Controlled Flight

Into Terrain (CFIT)

The Problem That Never
Went Away

Robert Sumwalt
US National Transportation Safety Board
 Gulfstream GII Accident

September 26, 1976 Hot Springs, Virginia

11 Fatalities
 Cessna 401 Accident

October 24, 1976 Hot Springs, Virginia 0 Fatalities

A great CFIT
resource!
 CFIT Defined

When an airworthy aircraft under the

control of the flight crew is flown
unintentionally into terrain, obstacles
or water, usually with no prior
awareness by the crew.

Source: CFIT Training Aid

 In the past 3 ½ years:

• CFIT has claimed over 500 lives in

worldwide airplane crashes
– In the vast majority
of these crashes,
the aircraft was
not equipped with an
operational TAWS.
Source: Boeing
 CFIT Accidents: 2014

Date Location Aircraft type Fatalities

3 February 2014 Oklahoma, USA Cessna 525 0
8 April 2014 Alaska, USA Cessna 208 2
19 April 2014 Mexico BAe-125-700 8
8 May 2014 Colombia DC-3 5

Source: Don Bateman (Honeywell); NTSB files; Jim Burin (Flight

Safety Foundation)
 CFIT Accidents: 2013
Date Location Aircraft type Fatalities
23 January 2013 Antarctica DHC-6 3
29 January 2013 Kazakhstan CRJ-200 21
4 March 2013 Congo Fokker 50 0
13 April 2013 Indonesia Boeing 737-800 0
10 October 2013 Malaysia DHC-6 2
16 October 2013 Laos ATR-42 49
19 October 2013 Papua New Guinea ATR-42 0
3 November 2013 Bolivia Metro III 8
10 November 2013 Ontario Canada Metro IV 5
29 November 2013 Alaska. USA Cessna 208 4
2 December 2013 Puerto Rico Metro III 2
26 December 2013 Russia An-12 9
 CFIT Accidents: 2013

Date Location Aircraft type Fatalities

30 January 2012 Congo An-28 2
15 March 2012 Sweden C-130J 5
9 May 2012 Indonesia Su-95 45
14 May 2012 Nepal Dornier 228 15
22 June 2012 West Virginia, USA Beech King Air C90GT 1
19 August 2012 Sudan An-24 31
12 September 2012 Russia An-28 10
30 November 2012 Congo IL-76 32
17 December 2012 Peru An-26 4
18 December 2012 Montana, USA Beech King Air 100 2
25 December 2012 Myanmar Fokker 100 2
 CFIT Accidents: 2011
Date Location Aircraft type Fatalities
2 February 2011 Congo L-410 2
2 February 2011 Honduras L-410 14
8 February 2011 South Africa PC-12 9
4 April 2011 Congo CRJ-100 31
20 June 2011 Petrozavodsk TU-134 44
6 July 2011 Kabul IL-76 9
10 July 2011 Congo Boeing 727 63
9 August 2011 Russia An-24 0
20 August 2011 Canada Boeing 737-200 12
7 September 2011 Bolivia SA-227 8
25 September 2011 Nepal Beech 1900D 19
29 September 2011 Indonesia Casa 212 18
23 November 2011 Arizona, US Aero Commander 690 6
 Helicopter CFIT in United
States: 2008 - present
• Since January 1, 2008 – present:
- 22 Helicopter CFIT accidents in US
- 37 Fatalities
Don Bateman
 Terrain Warning and
Alerting System (TAWS)
 TAWS

• Worldwide terrain database

• Through GPS and FMS, the system
knows aircraft position and altitude
• Scans ahead to check for terrain threats
• Provides aural and visual WARNINGS/
CAUTIONS up to 60 seconds before
predicted terrain conflict
 Probable Cause

• The pilot's failure to maintain a safe ground

track and altitude combination for the moonless
night visual flight rules flight, which resulted in
controlled flight into terrain.
• Contributing to the accident were the pilot's
complacency and lack of situational awareness
and his failure to use air traffic control visual
flight rules flight following or minimum safe
altitude warning services.
• Also contributing to the accident was the
airplane's lack of onboard terrain awareness
and warning system equipment.
A Threat & Error Management (TEM)
Approach to Reducing CFIT
 “Threats”
• Those things that can increase the
operational complexity, and if not
handled correctly, can decrease the
safety margins
- Weather - Time pressure
- Delays - Distractions
- Mechanical Malfunctions - ??
- Stress
 Threats

• Threats
– Threats can increase error potential
– Threats “put holes in” or weaken our barriers
against error

• Threats = Red Flags

 Be aware of threats!
• “Snakes in the grass”
– What are the things that can bite you on this flight?
• We want crewmembers to identify, talk about and think
about threats, and
• those things that are different about this operation or
flight
– Unfamiliar airport
– Flying with new pilot
– New procedures
• This puts the threats in the employees “mental RAM”
and makes it readily available for retrieval
– Example: mentally rehearse CFIT escape maneuver
Errors
“To err is human”

“Errar e humano”
 Why error management?
• Traditional thinking focused on eliminating
human error in aviation
• Contemporary thinking acknowledges that
error is a way of life
– given the acceptance that human error may occur, the
focus has become “How do you effectively manage
error?”
– proper error management greatly enhances safety
 Errors will occur
“So we must create an error
management system in which the crew
recognizes and corrects errors before
negative consequences occur.”

- Captain Frank J. Tullo

“Aviation Week and Space Technology”
May 21, 2001
Threat and Error Management

Helps us avoid and trap errors.

 Avoiding Errors

• Good training
• High levels of proficiency
• Following SOPs
• Minimizing distractions
• Planning ahead
• Maintaining situational awareness
• CRM – the effective use of all available
resources
 Trapping Errors
• Once an error is committed, it is difficult
to catch (trap) your own error
• Other people are often more likely to
catch your error
• Therefore, redundancy
is one strong defense
against error
Layers of Defense (barriers)
to trap crew errors
Onboard Alerting External
Equipment Alerting,
i.e., ATC

PNF/PM
Pilot Flying
 Examples of how “holes in
defenses” can be formed
• Procedural non-
• Increasing workload
compliance
• Time pressure • Poor crew coordination
• Fatigue • Interruptions / Distractions
Layers of defense help deflect
errors from becoming hazards

Potential
Hazard

Error

Error Trapped.
Hazard Averted
Learjet 35A
October 24, 2004
San Diego, CA
5 Fatalities
SAN DIEGO, CA
BROWN FIELD MUNI

DEPARTURE PROCEDURE: Rwys 8L,8R,

climbing left turn. Rwys 26L,26R, climbing right
turn. All aircraft climb heading 280° to intercept
MZB R-160 northwestbound to MZB VORTAC.
Departure Airport Crash Site
 Holes in defenses Accident

ATC does not

No TAWS
issue MSAW

F/O does not get weather

Error – crew does not Captain decides to depart

follow terrain avoidance without IFR clearance
procedure
 Probable Cause
The failure of the flight crew to maintain terrain
clearance during a VFR departure, which resulted
in controlled flight into terrain; and,

The air traffic controller’s issuance of a clearance

that transferred the responsibility for terrain
clearance from the flight crew to the controller,
failure to provide terrain clearance instructions to
the flight crew, and failure to advise the flight crew
of the MSAW alerts.
 Contributing Factors

Contributing to the accident was the

pilots’ fatigue, which likely contributed
to their degraded decision-making.
 Threat and Error
Management ABCD’SS

Acknowledge that we
are error prone
 Threat and Error
Management ABCD’SS

• This does not mean that errors are okay

– Naturally we would prefer not to make them
– However, the reality is that we will make
mistakes, so acceptance and awareness are vital
• Acknowledge that threats can affect
performance

Acknowledge errors
 Threat and Error
Management ABCD’SS

Maximize Barriers
 Realize the importance of
redundancies

• Keep as much redundancy in the operation, for

as long as possible
• Plan best time for being “out of the loop” (split
cockpit)
– lowest workload
– least risk
• Both pilots “cross-verify” critical checklist items
(“killer items”) and ATC clearances

Maximize Barriers
 Flight Crew Example:

• Climbing out
of 10,000 feet,
with clearance
to 12,000
– Timing of “10,000
foot announcement”

Maximize Barriers
Planing and awareness are
the keys
• We’re not saying don’t do these things -
obviously you must do them
• The point is to PLAN them (when able) to
conduct them during lowest workload,
least risk periods
• We realize that not everything can be
planned, so when one pilot is out of loop,
be very aware of reduced redundancy

Maximize Barriers
 Threat and Error
Management ABCD’SS

Communicate
Threats and Intentions
Effectively
 Communicate

Anything that can:

• Reduce your ability
to detect errors
• Anything that can
increase your
chance of making
errors Communicate
 Communicate threats

• “Snakes in the grass”

– What are the things that can bite you on
this flight or operation?
– Identify, discuss and think about these
things (threats) and those that are
different about this operation

Communicate
 Ways communications
can be improved
• Research shows that the way a crew
communicates can be a predictor of the
way that the crew performs.
– Crews who communicated better were those
crews who made fewer errors

Communicate
 Improving
communications
• Improved performance (i.e., fewer errors)
was associated with crews who showed
increased number of :
– commands
– inquiries
– acknowledgements
– verbal observations about flight status

-Foushee & Manos (1981)

- Foushe, Lauber, et al (1986)

Communicate
“Hint and Hope”
• Someone drops a
subtle hint, hoping
the other person will
get the message
– Ineffective
– Very Risky

Communicate
 Effective Assertion Model
1. Opening
2. Statement of Concern
3. State the problem
4. Propose a solution
5. Achieve agreement

Pilot Example: Robert, I’m concerned. There is

high terrain to the east. I think we should
get our IFR clearance before we depart.
What do you think?
 Threat and Error
Management ABCD’SS

Distractions and
Interruptions
Distractions & Interruptions
can form “holes in defenses”

Manage Distractions
Distractions & Interruptions
are Red Flags

• Treat Distractions
and Interruptions
as Red Flags

Manage Distractions
 “Interruptions Always
Distract”
IAD

Identify – the interruption

Ask – what was I doing before being interrupted?

Decide – what action to take to get back on track

Manage Distractions
 Threat and Error
Management ABCD’SS

Follow SOPs
Standard Operating Procedures
 Accident Prevention
Strategies
Hull-loss Accidents over 10 Year Period
Percentage of Accidents
Primary Factor 10 20 30 40 50 60
Pilot Flying (PF) adherence to procedure
Other operational procedural
considerations
Pilot Not Flying (PNF/PM) adherence to
procedure
Embedded piloting skills
Design improvement
Captain or instructor pilot exercise
of authority
Maintenance or inspection action
Approach path stability
ATC system performance
First officer’s cross-check 138 Accidents 5,686 Fatalities
performance as non-flying pilot Each bar represents the percentage of
hull-loss accidents that contained at
Go-around decision least one instance of the listed
Runway hazards prevention strategy.

Source: Boeing study of accident prevention strategies

 Accident Prevention
Strategies
Hull-loss Accidents over 10 Year Period
Percentage of Accidents
Primary Factor 10 20 30 40 50 60
Pilot Flying (PF) adherence to procedure
Other operational procedural
considerations
Pilot Not Flying (PNF/PM) adherence to
procedure
Embedded piloting skills
Design improvement
Captain or instructor pilot exercise
of authority
Maintenance or inspection action
Approach path stability
ATC system performance
First officer’s cross-check 138 Accidents 5,686 Fatalities
performance as non-flying pilot Each bar represents the percentage of
hull-loss accidents that contained at
Go-around decision least one instance of the listed
Runway hazards prevention strategy.

Source: Boeing study of accident prevention strategies

 How SOPs relate to error
• Line Operations Safety Audit (LOSA)
data show that crews who intentionally
erred by not following SOPs were 3
times more likely to commit another
error with consequential results

• “Normalization of Deviance”

Follow SOPs
 Standard Operating
Procedures
• SOPs establish a consistent baseline for
performance
• Because the baseline is established,
deviations from it can be identified easier
– “Hmm, I don’t usually miss things like that.”
• Allows crewmembers to concentrate on
issues not covered by SOPs

Follow SOPs
 Threat and Error
Management ABCD’SS

Sensible?
 Sensible?

• Ask yourself and make sure that

what you are doing (and are about to
do) is sensible

Sensible?
 Threat and Error
Management ABCD’SS
A Acknowledge
B Barriers
C Communicate
D Distractions
S SOPs
S Sensible
 Controlled Flight Into Terrain:
The problem that never went away
CFIT is still a safety problem!
A good defense against CFIT is having an operational
TAWS with latest software updates.
TAWS is not the absolute answer.
Practice ABCD’s of Threat and Error Management.

Share this message with those that you fly with and your
co-workers.