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 ** reviews of air carriers' audit procedures, assessment processes, and documentation supporting review conclusions to ensure the consistency, quality, and effectiveness of the review results;
 * comprehensive audits of a sample of safety assessments to confirm that carriers have applied agreed upon standards and procedures in conducting the assessments; and
 * procedures to, if necessary, perform on-site inspection of aircraft used in code share operations.

 * Require that FAA staff perform risk assessments using available safety data on foreign carriers and review results of air carrier safety assessments, if made available, as part of its safety advice to OST on code share applications. This interim procedure should be used no more than 3 months, until the Department finalizes new code share procedures.

1.18.1.1 Postaccident Actions Taken by the Federal Aviation Administration

On August 15, 1997, the FAA announced in a press release that, as a "routine precaution," it had ordered MSAW testing and recertification after the Safety Board's investigation of the flight 801 accident raised questions about the MSAW's performance. The FAA reported that, of the 192 in-service MSAW software functions at radar approach control facilities, all but 2 were found to be working properly. According to the press release, the software functions were corrected, and all of the functions were recertified as operating properly. Also, in response to inquiries from Safety Board staff, the FAA created special teams of automation experts to completely examine all site adaptation parameters for the 192 MSAW systems located throughout the United States. The FAA directed ATC managers at these locations to document and report any MSAW problems. Further, the FAA's Associate Administrator for Air Traffic Services directed a factfinding review of MSAW equipment and operational procedures at 10 ATC towers The review included a survey of 105 air traffic personnel and 33 airway facilities personnel.

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Rh have no doubt, that they were about on par with them in intelligence and civilization.

In the next room we saw the identical royal banner of Spain, which Cortez unfolded before the eyes of the astonished and delighted Tlaxcalan emissaries at San Juan de Ulloa, and which, after the conquest of Mexico; he presented to the city of Tlaxcala in acknowledgement of the eminent services rendered by the Tlaxcalans, in overthrowing the old Aztec Empire. Though three hundred and forty years have passed away since it was unfurled on the shore of Mexico, it' is almost perfect to-day. It is some nine or ten feet long, and six broad "and swallow tailed" in pattern. The material is rich, heavy, silk brocade, originally of a light "maroon" or possibly "ashes of roses" color, and not badly faded. The cords and tassels and the points of the banner are a little frayed and worn, but not badly so. The Shield with the royal coat of arms, the two castles, and two lions rampant, is embroidered in red, on yellow silk, and sewed upon the upper right hand corner of the, banner. The iron open-work spear-head with the monogram of the sovereigns of Spain in the center, once gilded, and the broken staff on which the banner was carried, are still with it. Vast sums have been offered for this old banner to be carried back to Spain, but the city of Tlaxcala has steadily refused to part with it at any price.

Then we were shown numerous old banners, including those of the ancient city and Republic of Tlaxcala before the Spanish conquest, very rude and very curious, and numberless manuscripts of great age and interest. One of these old illuminated manuscripts, is an authenticated translation of the original Indian

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 According to the FAA's executive summary of the MSAW fact-finding review (dated September 1997), "air traffic staff and operational personnel, except for those with automation training, claimed little knowledge of the parameters or components that make up MSAW." The executive summary indicated that very few of the air traffic survey respondents could remember receiving facility training about different MSAW areas and that most reported that their only MSAW training was an overview during the initial air traffic course.

According to the executive summary, the air traffic survey respondents indicated that a check of the MSAW aural alarm was required at the beginning of each shift, but they gave varying answers concerning what should be done if the MSAW was not functioning properly. Likewise, these survey participants believed that controllers should issue an advisory if an aircraft generates an MSAW alert, but the participants were not consistent in their answers regarding who was responsible for responding to the MSAW alert at a satellite tower. In addition, the air traffic personnel in the survey gave different answers regarding who had the authority to adjust MSAW parameters and "vague" answers regarding MSAW general notices.

All of the airways facilities personnel in the survey indicated that daily functional checks of aural MSAW alarms were required, and they knew where this check was documented. However, these personnel gave varying answers concerning how they would complete the check if an MSAW system were inhibited. Further, these respondents indicated that their MSAW training ranged from initial hardware training and on-the-job training to only on-the-job training for those personnel who completed initial schooling before the MSAW system was implemented.

The fact-finding review also found that the ARTS IIA and IIIE parameter documentation was unclear and confusing to automation specialists and that there were "no guidelines or standards defined in any document concerning the proper way to adapt the MSAW site variables." The survey revealed that, as a result of inadequate reference material, the MSAW altitudes at one ATC tower and two TRACONs were set incorrectly. These facilities had adapted the MSAW approach path monitor altitudes to be agl values when the system was intended to provide msl values. As a result, all the altitudes used for the MSAW system were hundreds of feet too low at the ATC tower and one of the TRACON facilities; the altitude discrepancy at the other TRACON was "negligible" because of its approximate sea level elevation.

On the basis of its fact-finding review, the FAA made several internal recommendations, including the following:
 * a standardized comprehensive training program should be established to provide a basis for entry-level and periodic refresher training in the operation and maintenance of MSAW equipment, and a certification process should be established for personnel who have completed this training;
 * uniform site adaptation/system parameters should be established for MSAW equipment operation;

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 * provisions for periodic evaluation of MSAW equipment should be established to ensure system integrity and reliability; and
 * configuration management of all software should be reflected in appropriate documents and centrally controlled.

In addition, in an October 1997 briefing to Safety Board investigators, FAA officials presented the agency's planned corrective actions for the national MSAW system. The officials stated that the FAA was developing a central oversight process for the MSAW program and that MSAW systems would be flight checked and ground certified as part of the commissioning process for a new radar and then periodically thereafter. Further, the officials said that the FAA had approved a new MSAW software management policy that "established strict management oversight and control" for MSAW software modifications.

1.18.1.2 Previous Safety Board Recommendations on the Minimum Safe Altitude Warning System

The Safety Board has issued numerous safety recommendations regarding the MSAW system. Recent MSAW safety recommendations have addressed the installation of MSAW equipment in VFR terminal facilities that receive radar information from a host radar control facility (as is the case with the Agana tower), as well as the inspection and testing of MSAW speakers to ensure the integrity of MSAW systems.

Development of an MSAW System (A-73-46)

On December 29, 1972, Eastern Air Lines flight 401, a Lockheed L-1011, N310EA, crashed near Miami, Florida. In its final report, the Safety Board stated that its investigation ...revealed another instance where the ARTS III system conceivably could have aided the approach controller in his ability to detect an altitude deviation of a transponder-equipped aircraft, analyze the situation, and take timely action...to assist the flight crew. In this instance, the controller, after noticing on his radar that the alphanumeric block representing flight 401 indicated an altitude of 900 feet, immediately queried the flight as to its progress. An immediate positive response from the flight crew, and the knowledge that the ARTS III equipment, at times, indicates incorrect information for up to three scans, led the controller to believe that flight 401 was in no immediate danger.

As a result of its findings, the Safety Board issued Safety Recommendation A-73-46, which asked the FAA to

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 Review the ARTS III program for the possible development of procedures to aid flight crews when marked deviations in altitude are noticed by an air traffic controller.

In a May 31, 1977, letter, the FAA advised the Safety Board that an MSAW system had been developed as an integral function of the ARTS III program and that controllers had received guidance on its use. On September 16, 1977, the Safety Board classified Safety Recommendation A-73-46 "Closed--Acceptable Action."

Minimizing MSAW Inhibited Areas (A-90-130)

On September 8, 1989, USAir flight 105, a 737-200, N283AU, struck four electronic transmission cables while executing the localizer backcourse approach to runway 27 at Kansas City International Airport in Kansas City, Missouri. The Safety Board's final report on this incident concluded that, although the Kansas City airport's ATC facility was equipped with MSAW software, the MSAW alert failed to activate during the premature descent of flight 105 because the descent had occurred more than 1 mile from the runway threshold and inside an area that had been designed to inhibit the MSAW to reduce false alerts. The Safety Board's report said that "...this incident indicates the need to revise the parameters controlling the size of the MSAW inhibit areas." The report urged the FAA "to provide site adaptations guidance to encourage modification of MSAW parameters, as appropriate, to increase the MSAW protection areas and to minimize the extent of inhibited areas." On the basis of its findings, the Safety Board issued Safety Recommendation A-90-130, which asked the FAA to

Provide site adaptation guidance to encourage modification of Minimum Safe Altitude Warning parameters, as appropriate, to minimize the extent of inhibit areas.

In an October 6, 1993, letter, the FAA stated that it had issued a change to FAA Order 7210.3K, "Facility Operation and Administration," which provided for site adaptation guidance to minimize the extent of MSAW inhibited areas. Because the FAA's response met the intent of Safety Recommendation A-90-130, it was classified "Closed-- Acceptable Action" on January 28, 1994. MSAW Site Variables and Capture Boxes (A-94-187)

On June 18, 1994, a Transportes Aereos Ejecutivos, S.A. (TAESA) Learjet 25D, operating under 14 CFR Part 129, was executing an ILS approach in IMC when the airplane crashed 0.8 nm south of the runway 1R threshold at Dulles International Airport, Chantilly, Virginia. The 2 flight crew members and all 10 passengers were killed. The Safety Board's investigation determined that the accident airplane did not generate any

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 MSAW alerts while on the approach to the airport. The investigation also determined that the MSAW site variable parameters at the airport required two "current position" radar returns or three "predicted position" radar returns below the 500-foot floor before the aural and visual alerts would activate. A review of the radar data revealed that the airplane generated one radar return below the alert altitude of the runway 1R MSAW capture box.

The Safety Board's investigation of this accident revealed discrepancies with the airport's MSAW equipment. Specifically, the MSAW site variable parameters for runway 1R indicated a discrepancy between the MSAW-defined runway location and the actual threshold location. The FAA said that, when the ARTS III software was programmed for a 10° west variation (the angular difference between true north and magnetic north at Dulles Airport), the computed position for the runway threshold did not correlate to the actual geographic runway location. Further, the "radar-established" runway position was 700 feet northeast of the actual runway threshold. The Safety Board found that the error in the radar position for the runway 1R threshold resulted in a similar displacement of the radar MSAW capture box from its intended position with the actual approach path to runway 1R. The Safety Board concluded that such displacement might compromise the protective intent of the MSAW system.

On November 21, 1994, the Safety Board issued Safety Recommendation A-94-187, which asked the FAA to Conduct a complete national review of all environments using MSAW systems. This review should address all user-defined site variables for the MSAW programs that control general terrain warnings, as well as runway capture boxes, to ensure compliance with prescribed procedures.

In a March 20, 1995, letter, the FAA stated that it planned to review the MSAW site variables to ensure compliance with prescribed procedures. According to the FAA, the

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420, ordering, on behalf of the Republic of Tlaxcala, eighty thousand picked men, to march with Cortez against Mexico. This was translated by the order of Cortez himself. Other documents beautifully illuminated, signed "Yo el Rey" (I the King,) and of the time of the Conquest, are there in abundance, with hundreds of later date, hardly less interesting. We could have spent days in looking over these curious old records of the dead and now almost forgotten past, but had only an hour or two at our command.

Among the curiosities in this room, is the war-drum of the Tlaxcalans, a curiously carved and hollowed log of dark, hard wood, like rose-wood, some thirty inches in length and six or eight in thickness, of which a full description and good illustration is given by Prescott. Two lips left on the upper surface, have play enough to give off sharp musical notes when struck by the hand, or with a stick, and the instrument, in the hand of a first-class professor of Tlaxcalan music, would doubtless be made to produce as inspiring strains as the old Scotch bagpipes, though I think one of our modern military bands in full play would discourage him.

One old document is particularly illustrative of the character of the pious people who spread religion and desolation through the land of the Aztecs. It recites, that after the conquest, a sub-tribe of the Tlaxcalans used to bring in large quanties of gold-dust from some placer in the vicinity, the locality of which they refused to disclose. They gave enough of this gold to the Church to make and pay for the crown of the Virgin of Guadaloupe at Mexico, which cost eighty thousand dollars. The Spaniards, excited by the sight of this wealth, took some of the Indians, tied them up in


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 review would address all user-defined site variables for the MSAW program that control general terrain warnings, as well as runway capture boxes, to ensure compliance. The FAA stated that its review of 190 ATC facilities (128 operational ARTS IIA and 62 operational ARTS IIIA sites) would begin in April 1995 and be concluded by July 1995. On November 20, 1995, the Safety Board stated its concern that the FAA's review process for the 190 ATC facilities with MSAW was taking longer than originally anticipated.

On January 26, 1996, the FAA stated that it had completed its review of the 190 ATC facilities. Further, the FAA stated that, as of October 1995, proper alignment of the MSAW capture boxes had been verified at all 128 ARTS IIA and 62 ARTS IIIA sites. On April 8, 1996, the Safety Board stated that, because this action met the intent of Safety Recommendation A-94-187, it was classified "Closed--Acceptable Action."

MSAW Aural Alerts in VFR Facilities (A-95-120)

On January 29, 1995, a Beechcraft A36 crashed during a missed ILS approach to DeKalb-Peachtree Airport in Chamblee, Georgia. The pilot, the sole occupant of the flight, was killed. The Safety Board determined that, before the accident, the airport tower had received four MSAW general terrain warning alerts from the Atlanta TRACON, which was providing approach control services. The tower was equipped with a D-BRITE radar display with visual MSAW alerting only.

The Safety Board's investigation found that, if a full MSAW system (including an aural alert) had been installed in the DeKalb-Peachtree tower, the controller would have received an aural MSAW alert along with the visual alert that had been depicted on the radar. Further, the tower controller told Board investigators that he did not observe the visual MSAW alert on the D-BRITE because he had been involved with other duties before the accident that did not allow him to continually monitor the data block for the airplane.

As part of its investigation into the accident, on February 8, 1995, the Safety Board requested that the FAA provide its policy on installation of aural MSAW alerts at low-density ATC towers equipped with D-BRITE radar displays. On June 27, 1995, the FAA stated that "...no policy exists for the operation of an aural alarm associated with MSAW in VFR towers that are not combined with full radar approach control facilities."

On November 30, 1995, the Safety Board issued Safety Recommendation A-95-120, which asked the FAA to

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 Within 90 days from the receipt of this letter, develop a policy that would require the installation of aural minimum safe altitude warning (MSAW) equipment in those visual flight rules terminal facilities that receive radar information from a host radar control facility and would otherwise receive only a visual MSAW alert.

On February 21, 1996, the FAA stated that it would conduct a cost-benefit analysis to determine the feasibility of implementing this safety recommendation. The FAA further stated that the analysis would be completed by the end of March 1996. In June 1996, the FAA completed the cost-benefit analysis and determined that it was feasible to implement the recommendation. The FAA expected that implementation would be accomplished by the end of March 1997.

In its July 15, 1996, letter to the FAA, the Safety Board stated that, although the FAA's implementation of the requirement for the aural alert was not accomplished within the 90 days specified in the safety recommendation, the Board was pleased that the FAA had proceeded with the implementation. The Board indicated that it would wait to receive a list of the affected facilities and anticipated installation dates.

On July 31, 1997, the FAA stated that it had conducted a survey to determine the total number of ATC facilities that did not have aural MSAW alerts installed. The FAA found that 43 remote displays had been equipped with aural alarms but that 69 remote displays did not have aural alarms. The FAA anticipated that the aural alarms at those 69 remote displays would be implemented by February 1998.

On December 30, 1997, the Safety Board said that it was encouraged that the FAA was moving forward and urged the FAA to keep the program on track and within its anticipated milestones. On May 14, 1998, the FAA said that, as of April 10, 1998, kits had been delivered to all 69 remote sites and that all alarms would be operational during May 1998. However, at the Safety Board's public hearing in March 1998, the FAA's Deputy Director for Air Traffic Operations testified that the new projected completion date for installation of aural alarms at VFR towers, including the tower at Guam, was April 2000.

On October 19, 1998, the Safety Board stated that the primary intent of this recommendation was to ensure that VFR tower controllers who have a visual representation from a distant host radar receive an aural alert when aircraft under their control and with whom they are in radio communication descend below the minimum safe altitude. If the tower controller was engaged in visually scanning for other aircraft, the aural alert would allow the controller to determine the aircraft call sign and transmit the appropriate warning to the pilot. The Board's letter indicated that the FAA was unclear about whether controllers at VFR terminal facilities would receive an aural alert for those aircraft with whom they are in communication. Further, Safety Board staff had determined that, in at least one location, the VFR tower would not receive an aural warning. (The Board's letter did not identify the location of this facility.) The Board requested that the FAA ensure that controllers at all VFR towers with visual representation systems from a distant host radar receive an aural alert when aircraft within their traffic pattern and with whom they are in communication descend below the minimum safe altitude. Pending the

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 receipt of this information from the FAA, Safety Recommendation A-95-120 was classified "Open--Acceptable Response."

On September 29, 1999, a representative from the FAA stated that the agency's management had indicated that the Agana tower was currently receiving aural MSAW alerts. At an October 7, 1999, briefing attended by the FAA Administrator, the Safety Board Chairman, and staff from both agencies, the FAA indicated that 69 MSAW aural alarms had been delivered and that 51 alarms were to be delivered. The FAA expected that the acquisition of these 51 alarms would be completed by October 2000 and that their installation in VFR towers would be completed by April 2001.

On October 12, 1999, the FAA Program Director for Serco Aviation Services told Safety Board staff that the Agana tower has the capability to receive an aural MSAW alert but that, unless the Guam CERAP transfers responsibility for the aircraft's data block, the tower will not receive the aural warning. The official added that the CERAP does not currently transfer responsibility for the aircraft's data block to the Agana tower; therefore, the tower does not receive an aural MSAW alert.

On October 14, 1999, the FAA Program Director for Air Traffic Operations confirmed that Agana tower was not receiving aural MSAW alerts. In an October 15, 1999, facsimile, the program director indicated that the Agana tower "has the software and hardware capability in place to receive aural alarms." The director further indicated that the FAA had issued a policy "to ensure that the facility that is in direct radio communications with the aircraft receives the aural alarm" and that the policy would become effective by November 15, 1999. (The FAA subsequently indicated that, under the new procedures, the Guam CERAP would transfer responsibility for the aircraft's data block to the Agana tower and that the aural MSAW alert would be transferred to the tower upon its acceptance of the transfer of the data block. The tower would advise the CERAP after an MSAW alert was issued.) The program director stated, in a followup telephone conversation with the Safety Board's Director of the Office of Aviation Safety, that a national policy would be issued to ensure that procedures similar to those being implemented at Guam are followed at other VFR towers.

On October 25, 1999, the FAA indicated that the MSAW aural alarms for the ARTS IIA system at Guam were reconfigured on October 24, 1999. The FAA stated that, in the event of a low-altitude alert for an aircraft operating in the vicinity of Guam International Airport, aural alarms will be simultaneously generated at the CERAP and the Agana tower, along with visual low-altitude alerts on the radar displays at both facilities.

On November 2, 1999, the Safety Board received a copy of draft FAA Notice N7210.485, "Minimum Safe Altitude Warning for Remote Tower Displays." According to the notice, facility managers at ATC towers that have aural alarms for MSAW are to ensure that "the operational support facility has adapted the software functionality to ensure the aural alarms operate in the ATCT [air traffic control tower]" and that "aural alarms are received in the ATCT upon transfer of communications." The FAA indicated that the effective date for this notice would be February 1, 2000.

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Rh the plaza in front of the hall in which we read the records, and whipped them most unmercifully to compel them to reveal the locality of the mine. The Indians bore the torture in grim silence, and next day twenty thousand of them, including all who knew the secret, left for Guatamala, and the locality of the placer remains undiscovered to this day.

The same thing is now going on in a district between Puebla and Tuxpan. The Indians are bringing in, from time to time, quantities of gold dust, for sale, at a small town near which has been recently discovered the ruins of an ancient city. They also brought in a box of stones which have been pronounced diamonds of the first water, by the jewelers of Mexico, but refused to tell where the gold and stones came from. It is suspected that they came from the ruins, and a party of my personal friends are now being fitted out in the city of Mexico, to go and make a thorough exploration of the locality.

The Virgin of Guadaloupe has a rival in this locality, in the Virgin who has a church on the hill above the city of Tlaxcala. It is said that the Bishop of Tlaxcala being pursued at night, by his enemies and the enemies of the Faith, saw the Virgin among the limbs of a pine-tree, and just at the moment of his direst extremity, the trunk of the tree flew open, and shutting again like the trap-door in a pantomime, enclosed him within it. The enemy ran past without discovering his whereabouts, or, what is more singular, noticing the luminous Virgin roosting in the tree overhead, and the tree, opening again, let him out in safety. Of course this miracle could not be kept secret, and the church which was erected on the spot, rivals that of


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 The Safety Board's evaluation and classification of Safety Recommendation A-95-120 are discussed in section 2.6.2.

Inspections and Tests of MSAW Speakers and the Standard Terminal Automation Replacement System Program (A-97-22 Through A-97-27)

On October 2, 1996, a Piper PA-32-300, N2881W, crashed in a heavily wooded area in Brandywine, Maryland, while on approach to Washington Executive/Hyde Field Airport in Clinton, Maryland. The pilot and two passengers were killed, and the airplane was destroyed. According to MSAW data retrieved from the Washington National TRACON, the accident airplane generated four general terrain warning MSAW alerts during the approach to the airport. A controller-in-training and a fully certified instructor were providing ATC services to the accident airplane from the TRACON's F-2 radar position. In a postaccident interview, both controllers stated that they did not recall seeing or hearing any MSAW alerts. Several other controllers and a supervisor who were stationed at nearby positions about the time of the accident also stated that they did not recall hearing or observing any low-altitude warnings before the accident.

As part of the Safety Board's investigation of this accident, a Board investigator toured the TRACON radar room to observe the control position that provided ATC services to the accident pilot. During this tour, the investigator noted that the MSAW aural alarm speaker, located directly above the F-2 radar position (and the only MSAW speaker in the radar room), was covered with heavy paper held in place with what appeared to be masking tape.

On the basis of its findings during this accident, the Safety Board issued Safety Recommendations A-97-22 through -27 on April 16, 1997. Safety Recommendations A-97-22 and -23 asked the FAA to

On July 1, 1997, the FAA stated that it agreed with the intent of Safety Recommendations A-97-22 and -23. The FAA stated that, on May 7, 1997, it had ordered air traffic division managers to brief facility managers on the issue of muted MSAW speakers and instructed supervisors to conduct a visual inspection of MSAW speakers and remove "any muting devices" from these speakers. In addition, the FAA issued a general

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 notice on June 7, 1997, to implement the requirement for supervisors to check the MSAW speakers as part of the shift checklist and record the completion of this inspection on the appropriate facility logs. The FAA also revised Order 7210.3, "Facility Operation and Administration," to reflect the change in policy and procedures.

On February 27, 1998, the Safety Board stated that, because the actions taken by the FAA addressed the intent of Safety Recommendations A-97-22 and -23, they were classified "Closed--Acceptable Action."

Safety Recommendation A-97-24 asked the FAA to

Require that all affected terminal personnel be briefed on the contents of this safety recommendation letter. This briefing should focus on generating awareness and vigilance in those situations in which a safety alert might occur and controllers must be prepared to respond, as directed in FAA Order 7110.65, "Air Traffic Control."

On July 1, 1997, the FAA stated that it complied with this safety recommendation in a June 9, 1997, memorandum to facility managers, requiring that controllers be briefed on how to respond to MSAW alerts. The facility managers were directed to ensure, within 2 weeks after the receipt of the memorandum, that all operational personnel were briefed on the requirements of FAA Order 7110.65, "Air Traffic Control," paragraph 2-1-1, "Duty Priority;" 2-1-6, "Safety Alerts;" and 5-15-57, "Inhibiting Minimum Safe Altitude Warnings (MSAW)." All operational personnel were also expected to be briefed on the actions to be taken when controllers are alerted by the MSAW of an aircraft's proximity to terrain.

On February 27, 1998, the Safety Board stated that it had received a copy of the FAA's June 9, 1997, memorandum but that, in light of the Korean Air flight 801 accident on August 6, 1997, the Board had not received written confirmation that the actions directed by the memorandum were completed for the Guam ATC facilities. On September 25, 1998, the FAA stated that it had accomplished the briefing to Guam ATC facility personnel on July 18, 1997. As a result, the Safety Board classified Safety Recommendation A-97-24 "Closed--Acceptable Action" on January 14, 1999.

Safety Recommendation A-97-25 asked the FAA to

Modify the software for the minimum safe altitude warning system to enhance conspicuity of those aircraft that may require the controller's immediate attention and action. Such modifications might be accomplished by placing the target and data block within a flashing circle.

The FAA stated in its July 1, 1997, letter that it reviewed the feasibility of modifying the software for the MSAW system to enhance the conspicuity of the data block. The FAA concluded that the existing MSAW processing generated sufficient alarms and was completely adequate; thus, no further action would be necessary.

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On February 27, 1998, the Safety Board stated that it was disappointed with the FAA's response to this safety recommendation and the FAA's continued belief that the design of the current MSAW visual display is adequate. Further, the Safety Board stated that the evidence in the Brandywine, Maryland, accident clearly demonstrated that multiple MSAW visual and aural warning alerts were generated in the operational quarters of the TRACON but that the controller failed to respond to these alerts. The Safety Board believed that the FAA should reconsider its position not to remedy the deficiencies that led to the issuance of this recommendation.

On September 25, 1998, the FAA stated that color displays, now under development for the Standard Terminal Automation Replacement System (STARS), would provide the increased conspicuity suggested in this safety recommendation. According to the FAA, the STARS early display configuration initial operational capability was scheduled for Ronald Reagan Washington National Airport in March 1999, and the early display configuration operational readiness demonstration was scheduled for June 1999. The early display configuration was to include the color red for alerts in addition to flashing data blocks. All ARTS data, except for alerts, would be monochrome.

On January 14, 1999, the Safety Board stated that, pending the commissioning of STARS and the FAA's inclusion of the flashing red MSAW display feature in the system's final operational configuration, Safety Recommendation A-97-25 was classified "Open-- Acceptable Response."

On August 13, 1999, the FAA stated that the delivery of STARS had been delayed. The FAA indicated that, on April 26, 1999, it announced a revised plan for the STARS program. According to the revised plan, the STARS early display configuration (which includes existing MSAW capability) is to begin initial operations at Syracuse, New York, and El Paso, Texas, in December 1999 and January 2000, respectively. Also, the FAA stated that, as part of the revised plan, it would procure ARTS color displays (which display the alert data blocks in flashing red) for the largest TRACONs and any new facilities while STARS development continues. The ARTS color displays are scheduled to begin operations at the New York TRACON in August 2000.

The FAA indicated that, when the STARS full-service system is deployed, the MSAW alerts will flash in red. However, the FAA stated that it did not plan to modify the existing MSAW system as requested in this safety recommendation because the existing system provides both aural and visual alarms and is completely adequate when operated according to design.

On November 3, 1999, the Safety Board stated that it was deeply concerned about the significant delay in fielding STARS and that it could not continue to maintain the classification of this recommendation, which was evaluated to be "Open--Acceptable Response" in January 1999, if the implementation of STARS according to its current schedule was the FAA's only means for complying with the recommendation. The Board urged the FAA to expedite the implementation of STARS by significantly accelerating the current schedule. The Board also urged the FAA to reconsider its position on modifying existing MSAW software if the STARS implementation schedule cannot be accelerated.

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422 in sanctity and attraction for the Indians of Tlaxcala and its vicinity. I think it is but right that it should do so under all the circumstances.

We went with the Governor to the ancient church of Tlaxcala, which was commenced in 1529, and is, unquestionably, the oldest structure devoted to the worship of God on the North American continent. It is in excellent preservation, but was never very rich in ornamentation, falling far behind many others we had seen in obscure parts of the country. The paintings too are poor and if it were not for its history there would be little to attract a visitor. But there we saw the pulpit which bears an inscription showing that it was the first erected in "New Spain," and from whence the gospel of the Cross was first preached to the natives of the New World.

Then we saw the great baptismal font, hollowed from a single block of lava, in which were baptised the four Chiefs of the Republic of Tlaxcala, and the General in command of the armies before the advance upon the City of Mexico. There are many old paintings of no artistic merit, representing martyrdoms and persecutions of the saints in all forms. Those old saints must have had a very rough time of it from all accounts and after seeing what they had to suffer, I am thankful enough that an all-wise Providence never designed me for one. I don't think I could fill the position with any degree of credit to all parties concerned. One picture represents the Pope in a triumphal car drawn by four fat and healthy horses, each led by a fat and healthy angel, riding over the bodies of the "Reformers," and dragging behind him in chains and disgrace, Luther and Calvin. Rather rough, this on the


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 Pending the FAA's reconsideration of this issue or a change in the implementation schedule for STARS, Safety Recommendation A-97-25 remained classified "Open-- Acceptable Response."

Safety Recommendation A-97-26 asked the FAA to

Require that the Standard Terminal Automation Replacement System program include a minimum safe altitude warning (MSAW) speaker at each radar display, a capability for the controller to momentarily override and mute an MSAW alert, and a computerized recording of the muting of such an alert.

On July 1, 1997, the FAA outlined the specifications for STARS and the MSAW system. On February 27, 1998, the Safety Board stated its belief that, for those aircraft that qualify under the MSAW system as part of the routine ATC services, the controller should not be given the option to permanently inhibit the MSAW processing. The Board clarified the intent of this safety recommendation by restating that the controller should be permitted to temporarily mute an alert to acknowledge that warning was received and then act on such an alert, if required. Further, the Board stated that, although the FAA provided specifications regarding the STARS and MSAW system, it did not address the intent of the recommendation.

On September 25, 1998, the FAA said that STARS terminal controller workstations and tower display workstations contained individual aural alarm speakers and that STARS would permit MSAW alert inhibits for either a specified aircraft or workstation. The FAA also stated that STARS was designed to permit temporary inhibits resulting from specific aircraft operation characteristics or possible system malfunctions and that all inhibit actions would be recorded. According to the FAA, STARS allows a controller to silence a routine aural alert by hitting an "acknowledge" key. The FAA indicated that, although the aural alarm would be silenced, the alert would remain displayed until the violation condition ceased. On January 14, 1999, the Safety Board stated that, because STARS incorporated all components suggested in Safety Recommendation A-97-26, it was classified "Closed--Acceptable Action."

Safety Recommendation A-97-27 asked the FAA to

Require, under the Standard Terminal Automation Replacement System program, that minimum safe altitude warning alerts on instrument flight rules aircraft be duplicated at a position in the operational quarters designated for supervisory personnel and that the supervisor determine the validity of the alert and whether appropriate corrective action has been initiated or is required.

The FAA's July 1, 1997, letter indicated that there is no operational requirement under STARS to duplicate MSAW alarms at supervisory positions. The FAA also stated that supervisory positions did not include controller displays and that it did not plan to provide displays to supervisory personnel. According to the FAA, STARS would provide

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 a supervisor with the ability to monitor MSAW alerts immediately from every controller position that displays an alert.

On February 27, 1998, the Safety Board stated its understanding that the current STARS operational documentation contained no requirement to duplicate the MSAW alerts at supervisory positions and that STARS would provide a supervisor with the ability to monitor MSAW alerts immediately from every controller position that displays an alert. The Board explained that it was not the intent of this recommendation to have a controller workstation be designed for the supervisor but rather to enable the supervisor to be "in the loop" if an MSAW alert was generated. The Board believed that such an arrangement would serve as a form of redundancy that could enhance the benefits of the MSAW system and STARS.

In its September 25, 1998, letter, the FAA stated that supervisors should be aware whenever MSAW alerts are generated. Further, the FAA stated that, in STARS, supervisor awareness of MSAW events is accomplished through aural alarms at each controller position. According to the FAA, supervisors are expected to be on the control room floor to monitor all areas of the operation, including MSAW alerts, and are expected to spend a minimal amount of time at supervisory workstations.

On January 14, 1999, the Safety Board stated that the individual aural alert speakers located at each controller position should alert a supervisor to the sector experiencing an MSAW alert. Therefore, supervisors should be able to react to each alert from their workstation or throughout the operating floor. Because the intent of Safety Recommendation A-97-27 was satisfied in an alternative manner, it was classified "Closed--Acceptable Alternate Action."

1.18.2.1 Traditional Ground Proximity Warning System Traditional GPWS uses numerous input signals to determine if a terrain collision threat exists. Inputs from the aircraft systems include the radio altitude, descent rate and airspeed, landing gear position, landing flap position, and glideslope information. This information generates the visual and aural annunciations to the flight crew. GPWS uses the radio altimeter to calculate closure rate with terrain to predict a potential collision threat. However, if the terrain rises steeply (for example, a sheer cliff), the system cannot provide a timely warning to the flight crew. The optional altitude callout

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The Encyclopedia Americana (1920)/Fisher, John

FISHER, John, English prelate: b. Beverley, Yorkshire, 1459; d. London, 22 June 1535. He was educated at Michaelmas College, Cambridge, graduating in 1487. In 1501 he was made vice-chancellor of the University of Cambridge (chancellor 1504), and in 1503 became the first Margaret professor of divinity at Cambridge and in the same year president of Queen's College. In 1504 he was promoted to the see of Rochester. Deeply prepossessed in favor of the ancient faith he opposed with zeal and perseverance the principles of Luther and his followers. But the same conscientious motives which induced Fisher to become the champion of Henry VIII impelled him to offer resolute opposition to the king's measures for procuring a divorce from his wife, and declaring himself head of the Church. In 1527 he was the only prelate who had the courage to refuse to sign a declaration that the marriage of the king was unlawful. He was subsequently sent to the Tower for refusing to submit to the provisions of an act of Parliament which annulled the king's marriage with Catharine of Aragon and confirmed his subsequent union with Anne Boleyn. Pope Paul III thought proper to reward his zealous adherent by giving him a cardinal's hat (May 1535). The king exclaimed in a passion, “Mother of God! he shall wear it on his shoulders, for I will leave him never a head to set it on.” As no evidence against him existed sufficiently strong to affect his life, Henry employed crafty emissaries to entrap Fisher into a positive denial of the king's

in the Church. The plot succeeded, the bishop was tried and convicted, and was beheaded on Tower Hill. Bishop Fisher was an able theologian, genuinely attached to learning, and the author of a commentary on the Seven Penitential Psalms; of sermons, controversial and devotional treatises, etc.; his writings being partly in Latin, partly in English. Consult his ‘Life’ by Lewis, ed. by Turner (1855); and by Bridgett (1890); Mason, ‘Lectures on Colet, Fisher and More’ (1888).


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 advisories generated by GPWS are the aircraft's altitude above the ground as calculated by the radio altimeter.

1.18.2.2 Enhanced Ground Proximity Warning System Enhanced GPWS has the ability to "look ahead" of the aircraft to determine the terrain elevation along the flightpath. Enhanced GPWS can therefore provide pilots with visual and aural alerts in advance of an impending impact with terrain, thus allowing pilots more time than with traditional GPWS to determine the necessary corrective actions to be taken.

Enhanced GPWS compares the aircraft's position, as determined by its on-board navigational systems (that is, the flight management system [FMS], inertial reference system, or GPS), with a stored terrain database. Terrain and ground obstructions that may pose a collision threat along the flightpath of the aircraft result in aural and visual warnings. The visual warning information is provided to the pilot using the color graphics capabilities of a dedicated display screen, the color weather radar, or an Electronic Flight Instrument System map display (depending on the particular installation).

Further, unlike traditional GPWS, enhanced GPWS utilizes an airport position database to establish a "terrain clearance floor" around all airports. This feature ensures sufficient terrain clearance regardless of the airplane's landing gear and flap configuration.

1.18.2.2.1 Notice of Proposed Rulemaking for Enhanced Ground Proximity Warning Systems

On August 26, 1998, the FAA issued a notice of proposed rulemaking (NPRM) addressing the development and installation of a TAWS (Docket No. 29312, Notice No. 98-11). The NPRM stated that Technical Standard Order (TSO) C151, titled "Terrain Awareness and Warning System," was being developed through the FAA's TSO process and that, once the TSO has been completed, the FAA would issue an advisory circular (AC) addressing an acceptable means of obtaining installation approval.

The FAA believed that the installation of a TAWS would ensure that all applicable airplanes operated under Parts 91, 121, and 135 would have state-of-the-art equipment to aid in the prevention of CFIT accidents. The FAA's proposal also applies to operators conducting flights under Part 125 and operators of U.S.-registered airplanes under Part 129.

The FAA proposed that, for operations conducted under Part 121, the rule would apply to all turbine-powered airplanes and that, for operations under Parts 91, 125, 129,

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 and 135, the rule would apply to all turbine-powered airplanes type certificated to have six or more passenger seats, excluding any pilot seat. (The FAA stated in the NPRM that the proposed rule applied only to turbine-powered airplanes, but the FAA indicated that it would consider comments on whether the installation of a TAWS on reciprocating enginepowered airplanes should be required. The FAA also stated that it would study data and information submitted by respondents before making a determination whether TAWS should be required for reciprocating engine-powered airplanes.)

The FAA proposed that, beginning 1 year after the effective date of the final rule, U.S.-registered turbine-powered airplanes manufactured after that date be equipped with TAWS and that existing turbine-powered airplanes be equipped with TAWS within 4 years after the effective date of the final rule. The FAA also proposed to amend 14 CFR Sections 121.360 and 135.153 to add an expiration date of 4 years after the effective date of the final rule for the use of current GPWS systems; thereafter, compliance with those sections would not be allowed instead of the provisions proposed within the NPRM. In addition, the FAA's proposal would also require operators to include in their airplane flight manuals the appropriate procedures for operating and responding to the audio and visual warnings of the TAWS.

In a December 24, 1998, letter to the FAA, the Safety Board indicated that the NPRM, if promulgated, would have a positive effect on aviation safety by reducing the possibility for CFIT accidents. However, on May 12, 1999, the Safety Board concluded that the 4-year installation time frame proposed by the FAA should be shortened to 3 years for airplanes that currently lack any GPWS protection (see section 1.18.2.4).

The FAA indicated that it expected to issue the final rule by March 2000, with an effective date 1 year after the date of issuance. According to the FAA, the final rule would mandate the installation and use of TAWS within 1 year after the effective date on new-production airplanes and within 4 years after the effective date for existing airplanes.

1.18.2.3 Department of Transportation Studies on Traditional and Enhanced Ground Proximity Warning Systems

In 1995, the FAA commissioned the DOT's Volpe National Transportation Systems Center to examine the effectiveness of GPWS and enhanced GPWS in preventing CFIT accidents in 14 CFR Part 91 operations. The center studied 44 CFIT accidents that occurred between 1985 and 1994 and involved airplanes operating under 14 CFR Part 91 with 6 to 10 passenger seats. Of the 44 airplanes, 11 were turbojets and 33 were turboprops, and none of the airplanes had GPWS installed. The center used computer modeling techniques to conclude that (1) GPWS could have prevented 33 of the 44 accidents (75 percent) and 96 fatalities and (2) enhanced GPWS could have prevented 42 of the 44 accidents (95 percent) and 126 fatalities.

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Rh reformers, but it is their business, not mine, and if they can stand it, I can. The ceiling under the roof of this old church is a marvel of beauty. It is of cedar colored by time to the hue of mahogany, wrought with exquisite skill, gilded in places, and varnished. Tradition says that this work was done by the angels in the night, and that when the Bishop came at morning to begin it, he found to his astonishment that they had completed the church and left him nothing more to do. All over the country the same or similar work was done on the churches, the angels in most cases doing as much at night as the workmen did during the day, and so the structure was half mortal and half immortal in its origin. In this case they did the ceiling entire, and it stands unharmed by time in all its perfect beauty to this hour. If I were a doubter or scoffer—which I am not—I might be tempted to suggest that the miracle would have been more conclusive and effective, if the angels had come down in broad daylight, and performed the work in sight of the people; but my faith enables me to see that their doing it after dark, in silence, and without even a candle or lantern to attract the attention of the public, makes the miracle all the more wonderful, and the work more glorious. The job was done, that is certain, for there is the delicate fretted ceiling, as perfect to-day as it was three hundred and forty years ago, and I for one, find it cheaper and easier to believe at once, than to waste time in raising doubts and discussing questions which profit a man nothing.

After we left the church, a party of irreverent people from California, who came down by a train from Mexico, visited it, and carrying a basket of champagne


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 Later in 1996, the FAA commissioned the DOT's Volpe National Transportation Systems Center for a second study that examined the effectiveness of GPWS and enhanced GPWS in preventing CFIT accidents involving airplanes operating under 14 CFR Part 121 and 135 or their foreign equivalents. The center studied 47 domestic and 104 foreign CFIT accidents that occurred between 1985 and 1995; 38 of the domestic accidents and 96 of the foreign accidents involved fatalities. The center developed a methodology and scheme for selecting a representative sample, and nine accidents were selected for detailed study and analysis.

The Volpe center found that four of the nine accidents (44 percent) should have been prevented by the basic GPWS equipment that had been installed. In two of these four accidents, the GPWS equipment either was disconnected or malfunctioned; in the other two accidents, poor flight crew coordination after the GPWS warning led to inaction rather than decisive recovery maneuvers.

The Volpe center further found that, for all nine accidents, enhanced GPWS would have provided more warning time than GPWS (which was assumed to be 12 to 15 seconds). For seven of the accidents, warning times with enhanced GPWS would have exceeded those of GPWS by more than 20 seconds; two of the accidents would have involved differences of more than 1 minute. The center concluded that "in general, [enhanced GPWS] should have provided an additional margin in which flight crews could assess their situation, discover errors, regain situational awareness, and take appropriate action before impact." The center noted only one accident for which an assumed enhanced GPWS warning duration would have been only slightly above the 12- to 15-second GPWS warning. The center argued that this case, which involved a pilot's fatal wrong turn toward mountains, might have been prevented by the visual forward-looking terrain display installed in enhanced GPWS. Thus, the center believed that it was reasonable to assume that enhanced GPWS could have prevented all nine (100 percent) of these accidents.

The Part 121 and 135 study credited GPWS as a significant factor in reducing the frequency of CFIT accidents since 1975. However, the center concluded that "there is compelling evidence of the potential effectiveness of [enhanced GPWS] in preventing CFIT accidents." The study emphasized that CFIT accident prevention would result not only from the increased warning time after the enhanced GPWS detected terrain threats but also from the system's continuous terrain display, which would enable flight crews to perceive terrain threats and respond to them well before enhanced GPWS would generate its warnings.

1.18.2.4 Previous Safety Board Recommendations on Traditional and Enhanced Ground Proximity Warning Systems

In 1971, the Safety Board began issuing numerous recommendations to the FAA regarding the installation and upgrade modification of GPWS. (The FAA first mandated

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 the installation of GPWS in 1974 for all 14 CFR Part 121 carriers.) More recently, the Safety Board has issued recommendations addressing the additional benefits of installing enhanced GPWS.

GPWS Development (A-71-53, A-72-19, and A-72-35)

On February 17, 1971, a Southern Airways Douglas DC-9-15, N92S, struck an electric transmission line static cable during a VOR approach to runway 31 at the Municipal Airport in Gulfport, Mississippi A successful missed approach was accomplished, and the aircraft landed safely. On the basis of the results of its investigation, the Safety Board issued Safety Recommendation A-71-53, asking the FAA to

Develop a ground proximity warning system for use in the approach and landing phases of operation, which will warn flight crews of excessive rates of descent, unwanted/inadvertent descent below minimum descent altitudes, or descent through decision heights. It would be desirable if the equipment now installed could meet this need.

The FAA responded that it believed that "the present instrumentation and procedures are safe and adequate provided cockpit disciplines are maintained." The Safety Board subsequently classified this recommendation "Closed--No Longer Applicable" because it was superceded by Safety Recommendation A-72-19. That recommendation was issued as a result of the June 22, 1971, accident involving a Northeast Airlines McDonnell Douglas DC-9-31, N982NE, which struck the water during a nonprecision instrument approach to runway 24 at the airport at Martha's Vineyard, Massachusetts. The Safety Board issued Safety Recommendation A-72-19, asking that

The Administrator require all air carrier aircraft to be equipped with a functional ground proximity warning device, in addition to barometric altimeters.

On November 14, 1972, Southern Airways charter flight 932, a DC-9, N97S, crashed during a nonprecision instrument landing approach to runway 11 at the Tri-State Airport, Huntington, West Virginia. The airplane impacted trees on a hill approximately 1 mile west of the runway threshold. All 71 passengers and 4 crewmembers were killed, and the airplane was destroyed. As a result of its investigation, the Safety Board issued Safety Recommendation A-72-35 to the FAA, asking that

The Administrator evaluate the need for the installation and use of ground proximity warning devices on air carrier aircraft.

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 In its November 2, 1973, letter to the FAA, the Safety Board classified Safety Recommendation A-72-19 "Closed--Acceptable Alternate Action." Also, the Board classified Safety Recommendation A-72-35 "Closed--No Longer Applicable" in the same letter.

GPWS Installation for 14 CFR Part 135 Operations (A-86-109)

On August 25, 1985, Bar Harbor Airlines flight 1808, a Beech B99, N300WP, crashed during an ILS approach to Auburn-Lewiston Airport, Auburn, Maine. The airplane struck trees at an elevation of 345 feet msl in a wings-level attitude 4,000 feet from the end of the runway threshold and 440 feet to the right of the extended runway centerline. All eight airplane occupants were killed.

On September 23, 1985, Henson Airlines flight 1517, a Beech B99, N339HA, crashed during an ILS approach to Shenandoah Valley Airport, Weyers Cave, Virginia. The airplane struck trees at an elevation of 2,400 feet msl in a wings-level attitude about 6 miles east of the airport. All 14 airplane occupants were killed.

On March 13, 1986, Simmons Airlines flight 1746, an Embraer EMB-110P1, N1356P, crashed during an ILS approach to Phelps Collins Airport, Alpena, Michigan. The airplane struck trees at an elevation of 725 feet msl in a wings-level attitude about 1 ½ miles from the end of the runway threshold and about 300 feet to the left of the extended runway centerline. Three of the nine airplane occupants were killed, five occupants received serious injuries, and one occupant received minor injuries.

The Safety Board's investigation of these accidents revealed that the accidents occurred while the airplanes were in controlled flight and the flight crews were attempting to complete precision instrument approaches in IMC. None of the flight crews indicated that they were experiencing airplane or equipment problems, and none of the postaccident examinations disclosed airplane or equipment problems that would explain the accidents. As a result of these three accidents, the Safety Board issued Safety Recommendation A-86-109, which asked the FAA to

Amend 14 CFR Section 135.153 to require after a specified date the installation and use of ground proximity warning devices in all multiengine, turbine-powered fixed-wing airplanes, certificated to carry 10 or more passengers.

On January 8, 1987, the FAA stated that it initiated a proposed regulatory project for the development of an NPRM for a GPWS requirement for 14 CFR Part 135 operators. According to the FAA, the rationale and requirements for the NPRM were finalized and would be presented to the Regulatory Review Board in early 1987. On May 15, 1987, the Safety Board asked for an update on the status of the NPRM.

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424 up to the belfrey, proceeded to drink it and ring the bells in our honor, as we drove off for Santa Anna again.

Among the decorations of this primitive church, are several effigies and pictures of Christ, of a character so utterly revolting as to fairly make one sick. It is alleged in explanation, that the Indians required very vivid illustrations, to excite their imagination and fix religious impressions in their minds. These ought to fetch them. In one chapel there is a full-sized effigy of Christ upon the cross. His head is covered with an enormous shock wig of brown-red hair, the eyes, mouth, and nose discharging blood, wounds and bruises on every limb and feature, and the agony and pallor of the dying struggle so fearfully counterfeited as to produce, in my mind at least, a sense of loathing and nausea almost uncontrollable. I would as soon think of going to a slaughter-house to worship the All-Merciful God who created the Heaven and the Earth, and made man in his own image and a little lower than the Angels, as to that chamber of horrors, in the first Christian church erected on the American Continent.

There are some old skulls lying about the church, and the Californians put two of them into the shawl which Mr. Gliddon was carrying. He did not discover the trick for some time, and when he did so he restored them to their place with the quiet remark, that as the superintendent of trains on the railway, he had been carrying so many "dead-heads" of late, that he did not notice the presence of one or two, more or less, unless his attention was specialy drawn to them. We got back to Santa Anna at 6, and returned to Puebla to dinner.


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 On May 16, 1989, the FAA stated that the March 1989 Volpe National Transportation System Center report, titled Investigation of Controlled Flight Into Terrain (DOT-TSC-FA994-89-10), presented an investigation of CFIT accidents involving multiengine, fixed-wing, turbine-powered aircraft operating in accordance with 14 CFR Part 135 at the time of the accident and the potential application for a GPWS. The FAA stated that, as a result of the Volpe report and the availability of a GPWS at a more reasonable cost to commuter aircraft, the FAA was considering the issuance of an NPRM to address the intent of Safety Recommendation A-86-109. On June 20, 1989, the Safety Board stated that it was pleased that the FAA was considering the issuance of an NPRM.

On April 24, 1992, the FAA stated that, on March 17, 1992, it issued a final rule (Docket No. 26202; Amendment No. 135-42) to require that all turbine-powered (rather than only turbojet) airplanes with 10 or more seats be equipped with an approved GPWS. On June 10, 1992, the Safety Board stated that it was pleased to note that the FAA had issued the final rule and that, as a result, Safety Recommendation A-86-109 was classified "Closed Acceptable Action."

GPWS Installation for 14 CFR Part 91 Operations (A-92-55 and A-95-35)

On December 11, 1991, a Bruno's, Inc., Beechjet 400, N25BR, operating under 14 CFR Part 91, impacted mountainous terrain approximately 3 minutes after takeoff from Richard B. Russell Airport near Rome, Georgia. The two flight crewmembers and all seven passengers were killed. The airplane was not equipped with a GPWS and was not required by the FARs to be so equipped. The Safety Board concluded that, if a GPWS had been installed on the airplane, a warning would have sounded about 12 seconds before impact and would have most likely provided sufficient time for the pilots to take action to avoid flying into terrain. As a result of the accident, the Board issued Safety Recommendation A-92-55, which asked the FAA to Require all turbojet-powered airplanes that have six or more passenger seats to be equipped with a ground proximity warning system.

The FAA, however, did not agree with this recommendation. In an October 13, 1992, letter to the Safety Board, the FAA stated that, in making the determination not to require a GPWS on all turbojet-powered airplanes with six or more passenger seats, it considered, "among other factors, the operating environment most prevalent for turbojetpowered airplanes, the extent of radar service in the air traffic control system, and the employment of the minimum safe altitude warning system." On January 6, 1993, the Board classified Safety Recommendation A-92-55 "Closed--Unacceptable Action." After the June 18, 1994, TAESA Learjet accident at Dulles International Airport, the Safety Board issued Safety Recommendation A-95-35, which asked the FAA to

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Rh On the 20th of December, our party re-enforced by a number of friends from the capital, started in carriages for Cholula, to visit the pyramid of which nearly every school-boy has seen a picture in his geography. A ride of two leagues over a rough and dusty road, through an open country, brought us to the ancient city, said to have once contained four hundred thousand people. It is situated in an open plain, with the grand circle of great mountains, Popocatapetl, El Muger en Blanco, Malinchi, Orizaba and the lesser peaks in the distance. It must have suffered fearfully from the Spanish conquerors, and has been steadily declining in importance to the present day, being now but a mere fragment of its former self.

The people are nearly all of unmixed Indian blood, hardy, industrious, and peculiarly respectful and well-behaved. They cultivate a wide area of fertile valley land, in a manner reminding one of the Chinese, and supply the City of Puebla, almost exclusively, with market vegetables.

After the party entered the Valley of Mexico, the appearance of Mr. Seward seldom produced any remarkable demonstrations of enthusiasm among the common people, and we had no reason to expect any different reception at Cholula, in view of the apathy manifested at Puebla, so near at hand. But we were destined to witness a display, as novel and curious as it was unexpected.

The whole country abounds with old churches, all of which have chimes of fine-toned bells still remaining in their towers, though the greater portion of them have but a limited number of worshipers within their walls at any time in these latter and degenerate days. As we neared Cholula the people were seen running


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On June 14, 1995, the FAA stated that it had asked the Volpe National Transportation Systems Center to study CFIT accidents involving turbojet-powered airplanes equipped with six or more passenger seats and document those CFIT accidents that would have been avoided if GPWS or enhanced GPWS had been installed. The FAA stated that it would review the results of the study to determine any regulatory action that would need to be initiated. On August 29, 1995, the Safety Board stated that it would wait for the study to be completed and then evaluate the actions taken by the FAA in response to the study's findings.

On April 17, 1997, the FAA stated that it had initiated rulemaking proposing to mandate the installation of enhanced GPWS on all turbine-powered airplanes with six or more passenger seats. The FAA also indicated that the White House Commission on Aviation Safety and Security issued a recommendation that urged the installation of enhanced GPWS on commercial aircraft. The FAA stated that it was proposing to revise 14 CFR Parts 91, 121, and 135 to address the Board's and White House's recommendations.

On July 31, 1997, the Safety Board said that it reviewed the results of the study by the Volpe National Transportation Systems Center. The Board stated that it was pleased that the FAA had initiated rulemaking activity to revise 14 CFR Parts 91, 121, and 135 to mandate enhanced GPWS on all turbine-powered airplanes with six or more passenger seats. The Board indicated that nearly 1 year had passed since the study was completed, and the Board hoped that the FAA's important rulemaking action would not be further delayed.

On January 13, 1998, the Houston Gates Learjet accident occurred. This accident, which was briefly discussed in section 1.18.1.2, involved a positioning flight operating under 14 CFR Part 91. The airplane departed from Hobby Airport in Houston for George Bush Intercontinental Airport, where five people were waiting to board the airplane for a 14 CFR Part 135 charter flight to Fargo, North Dakota. The captain and first officer--the sole occupants aboard the flight--were killed when the airplane struck trees and impacted the ground, and the airplane was destroyed by impact forces and fire. The airplane was not equipped with a GPWS and was not required by the FARs to be so equipped. Although the Safety Board determined that the probable cause of this accident was flight crew error, the Board also found that the lack of an FAA requirement for a GPWS on the airplane was a factor in the accident.

On May 12, 1999, the Safety Board stated that the circumstances of the Houston Learjet accident, the TAESA Learjet accident, and the Bruno's Beechjet accident clearly

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 indicated the potential to reduce CFIT accidents by requiring the installation of a GPWS in turbojet-powered airplanes equipped with six or more passenger seats. The Board further stated that the 1996 DOT study provided compelling evidence that Safety Recommendation A-95-35 should be broadened to include turboprop-powered airplanes and require the installation of enhanced GPWS. As a result, the Safety Board classified Safety Recommendation A-95-35 "Closed--Acceptable Action/Superseded."

Enhanced GPWS for Transport-Category Airplanes (A-96-101)

On December 20, 1995, American Airlines flight 965, a Boeing 757, N651AA, was on a regularly scheduled 14 CFR Part 121 flight from Miami, Florida, to Cali, Colombia, when it struck trees and crashed into the side of a mountain in night VMC. Of the 8 crewmembers and 156 passengers aboard the airplane, all but 4 were killed. The airplane was equipped with a GPWS, as required. Approximately 12 seconds before impact, the GPWS began issuing aural warnings of "TERRAIN" and "PULL UP." However, the GPWS did not provide the warning in time for the flight crew to successfully avoid crashing into the mountainous terrain. As a result of this accident, the Safety Board issued Safety Recommendation A-96-101, asking the FAA to

Examine the effectiveness of the enhanced ground proximity warning equipment and, if found effective, require all transport-category aircraft to be equipped with enhanced ground proximity warning equipment that provides pilots with an early warning of terrain.

On December 31, 1996, the FAA stated that it had begun evaluating the effectiveness of enhanced GPWS. Further, the FAA stated its belief that enhanced GPWS would perform as intended and should significantly increase a pilot's situational awareness. The FAA indicated that evaluations to date revealed that enhanced GPWS would be a valuable aid in preventing CFIT accidents. The FAA anticipated completing its evaluation by March 1997 and stated that it would initiate appropriate action based on the results of the evaluation.

On April 11, 1997, the Safety Board acknowledged that the FAA was considering the issuance of an NPRM to require enhanced GPWS equipment on all civil, turbinepowered aircraft with six or more passenger seats. The Board indicated that it would wait to review the FAA's final action.

On May 4, 1999, the FAA stated that, in August 1998, it issued an NPRM proposing to require the installation and use of TAWS on any U.S.-registered turbinepowered airplane with six or more passenger seats operating under 14 CFR Parts 91, 121, and 135. According to the FAA, because operators under 14 CFR Part 125 and operators

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 of U.S.-registered airplanes under 14 CFR Part 129 must comply with 14 CFR Part 91, they would also have to meet the proposed requirements of the NPRM. The FAA further indicated that it had issued TSO C151, "Terrain Awareness and Warning System," for public comment. According to the FAA, TSO C151 would prescribe the minimum operational performance standards that a TAWS must meet. The FAA stated that the comment period for TSO C151 was from November 4, 1998, to January 26, 1999. The FAA also stated that it had extended the ending date of the comment period for the NPRM from November 24, 1998, to January 26, 1999, to coincide with the ending date of the comment period for the TSO.

On July 13, 1999, the Safety Board stated that, pending the issuance of the final rule on the installation and use of TAWS and TSO C151, Safety Recommendation A-96-101 was classified "Open--Acceptable Response." In an October 1, 1999, response, the FAA stated that it had issued the final TSO on August 16, 1999. The FAA also stated that it expected to issue the final rule by March 2000 with an effective date of 1 year after the date of issuance.

The Safety Board's evaluation and classification of Safety Recommendation A-96-101 are discussed in section 2.8.2.

Enhanced GPWS for Turbine-Powered Airplanes (A-99-36)

As part of its investigation into the 1998 Houston Learjet accident (see the discussion regarding Safety Recommendation A-95-35), the Safety Board concluded that the 4-year TAWS installation time frame should be shortened for airplanes that lack any GPWS protection. On May 12, 1999, the Safety Board issued Safety Recommendation A-99-36, which asked the FAA to

Require, within 3 years, that all turbine-powered airplanes with six or more passenger seats that are not currently required to be equipped with a ground proximity warning system (GPWS) have an operating enhanced GPWS (or terrain awareness and warning system).

On July 26, 1999, the FAA stated that, in August 1998, it had issued an NPRM on the installation and use of TAWS on any U.S.-registered turbine-powered airplane with six or more passenger seats operating under 14 CFR Parts 91, 121, and 135. The FAA indicated that the NPRM proposed adding new rules that would prohibit the operation of certain airplanes unless those airplanes were equipped with a TAWS that met the minimum operational performance standards prescribed in TSO C151, "Terrain Awareness and Warning System."

The FAA also stated that, on May 27, 1999, it published a change to the proposed TSO to include two classes (A and B) of TAWS equipment. According to the FAA, TSO C151 Class A equipment would be required for airplanes operated under 14 CFR Part 121 and for airplanes configured with 10 or more passenger seats operating under 14 CFR

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426 through the fields towards the town, and the bells commenced ringing from every tower in the city and its suburbs. The number of bells which thus at once sent forth their voices in welcome to the stranger, could hardly have been less than one hundred, and the ringers worked as if life and death depended on their exertions.

When the procession reached the Plaza, two fine brass-bands—all the musicians being natives of Cholula—struck up their liveliest airs, the Prefecto Politico and the Ayuntemento of the town came forward to welcome Mr. Seward, and the party, dismounting from the carriages, marched to the town-hall, the entire population, men, women, and children, with eager curiosity depicted on their features, following, or running by their side. In the hall, behind the desk of the Prefecto, was a full-length portrait of the Virgin of Guadaloupe, and on the desk lay two silver maces with globes at the end surmounted with the eagle and nopal of Mexico. These emblems of authority are not unlike in appearance to the mace represented in the picture of Cromwell disbanding the Long Parliament, when he exclaims, "take away that fool's bauble!"

The Prefecto made a warm and sensible speech in behalf of the people and Ayuntemento of Cholula, welcoming Mr. Seward and his friends to the hospitalities of the ancient city, and alluding in warm terms to the services rendered to the cause of Mexican independence, through him, by the Government and people of the United States; to which Mr. Seward replied:


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 Part 135, and TSO C151 Class B equipment would be the minimum requirement for airplanes operating under 14 CFR Part 91 and for airplanes configured with six to nine passenger seats operating under 14 CFR Part 135. The FAA indicated that both classes of equipment would include the TAWS features of comparing airplane position information with an on-board terrain database and providing appropriate caution and warning alerts, if necessary. Further, the FAA stated that it revised the proposed TSO to include the airworthiness requirements for both classes of equipment.

The FAA indicated that it expected to issue the final TSO by September 1999 and the final rule by March 2000, with an effective date 1 year after the date of issuance. According to the FAA, the final rule would mandate the installation of TAWS within 1 year after the effective date on new-production airplanes and within 4 years after the effective date for existing airplanes. The FAA indicated that these compliance dates, which were established in the current NPRM, were developed based on product availability and the anticipated manufacturing approval process. The FAA further indicated that a change in the compliance dates, as recommended in this safety recommendation, would require publishing a supplemental NPRM. The FAA believed that any change to the current rulemaking effort would delay the implementation of TAWS well beyond the proposed dates of the current final rule, as well as the compliance dates included in the recommendation. On October 1, 1999, the FAA stated that it had issued the TSO C151 on August 16, 1999.

The Safety Board's evaluation and classification of Safety Recommendation A-99-36 are discussed in section 2.8.2.

1.18.3.1 Flight Safety Foundation Study of Controlled Flight Into Terrain Accidents

In the early 1990s, the Flight Safety Foundation (FSF) created a CFIT Awareness Task Force to promote general CFIT awareness. This task force evolved into an international Approach and Landing Accident Reduction Task Force, working under the auspices of the FSF. According to statistics compiled by the task force, CFIT accidents have killed more than 9,000 passengers and crewmembers since the beginning of commercial jet operations in the late 1950s. The statistics also indicate that, between 1988 and 1997, more than 2,800 people were killed in 39 CFIT-related accidents worldwide.

The FSF task force estimated that about 25 CFIT accidents occur worldwide each year involving large commercial jet transports and large commuter and regional turboprop airplanes. Several factors that frequently appeared in CFIT accident reports included night and limited visibility conditions, terrain not observed until just before impact, loss of horizontal or vertical situational awareness, unfamiliarity with terrain and obstructions, flight crew uncertainty about altitudes and distance from the airport, navigational equipment improperly set or misinterpreted by the flight crew, and an unstabilized approach.

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 The FSF, using statistics from the United Kingdom's CAA global database, found that 287, or 46 percent, of the 621 fatal CFIT accidents worldwide between 1980 and 1986 occurred during the approach and landing phase of flight. A study commissioned by the CAA for the FSF examined these 287 fatal approach and landing accidents. According to the study, these 287 accidents resulted in 7,185 fatalities to passengers and crewmembers, which averaged 25 fatalities per accident, or 63 percent of the total aircraft occupants.

The study indicated that 75 percent of the accidents occurred when a precision approach aid was neither available nor used and that nighttime accidents occurred at three times the rate of those that occurred during daylight conditions. The lack of ground aids was cited in at least 25 percent of the accidents. The study concluded that the "most frequent circumstantial factors were non-installation of currently available safety equipment (generally GPWS systems) and the failure to emphasize the use of crew resource management."

The study determined that, in 279 of the accidents, the 5 most frequently identified primary causal factors--omission of action/inappropriate action, lack of positional awareness in the air, flight handling, "press-on-itis," and poor professional judgment/airmanship--accounted for 71 percent of the accidents. According to the FSF, omission of action/inappropriate action generally referred to the crew continuing the descent below the DH or MDA without visual reference or when visual cues were lost. Lack of positional awareness in the air generally involved a lack of appreciation of the aircraft's proximity to high ground, frequently when the aircraft was not equipped with a GPWS and when precision approach aids were not available. Press-on-itis referred to a flight crew's "determination to get to a destination or persistence in a situation when that action is unwise." The study also determined that all five primary causal factors involved crewmembers.

The study reported that the number of accidents and the number of fatalities showed an overall increasing trend and that, if the trend were to continue, "...by 2010 there will be 23 fatal ALAs [approach and landing accidents] with a total of 495 fatalities annually involving Western-built aircraft (commercial jets, business jets and turboprop airplanes)...." On the basis of the results of this study, the FSF Approach and Landing

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 Accident Reduction Task Force issued nine conclusions and recommended several initiatives to support each conclusion.156 (The recommendations for each conclusion are detailed in appendix C.) The conclusions were as follows:

 * Establishing and adhering to adequate standard operating procedures and CRM processes will improve approach and landing safety.
 * Improving communication and mutual understanding between ATC services and flight crews of each other's operational environment will improve approach and landing safety.
 * Unstabilized and rushed approaches contribute to ALAs.
 * Failure to recognize the need for and to execute a missed approach, when appropriate, is a major cause of ALAs.
 * The risk of ALAs is higher in operations conducted during low light and poor visibility, on wet or otherwise contaminated runways, and with the presence of optical physiological illusions.
 * Using the radio altimeter as an effective tool will help prevent ALAs.
 * When the PIC [pilot-in-command] is the PF and the operational environment is complex, the task profile and workload reduce PF flight management efficiency and decision-making capability in approach and landing operations.
 * Collection and analysis of in-flight parameters (for example, flight operations quality assurance programs) can identify performance trends that can be used to improve the quality of approach and landing operations. Global sharing of aviation information decreases the risk of ALAs.

1.18.3.2 Factors Involved in Recent Controlled Flight Into Terrain Accidents and Incidents

A British Airways Boeing 777 captain who was a member of the FSF's Approach and Landing Accident Reduction Task Force and CFIT Awareness Task Force testified at the Safety Board's public hearing about the factors that have been involved in CFIT accidents and incidents. The captain testified that five of six CFIT accidents in 1996 and 1997 occurred during nonprecision approaches. The captain also said that, from 1988 to 1997, one-half of the commercial jet CFIT accidents were during step-down approaches, even though most of those airplanes had DME available.

The captain testified that, according to the accident data, the chances of a CFIT accident occurring during a nonprecision approach is five times greater than during a

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 precision approach. The captain also stated that nonprecision approaches are generally much more complex than precision approaches because, for many pilots, nonprecision approaches are less familiar, are more prone to error, and require more comprehensive briefing. Further, the captain stated that nonprecision approaches need particularly careful and accurate monitoring and that it is possible, with complex step-down procedures, for steps to be missed or taken out of order. The captain added, "in other words, to get one step ahead of the airplane could be fatal." He recommended eliminating step-down nonprecision approaches "...because the accident data says we should...." In addition, the captain testified that nonprecision approaches need much more carefully managed airplane crew and checklist management because many CFIT accidents occur when the crew is preoccupied or distracted by other tasks.

The captain stated that 70 percent of the CFIT accidents occurred on final approach and that most of these aircraft were "...in line with the runway." The captain also stated that "...many accident aircraft [were] underneath the three-degree glideslope [of a precision approach]." Figure 10 shows vertical profile information that was available from the 40 CFIT accidents and incidents that occurred between 1986 and 1990, as prepared by Boeing and provided by the FSF's CFIT Awareness Task Force.

Figure 10. Vertical profile information from the 40 CFIT accidents and incidents between 1986 and 1990.

Reproduction courtesy of The Boeing Company and the Flight Safety Foundation's Controlled Flight Into Terrain Awareness Task Force.

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Rh


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 The captain stated his belief that no single measure or piece of aircraft equipment can prevent CFIT accidents and that a range of measures suited to a particular operator and operating environment is needed. The captain added that ICAO has planned a series of CFIT-related actions, including the following:

 * the adoption of colored terrain and minimum safe altitude contour presentation on approach procedure charts to improve their readability and understanding by a flight crew, particularly in the cockpit environment at night;
 * new requirements and new emphasis on standard operating procedures (specifically, altitude awareness procedures), including the use of standard or automated callouts, guidance on the use of autopilot, and the incorporation of stabilized approach procedures concepts;
 * changes to instrument approach procedure design, including the optimum angle for nonprecision approaches and the application of vertical navigation (VNAV) or FMS during nonprecision approaches; and
 * the translation of the FSF's Education and Training Aid (see section 1.18.3.3) from English into the other five languages used by ICAO.

1.18.3.3 Controlled Flight Into Terrain Training Aids

The Boeing Commercial Airplanes Group, along with the FAA, and the FSF have developed and published CFIT educational materials and training aids for use by operators. The purpose of each aid is to heighten flight crew awareness to CFIT precursors and the methods and techniques to avoid this type of accident.

The Boeing/FAA CFIT Education and Training Aid, which became available to air carriers in 1997, is presented in five sections. According to the FAA, this training aid, along with a new videotape, was distributed to all 14 CFR Part 121 and 135 operators for inclusion in their training programs. Section one provides a broad overview for airline executives of CFIT problems and possible solutions. Section two, titled "A Decision Maker's Guide," describes airline operations, aviation industry regulators, and industry efforts to eliminate CFIT. Section three, titled "An Operator's Guide," describes causal factors of CFIT accidents, the traps in which flight crews can find themselves, and specific in-flight escape maneuvers. Section four describes a model CFIT airline education program. Section five provides additional background information on CFIT and references selected reading materials and accident and incident information.

The FSF's CFIT Task Force developed a CFIT checklist in 1993 to aid in the avoidance of CFIT accidents. The checklist was designed so that the user, before a flight, could evaluate the risk factors and identify the potential for a CFIT accident. For example, the checklist indicated that flying in night IMC significantly increases the risk of a CFIT accident occurring. The checklist is divided into two diagnostic parts. The first part, titled "CFIT Risk Assessment," includes negative destination CFIT risk factors, such as VOR/DME approaches, airports near mountainous terrain, and radar coverage limited by

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 terrain masking. Further, this assessment evaluates risk multipliers, such as IMC weather and extended crew duty days. The second part, titled "CFIT Risk Reduction Factors," includes positive company management traits and the availability of CFIT training programs.

1.18.3.4 Previous Safety Board Recommendations Related to Controlled Flight Into Terrain

Since the early 1970s, the Safety Board has issued numerous safety recommendations to the FAA in response to CFIT accidents, including those discussed as part of the GPWS and enhanced GPWS recommendations in section 1.18.2.4 and approach procedure design recommendations in section 1.18.4.4. This section provides information on other CFIT-related safety recommendations. On December 20, 1995, the American Airlines flight 965 accident near Cali, Colombia, occurred.

On October 16, 1996, the Safety Board issued Safety Recommendations A-96-93 through -95, A-96-102, and A-96-106 as a result of the findings from this accident investigation.

Safety Recommendation A-96-93 asked the FAA to

Evaluate the terrain avoidance procedures of air carriers operating transportcategory aircraft to ensure that the procedures provide for the extraction of maximum escape performance and ensure that those procedures are placed in procedural sections of the approved operations manuals.

On April 23, 1997, the FAA stated it agreed with the intent of Safety Recommendation A-96-93 and that it had completed its efforts to evaluate terrain avoidance procedures. The FAA stated that, in January 1997, it developed and published the CFIT Education and Training Aid along with Boeing (see section 1.18.3.3). The FAA also stated that, on February 25, 1997, it issued a revision (Change 2) to AC-120-51B, "Crew Resource Management," Appendix 3, "Appropriate CRM Training Topics," paragraph 2(1), to recommend that CRM training in LOFT or Special Purpose Operational Training for flight crewmembers contain a CFIT scenario. According to the FAA, this paragraph recommends that the training should emphasize prevention through effective

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 communication and decision behavior and the importance of immediate, decisive, and correct response to a ground proximity warning.

On November 13, 1997, the Safety Board acknowledged the progress made by the FAA but noted that the FAA's response did not address whether the escape/terrain avoidance procedures would be included in the procedural sections of approved operations manuals. Pending further information from the FAA, Safety Recommendation A-96-93 was classified "OpenAcceptable Response."

On August 11, 1999, the FAA stated that it would issue a flight standards information bulletin that directed POIs to ensure that the aircraft-specific procedure for maximum escape performance (as depicted in the CFIT training aid), or an equivalent of that procedure, was contained in each appropriate FAA-approved operations manual. The FAA indicated that it planned to issue the bulletin by the end of August 1999.

On October 20, 1999, the FAA indicated that it had issued Flight Standards Information Bulletin for Air Transportation 99-08, "Controlled Flight Into Terrain (CFIT) Training," on October 5, 1999. According to the FAA, the bulletin announces the publication of the CFIT Education and Training Aid and informs POIs that the training aid is posted on the FAA's Web site. The FAA stated that the bulletin also directs POIs to ensure that the aircraft-specific procedure for maximum escape performance is contained in each appropriate FAA-approved operations manual.

Safety Recommendation A-96-94 asked the FAA to

Require that all transport-category aircraft present pilots with angle-of-attack information in a visual format and that all air carriers train their pilots to use this information to obtain maximum possible airplane climb performance.

On December 31, 1996, the FAA stated that it had begun an evaluation to assess the operational requirements for an angle-of-attack indicator. The FAA indicated that the evaluation should be completed by March 1997.

On April 11, 1997, the Safety Board stated its understanding that the FAA's assessment would include implementation and training requirements, the complexity and cost of the system, and other functions and would indicate the angle-of-attack for maximum rate climb. The Safety Board also stated its understanding that, if angle-ofattack indicators were warranted, the FAA would take appropriate regulatory action. Pending an evaluation of the FAA's completed action, Safety Recommendation A-96-94 was classified "OpenAcceptable Response."

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Factual Information On May 4, 1999, the FAA stated that it had evaluated the requirements for the display of angle-of-attack information to obtain the maximum airplane climb performance. The FAA indicated that angle-of-attack information during an escape maneuver could provide some improvement in climb performance but that the prevention of terrain escape maneuvers would provide much greater safety benefit than the climb performance improvements gained by the display of angle-of-attack-information.

The FAA indicated that it had reviews CFIT accidents and analyses of CFIT accident data prepeared by various organisations. The FAA stated that its review found that accdients haveonly rarely been cuased by failure to obtain the maximum possible airplane climb performance during the ground proximity escape maneuver. Thus, the FAA believed that more effective prevention of CFIT accidents would yield the greatest saftey benefit.

The FAA cited initiative to prevent CFIT accidents, including TAWS and the use of FMS with VNAV capability for constant angle of descent approaches. The FAA believed that these initatives would greatly improve pilots' situational awareness with regard to terrain and would directly reduce the likelihood that pilots using these systems would need to perform a ground proximity escape maneuver. Further, the FAA belived that the safety gains from improvements in escpae maneuver climb performance, gained by the intorductionof angle-of-attack information, would be overshadowed by the safety gains from the implementation of TAWS, especially when that system is combined with other technologies, such as FMS with VNAV capability and GPS.

Reagrding the training position of Safety Recommendation A-86-94, the FAA stated that it was revising air carrier pilot training requirements contained in 14 CFR Part 121 to include mandatory training in the ground proximity escape maneuver recommended by manufacturers for their specifc airplane(s). The FAA indicated that one objective of this training would be to improve pilot actions in achieving maximum airplane climb performance during the escape maneuver. In addition, the FAA stated that the regulatory proposal would refer to the guidance in the CFIT Education and Training Aid, which provides instructions on how to achieve the optimum angle-of-attack (given the indications available in the airplane) and the manufacturers' recommended ground proximity escape maneuvers.

 * Saftey Recomendation A-96-95 asked the FAA to
 * Develop a controlled flight into terrain training program that includes realistic simulator exercises comparable to the successful windshear and rejected takeoff training programs and make training in such a program mandatory for all pilots operating under 14 CFR Part 121.

On April 23, 1997, the FAA stated it agreed with the intent of Safety Recomendation A-96-95 and that it had completed its efforts to evaluate terrain avoidance procedures. The FAA stated that, in January 1997, it developed and published the CFIT Education and Training Aid along with Boeing. The FAA also stated that, on February 25, 1997, it issued Change 2 to AC-120-51B Appendix 3, paragraph 2(1) to

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