. 3). The advisory circular went further to provide specific risk mitigation recommendations as well as comprehensive additional information including guidance on regulatory interpretation and technique. The Runway Excursion Risk Reduction Toolkit offers an excellent presentation on Managing the Risks During Approach and Landing: How to Avoid a Runway Overrun

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Un-stabilized Approach

• There are strong associations with unstable approaches and long/hard/fast landings

• However data exists to show that landing risks exist following both stabilized and un-stabilized approaches

• Failure to Go-Around contributed to one-third of all landing excursion accidents.

• Could be avoided by a go-around as required with stabilized approach criteria

Presenter

Presentation Notes

The FSF RSI report indicated that the failure to go-around following an un-stabilized approach contributed to one-third of all landing excursion accidents. Furthermore, the resulting landing attempt contributed to long landings, fast approaches, and fast and hard touchdowns. Complicating the issue with un-stabilized approaches is the fact that they typically co-exist with other risk factors; for example, unstabilized approach was cited in 77 of 87 long/fast overrun landing events (88%), and 20 of 39 hard landing veer off events (51%).

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Un-stabilized Approach

• Why do pilots continue to attempt to salvage un-stabilized approaches?

• Four possible behaviors: – excessive confidence in a quick recovery; – excessive confidence because of runway or environmental

conditions; – inadequate preparation or lack of commitment to conduct a go-

around; or, – absence of decision because of fatigue or workload

Presenter

Presentation Notes

The question remains, why do pilots continue to attempt to salvage unstabilized approaches? The ALAR Toolkit indicated four possible behaviors: excessive confidence in a quick recovery; excessive confidence because of runway or environmental conditions; inadequate preparation or lack of commitment to conduct a go-around; or, absence of decision because of fatigue or workload (ALAR, Briefing Note 7.1, p. 136).

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Excess Airspeed

• Excess airspeed has been a cause factor in nearly 15% of landing excursion accidents

• The performance data is normally based upon Vref not Vapp at a height of 50 feet above the threshold – Corrections to Vref are meant to be bled off to arrive at

threshold on speed • Excess Speed affects either airborne or ground landing

distances – or both

Presenter

Presentation Notes

Typically, the Vref speed is used to determine an approach speed which is maintained while on final approach in the landing configuration. Normally five or ten knots is added to the Vref speed, and perhaps also corrected for strong or gusty winds, or other conditions. The approach speed; however, must be reduced to Vref to cross the threshold at the 50 foot crossing height, as the performance data is based upon that speed.

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Excess Airspeed

• Airborne Landing Distance Effects: – 230 feet per knot of increased landing flare distance

• Ground Landing Distance Effects (Dry): – 20-30 feet per knot of increased landing distance

• Ground Landing Distance Effects (Wet): – 40-50 feet per knot of increased landing distance

Presenter

Presentation Notes

AC 91-79 provides a breakdown of the increased landing distances as follows: Airborne Distance – 230 feet per knot of increased landing flare distance; or Ground distance – Dry – 20-30 feet per knot of increased landing distance; or Ground distance – Wet – 40-50 feet per knot of increased landing distance; Note: Ground distance – Contaminated – not indicated in the circular. For example, an approach with 10 knots of excess airspeed at the 50 threshold crossing height may result in a 2300 foot extended flare or a 200-300 foot increased landing roll.

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Excess Airspeed

• A 10 knot excess airspeed has the potential of extending the landing distance by – 2300 feet with an extended float/flare; or – 200-300 feet (dry) with a fly on landing in the touchdown zone

• Floating the landing has a 10X effect on landing distances

Presenter

Presentation Notes

For example, an approach with 10 knots of excess airspeed at the 50 threshold crossing height may result in a 2300 foot extended flare or a 200-300 foot increased landing roll. It is important to note that the effects of excess airspeed at the threshold are ten times greater if the pilot elects to bleed the energy off in the flare, rater than flying the airplane onto the runway and promptly transitioning to the braking configuration. If the operator had a hypothetical 3000 foot dry landing distance; then the 10 knot excess airspeed would have resulted in an actual landing distance of up to 5300 feet. Even if the operator is in the habit of factoring landing distances, or adding safety margins, this seemingly innocuous airspeed error would have greatly reduced those expected margins.

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Excess Threshold Crossing Height

• Represents a high energy situation which logically will result in an extended airborne landing distance or ground roll out

• AC 91-79 estimates that this distance is equivalent to 200 feet for each 10 feet of excess TCH

50’ TCH = 1000’

100’ TCH = 2000’

150’ TCH = 3000’

Presenter

Presentation Notes

A TCH of 100 feet would extend the landing distance by 1000 feet (AC 91-79, p. 10). Excess TCH normally leads to long landings, beyond the desired touchdown point, as the pilot seeks to maintain a continuous stabile approach angle to a revised aim point, increasing the airborne distance; or, noses over the aircraft to achieve the desired touchdown point thus increasing the airspeed and the ground roll distance.

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Landing Long The Touchdown Zone • Most airplanes are certified to touchdown

following a 3 or 3½ degrees approach slope with as much as an 8 foot per second sink rate (480 FPM), giving

• Touchdown points approximately 1000 feet from the threshold

• Painted Runway Marking aim points are depicted at approximately 1000 feet from the threshold, which corresponds to most type certifications

• Touchdown Zones – 1000-1500 from threshold – allows for cushioned landings

Presenter

Presentation Notes

While excess airspeed and high TCH may contribute to landing beyond the touchdown point, other potential contributors are negative runway slope, shallow approach, tailwind conditions and landing technique.

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Landing Long

• Shallow approaches will also increase the airborne distance, as will a negative slope on the runway; approximately adding a 10% penalty to landing distances

• Pilots should seek to accomplish firm landings in the landing zone; which is defined as the first third, or 3000 feet of the runway whichever is less.

Presenter

Presentation Notes

While excess airspeed and high TCH may contribute to landing beyond the touchdown point, other potential contributors are negative runway slope, shallow approach, tailwind conditions and landing technique. While most airplanes are certified to touchdown following a 3 or 3½ degrees approach slope with as much as an 8 foot per second sink rate, it is rare that pilots will operationally use this same technique. As AFM landing distance calculations are based upon this technique, pilots must make efforts to achieve touchdowns close to the intended touchdown point; otherwise, landing distances will not be accurate.

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Adverse wind conditions Tailwinds on Landing

• Most aircraft are certified with 10 or 15 knots maximum tailwind

• Tailwind conditions serve to increase the groundspeed which extends the airborne distance during the flare

• Any tailwind on contaminated runways is not encouraged due to the inherent hazards

Presenter

Presentation Notes

Tailwind conditions can also complicate landings when they co-exist with other risk factors, such as contaminated runway conditions. Indeed, manufacturers will often have specific limitations prohibiting tailwind conditions when contaminated runway conditions are present. Gulfstream specifically cautions operators, “Operations with any tailwind on contaminated runways is not encouraged due to the inherent hazards of operating on such runways”

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• According to the RSI report, crosswinds, wind gusts and turbulence are also associated with runway excursion accidents.

• Adverse wind conditions were involved in 33% of accidents between 1984-1997, and

• When wet runways co-existed, adverse winds were involved in the majority of the runway excursions

Adverse wind conditions Crosswinds and Gusts on Landing

Presenter

Presentation Notes

Pilots must consider that when adverse wind conditions are combined with adverse runway surface conditions they should seek alternative runways with preferable conditions.

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Adverse wind conditions Crosswinds and Wet/Contaminated Runway

• Assess the runway condition

• Apply correction factors using chart

• ALAR Toolkit provided detailed guidance concerning landings in crosswind conditions (ALAR, 8.7)

Presenter

Presentation Notes

If landings must be conducted, pilots are strongly encouraged to consult tools such as the Gulfstream Crosswind Limits Based on the Canadian Runway Friction Index or Braking Coefficient Chart and have a plan to go around should the landing prove to be hazardous.

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Failure to assess required landing distance

• 50 percent of the operators surveyed did not have adequate policies in place for assessing whether sufficient landing distance exists at the time of arrival at the destination airport (AC 91-79)

• Two fundamental elements; – Correctly assessing the environmental conditions of the

runway, and – Properly assessing the correct aircraft performance given the

actual runway conditions

Presenter

Presentation Notes

“A survey of numerous operators’ Flight Operations or General Operating Manuals by the FAA’s Landing Performance Team indicated that approximately 50 percent of the operators surveyed did not have adequate policies in place for assessing whether sufficient landing distance exists at the time of arrival at the destination airport” (AC 91-79, App. 1, p. 7).

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• Operators need to develop policies to compel flight crew to verify the runway condition prior to landing and apply sufficient safety margins to certified landing distances

• The use of factored landing distances can assist with the ease of in-cockpit calculations (ALAR 8.3)

• It is critical that pilots understand that AFM landing distances are based upon landings which are not normally operationally achievable and represent the starting point for determining accurate landing distances

Failure to assess required landing distance

Presenter

Presentation Notes

As most certified landing performance does not include wet or contaminated data, un-approved data offered by the manufacturer should be used to determine landing distance requirements. Often, those data are not easily accessible in the cockpit as the data cannot be programmed into flight management system computers. Operators need to ensure that methodology is developed to allow crews to quickly refer to data and apply it to landing distance calculations. The ALAR Toolkit Briefing Note 8.3 provides a quick reference for pilots when considering landing distance factors. Pilots should be cautioned that simply factoring dry landing distances will only account for the known and planned performance deviations; unplanned deviations may quickly squander any/all safety margins and pilots should always strive to achieve planned performance distances. AC 91-79 Appendix 1 is an excellent reference to understand the complexities of landing distance calculations.

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Consequences of Approach and Landing Accidents

Loss of control in flight

Ground collision with object

Post-impact fire

Undershoot Collision (non-CFIT)

Accident consequence

CFIT Overrun Veer-off

CFIT = controlled flight into terrain

Presenter

Presentation Notes

Not shown on this slide is the most frequent — and obvious — consequence of ALAs: significant damage to the airplane, which was the result of 466, or 46 percent, of the 1,007 approach and landing accidents in 1995–2007.

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Top Five Causal Factors of Approach and Landing Accidents

Slow/ delayed reaction

Aircraft handling

Failure in CRM

Poor professional judgment/ airmanship

Omission of action/ inappropriate action

Causal factor

Presenter

Presentation Notes

This slide shows the top five causal factors of approach and landing accidents from 1995 through 2007.

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Top Five Circumstantial Factors in Approach and Landing Accidents

Training inadequate

Runway contamination

Poor visibility

Other weather factors

CRM failure

Circumstantial factor

CRM = crew resource management

Presenter

Presentation Notes

This slide shows the five most frequent circumstantial factors in approach and landing accidents.

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Stabilized Landing

• A landing conducted where the aircraft is positively controlled from a point 50 feet above the threshold to a full stop on the landing surface, without any unintended or adverse aircraft deviations from the planned and briefed maneuver.

Presenter

Presentation Notes

Arriving at the threshold, following a stabilized approach, represents the transition point from the approach to the landing phase of flight. It is also the last opportunity for the pilot to assess the performance conditions and determine if it is safe to continue the landing; or, should the flight parameters be not as briefed or desired, conduct an immediate go-around.

Safe Landing Guidelines The risk of an approach and landing accident is increased if any of the following guidelines is not met. If more than one guideline is not met, the overall risk is greatly

increased

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• Fly a stabilized approach

• Height at threshold crossing is 50’

• Speed at threshold crossing is not more than Vref + 10 knots indicated airspeed and not less than Vref

• Tailwind is no more than 10 knots for a non-contaminated runway, no more than 0 knots for a contaminated runway

• Touchdown on runway centerline at the touchdown aim point

• After touchdown, promptly transition to the desired deceleration configuration

• Speed is less than 80 knots with 2,000 feet of runway remaining

Presenter

Presentation Notes

The fundamental principle of strategy planning is: plan for the worst – hope for the best. This principle allows for the maximum margin for error.

Note: Once thrust reversers have been activated, a go-around is no

longer an option.

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Safe Landing Guidelines

Presentation Outline

Strategies to reduce the risk of runway excursions: CRM Data Collection and Analysis How to move from being Reactive to Predictive

JR Russell – Chairman ProActive Safety Systems Inc

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Major References

• Flight Safety Foundation. (2010) Approach and Landing Accident Reduction Toolkit Update

• Flight Safety Foundation. (2009). Reducing the Risk of Runway Excursions. Runway Safety Initiative Report

• US DOT. Federal Aviation Administration. (11/06/07). Advisory Circular 91-79. Runway Overrun Prevention

• US DOT. Federal Aviation Administration. (6/3/99).Advisory Circular 25-7A Change 1. Flight Test Guide for the Certification of Transport Category Airplanes

Contact Information

• [email protected] – 804-218-9165

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mailto:[email protected]

Questions

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Reducing The Risk of Runway Excursions

Jim Burin Director of Technical Programs

Presenter

Presentation Notes

It was 11 years ago that the Foundation’s report titled “Killers in Aviation” addressing the ALA and CFIT challenge was released. It has been 8 years since the original ALAR toolkit was released. There are now over 40,000 ALAR tool kits distributed In the last 8 years the Foundation’s CAAG team has conducted 34 ALAR workshops around the world In 2006 the Foundation conducted a runway safety initiative to address the risk of runway excursions.

http://www.rushprnews.com/press/wp-content/2008/09/accident-photo-4.jpg

Major Accidents Business Jets

1 January 2010 to 31 December 2010

Date Operator Aircraft Location Phase Fatal

5 January Royal Air Freight Lear 35 Chicago, IL, USA Approach 2

14 February Time Air Citation Bravo Schona, Germany Enroute 2

15 July Prince Aviation Citation Bravo Bol, Croatia Landing 0

12 August Ocean Air Taxi Lear 55 Rio de Janeiro, Brazil Landing 0

31 August Trans Air Citation II Misima, PNG Landing 4

6 October Aviones Taxi Citation I Veracruz, Mexico Enroute 8

19 November Frandley Avn Ptn Citation I Birmingham, UK Landing 0

19 December Windrose Air Hawker Premier St. Moritz, Switzerland Approach 2

Source: Ascend

Presenter

Presentation Notes

This chart lists the major accidents that occurred in 2010 to business type turbojet aircraft. As you can see, there were 8 major accidents, which is a good year safetywise. But look at the phase of flight for these accidents Now 2010 was a bad year all around for ALA �

2010 Approach and Landing Accidents

• Commercial Jets: 15 of 19 (80%)

• Business Jets: 6 of 8 (75%)

Presenter

Presentation Notes

Many of these were runway excursions. In fact, we found the following………………

Runway Safety Data 1995–2009

Runway Excursion Data

• 36% of turbojet accidents

• 24% of turboprop accidents

Presenter

Presentation Notes

Breakdown of excursions by Jets and Turboprops for the last 15 years. CFIT – 15 years not valid – TAWS�Mid –Air - 15 years not valid – TCAS Excursions – 15 years OK – and consistent !! 1 in 3 jet accidents is an excursion 1 in 4 Commercial turboprop accidents is an � Excursion The 2010 numbers were very close to these averages

Major Accidents Business Jets

1 January 2011 to 1 October 2011

Date Operator Aircraft Location Phase Fatal

6 January Priester Aviation Lear -35 Springfield, IL, USA Landing 0

4 February Sky Lounge Hawker 900 Sulaymaniyah, Iraq Climb 7

18 February Escuela de Aviacion Lear 24 Villasana, Mexico Landing 2

28 March Hong Fei General Citation II Missing - China Enroute 3

5 May Jorda LLC HS-125 Loreto Bay, Mexico Approach 0

25 May Jet Suite Air EMB Phenom Sedona, AZ, USA Landing 0

Source: Ascend

Presenter

Presentation Notes

This chart lists the major accidents that have occurred up to 1 October to business type turbojet aircraft. As you can see, there have been 6 major accidents so far this year. Again, look at the phase of flight – 4 of 6 are ALA �

6

Presenter

Presentation Notes

From our origninal ALAR accident data, we know that 83% of the time when a go around was warranted none was conducted

Landing Excursions – Top 10 Factors

0%

5%

10%

15%

20%

25%

30%

35%

40%

Presenter

Presentation Notes

#1 risk factor for landing excursions is the lack of a go around

• Lack of go-arounds is a leading risk factor in approach and landing accidents

The Go-Around

• Lack of go-arounds is the #1 cause of landing runway excursions

• Many approach and landing accidents result from poorly executed go-arounds

• When is it appropriate NOT to go around: - Wheels on the runway and - Thrust reversers activated

--However---

Presenter

Presentation Notes

Data proves that the risk of an approach and landing accident increases with an unstable approach. However, it should be noted that the go around itself can present some extra risk And there is a time when a go-around is not appropriate Here is an example of when not to go around

East Coast Jets

Owatonna, MN July 31, 2008

8 fatalities

Accident sequence

• Wet runway, 8 knot tailwind • After touchdown, Captain delayed 7 seconds before deploying lift dump • 17 seconds after touchdown, captain

initiated go-around attempt - 1,200 feet from runway end - Approximately 75-80 Kts

Presenter

Presentation Notes

He was not successful

Presenter

Presentation Notes

The aircraft collided with the localizer antenna 8 fataliites So that is an example of when not to go around But how about when it is the right decision

The two primary issues with a go-around

The Go-Around

1. Making the decision to go-around

2. Executing the go-around

Presenter

Presentation Notes

Data proves that the risk of an approach and landing accident increases with an unstable approach. So that the go around decision is easier, most organizations have stabilized approach criteria Does this assist in the go around decision ?

• 4% of all approaches were unstable • 97% of unstable approaches are

continued to landing – 10% result in abnormal landings

• Only 3% of unstable approaches lead to a Go-Around

• When a GA occurs – it is often poorly performed – Usually a surprise to the crew – Very rarely occurs at (the briefed) missed

approach point

LOSA Data

Presenter

Presentation Notes

This is data from hundreds of thousands of LOSA flights Interesting – but not surprising – data. Only 3% of the unstable approaches go around. Why have stabilized approach criteria ???

• Over 1 million flights analyzed • 3.5% of approaches are unstable

(35,000) • Only 1.4% of them lead to a Go-Around

(490)

•Looked for Landings with High Risk events • Unstable 8.0 % (80,000) • Stable 6.2% (62,000)

• This was not the expected result

Data Study

Presenter

Presentation Notes

More on this later

Above 500 ft56%

Between 500ft and flare

31%

Below 100ft13%

Industry study on Go-Arounds

Presenter

Presentation Notes

For the flights that did go around, this lists where the go around occurred Where do you train for go arounds ?

The Sad truth about the #1 risk factor in ALA

• 9 out of 10 unstbilized approaches do not go around

Presenter

Presentation Notes

WHY ??? Here is an example of when a go around was appropriate, but not conducted

Air France A-340, Toronto 309 onboard – no fatalities

- Weather bad – tsm/lightning in vicinity

- Fast/High on approach

- Lost sight of runway in flare – landed left

- Floated landing * landed 3,800 feet down 9,000 foot runway

- Late Thrust reversers ( 12.8 sec, 16.3 sec)

- Off end at 80 knots

Presenter

Presentation Notes

Landed long----- 3,800 feet down 9,000 foot runway i.e. a 4,200 foot runway in an A340 Late thrust reverse ---- 12.8 until selected, 16.3 until max

Presenter

Presentation Notes

309 people aboard----- 0 FATALITIES !!! So we have some challenges with go-arounds

Challenges

• Approach and Landing accident Reduction

Excursions - Success in raising awareness - Calculations and expectations

Go arounds - Decision - Execution

Safe Landing Guidelines

Presenter

Presentation Notes

Lots of issues – some discovered in our runway excursion effort that were not addressed in our ALAR work It is an extension of our ALAR effort and it came about after we completed our runway excursion project and saw some gaps we had not addressed.

Safe Landing Guidelines Note: The risk of an approach and landing accident is increased if any of the following guidelines

is not met. If more than one guideline is not met, the overall risk is greatly increased

1. Fly a stabilized approach

2. Height at threshold crossing is 50 feet 3. Speed at threshold crossing is not more than Vref + 10 knots indicated airspeed and not less than Vref 4. Tailwind is no more than 10 knots for a non-contaminated runway, no more than 0 knots for a contaminated runway 5. Touchdown on runway centerline at the touchdown aim point 6. After touchdown, promptly transition to desired deceleration configuration - Brakes - Spoilers/speed brakes - Thrust reversers (Note: Once thrust reversers have been activated, a go-around is no longer an option) 7. Speed is less than 80 knots with 2,000 feet of runway remaining

Presenter

Presentation Notes

Risk of ALAR increased if these not met Combos are most dangerous (e.g. long, fast: contaminated and tailwind) Each 10’ high TCH = + 200’ TDP 10 Kts fast = + 20% landing distance Tie together 20 years of ALAR and our recent RE work Just guidelines– but Based on RE data and 20 yrs ALAR experience We are not advocating these guidelines be copied and handed out to crews. They should be used as their title indicates - guidelines for an organization to use, in conjunction with information from their aircraft manufacturer, to create their own rules and policy. Every operator should have an SOP addressing this risk area and should monitor their operational data to determine the effectiveness of their SOP. Let me give you a final example of the risk of an unstabilized approach. See how many of the guidelines are met in this e.g.

Air India Express

Manglaor, India 22 May 2010 158 fatalities

Air India Express B-737 158 fatalities

- Late descent clearance - Rate of descent > 4,000 fpm, still high - TCH 200 feet, speed 160 kts (50/144 normal)

- 3 calls from F/O to go around, EGPWS also

- PIC asleep until 25 minutes from landing

- Touchdown 5,000’ feet down 8,000’ runway

- Touchdown, thrust reversers, braking

- 6 seconds after touchdown, tried to go around

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Presentation Notes

Not successful Did generate enough energy to go through the RESA and over a ridge

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Presentation Notes

This is beyond unstable – it is unsafe !!

Adoption of “Safe Landing” Guidelines

The keys to minimizing the risk of an approach and landing accident

Go arounds

- Decision - Execution

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Presentation Notes

FSF Goal: Make Aviation Safer by Reducing

The Risk of an Accident

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This is the Flight Safety Foundation’s goal We have had a lot of success toward achieving this goal, but there are still challenges that need to be addressed. The Safe Landing Guidelines will help the Foundation and you reduce the risk of an accident.

Put Your SMS to Work

• Look into your SMS toolbox to find ways to mitigate the risk of Runway Excursions

• The first step is communication – every SMS has the “communication tool” at it’s disposal – communicate the threats associated with Runway Excursions: – Unstable approaches - Short runways – Landing long - Contaminated runways – Too fast - Fatigue – Too high - X/Winds To name a few…the point is…to get people thinking about these threats

Pro-Active Safety Systems, Inc.


• Another tool is CRM

– Make sure everyone is aware that their input is valued and to speak up if uncomfortable with a situation

– Thorough departure and approach

briefings are critical in mitigating the risk of Runway Excursions



• Safety data is another tool to utilize – Industry Data/News – Employee Reports – FOQA/FDM data Analyzing safety data will allow an operator to recognize negative trends developing. Do something before the negative trend leads to an incident or accident.


In other words, become…

Proactive and even

Predictive

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This is the time for open discussion about each of these…reactive, proactive, predictive.

Risk Management Approaches

REACTIVE

PROACTIVE

PREDICTIVE

REDUCING RISK

INC

REA

SIN

G S

AFET

Y

Reactive = Inefficient Proactive = Efficient Predictive = Very efficient

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Script: We will discuss the various approaches along this moving slide to optimize our ultimate goal of improved Safety and minimizing Risk by utilizing our FOQA and ASAP data to reach this desired end state.

Reactive Safety

An unstable approach into XYZ led to a runway excursion. An investigation is done, and a report is generated with recommendations to prevent a similar incident.

Reactive… Focused on the outcome

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Presentation Notes

Script: First, we have: Reactive. Many incidences or situations are based on reactive. In this case we are always being, trying to catch up. Often we are so busy playing catch up or putting out small fires that we don’t see what the source of the problem is and address that issue. Unfortunately, this approach is used much too often. (transition to next slide) As we make an effort to reduce risk and thereby increase safety we move along to PROactive.

Proactive…

Safety data indicates a rise in unstable approaches to runway 28L at XYZ airport

Further investigation reveals the glide-slope to 28L is OTS due to runway construction

Hazards are identified from the information gleaned from safety data.

Presenter

Presentation Notes

Script: As we move forward from Reactive we are putting measures into place that will help prevent an incident/accident. Reviewing data for trends, gleaning through reports to identify areas of concern are some of the methods to make data useful in developing procedures to reduce or eliminate error.

http://www.123rf.com/photo_2047506.html

Predictive…

Unstable approaches trended upward when airport XYZ experienced runway construction, causing the glide slope to be unusable. Based on that knowledge, we can predict a rise in unstable approaches into airport ABC due to the proposed runway construction.

Ability to identify a potential hazard based on previous data/models/reports obtained.

Presenter

Presentation Notes

Script: First we have Reactive and unfortunately it happens all too often. Next we looked at Proactive. Proactive is good if we put measures into place that will help prevent an incident/accident. Excellent example of this is SOP, training and bulletins. Last we will explore Predictive.. This step is crucial and unless unless steps are taken, UAL will experience an incident/accident.

Questions

Thank you!

JR Russell Pro-Active Safety Systems, Inc. 303-589-7430 [email protected]

Safe Landing Guidelines (The risk of an approach and landing accident is increased if any of the following guidelines is not

met. If more than one guideline is not met, the overall risk is greatly increased)

1. Fly a stabilized approach1

2. Height at threshold crossing is 50 feet

3. Speed at threshold crossing is not more than Vref + 10 knots indicated airspeed and not less

than Vref

4. Tailwind is no more than 10 knots for a non-contaminated runway, no more than 0 knots for a

contaminated runway

5. Touchdown on runway centerline at the touchdown aim point 2

6. After touchdown, promptly transition to the desired deceleration configuration

- Brakes

- Spoilers/speed brakes

- Thrust reversers

(Note: Once thrust reversers have been activated, a go-around is no longer an option.)

7. Speed is less than 80 knots with 2,000 feet of runway remaining

Notes: 1. Stabilized approach:

Recommended Elements Of a Stabilized Approach All flights must be stabilized by 1,000 feet above airport elevation in instrument meteorological conditions (IMC)

and by 500 feet above airport elevation in visual meteorological conditions (VMC). An approach is stabilized when

all of the following criteria are met:

1. The aircraft is on the correct flight path; 2. Only small changes in heading/pitch are required to maintain the correct flight path; 3. The aircraft speed is not more than VREF + 20 knots indicated airspeed and not less than VREF; 4. The aircraft is in the correct landing configuration; 5. Sink rate is no greater than 1,000 feet per minute; if an approach requires a sink rate greater than 1,000 feet per minute, a special briefing should be conducted; 6. Power setting is appropriate for the aircraft configuration and is not below the minimum power for approach as defined by the aircraft operating manual; 7. All briefings and checklists have been conducted; 8. Specific types of approaches are stabilized if they also fulfill the following: instrument landing system (ILS) approaches must be flown within one dot of the glideslope and localizer; during a circling approach, wings should be level on final when the aircraft reaches 300 feet above airport elevation; and, 9. Unique approach procedures or abnormal conditions requiring a deviation from the above elements of a stabilized approach require a special briefing.

An approach that becomes unstabilized below 1,000 feet above airport elevation in IMC or below 500 feet above

airport elevation in VMC requires an immediate go-around.

2. Touchdown aim point (distance from runway threshold):

- FAA: 1,000 feet

- ICAO: Landing area available: <800m 800m -1,200m 1,200m -2,400m >2,400m

Touchdown point: 150m 250m 300m 400m

The touchdown aim point markings start at the distance indicated above and are 150 foot

long solid white rectangular stripes, one on each side of the runway centerline. The width

of the aim point markings varies with the width of the runway.

stabilized landings - nbaa · stabilized landings ... airbus – toronto . boeing ... unstabilized...

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