National Transportation Safety Board

“ The CFIT checklist, for those of you that may have seen it, is a fairly complicated list of factors which enables airline management, not operating flight crew members, but airline managements to assess the nature of their operation and to come out with a risk-degree factor at the end of it which may cause them to select appropriate measures that reduce that risk, various policies.
I mean, for instance, how one flies non-precision approaches or the use of the monitored or shared approach, those sorts of things. They are mitigating factors against a risk of a particular type. ”

“ What I intend to talk about this afternoon is an overview of the Minimum Safe Altitude Warning system, the purpose that it was designed for, an overview of the history as to why it was developed, a brief description of how it functions, and steps that we have taken to optimize its performance and maintenance.
The Minimum Safe Altitude Warning is a function designed solely as a controller aid in detecting potentially unsafe aircraft proximity to terrain or obstructions. It generates an alert to the controller when a pilot is below or is predicted to be low -- below a specified altitude. ”

“ Training and Qualification on the IIT Simulator—The Safety Board is aware that computer-aided simulators, such as the IIT equipment used in the Amtrak engineer training program, have been increasingly accepted as training aids in the transportation industry. Simulators are very useful in addressing in a controlled environment operating behaviors that are either too dangerous to undertake using actual equipment or that must be evaluated more precisely than is possible through observation alone. ”

“ The third and most legitimate point FAA raises is that it has limited resources and already is resource-constrained in exercising oversight of U.S. aircraft and U.S. crew operations. Adding code share agreements to the workload would be an additional burden and raise expectations. We believe the answer to this is that U.S. carriers seeking approval for a code share agreement can reasonably be expected to perform most of the work and provide FAA assurances that the foreign carrier that will operate as a U.S. flight is compliant with applicable safety requirements. ”

“ Public hearings such as this arc exercises in accountability: accountability on the part of the Safety Board that it is conducting a thorough and fair investigation, accountability on the part of the FAA that it is adequately regulating the industry, accountability on the part of the airline that it is operating safely, accountability on the part of manufacturers as to the design and performance of their products, and accountability on the part of the working force -- pilots and machinists -- that they are performing up to the standards of professionalism expected of them. ”

“ Communication Between Head-end and Helper Engineers.—On the day of the train derailment, there were no requirements that the head-end engineer and helper engineer communicate with each other regarding the condition of their respective locomotive units. Both the road foreman of engines and the general road foreman of engines testified that based on their review of the radio transcripts between the head-end engineer and the helper engineer on the day of the derailment, the amount of communication that took place was less than what they would have expected. ”

“ The CFIT checklist is quite complex and really is not a factor for them because most flight crew are not the determinants of operating policies and procedures. That's the airline management's.
CHAIRMAN FRANCIS: Excuse me, Malcolm. This is aimed -- the CFIT checklist is aimed at the issue that we're all talking more and more about, and that is that safety is not just the pilot ran the airplane into the water or into the mountain. Safety is ultimately the responsibility of corporate management in whatever company it is, and that this starts at the top of the management. ”

“ What is Korean Air's goal in requiring an approach briefing? What is the intent? I'll further clarify. Which approach is required to be briefed upon arrival at -- at an airport?
THE WITNESS: Approach briefing is absolutely necessary for the sake of safe landing of an aircraft. In addition, a pilot must have constantly watch out on the weather conditions and the traffic conditions atthe destination airport. In addition, a pilot must also keep it under consideration that in case the situation at the destination airport becomes so bad that wouldn't allow safe landing. ”

“ MR. WENTWORTH: For an off-airport crash, do you still retain responsibility to initiate the crash/fire/rescue response?
THE WITNESS: Yes, sir. I would make the notification as soon as I become aware of it to ramp control, which would then make the notifications to the appropriate Government of Guam agencies.
MR. WENTWORTH: And now I'd like you to go to 3H, please, Marty. This is the facility accident incident notification record. ”

“ Speed/distance calculations show that about 40 seconds elapsed as Amtrak train 66 traveled from the usual braking location to the point at which the event recorder indicates the full-service application was made. Why the engineer did not take action to slow the train during this time is not certain. Forty seconds is more than the time needed to instruct the apprentice to make a brake application and to cross the cab from the fireman's seat to the engineer's position, if necessary, to accomplish any brake application instructions that were not promptly executed. ”

“ 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. ”

“ It is the one most flight crews are performing most of the time. So, let's make non-precision approaches as similar as possible to precision approach.
The accident record of decades shows that jet aircraft have crashed for failure to follow stabilized approach concepts. So, let's incorporate stabilized approach into non-precision, which means continuous descent powers rather than step-down approaches which are inherently unstable. ”