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 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 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 indicate that the newly developed CFIT training program was mandatory, as urged by the recommendation. Pending further information from the FAA, Safety Recommendation A-96-95 was classified "Open-- Acceptable Response."

On August 11, 1999, the FAA stated that it had initiated an NPRM proposing to mandate training in CFIT, including flight training in simulators and the ground proximity escape maneuver. The FAA indicated that the NPRM was expected to be published in December 2000.

The Safety Board's evaluation and classification of Safety Recommendation A-96-95 are discussed in section 2.8.

Safety Recommendation A-96-102 asked the FAA to Require that all approach and navigation charts graphically present terrain information.

On December 31, 1996, the FAA stated that it agreed with the intent of this recommendation. However, the FAA stated that it was not necessary to depict terrain on IFR en route low-altitude charts because the off-route obstruction clearance altitudes adequately presented terrain and obstruction clearance information. In addition, the FAA indicated that the Government/Industry Charting Forum, chaired by the FAA's Air Traffic Service, was evaluating the possibility of adding terrain information (contour lines and shading) graphically on approach charts.

On April 11, 1997, the Safety Board stated that, although the FAA's action regarding approach charts was appropriate, the Board did not agree with the FAA that current off-route obstruction clearance altitudes adequately presented terrain and obstruction clearance information. The Board reiterated that the intent of this recommendation was to have terrain information graphically presented on all approach and navigation charts.

On February 19, 1998, the FAA stated that the Task Group 31 from the Air Cartographic Committee (a Government interagency and aviation industry committee) was evaluating the possibility of adding contour lines and shading on the plan view

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 portion of approach charts for terrain-impacted airports only. The FAA also stated its belief that the addition of contour lines and tinting to IFR en route charts has not been supported by users and industry personnel and that sufficient information on en route charts obviates the need for such changes. Further, the FAA stated that overlaying additional information into charts that already contained a considerable amount of information could diminish the clarity of existing information on those charts.

On September 3, 1998, the Safety Board stated that the points the FAA raised with regard to adding information to en route charts were valid. However, the Board noted that these concerns did not apply to terminal navigation charts and approach charts. The Safety Board continued to believe that the FAA should do all it can to enhance pilots' situational awareness regarding proximity to terrain and that adding readily interpretable terrain information to navigation charts would be an economical way to accomplish this goal.

The Safety Board indicated that it would await FAA action regarding approach charts after the efforts of Task Group 31 were completed. Because the FAA appeared unwilling to require that terminal charts graphically portray terrain information to help prevent CFIT accidents, Safety Recommendation A-96-102 was classified "Open-- Unacceptable Response."

On July 7, 1999, the FAA stated that it met with the Safety Board on March 12, 1999, to clarify the intent of this safety recommendation and discuss the issue of adding terrain contours to all charts. At this meeting, the FAA indicated that it would consider placing terrain contours only on en route area charts. According to the FAA, this plan was proposed in April 1999 at the Government/Industry Aeronautical Charting Forum, which endorsed the proposal. The FAA stated that it was developing funding requirements with the National Oceanic and Atmospheric Administration and that, pending funding approval, it would submit a requirements document to the Interagency Air Cartographic Committee to amend the chart specifications to add terrain contours to en route area charts. The FAA also stated that it was planning to add terrain contours on instrument approach procedure charts for terrain-impacted airports.

On September 24, 1999, the Safety Board stated that, on the basis of the FAA's commitment to consider adding terrain contours to en route area charts only, Safety Recommendation A-96-102 was classified "OpenAcceptable Alternate Response."

Safety Recommendation A-96-106 asked the FAA to

Revise Advisory Circular 120-51B to include specific guidance on methods to effectively train pilots to recognize cues that indicate that they have not obtained situational awareness, and provide effective measures to obtain that awareness.

On December 31, 1996, the FAA stated that it would fund a research project to determine cues that flight crewmembers could readily recognize to indicate situational awareness problems. According to the FAA, this project would focus on developing specific cues for situational awareness in automated cockpits. The FAA indicated that, as soon as this project was completed, it would revise AC 120-51B to include guidance on

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 training flight crews in cue recognition. On April 11, 1997, the Safety Board stated that it was waiting to evaluate the FAA's revised version of AC 120-51B.

On August 3, 1998, the FAA stated that the results of its research project were outlined in a report, titled Guidelines for Situation Awareness Training, which was published in February 1998. According to the FAA, the report included an overview, specific training tips, and sample training courses for use by the aviation community. The FAA indicated that it would incorporate guidance on cue recognition training for flight crewmembers in AC 120-51B. On November 2, 1998, the Safety Board restated that it would wait to evaluate the FAA's revised version of AC 120-51B.

On December 11, 1998, the FAA stated that, on October 30, 1998, it issued AC 120-51C, "Crew Resource Management Training," a revision to AC 120-51B. The FAA stated that Appendix 3, "Appropriate CRM Training Topics," paragraph 2(m), specifically addressed training for pilots in recognizing cues that indicate lack or loss of situational awareness in themselves and others and training in countermeasures to restore that awareness. According to the FAA, paragraph 2(m) reiterates that training should emphasize the importance of recognizing each pilot's relative experience level, experience in specific duty positions, preparation level, planning level, normal communication style and level, overload state, and fatigue state. Further, the FAA stated that training should emphasize that improper procedures, adverse weather, and abnormal or malfunctioning equipment might reduce situation awareness. In addition, the FAA stated that AC 120-51B references the Guidelines for Situation Awareness Training report because of the AC's expanded guidance on cues and countermeasures.

On March 1, 1999, the Safety Board stated that the amendments to AC 120-51B, which resulted in the issuance of AC 120-51C, met the intent of this recommendation. Accordingly, Safety Recommendation A-96-106 was classified "Closed-- Acceptable Action."

1.16.3.5 Previous Controlled Flight Into Terrain Accidents Related to Nonprecision Instrument Approach Procedures

As stated in section 1.18.3.2, accident data has shown that the chances of a CFIT accident occurring during a nonprecision approach is five times greater than during a precision approach. In addition to the CFIT events discussed previously (including the USAir flight 105 incident in Kansas City, Missouri, and the American Airlines flight 965 accident in Cali, Colombia) and in section 1.18.4.4 (American Airlines flight 1572 in East Granby, Connecticut), the Safety Board has investigated the following CFIT accidents that occurred while the airplane was on a nonprecision approach:

On February 18, 1989, a Flying Tigers Boeing 747-200, operating as a cargo flight under 14 CFR Part 121, crashed while on an NDB approach to Subang International Airport in Kuala Lumpur, Malaysia. Night visual conditions prevailed around the airport at the time of the accident. All four airplane occupants were killed, and the airplane was destroyed. The investigation into this accident was being conducted by the Department of Civil Aviation of the Government of Malaysia with the assistance of the Safety Board.

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428 The party, on the conclusion of Mr. Seward's remarks, were escorted to the house of the Prefecto for a brief rest. At 2, the bands drew up in front of the house, and the party, escorted as before by the whole population, started for the fine old parochial church of Cholula, the second in age in Mexico. This church, though of enormous size and surrounded by an immense flagged court or plaza, is not to be compared to many others in the country for magnificence. In style it is purely Moorish and quite unique. There are fifty-six low Moorish arches, supported by sixty-four columns painted in brilliant lime colors, and the altar and other appurtenances are all curiously antique in style and character. There are, of course, many old pictures, but none of them struck me as particularly fine. The church was commenced in 1530, and stands to-day exactly as it was finished more than three and a quarter centuries ago.

The scene on the entry of the party to the church, was worthy the pencil of a painter, and curiously illustrative of time's revenges. Where Cortez and his companions had bowed the knee, and knelt with uncovered heads when the Host was raised above the multitude, came an old grey-headed statesman, from a land then unknown, who had slept in Maximilian's bed the previous night, walking by the side of a descendant of those who crucified the Savior on Mount Calvary, and escorted by the authorities of this ancient strong-hold of the Faith, while an American—Col. Green—with pale, sharp-cut, representative face, and, tall, slender figure, clad in the uniform of the Mexican Army, led on the band of swarthy Aztecs, who were playing with a will, the "March of Zaragoza," an air as obnoxious to


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 On June 2, 1990, about 0937 Alaskan daylight time, Markair, Inc., flight 3087, a Boeing 737-2X6C, N670MA, operating under 14 CFR Part 121, crashed about 7 ? miles short of runway 14 at Unalakleet, Alaska, while executing a localizer-only approach in IMC. One flight attendant received serious injuries; the captain, the first officer, and a flight attendant received minor injuries; and the aircraft was destroyed. The Safety Board determined that the probable cause of the accident was deficiencies in flight crew coordination, the crew's failure to adequately prepare for and properly execute the localizer-only runway 14 nonprecision approach, and the crew's subsequent premature descent. On April 3, 1996, a U.S. Air Force CT-43A (737-200) carrying the Secretary of Commerce, other Government officials, and a delegation of business executives crashed on a mountainside while on an NDB approach to Cilipi Airport in Croatia. All 35 people aboard the airplane were killed. The Safety Board provided technical assistance to the Air Force during its investigation.

1.18.4.1 Nonprecision Approach Procedures According to the Air Line Pilots Association (ALPA), limited data indicate that airline transport crews conduct only about one to three nonprecision approaches per year and practice these approaches in a simulator "just as infrequently." Thus, ALPA concluded that the risk associated with this "inherently less safe type of approach" is compounded by the infrequency of flight crew exposure and practice. ALPA stated that most nonprecision approaches are presented in a series of step-down altitudes and that, although step-down altitudes may be satisfactory for light, slow, maneuverable aircraft, they are unacceptable for transport-category aircraft. ALPA further stated that these step-down altitudes are in fact directly contrary to the underlying concept of the stabilized approach because they require multiple power and pitch changes to be flown as charted. ALPA believed that approach charts and procedures should be modified to provide the information necessary to conduct a stabilized descent without explicit vertical guidance.

The issue of nonprecision approaches flown by air carrier (primarily turbojet) airplanes has been debated, especially in light of the recent CFIT accidents that occurred during the execution of a nonprecision approach. ALPA stated that "all turbojet air carrier airports need to have a precision approach available at all times in the appropriate landing direction." Further, ALPA believed that it is "problematic at best" for a "500,000 pound

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 aircraft to transition from level flight (at MDA) and very high thrust settings, to a stabilized approach and touchdown in 15 to 20 seconds (the distance covered in one mile visibility at 180 knots)" because of the size of the aircraft and approach speeds at which the nonprecision approaches are flown.

1.18.4.2 Approach Chart Terrain Depiction

According to testimony at the Safety Board's public hearing by the Senior Corporate Vice President of Flight Information Technology and External Affairs for Jeppesen Sanderson, Inc., approach chart manufacturers use various methods to depict obstructions and high terrain on published approach charts. Some en route charts and the plan view of some terminal approach charts use contour lines and color shading to depict various height gradients with symbols for high obstructions. Other charts use broader colored areas for terrain depiction and specify a minimum sector altitude for obstacle clearance in segmented areas around the airport. In some instances, terrain may be depicted on the plan view of some approach charts but not on other charts published by the same manufacturer.

Currently, no chart publisher depicts terrain or obstructions on the profile view, which depicts the inbound course descent profile from the IAF to the landing or MAP. Further, the FAA Terminal Instrument Procedures (TERPS) manual contains no requirement for a standardized format that chart manufacturers must adhere to when depicting terrain on an approach chart, except for the requirement to depict the height of certain obstructions.

The Jeppesen Sanderson official testified that "the Agana ILS 6 Left approach did not have terrain [depicted on the chart]...because through the agreements that we've had with our airlines, seminars in the airline community, as well as a lot of the general aviation input, it is believed by Jeppesen that...there should be criteria because you don't want terrain to be on all charts; you want it there when it's significant." The official added that, for Jeppesen to depict terrain on a chart, there needs to be at least one elevation that is 4,000 feet or greater above the airport in at least one plan view of the airport or, if there is one elevation that is 2,000 feet above the airport within 6 miles, then contour lines need to start at the nearest 1,000 feet to the airport elevation and appear at 1,000-foot intervals all the way up to the top altitude that is depicted.

The Jeppesen official's testimony discussed the difficulties of obtaining accurate worldwide terrain data through public sources. The official said that inaccurate information was one of several reasons for not providing terrain information on the charts. The official further stated that there are many sources for terrain information but that the information needs to be publicly available so that chart manufacturers can have ready access.

The Chief Engineer of Flight Safety Systems at AlliedSignal, Inc., testified at the Safety Board public hearing about the acquisition and accuracy of terrain data. The official indicated that terrain data needs to be collected to build the database not only for chart manufacturers but also for companies that are incorporating such data into enhanced

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Rh the strict high church party, as is the Marseillaise to Napoleon III. The tall form of Mr. Nelson, the United States Minister, towered above the crowd behind; by his side walked General Slaughter—late of the Confederate army—or of the late Confederate army—and after them came a crowd of Californians whose devotion to the cause of liberty is undoubted, but whose religious convictions of any kind, never deprived them of their capacity for imbibing champagne, nor kept them awake at night. A thousand curious natives followed, and seemed to heartily enjoy the entertainment.

After a half-hour spent in viewing the old church, the party started to ascend the great pyramid, which stands on the outskirts of the town, but five minutes' walk from the church. All the world knows at this day all that anybody knows, of the history of this pyramid. That it dates back to the days when the people of Egypt were erecting the pyramids which still form the land-marks in the Valley of the Nile, cannot be doubted, and that it upheld a heathen temple, and was drenched with the blood of thousands on thousands of the human race, offered up as sacrifices to savage gods, is, unfortunately, too well authenticated. The pictures I have seen of the pyramid give no clear idea of it, as they represent the sides and angles of the terraces, as too sharp and well defined. I think, that at no time since the conquest has the pyramid presented an appearance much different from what it does at present.

One of the gentlemen in attendance on the Governor told me that the pyramid covered a space equal to a little more than forty-three acres at the base, and that its height was one hundred and seventy-nine feet, English, or thereabouts. I should, at a venture, have


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 GPWS or TAWS. The official also testified that some countries still consider terrain data to be a military secret.

1.18.4.3 Federal Aviation Administration Form 8260

FAA Form 8260 provides charting companies with information for publishing instrument procedures. This form includes data for the terminal area and final and missed approach standards. The manager of the FAA's Western Flight Procedures Development Branch testified at the Safety Board's public hearing that the FAA distributes approach procedures to industry user groups (including ALPA, the Air Transport Association, and the Aircraft Owners and Pilots Association) and airport operators for comment. The manager testified that the user groups receive information that describes the approach in words or numbers and does not depict the proposed published approach. According to ALPA's submission, the information that the FAA releases "bears no resemblance to the final user product," which "seriously hampers the ability to readily and effectively critique the proposed approach procedure."

1.18.4.4 Previous Safety Board Recommendations Related to Approach Procedure Design

On November 12, 1995, American Airlines flight 1572, a McDonnell Douglas MD-83, N566AA, collided with trees in East Granby, Connecticut, while on final approach to runway 15 at Bradley International Airport in Windsor Locks, Connecticut. The airplane then landed safely at the airport. Of the 78 airplane occupants, 1 passenger received minor injuries during the emergency evacuation. The Safety Board determined that the probable cause of this accident was the flight crew's failure to maintain the required MDA until the required visual references identifiable with the runway were in sight. As a result of its investigation, the Board issued Safety Recommendations A-96-128, A-96-129, and A-96-131 through -133 on November 13, 1996.

Safety Recommendation A-96-128 asked the FAA to

Evaluate Terminal Instrument Procedures design criteria for nonprecision approaches to consider the incorporation of a constant rate or constant angle of descent to minimum descent altitude in lieu of step-down criteria.

On February 24, 1997, the FAA stated that it would begin implementation of instrument approach development proposals in late 1997. On June 26, 1997, the Safety Board stated that it was waiting to review the pending FAA proposals in response to this recommendation. On January 28, 1998, the FAA stated that it developed draft criteria to provide a constant angle of descent for aircraft with area and vertical navigation and that these criteria were incorporated into a draft order, which was being coordinated with

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 industry. The FAA anticipated that the final order would be published in June 1998. On April 15, 1998, the Safety Board stated that it would wait to review the final order.

On August 7, 1998, the FAA stated that, on February 13, 1998, it issued a revision (Change 17) to Order 8260.3B, "United States Standard Terminal Instrument Procedures (TERPS)," which requires descent angles and descent gradients to be computed for nonprecision approaches by the FAA and subsequently depicted on aeronautical charts supplied by the National Ocean Service. The FAA indicated that the angles and descent gradients would be integrated during biennial reviews of each instrument approach procedure. According to the FAA, Change 17 states that the optimum gradient on the final approach segment is 318 feet per nautical mile, which approximates a 3° descent angle and allows VNAV-equipped aircraft to perform a stabilized descent on final approach using a computed VNAV path. Depiction of a descent gradient allows pilots to determine a target rate of descent to be maintained to fly a stabilized final approach path. Change 17 also addresses the elimination of a step-down fix through manipulation of either the FAF altitude/location or the step-down fix altitude/location. When use of the step-down fix cannot be avoided, the descent angles are provided for the portion of the final segment from the step-down fix to the runway threshold.

Additionally, the FAA stated that, on May 26, 1998, it issued Order 8260.47, "Barometric Vertical Navigation (VNAV) Instrument Procedures Development." According to the FAA, this order contains criteria for design of stand-alone area navigation approaches using barometric VNAV guidance on the final approach segment. Approaches so designed are to specify the vertical path angle from the FAF to the runway threshold. In addition, the MDA of a conventional nonprecision approach has been replaced by a decision altitude. The FAA stated that the use of a decision altitude was authorized because an allowance has been made for height loss during a missed approach and an obstacle assessment has been conducted of the visual segment (runway threshold to decision altitude point) and found to be clear of obstructions.

Because the new standards met the intent of Safety Recommendation A-96-128, it was classified "ClosedAcceptable Action" on December 8, 1998.

Safety Recommendation A-96-129 asked the FAA to

Examine and make more effective the coordinating efforts of the flight inspection program and the procedures development program, with emphasis on ensuring quality control during the development, amendment, and flight inspection process for instrument approaches.

On February 24, 1997, the FAA said that it had established a test program to ensure interaction between the flight inspection program and the procedures development program. On June 11, 1997, the FAA stated that it completed its first test program to ensure interaction between the flight inspection program and the procedures development program. According to the FAA, the test program involved the placement of a liaison position (effective March 16, 1997) in the flight inspection central operations office to respond to queries and ensure resolution of all issues. The FAA added that the individual

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 in this position served as a focal point for the two offices to correct discrepancies found during flight, enhanced the interaction between the offices, conveyed information to flight inspection crews, and ensured standardization.

On September 8, 1997, the Safety Board stated that the actions taken to effectively coordinate the functions of the procedures development and flight inspection programs had satisfied the intent of the recommendation. Therefore, Safety Recommendation A-96-129 was classified "ClosedAcceptable Action."

Safety Recommendation A-96-131 asked the FAA to

Include a more comprehensive set of guidelines concerning precipitous terrain adjustments in the Terminal Instrument Procedures (FAA Order 8260.3B) Handbook, clarifying the definition of precipitous terrain and establishing defined criteria for addressing the potential effect of such terrain.

On January 28, 1998, the FAA stated that it was developing a plan to revise the guidelines concerning precipitous terrain adjustments currently contained in the TERPS handbook. The FAA noted that it received appropriate funding and negotiated a contract with the National Center for Atmospheric Research to develop a plan to address this recommendation. The FAA expected that it would be provided with the findings of the center's effort by the end of fiscal year 1998. On April 15, 1998, the Safety Board indicated that it would await further information from the FAA.

On June 17, 1999, the FAA stated that it was continuing its efforts to revise the guidelines concerning precipitous terrain adjustments currently contained in the TERPS Handbook. According to the FAA, the National Center for Atmospheric Research developed a prototype software package that examines digital terrain elevation data from the Defense Mapping Agency's terrain elevation database. This software uses weighted parameters to determine if the terrain underlying the primary, secondary, and buffer area approach segments are high, steep, or rough enough to be considered precipitous. The output of this software specifies the minimum adjustment to the required obstacle clearance for precipitous terrain in each segment. The FAA indicated that the TERPS Handbook would be revised to require the use of this software in identifying precipitous terrain and determining the minimum required adjustment for such terrain. On August 20, 1999, the Safety Board stated that, pending final modification of the TERPS Handbook, Safety Recommendation A-96-131 was classified "OpenAcceptable Response."

Safety Recommendation A-96-132 asked the FAA to

Review and evaluate the appropriateness of the let-down altitudes for all nonprecision approaches that have significant terrain features along the approach course between the initial approach fix and the runway. Airline safety departments and pilot labor organizations, such as the Allied Pilots Association and the Air Line Pilots Association, should be consulted as part of this review.

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 On December 30, 1997, the FAA said that it established a mandatory review for significant terrain features as part of its biennial review process. The FAA stated that Order 8260.19C, "Flight Procedures and Airspace," section 8, includes procedures for reviews of instrument procedures, which are to be conducted every 2 years or more frequently when deemed necessary. According to the FAA, the reviews are to be conducted in accordance with Order 8260.3B, "United States Standard Terminal Instrument Procedures (TERPS)," chapter 3, "Takeoff and Landing Minimums." Paragraph 323a, "Precipitous Terrain," states that "when procedures are designed for use in areas characterized by precipitous terrain, in or outside of designated mountainous area, consideration must be given to induced altimeter errors and pilot control problems which result when winds of 20 knots or more move over such terrain." The paragraph also states that, for areas in which these conditions are known to exist, the required obstacle clearance in the final approach segment should be increased.

The FAA added that Order 8260.19C stated that user comments should be solicited to obtain the best available local information to ensure that requirements for obstacle clearance, navigational guidance, safety, and practicality were met. The FAA also indicated that, on June 2, 1997, it reemphasized the procedures to be followed when conducting a periodic review of an instrument procedure. According to the FAA, the procedures require that obstacles, including terrain, be considered as potential precipitous terrain when developing or amending a standard instrument approach procedure and that these obstacles are to be evaluated and appropriate adjustments are to be made according to existing FAA orders and guidelines. The procedures also require that discussion and coordination with the users, airline safety departments, and pilot labor organizations are included in the review process.

On April 7, 1998, the Safety Board noted that the FAA had established a mandatory review for significant terrain features as part of its biennial review process. The Board also noted that the FAA had reemphasized that these procedures be followed when conducting a periodic review of an instrument procedure. Because these actions met the intent of Safety Recommendation A-96-132, it was classified "ClosedAcceptable Action."

Safety Recommendation A-96-133 asked the FAA to

Solicit and record user comments about difficulties encountered in flying a particular approach to evaluate approach design accurately.

On February 24, 1997, the FAA stated that it would "invite airspace users to comment on dangerous approaches." On June 11, 1997, the FAA said that it had sent letters to various organizations, including the Allied Pilots Association, ALPA, the Air Transport Association, and the Aircraft Owners and Pilots Association, to request comments and concerns from their members regarding instrument flight procedures.

On September 8, 1997, the Safety Board stated that it had received copies of the letters from the industry organizations that had responded to the FAA's letter. Because the

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430 the size of the base at less than half that stated, and the height at nearly double the figures given, but presume that accurate measurements must have been made at some time, and its real dimensions are probably known. The lower terrace is quite perfect, but the upper ones have become so washed by the rains and disturbed by the great trees which have taken root in the soil, that they are traceable, with certainty, only in a few places. A winding or zig-zag pathway, some thirty feet in width, and paved with lava, leads up to the summit of the pyramid. The old Spanish Zealots erected a Christian Church on the ruins of the ancient heathen temple, and that, too, becoming dilapidated and untenable with the lapse of years, was pulled down, and a new and very tasteful chapel, erected altogether by the labor of native Indian craftsmen, is now being finished, and will soon be dedicated to the service of the Christian's God. With the vanity of the human race, this pyramid has been selected, also, for a burial place, and we saw several new graves on the upper terrace, in the soil which has been soaked, time and time again, with the blood of human sacrifices.

Two immense cedar trees, which must have been standing on the summit in the days of Cortez, were cut down, or hopelessly mutilated by the workmen engaged in erecting the new chapel, and our party carried off numerous samples of the wood as souvenirs of their visit.

It has been the commonly accepted theory of the origin of the Pyramid of Cholula, that it was built as a temple and place for human sacrifice, altogether by the hand of man; but while standing on its summit, and


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 FAA's effort met the intent of Safety Recommendation A-96-133, it was classified "Closed--Acceptable Action."

1.18.5.1 Safety Board Study of Flight Crew Involvement in Major Accidents

In a 1994 safety study, the Safety Board examined the operating environments and errors made by flight crewmembers in 37 major accidents between 1978 and 1990. The safety issues examined in the report included the performance of flight crews when the captain was the PF, the performance of the PNF in monitoring and challenging errors made by the PF, and the adequacy of CRM training programs.

The study concluded that the captain was the PF in more than 80 percent of the 37 accidents reviewed. This result was significant because U.S. air carrier flights during the study's time frame were divided about equally between those flown by the captain and those flown by the first officer.

The Safety Board identified 302 flight crew errors in the 37 accidents; the median number of errors per accident was 7. Of the total number of errors, 232 were considered primary errors, and 70 were considered secondary errors. The primary error categories identified by the Safety Board included aircraft handling, communication, navigational, procedural (for example, not conducting or completing required checklists or not following prescribed checklist procedures), resource management, situational awareness (for example, controlling the airplane at an incorrect target altitude), systems operation, and tactical decision (for example, improper decision-making, failing to change a course of action in response to a signal to do so, or failing to heed warnings or alerts that suggest a change in the course of actions). Secondary errors resulted from the failure of a crewmember to monitor or challenge a primary error made by the other crewmember. Table 4 shows the distribution of the 302 errors identified in the 37 accidents by type of error.

The Safety Board's study determined that procedural, tactical decision, and resource management errors were largely errors of omission and that navigational and most of the aircraft handling, communication, and systems operation errors were errors of commission. Of the 232 primary errors identified, 123 (53 percent) were errors of omission, and 109 (47 percent) were errors of commission.

The safety study also determined that captains were responsible for 168 of the 302 identified errors. Of the 168 errors made by captains, 49 (29 percent) were tactical decision errors, the most common error type attributed to captains. The 49 tactical decision errors made by captains accounted for 96 percent of the 51 tactical decision errors made by all crewmembers, which is consistent with the captain's ultimate responsibility for decisions. The study also found that procedural (23 percent) and aircraft

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 Table 4. Distribution of errors identified in the 37 accidents reviewed in the Safety Board's 1994 safety study.

handling (20 percent) were the next most common error types made by captains. The aircraft handling errors made by captains accounted for 33 (72 percent) of the 46 aircraft handling errors made by all crewmembers, which is consistent with the captain conducting the PF duties on more than 80 percent of the accident flights reviewed in the study.

Further, the study stated that a common pattern in 17 of the 37 accidents was a tactical decision error by the captain (more than one-half of which constituted a failure to initiate a required action) followed by the first officer's failure to challenge the captain's decision. The study also concluded that, of the 49 tactical decision errors made by captains, 44 (90 percent) were made while the captain was serving as the PF and that 26 (59 percent) of these errors were errors of omission. Thus, the most common tactical decision error was the failure of a captain serving as the PF to take action when the situation demanded change. In addition, of the 26 tactical decision errors made by captains that were errors of omission, 16 (62 percent) involved the captain's failure to execute a goaround during the approach. These 16 errors were made during 10 different accident sequences. Of the 16 failures to execute a go-around, 8 involved an unstabilized approach.

The study found that the 70 monitoring/challenging errors committed by flight crewmembers occurred in 31 (84 percent) of the 37 accidents reviewed in the study and that most of these errors played very important roles in the accidents. The study concluded

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Rh looking on the grand landscape which surrounds it, a new theory suggested itself to me. The pyramids in the Valley of the Nile stand out bold and grand, the great central figures in the scene,—undwarfed by comparison with any great mountains in the vicinity. We can understand how men could seek to erect in such a locality, an enduring monument to their power and greatness. But here, in full view of Orizaba and Popocatapetl, the mightiest work of man is but a mole-hill hardly worthy of a moments notice, and even the egotism of the most barbaric nature must stand rebuked in the presence of these perfect works of the Almighty hand. I do not believe that there was ever a race on earth so vain as to erect such a monument in such a locality; and furthermore, there was no necessity for such an expenditure of time and labor as the erection of such a pile of adobe, in the Plain of Cholula, as this pyramid, if wholly artificial, would have called for. Scattered through all the valleys of Central Mexico, are detached hills, composed of washed gravel and earth, equal or superior in size to this pyramid. You can see a number of them from the point where we stood.

It seems to me quite probable that one of these hills stood here where the Cholulans built their city; and that in order to fit it for use as a temple, they merely cut away the sides, and terraced it into its pyramidal form. The angles and faces of the terraces thus formed, must be protected from the effects of the storms, which would soon wash down the entire mound, and so they faced it over with adobes, laid up with care and intermixed with lava, which soon became a solid, concrete mass, as we see it to day. The adobes and layers of lava are perfect at many points, but in other places,


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 that the highest percentage of the unmonitored/unchallenged errors were tactical decision errors (40 percent).

In addition, the study found that, of the 15 accidents for which information was available, 11 (73 percent) occurred during the first duty day together for the captain and first officer. Of the 16 accidents for which data were available, 7 (44 percent) occurred during the crewmembers' first flight together. According to the study, these rates are substantially higher than the percentage of crews who would be expected to be paired for the first time on any given flight or day.

Finally, the study examined the effect of the length of time since awakening (TSA) on the errors committed by flight crewmembers in the accident sequence. The performances of flight crews in which both the captain and the first officer had been awake a long time (average TSA length, 13.6 hours) were compared with flight crews in which both the captain and the first officer had been awake a short time (average TSA length, 5.3 hours). The Safety Board found that both the number and type of errors made by the flight crews varied significantly according to the TSA length. Specifically, high TSA crews made an average of 40 percent more errors (almost all of which were errors of omission) than low TSA crews.

High TSA crews made significantly more procedural errors and tactical decision errors than low TSA crews. These results suggested that the degraded performance by high TSA crews tended to involve ineffective decision-making (such as failing to perform a missed approach) and procedural slips (such as not making altitude awareness callouts) rather than a deterioration of aircraft handling skill. Also, the number and types of errors made by the flight crews varied according to the TSA length before the accident. The median TSA periods were quite high: 12 hours for captains and 11 hours for first officers. Those pilots who had been awake longer than the median TSA length for their crew position made more decision-making errors and procedural errors than pilots who had been awake for less time.

1.18.5.2 Previous Safety Recommendations on Flight Crew Decision-making

On the basis of the findings of its safety study, the Safety Board issued Safety Recommendations A-94-3 and A-94-4 on February 3, 1994. Safety Recommendation A-94-3 asked the FAA to

Require U.S. air carriers operating under 14 CFR Part 121 to provide, for flight crews not covered by the Advanced Qualification Program, line operational simulation training during each initial or upgrade qualification into the flight engineer, first officer, and captain position that (1) allows flight crews to practice, under realistic conditions, nonflying pilot functions, including monitoring and challenging errors made by other crewmembers; (2) attunes flight crews to the }}

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 hazards of tactical decision errors that are errors of omission, especially when those errors are not challenged; and (3) includes practice in monitoring and challenging errors during taxi operations, specifically with respect to minimizing procedural errors involving inadequately performed checklists.

On April 26, 1994, the FAA stated that it was amending AC 120-51A, "Crew Resource Management," to emphasize the areas detailed in the recommendation. On July 6, 1994, the Safety Board noted that including the recommendation's material in an AC would be an acceptable alternative to regulatory change. However, on May 8, 1995, the Safety Board expressed disappointment that the revised AC 120-51B (issued on January 3, 1995) made no specific reference to practicing PNF procedures, such as monitoring and challenging the errors of the other pilots, during line-oriented simulation training. Likewise, the AC contained no specific references to line-oriented simulation training in the areas of monitoring and challenging tactical decision errors or inadequately performed taxi checklist procedures.

On September 8, 1995, the FAA issued a revision (Change 2) to AC 120-51B. On January 16, 1996, the Safety Board stated that the revised AC's reference to line operational simulation was responsive to all aspects of Safety Recommendation A-94-3. The provisions for PNF functions, monitoring and challenging of errors made by other crewmembers, tactical decision errors that are errors of omission, and errors made during taxi operations would achieve the Board's objectives as an alternative to the regulatory change that was originally proposed. Therefore, Safety Recommendation A-94-3 was classified "ClosedAcceptable Alternate Action."

Safety Recommendation A-94-4 asked the FAA to

Require that U.S. air carriers operating under 14 CFR Part 121 structure their initial operating experience programs to include (1) training for check airmen in enhancing the monitoring and challenging functions of captains and first officers; (2) sufficient experience for new first officers in performing the nonflying pilot role to establish a positive attitude toward monitoring and challenging errors made by the flying pilot; and (3) experience (during initial operating experience and annual line checks) for captains in giving and receiving challenges of errors.

On April 26, 1994, the FAA stated that its actions in response to Safety Recommendation A-94-3 addressed the issues referenced in this recommendation. On July 6, 1994, the Safety Board reiterated that one intent of Safety Recommendation A-94-4 was for air carriers to provide crewmembers undergoing initial operational experience (IOE) with experience specifically in the PNF role. The Safety Board believed that the FAA should, at the very least, provide guidance to air carriers on this issue in the form of an AC.

On February 28, 1995, the FAA informed the Safety Board that, on January 3, 1995, AC 120-51B, "Crew Resource Management," was issued to provide emphasis for the PNF to monitor and challenge errors and for the PF to give and receive challenges of errors. On April 24, 1995, the Safety Board expressed its disappointment that AC 120-51B

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 made no reference to the structure of IOE, PNF experience in monitoring and challenging errors during IOE and LOFT, or experience for captains in giving and receiving challenges of errors.

On June 16, 1995, the FAA stated that, on April 21, 1995, it had issued a final rule to amend the pilot qualification requirements for air carrier and commercial operators. According to the FAA, the final rule requires that second-in-command pilots obtain operating experience while performing the duties of a second-in-command under the supervision of a qualified pilot check airman. Additionally, the FAA stated that it was revising AC 120-51B to provide emphasis on the role of the PNF in monitoring and challenging errors and for captains to gain experience in giving and receiving challenges of errors. The FAA indicated that the revisions to the AC would emphasize the training of check airmen so that they would be prepared to enhance the monitoring and challenging functions of captains and first officers.

On August 29, 1995, the Safety Board stated that it was pleased that the FAA had issued a final rule that required air carriers to provide newly qualified second-in-command pilots with IOE while actually performing the duties of, rather than while observing, a second-in-command pilot. The Board was also pleased that the FAA was revising AC-120-51B. The Board believed that check airmen who receive training in enhancing the monitoring and challenging functions of captains and first officers would be able to provide more effective operating experience for newly qualified pilots if air carrier IOE programs ensured that pilots receive sufficient experience performing PNF functions while under check airman supervision.

On November 17, 1995, the FAA informed the Safety Board that it had revised AC-120B. On January 16, 1996, the Safety Board stated that the revised AC's reference to training for check airmen in methods that could be used to enhance the monitoring and challenging function of captains and first officers was responsive to Safety Recommendation A-94-4 because the check airmen would apply their CRM skills during IOE for new captains and first officers. Because the FAA's revisions to AC 120-51B satisfied the intent of Safety Recommendation A-94-4, it was classified "ClosedAcceptable Alternate Action."

1.18.5.3 National Aeronautics and Space Administration's Flight Crew Decision-making Study

Researchers at the National Aeronautics and Space Administration's (NASA) Ames Research Center conducted a study that examined the Safety Board's findings in its 1994 safety study (see section 1.18.5.1). The purpose of the NASA study was to analyze the accident data to identify any contributing factors such as "ambiguous dynamic conditions and organizational and socially-induced goal conflicts."

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 The NASA researchers reexamined the 37 accidents included in the safety study to determine the most common decision errors and any themes or patterns in the context within which the errors occurred. NASA found that the most common decision errors occurred when the flight crew decided to "continue with the original plan of action in the face of cues that suggested changing the course of action." The NASA study stated:

Clearly, more cognitive effort is needed to revise one's understanding of a situation or to consider a new course of action than sticking with the original plan whose details have already been worked out.... It appears that evidence must be unambiguous and of sufficient weight to prompt a change of plan.

With regard to ambiguity and its effect on situation assessment and decisionmaking, the NASA study stated:

Cues that signal a problem are not always clear-cut. Conditions can deteriorate gradually, and the decision maker's situation assessment may not keep pace...a recurring problem is that pilots are not likely to question their interpretation of a situation even if it is in error. Ambiguous cues may permit multiple interpretations. If this ambiguity is not recognized, the crew may be confident that they have correctly interpreted the problem. Even if the ambiguity is recognized, a substantial weight of evidence may be needed to change the plan being executed.

The study noted that stress may limit the pilot's ability to properly evaluate the situation: Reaching decision...requires projection and evaluation of the consequences of the various options. If pilots are under stress, they may not do the required evaluations.... Under stress, decision makers often fall back on their most familiar responses, which may not be appropriate to the current situation.

Further, the NASA study determined that organizational and social pressures may contribute to the high incidence of "plan continuation errors" by creating goal conflicts, which may result in decision errors in the face of ambiguous cues and high-risk situations. The study noted that organizational and social factors that have the potential to create goal conflicts with safety include pressure for on-time arrival rates, fuel economy, and avoidance of diversions to reduce passenger inconvenience.

The NASA study concluded that, to reduce pressures on pilots, operators "must be willing to stand behind their pilots who take a safe course of action rather than a riskier one, even if there is a cost associated." The study noted that integrated flight displays that present up-to-date information on dynamic variables, such as weather and traffic, could reduce the ambiguity of events flight crews might encounter and that training to help flight crews develop "strategies for choosing a course of action" would be beneficial.

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1911 Encyclopædia Britannica/Pforta

PFORTA, or, formerly a Cistercian monastery dating from 1140, and now a celebrated German public school. It is in the Prussian province of Saxony, on the Saale, 2 m. S.W. of Naumburg. The remains of the monastery include the 13th century Gothic church, recently restored, the Romanesque chapel (12th century) and other buildings now used as dormitories, lecture rooms, &c. There is also the Furstenhaus, built in 1573. Schulpforta was one of the three Fürstenschulen founded in 1543 by Maurice duke, and later elector, of Saxony, the two others being at Grimma and at Meissen. The property of the dissolved monastery provided a good revenue for the new educational foundation, which now amounts to about £15,000 a year. Free education is provided for 140 boys, the total number of pupils being 185. After being in the possession of Saxony, Pforta passed to Prussia in 1815, and since this date the school has been entirely reorganized.

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432 where the storms of thousands of years have told most strongly, they seem to have disappeared, and I thought I could recognize the original formation of the hill beneath.

A little way off from the main pyramid is a smaller one, less regular in its outline, which is supposed by many—without any good reason that I can discover—to have been originally a part of the greatest structure; and a little farther away, an oblong pile of earth, with perfectly precipitous sides, resembling in shape a wagon load of hay or straw. Both these are evidently artificial. There are no excavations in any direction for many miles around the great pyramid, from whence the vast amount of material for building it could have been taken, and the finely cultivated fields which, cut by regular streets, radiate from the pyramid in all directions, indicate that the soil and surface of the ground in the vicinity, have never been disturbed. May it not be that the Cholulans, simply cut away the sides of the original hill as I have suggested, and with the earth thus removed, formed the smaller pyramid and lesser irregular pile near by? I do not care enough for any theory on any subject, to defend this one if it is ever attacked; but it seems to me to be a rational one under all the circumstances.

Members of the Ayuntamento accompanied us to the pyramid, a servant carrying before them the silver-headed canes which serve as badges of their office. After seeing all there was to be seen on the pyramid we descended, and returning to the Prefect's house partook of an elegant collation. Toasts were given and responded to freely, and in the midst of the festivities, in marched a band, of the ancient Aztec class.


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The Safety Board has investigated several accidents in which fatigue was either the cause or a contributing factor. A discussion of two such accidents follows.

Continental Express Jet Link Flight 2733

On April 29, 1993, Continental Airlines (d.b.a. Continental Express) Jet Link flight 2733, an Embraer EMB-120RT, N24706, crashed at Pine Bluff, Arkansas, during a forced landing and runway overrun at a closed airport. The flight was a scheduled 14 CFR 135 operation from Little Rock, Arkansas, to Houston, Texas. The 2 flight crewmembers and 15 passengers were uninjured, and the flight attendant and 12 passengers received minor injuries. The accident occurred on the third day of a 3-day trip sequence, and the accident flight was the seventh and last flight of the day.

As the airplane was climbing, the captain, who was the PF, increased pitch so that the flight attendant could begin cabin service. The autoflight was set in pitch and heading modes, contrary to company policy. The airplane stalled in IMC at 17,400 feet. Initial recovery was at 6,700 feet. Because of an improper recovery procedure, a second stall occurred, and recovery was at 5,500 feet. The left propeller shed three blades, the left engine cowling separated, and the left engine was shut down in descent. Level flight could not be maintained, and a forced landing was made. The captain overshot the final turn because of controllability problems, and the airplane landed fast with 1,880 feet of wet runway remaining. The airplane hydroplaned off the runway and received additional damage. No preaccident malfunction was found.

The Safety Board's review of the captain's schedule revealed that the first day of the trip involved 9.5 hours of duty time followed by 8.5 hours of rest time (a reduced rest period). The second day of the trip involved 3.8 hours of duty time. The captain was off duty at 1130 but did not go to sleep until between midnight and 0030. On the third day of the trip, the captain awoke about 0500 for an early duty time. At the time of the accident, the captain had been awake for about 11 hours.

The first officer's flight, duty, and crew rest schedules were the same as that of the captain for the 3-day trip sequence. The first officer went to bed between 2300 and midnight on the night before the accident and awoke about 0430 on the day of the accident. The first officer had also been awake about 11 hours at the time of the accident.

The Safety Board determined that the probable cause of the accident was the captain's failure to maintain professional cockpit discipline, his consequent inattention to flight instruments and ice accretion, and his selection of an improper autoflight vertical mode, all of which led to an aerodynamic stall, loss of control, and a forced landing.

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 A factor contributing to the accident was fatigue induced by the flight crew's failure to properly manage provided rest periods.

American International Airways Flight 808

On August 18, 1993, American International Airways (d.b.a. Connie Kalitta Services, Inc.) flight 808, a Douglas DC-8-61, N814CK, was on a nonscheduled 14 CFR Part 121 operation when it crashed in at the U.S. Naval Air Station at Guantanamo Bay, Cuba. The cargo airplane collided with level terrain approximately ¼ mile from the approach end of runway 10 at Leeward Point Airfield after the captain lost control of the airplane. The airplane was destroyed by impact forces and a postcrash fire, and the three flight crew members--the only occupants aboard the airplane--received serious injuries. The cargo airplane was on the last leg of a flight sequence that day from Atlanta, Georgia, to Norfolk, Virginia, and then Guantanamo Bay.

The flight crew had been on duty about 18 hours and had flown approximately 9 hours. The captain did not recognize deteriorating flightpath and airspeed conditions because of his preoccupation with locating a strobe light on the ground. The flight engineer made repeated callouts regarding slow airspeed conditions. The captain initiated a turn on final approach at an airspeed below the calculated approach speed of 147 knots and less than 1,000 feet from the shoreline, and the captain allowed bank angles in excess of 50? to develop. The stall warning stickshaker activated 7 seconds before impact and 5 seconds before the airplane reached stall speed. No evidence indicated that the captain attempted to take proper corrective action at the onset of the stickshaker. The Safety Board concluded that the substandard performance by this experienced pilot may have reflected the debilitating influences of fatigue. In its report on this accident, the Safety Board stated that three background factors are commonly examined for evidence related to fatigue: cumulative sleep loss, continuous hours of wakefulness, and time of day. The flight crew had received limited sleep in the 48 hours before the accident because of flight and duty time. Also, at the time of the accident, the captain had been awake for 23.5 hours, the first officer for 19 hours, and the flight engineer for 21 hours. In addition, the accident occurred about 1656 eastern daylight time (based on a 24-hour clock), at the end of one of the two low periods in a person's circadian rhythm. The Board also considered the captain's self-report (for example, his report of

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 feeling "lethargic and indifferent" in the last period before the accident) in evaluating whether fatigue was present.

The Safety Board determined that the probable cause of the accident was the impaired judgment, decision-making, and flying abilities of the captain and the other flight crewmembers because of the effects of fatigue; the captain's failure to properly assess the conditions for landing and maintaining vigilant situational awareness of the airplane while maneuvering onto final approach; his failure to prevent the loss of airspeed and avoid a stall while in the steep bank turn; and his failure to execute immediate action to recover from a stall. Additional factors contributing to the cause of the accident included the inadequacy of the flight and duty time regulations applied to 14 CFR Part 121 supplemental air carriers, international operations, and the circumstances that resulted in the extended flight and duty hours and fatigue of the flight crewmembers.

1.18.6.1 Previous Safety Recommendations Regarding Fatigue

On May 17, 1999, the Safety Board adopted a safety report entitled Evaluation of U.S. Department of Transportation Efforts in the 1990s to Address Operator Fatigue. In its report, the Board noted that in 1989 it issued three recommendations to the DOT addressing needed research, education, and revisions to hours-of-service regulations. The Board further noted that, since that time, it had issued more than 70 additional recommendations aimed at reducing the incidence of fatigue-related accidents.The Board stated that, even though the DOT and modal administrations had responded positively to the recommendations addressing research and education, little action had occurred with respect to revising the hours-of-service regulations.

The safety report discussed the activities and efforts by the DOT and the modal administrations to address operator fatigue and the resulting progress that has been made over the past 10 years to implement the actions called for in the Safety Board's fatiguerelated recommendations. The report also provided background information on current hours-of-service regulations, fatigue, and the effects of fatigue on transportation safety. As a result of its findings, the Safety Board issued Safety Recommendations I-99-1 and A-99-45.

Safety Recommendation I-99-1 asked the DOT to

Require the modal administrations to modify the appropriate Codes of Federal Regulations to establish scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and

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Rh The music produced by the three pieces, an Indian flute, kettle-drum, and a drum shaped like a flour barrel, and made like it of thin pieces of wood, hooped, with one end resting on the ground, bore a startling resemblance to that which you may hear any night in the Chinese theatres in San Francisco, being pitched at the same high key, and the air being almost identical with the "Song of the Jasmin Flower," which is the favorite, through all the central Flowery Empire.

The dark-hued, sandaled, and white-robed musicians played on through all stages of the entertainments, with faces as impassive as those of so many bronze statues. Only once did I see a look of startled interest for a moment steal over their faces. It was when the Prefecto gave the health of the President of the United States, and the health of President Juarez being given in response, the Americans gave three rousing cheers, and the Californians, springing to their feet, made the air of the sleepy, old town, ring with the wild yell of "the tiger." The look I had noticed faded from their faces as it came in an instant, and the music, so wild, and strange and weird, went on as before. When Colonel Green plied them with champagne, and whistled to them "Jordon am a hard road to travel," they took up the air, and played it with the same cold, quiet manner as they had played those of their native land; and when paid and dismissed, they marched away in grave, respectful silence, without a word or action to indicate whether they were pleased or displeased with the days—to them—novel proceedings.

Mr. Seward was presented with a certificate of honorary membership of the Ayuntamento, or Common Council of Cholula, and with wishes of success and a


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 consider circadian rhythms and human sleep and rest requirements. Seek Congressional authority, if necessary, for the modal administrations to establish these regulations.

Safety Recommendation A-99-45 asked the FAA to

Establish within 2 years scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.

On July 15, 1999, the FAA indicated that it agreed with the intent of Safety Recommendation A-99-45 and stated that, on December 11, 1998, it had issued NPRM 95-18, which proposed amending existing regulations to establish one set of duty period limitations, flight time limitations, and rest requirements for flight crewmembers engaged in air transportation. The FAA stated that the NPRM considered scientific data from studies conducted by NASA relating to flight crewmember duty periods, flight times, and rest and that Safety Recommendation A-99-45 would be included in this rulemaking project. The FAA further indicated that its Aviation Rulemaking Advisory Committee was tasked to review reserve issues related to the NPRM but was unable to agree on a recommendation. The FAA indicated that it was conducting a risk assessment to determine the probability of preventing future incidents related to fatigue and did not know when a supplemental NPRM would be issued. However, the FAA stated that, in the interim, it published a notice on June 15, 1999, indicating its intent to enforce the regulations concerning flight time limitations and rest requirements. At an October 7, 1999, meeting with the Safety Board's Chairman, the FAA Administrator indicated that a final rule would not be issued within the next 2 years.

A digital flight data recorder (DFDR) records values for parameters related to the operation of an airplane (for example, altitude, airspeed, and heading). The values are recorded in a serial binary digital data stream that must be converted either to engineering units or discrete states. The arrangement of the recorded values often varies among DFDR systems; consequently, accurate conversion of the recorded values to their corresponding engineering units or discrete states can be accomplished only when the configuration of the data has been thoroughly documented.

1.18.7.1 Previous Safety Board Recommendations on Flight Data Recorder Parameter Verification and Documentation

In the early 1970s, the Safety Board began issuing safety recommendations to improve FDR parameter verification and documentation. In 1991, the Safety Board issued two safety recommendations (A-91-23 and -24) to the FAA for developing a permanent

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 policy for FDR maintenance and record-keeping. In 1997, after a series of accidents that involved problems with extracting data from retrofitted FDRs, the Safety Board issued a safety recommendation (A-97-30) that asked the FAA to publish an AC addressing the certification and maintenance of FDRs.

Safety Recommendation A-91-23 asked the FAA to

{{Smaller|Issue permanent policy and guidance material for the continued airworthiness of digital flight data recorder systems, stating that the make and model of the flight data recorder and the make and model of the flight data acquisition unit, if installed, must be maintained as part of each aircraft's records, as well as at least the following information for each parameter recorded:
 * Location of parameter word (2 through 64 or 128). * Assigned bits (1 through 12).
 * Range (in engineering units when applicable).
 * Sign convention (for example, trailing edge up = +). * Type sensor (for example, synchro or low-level DC). * Accuracy limits (sensor input).
 * FAA requirement (that is, mandatory or not mandatory).
 * Subframe/superframe assignment: Documentation for engineering unit conversion.
 * General equation: Provide A0, A1, A2, and A3 for the equation Y = A0 + A1X + A2X2 + A3X3, where Y = output in engineering units and X = input in decimal or converted counts.
 * Nonlinear parameters: Provide a sufficient number of data samples (engineering units versus recorded decimal counts) to develop a conversion algorithm that will accurately define the full range of the parameter.
 * Discrete parameters: Status (that is, 1 = on, 0 = off).

Safety Recommendation A-91-24 asked the FAA to

{{Smaller|Require operators to maintain current information for each unique digital flight data recorder configuration in its inventory using a single, universally adopted format, such as that described in the standard being developed by Aeronautical Radio, Inc.}} {{rule}}{{Smallrefs}}

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 On May 9, 1991, the FAA stated that it was reviewing these safety recommendations. On August 1, 1991, the Safety Board stated that it was disappointed that the FAA failed to include any timetable for the completion of the review because untimely or missing DFDR documentation was adversely affecting ongoing investigations. The Board reemphasized its commitment to these recommendations, stating that it would continue to work with the FAA and the aviation industry to implement the recommendations.

On December 18, 1991, the FAA stated that it was planning to develop an AC to address the installation and maintenance of DFDRs and flight data acquisition units (FDAU). The FAA indicated that the AC would reference the appropriate regulatory requirements and contain the universal documentation format for each DFDR aircraft configuration and installation. The FAA further indicated that the baseline documents for the AC would be the universal format being developed by Aeronautical Radio, Inc., and the Board's proposed FDR configuration documentation standard.

On January 28, 1992, the Safety Board stated that it remained encouraged by the FAA's support for these safety recommendations. The Board believed that the FAA's plan to develop an AC that addresses the installation and maintenance of DFDR systems and references a universal documentation standard was a step in the right direction. However, the Board believed that the AC needed to be supplemented with permanent policy and guidance material so that FAA inspectors would require that the AC be implemented.

On April 22, 1994, the Safety Board stated that, in early 1993, FAA staff had indicated that the proposed AC had not been developed because the FAA was waiting for Aeronautical Radio, Inc., to publish the proposed documentation standard. Because Aeronautical Radio was unable to commit the resources needed to publish the proposed standard, the FAA proposed that the Board draft an AC that incorporated the draft Aeronautical Radio documentation standard. Safety Board and FAA staffs subsequently discussed and agreed on the principal elements of a draft AC based on the draft Aeronautical Radio documentation standards. On October 18, 1993, the Board provided a draft of the AC and DFDR documentation standards. However, the FAA made no progress toward implementing Safety Recommendations A-91-23 and -24, even with the Board's draft AC. The Safety Board continued to believe that the actions requested in these recommendations were essential and therefore urged the FAA to take the necessary actions.

On March 3, 1997, the FAA stated that it included information regarding the installation and maintenance of DFDRs and FDAUs in Notice N8110.65, "Policy and Guidance for the Certification and Continued Airworthiness of Digital Flight Data Recorder Systems." According to the FAA, the notice referenced the appropriate regulatory requirements and contained the universal documentation format for each DFDR aircraft configuration and installation. The FAA stated that the universal format developed by Aeronautical Radio, Inc., and the Board's proposed FDR configuration documentation standard were used as baseline documents for the notice.

On July 10, 1998, the Safety Board noted its disappointment that the AC had still not been completed. The Board stated that inclusion of guidance relating to FDR

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 maintenance documentation (which was addressed in FAA Notice N8110.65) in this AC would satisfy the intent of Safety Recommendations A-91-23 and -24, which had been issued 7 years earlier. The Board was concerned that the AC might still not be produced in a timely manner. Accordingly, the Safety Board classified Safety Recommendations A-91-23 and -24 "OpenUnacceptable Response" pending the FAA's completion of the AC.

Safety Recommendation A-97-30 asked the FAA to

Complete the planned flight data recorder (FDR) advisory circular (AC) to define FDR certification requirements and FDR maintenance requirements, and incorporate the FDR documentation standards contained in Notice N8110.65. The AC should be released no later than January 16, 1998.

On July 14, 1997, the FAA stated that it agreed with the intent of this safety recommendation. The FAA also stated that it would complete the AC for FDR certification and maintenance requirements by January 1998. On July 10, 1998, the Safety Board stated its disappointment that the AC, promised by the FAA to be issued by January 1998, had not been completed. The Board was concerned that the AC would not be produced in a timely manner. The Board stated that the guidance contained in this AC was essential to avoid widespread retrofit problems. Pending the FAA's completion of the AC, the Safety Board classified Safety Recommendation A-97-30 "Open--Unacceptable Response."

1.18.7.1.1 Digital Flight Data Recorder Advisory Circular

On October 5, 1999, AC 20-141, "Airworthiness and Operational Approval of Digital Flight Data Recorder Systems," was issued. The purpose of the AC is to provide "guidance on design, installation, and continued airworthiness of Digital Flight Data Recorder Systems." Appendix 1 to the AC, titled "Standard Data Format for Digital Flight Data Recorder Data Stream Format and Correlation Documentation," provides "a standard for the data stream format and correlation documentation that operators must maintain to aid accident investigators in interpreting recorded flight data." The appendix details how to develop a document for each airplane that would provide in detail the information that would assist Safety Board investigators in transcribing each parameter recorded by an FDR.

1.18.7.2 International Guidance Regarding the Documentation of Flight Data Recorder Parameters

ICAO provides guidance to Member States regarding the documentation of FDR parameters. ICAO Annex 6, "International Standards and Recommended Practices-- Operation of Aircraft, Part I--International Commercial Air Transport--Aeroplanes," includes Attachment D, Flight Recorders. Section 3 of the attachment, "Inspections of flight data and cockpit voice recorder systems," provides guidance on the continued

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434 pleasant reunion with old friends among the home scenes of our native land, the kind people of Cholula bid us good-bye, and in the gloaming of the evening we rode back to Puebla.

I shall attempt no elaborate description of the Cathedral of Puebla, for several good and sufficient reasons. One is, that no description could give the reader any adequate idea of the vast proportions, great wealth, and exceeding beauty and grandeur of this wonderful temple of the Christian faith, and another is, that so many descriptions have been attempted and resulted in failures, that I have no ambition to follow in the old, beaten track, knowing that I cannot command the language adequate for success.

The Seward party visited the cathedral, and saw all its wonders, from the grand choir, which outside is one mass of gilding and burnished precious metal, and inside a curious mosaic of beautiful woods inlaid with wonderful skill, the great altar, which is built of variegated marbles, alabaster, and other beautiful stones from the State of Puebla, and gold and silver by the cart-load, the great pillars of bluish-grey granite,


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 airworthiness of FDR systems, including how to conduct annual checks of every FDR parameter. Paragraph 3.2(c) states that "a complete flight from the FDR should be examined in engineering units to evaluate the validity of all recorded parameters." In addition, paragraph 3.2(d) states that "the readout facility should have the necessary software to accurately convert the recorded values to engineering units and to determine the status of discrete signals."

1.18.8 Special Airport Criteria and Designation

On October 19, 1996, Delta Air Lines flight 554, a McDonnell Douglas MD-88, N914DL, struck the approach light structure at the end of the runway deck during the approach to land on runway 13 at LaGuardia Airport in Flushing, New York. IMC conditions prevailed for the ILS DME approach. None of the two flight crewmembers and three flight attendants were injured, but 3 of the 58 passengers received minor injuries. The airplane sustained substantial damage.

According to the first officer of the flight, the approach to runway 13 requires landing over water, a 250-foot DH, and an offset localizer, and the approach to the opposite direction runway (31) requires maneuvering an airplane at high bank angles close to the ground. However, LaGuardia was not designated by the FAA as a special airport under 14 CFR Section 121.445. That section, titled "Pilot in command airport qualification: Special areas and airports," states the following:

(a) The [FAA] Administrator may determine that certain airports (due to items such as surrounding terrain, obstructions, or complex approach or departure procedures) are special airports requiring special airport qualifications and that certain areas or routes, or both, require a special type of navigation qualification. (b) ...no certificate holder may use any person, nor may any person serve, as pilot in command to or from an airport determined to require special airport qualifications unless, within the preceding 12 calendar months: (1) The pilot in command or second in command has made an entry to that airport (including a takeoff and landing) while serving as a pilot flight crewmember; or (2) The pilot in command has qualified by using pictorial means acceptable to the Administrator for that airport.

The Safety Board's investigation of the accident concluded, among other things, that the FAA's guidance on special airports was not sufficiently specific about criteria and

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 procedures for designation of special airports; therefore, the FAA's guidance might not always be useful to air carriers operating in and out of special airports. The Board also concluded that the requirements for special airport pilot qualifications might not be sufficient to ensure that qualified pilots have been exposed to the runways and/or approaches that make those airports "special."

As a result of its findings, the Safety Board issued Safety Recommendations A-97-92 through -94 on August 25, 1997. Safety Recommendations A-97-92 through -94 asked the FAA to

 * Expedite the development and publication of specific criteria and conditions for the classification of special airports; the resultant publication should include specific remarks detailing the reason(s) an airport is determined to be a special airport and procedures for adding and removing airports from special airport classification.(A-97-92)

 * Develop criteria for special runways and/or special approaches, giving consideration to the circumstances of this accident and any unique characteristics and special conditions at airports...and include detailed pilot qualification requirements for designated special runways or approaches.(A-97-93)

 * Once criteria for designating special airports and special runways and/or special approaches have been developed, as recommended in Safety Recommendations A-97-92 and -93, evaluate all airports against that criteria and update special airport publications accordingly. (A-97-94)

On November 13, 1997, the FAA stated that it was developing a flight standards handbook bulletin and revising AC 121.445. "Pilot-In-Command Qualifications for Special Area/Routes and Airports, Federal Aviation Regulations (FAR) Section 121.445." The FAA indicated that the bulletin and AC would address the issues discussed in the recommendations. The FAA anticipated that these documents would be issued in April 1998. On August 17, 1998, the Safety Board stated that, pending the FAA's completion of these documents, Safety Recommendations A-97-92 through -94 were classified "Open--Acceptable Response."

On September 21, 1999, the FAA stated that AC 121.445 was undergoing internal coordination and should be published in the Federal Register by November 1999. The FAA indicated that it would proceed with issuing the flight standards handbook bulletin as soon as the AC was completed. According to the FAA, both documents were expected to be issued by February 2000.

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The three Korean Air flight 801 flight crewmembers were properly certificated and qualified in accordance with applicable Korean Civil Aviation Bureau (KCAB) and U.S. Federal regulations, International Civil Aviation Organization (ICAO) standards, and Korean Air company requirements. No evidence indicated that any medical factors affected the flight crew's performance.

The airplane was properly certificated, equipped, and maintained in accordance with applicable KCAB and ICAO standards and Korean Air company procedures. The airplane was authorized to operate in U.S. airspace under the provisions of 14 Code of Federal Regulations (CFR) Part 129. The weight and balance of the airplane were within the prescribed limits for landing. No evidence indicated that the airplane experienced preimpact failures of its structures, flight control systems, or engines.

ATC personnel involved with the flight were properly certificated and qualified as full-performance level controllers. ATC radar and communications equipment were found to be functioning properly, although the FAA-maintained minimum safe altitude warning (MSAW) system had been intentionally inhibited.

This analysis examines the accident scenario, including weather factors, flight crew performance and decision-making, and other relevant factors during the approach, as well as flight crew fatigue issues. The analysis also examines the performance of ATC personnel, the effects of the MSAW system's intentional inhibition, and the timeliness and effectiveness of the emergency response to the accident site. In addition, the analysis examines Korean Air's flight crew simulator training, KCAB oversight of Korean Air's flight training programs, FAA oversight of Korean Air's operations under 14 CFR Part 129, and international efforts to reduce the number of controlled flight into terrain (CFIT) accidents.

A review of weather data indicated that variable clouds and scattered rain showers associated with a weak eastward-moving low-pressure trough were affecting the Guam area about the time of the accident and that the showers increased in intensity as they moved over the higher terrain of the island. However, Safety Board interviews with flight crewmembers who flew into Guam before and after the flight 801 accident indicated that the lights of the island were occasionally visible from as far away as 150 nm. In addition, CVR data indicated that the accident flight crew made visual contact with the island about 16 minutes before the accident (about 0126:25) when the flight engineer stated "it's Guam, Guam."

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Rh arches of the same material which uphold the immense weight of the solid stone roof, and the fourteen stations of the cross—each a marvel in itself—to the skeletons of the saints and martyrs, covered with wax and so artistically wrought into the semblance of fresh human forms as to cheat the eye completely, dressed in robes of great richness, and shodden with golden sandals set with gems, which lie in state, each in its own great casket, all around the building. Even the tomb of the Bishops was thrown open and inspected.

The mighty pillars were covered from their capitals down to the pavement, with crimson silk plush, edged and embroidered with gold, in preparation for the grand Christmas festivities, and the whole church was being cleaned and prepared for the occasion. The last time the metal work—then nearly all gold and silver—in this cathedral was cleaned, the work cost four thousand dollars in coin, though done at the least possible expense.

Much of the riches of this old cathedral have disappeared within a few years, it is said, but the eye of the stranger looks in vain for any trace of the hand of the despoiler, save where once hung near the main entrance, the great chandelier, which Miramon took down and melted up, to pay his troops for fighting the battles of the church against the Republicans. He got forty thousand dollars out of this chandelier, and the curses of all the pious Catholics of Mexico, who were quite willing he should fight for the church, but wished him to make the enemy—not the church—pay the cost, and denounced the act as one of sacrilege, sure to bring down destruction on its author.


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 On the basis of weather data and witness statements, flight 801 was likely to have initially encountered variable scattered to broken cloud layers below 5,000 feet msl during the final approach to Guam. Ground lights were likely occasionally visible along the coastline, and it is probable that only scattered clouds existed below the airplane in the vicinity of the FLAKE intersection, located 7 DME from the NIMITZ VOR (UNZ).

Doppler radar data indicated that a heavy to very heavy rain shower was centered over higher terrain about 4 nm southwest of the airport (along the approach corridor) about the time of the accident. Weather data indicated that, although the Apra Harbor area (about 5 DME on the approach course) would likely have been visible to the flight crew as the airplane descended through 2,000 feet msl, the airplane would have entered clouds and light precipitation shortly after passing Apra Harbor. Radar data indicated that the flight likely experienced rain of continuously increasing intensity as the airplane proceeded inbound toward the airport and that the flight encountered very heavy precipitation for a short time near the outer marker (GUQQY). About 0141:48, when the airplane was near the outer marker, the CVR recorded the captain stating "wiper on."

Although a hunter on Nimitz Hill stated that it was not raining at the time he observed the flight overhead, Doppler radar data indicated light to moderate rain shower activity between Nimitz Hill and the airport. Therefore, on the basis of weather radar and observation data, the Safety Board concludes that, after the flight crew made an initial sighting of Guam, Korean Air flight 801 encountered instrument meteorological conditions (IMC) as the flight continued on its approach to Guam International Airport. Further, the Safety Board concludes that, although flight 801 likely exited a heavy rain shower shortly before the accident, the flight crew was still not able to see the airport because of the presence of another rain shower located between Nimitz Hill and the airport.

The instrument landing system (ILS) glideslope (GS) inoperative, or localizer (LOC)-only, approach to runway 6L at Guam International Airport required the flight crew to maintain at least 2,000 feet from the FLAKE intersection (7 DME from the UNZ VOR) to the GUQQY (outer marker) final approach fix (FAF), which was located 1.6 DME from the UNZ VOR. After passing GUQQY, the crew was required to maintain at least 1,440 feet msl until passing the UNZ VOR. After passing the UNZ VOR, the next step-down fix was to 560 feet (the minimum descent altitude [MDA]), and the flight crew was required to maintain at least this altitude while counting up to 2.8 DME (the missed approach point [MAP]) from the UNZ VOR.

To properly fly this approach, the flying pilot's navigation receiver would need to be tuned to the localizer frequency, and the nonflying pilot's navigation receiver would

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 need to be tuned to the UNZ VOR to provide the pilots with DME information for FLAKE, GUQQY, and the MAP and allow them to identify station passage over the UNZ VOR. Station passage over UNZ would be marked by the following instrument indications: the TO/FROM indicator in the first officer's horizontal situation indicator (HSI) would have changed from TO to FROM, and the No. 2 (double) pointer in the captain's and first officer's radio magnetic indicator would have swung from pointing forward to aft. Although station passage is not defined by DME, station passage over the UNZ VOR would have been indicated by a DME countdown to near zero and then a count up as the airplane continued away from UNZ to runway 6L.

To use the autopilot and flight director (FD) during a nonprecision approach, the flying pilot would have set the Nav Mode Switch to VOR/LOC on the glareshield instrument panel once the airplane was established on the intercept heading to the localizer outside the FAF. The FD and autopilot flight mode annunciator (FMA) on the pilots' instrument panels would then indicate NAV armed and GS blank. After localizer capture, the pilots' and the autopilot's FMAs would indicate NAV capture, and the GS would remain blank. The autopilot would turn the airplane as needed to track the localizer. (Although the nonflying pilot's navigation receiver would be tuned to the VOR, a different frequency, that pilot's FMA would also indicate NAV capture because the UNZ 243° radial approximately overlays the localizer.) The FD command bars on the captain's and the first officer's instruments would provide left and right roll commands to maintain a capture on the respective courses.

When the airplane was descending, the flying pilot would normally have reset the altitude selector to the next (lower) altitude target and moved the VERT SPEED (vertical speed) wheel to position the airplane in about a 1,000-feet-per-minute rate of descent to reach the next crossing altitude. The FD pitch command bars would move up and down to provide guidance to maintain the desired rate of descent. (In a precision approach, the command bars would provide guidance to maintain the glideslope; in nonprecision approaches, they provide guidance to maintain the desired vertical speed.) Once the airplane had reached the altitude set in the altitude selector, the FDs and autopilot would capture and maintain that altitude. At no time during the localizer approach would the flight crew have armed the autopilot or FDs to capture a glideslope signal or have referenced or attempted to track any glideslope needle indications.

The Combined Center/Radar Approach Control (CERAP) controller vectored flight 801 to join the runway 6L localizer course between the FLAKE intersection and the GUQQY outer marker/1.6 DME fix. Although the flight was restricted to no lower than 2,000 feet msl in that portion of the localizer-only approach procedure (until crossing the GUQQY outer marker), flight 801 descended below 2,000 feet about 1.9 nm before reaching the outer marker.

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 Further, although the approach procedure specified that at least 1,440 feet msl should be maintained after passing the GUQQY outer marker and until passing the UNZ VOR, flight 801 descended below 1,440 feet about 2.1 DME before reaching the UNZ VOR. (None of the indications of UNZ station passage would have been presented on the flight crew's instrument panels at any time before impact.)

CVR information indicated that the captain was flying the airplane on autopilot during the approach. As flight 801 descended on the approach, the captain twice commanded the entry of lower altitudes into the airplane's altitude selector before the airplane had reached the associated step-down fix. After the captain heard the first officer call out "approaching fourteen hundred [feet]" about 0140:33, as the airplane was passing 5 DME at 2,400 feet msl, the captain directed the first officer to reset the altitude selector to 1,440 feet, replacing the step-down altitude of 2,000 feet before the autopilot had captured that altitude or reached the GUQQY outer marker/1.6 DME fix. Further, about 0141:33, with the flight neither having leveled off at 1,440 feet msl nor reached the UNZ VOR step-down fix, the captain instructed the first officer to set 560 feet, the MDA, in the altitude selector.

The altitude selector provides the basis for the altitude alert's aural annunciations and the autopilot's altitude capture functions. The captain's premature orders to reset the altitude selector indicated that he had lost awareness of the airplane's position along the final approach course. Therefore, as a result of the captain's commanded input to the altitude selector, the autopilot continued to descend the airplane prematurely through the 2,000- and 1,440-foot intermediate altitude constraints of the approach procedure. The CVR comments indicated no awareness by the captain that the airplane was descending prematurely below the required intermediate altitudes.

2.4.1.1 Approach Briefing

Korean Air cockpit procedures call for an approach (landing) briefing before descent. Also, company training instructs the flying pilot to conduct an approach briefing before descent. According to the Korean Air 747 landing briefing checklist card and testimony by Korean Air officials during the Safety Board's public hearing, this briefing should include a discussion of weather conditions, a review of the instrument approach

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 procedure, details of the approach's execution (including the minimum safe altitude, approach frequency and approach course, the runway touchdown zone elevation, and the missed approach procedure), crew actions and callouts, and any abnormal configurations or conditions.

CVR information indicated that the captain briefed a visual approach in his approach briefing, which he referred to as a "short briefing." However, the captain also briefed some elements of the localizer-only instrument approach, indicating that he intended to follow that approach as a supplement or backup to the visual approach. Specifically, the captain's briefing included a reminder that the glideslope was inoperative, some details of the radio setup, the localizer-only MDA, the missed approach procedure, and the visibility at Guam (stated by the captain to be 6 miles). However, the captain did not brief other information about the localizer-only approach, including the definitions of the FAF and step-down fixes and their associated crossing altitude restrictions or the title, issue, and effective dates of the approach charts to be used. The Safety Board notes that the landing briefing checklist did not specifically require the captain to brief the fix definitions, crossing altitudes, or approach chart title and dates, although it would have been good practice to do so.

Further, according to public hearing testimony by a Korean Air instructor pilot, company pilots were trained to conduct a more detailed briefing than the one specified in the landing briefing checklist for a nonprecision approach, such as the localizer approach to runway 6L at Guam. According to the instructor pilot, this more detailed briefing included a discussion of the "instrument approach in detail" and a discussion of the "stepdown altitudes and how they were determined." The Safety Board notes that this information is essential for a nonprecision approach briefing.

The Safety Board also notes that the captain did not brief the first officer and flight engineer on how he would fly the descent (including his planned autopilot/FD modes and his plan to fly either a constant angle of descent or a series of descents and level-off altitudes associated with the step-down fixes), and he did not discuss go-around decision criteria. Further, although not specifically required, it would have been prudent for the captain to note the need for special caution in the UNZ VOR area (which he had described as a "black hole" in his approach briefing to another first officer about 1 month earlier).

The Safety Board further notes that, in this case, a thorough briefing was especially important because the accident captain and first officer were flying together for the first time, which is a situation that has been linked to flight crew-involved accidents. The Safety Board According to recent human factors research, a good briefing is important to develop a "shared mental model" to ensure "that all crew members are solving the same problem and have the same understanding of priorities, urgency, cue significance, what to watch out for, who does what, and when to perform certain activities." The Safety Board

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