National Transportation Safety Board

“ 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. ”

“ It is my belief that that would put the procedure developer in a position to try to identify the terrain that they should chart, that if you ignored some piece of the other terrain would be accused of showing or requesting a terrain, and someone else would consider that another piece of terrain is the more significant one if they hit it, and if we fly the procedures as developed, the terrain is not a factor. ”

“ In spite of the efforts of the Flight Safety Foundation, the many individuals, some of whom are in this room today, and in spite of what we've now discovered about controlled flight into terrain accidents worldwide, they still continue to occur. Just ponder that. They still occur.
I believe that industry needs some degree of compulsion to take more effective action. It's not enough at the moment to have awareness and voluntary action. ”

“ Among airlines that have hesitated to use this approach or decided not to or are considering it, what are some of the concerns that are raised?
THE WITNESS: There is a difficulty when an airline has an established operation that may have existed for many years, and pilots are resistant to change. It's remarkable how pilots can adapt to new concepts with a new airplane that they're required to fly but are remarkably resistant to changes of policies and procedures because they defend that which they know best. ”

“ It is essential that the aggressive maneuver for a go-around is performed when at or near the minimum descent altitude or decision height, but when you are well away from it and commencing a go-around from more than a thousand feet away from such low altitudes, could be more gentle, and that may be an airline policy choice, but again have the data, use it, refine it, and then have confidence in how your pilots will perform. ”

“ The ATA Charting and Data Display Task Force has been doing a lot of work from a human factors that do flight tests of the actual changes that are recommended, and at the bottom is an important effort that was initiated because of an NTSB recommendation a couple years ago of a new task force called the ATA Charts Database and Avionics Harmonization Task Force, which really looks at the human factors of what all information a pilot has to look at and where they should be the same and where they cannot be, how do you go about training the pilot to understand where those differences are. ”

“ THE WITNESS: Okay. An instrument landing system is a ground-based electronics system composed of about six subsystems that provide lateral and vertical guidance and fixes or rough knowledge of position to the pilot along the approach path to an airport.
MR. PHILLIPS: Would you -- would we like to go ahead and put up Page 6 of Exhibit 9-E, Teddy? Would this help in your discussion?
THE WITNESS: Well, yes, thank you. This is the simplified but sufficient diagram of the nature of the needle indications that are provided to a pilot while flying an instrument landing system approach. ”

“ I'm not an expert in flight operational matters, though I am a pilot, but I think some of the -- I think all the airlines would -- would like the crews to take deliberate best approach procedures on hearing an alert that they shouldn't have -- should not be hearing at that point in the approach.
Glide scope is heard quite often, but it's -- it's an advisory. There's usually sufficient time, but in most cases, they take corrective action to get back on the glide scope, and that's the end of it. ”

“ It's at night. It's a non-precision approach. It's over unlit terrain, on and on and on. These all give you assessments of -- of the risk involved.
So, the crew certainly is not perhaps groomed or -- or up to speed on non-precision approaches. That doesn't mean that they're not -- not -- that they don't have the skill factors or not, but they probably may not be expecting it.
An insidious CFIT trap then to my mind is the only DME navigational aid located off the airport and no glide scope data. ”

“ Without human factors, a lot of the things that we do would not really come up the way that they should because the human factors experts find a lot of things that we, that are so close to it, don't find.
The Volpe National Transportation System Center has done a lot of human factors work on our charts with us, and the FAA sponsored a program which is a human factors program conducted by Dr. Bill Connor and Jill Cox, which did a complete human factors. There are numerous flight and simulator tests. Boeing has sponsored a study of what the pilot's eyes do when they look at the approach charts. ”

“ It is not Jeppesen's job to go in and make a change to an FAR.
What we do is if we find problems, then we go back to the FAA, and then they re-issue it because they're the only authority that can release and change FARs. That same thing is true for every international approach procedure that's included in each one of the state sovereign domains. So, the right of the content belongs to the government and not to us or to the chart-maker and that makes a difference in how we do the changes. ”

“ I think as a result of the non-precision approach accidents that have been happening over the last three or four years and the technology that's now here, the airlines are recognizing that they need to be doing this and are now starting to create an environment where all the approach procedures will be flown essentially the same regardless whether they're precision or non-precision. ”

“ I think many of us take that for granted, but I believe air traffic controllers need to have more knowledge in that area. They need to understand the stabilized approach procedure and what it means to us as pilots when they ask us to fly at certain speeds to certain short distances from touchdown.
They need to improve their awareness of GPWS performance and radar vectoring in the vicinity of terrain. They also, I think, need to have education in terms of operation at low temperatures or high winds when operating at low altitude in the vicinity of terrain. ”

“ If you have no means of establishing additional data points on the final approach, the constant descent without other than just a final approach fix requires the calculation of an estimated rate of descent based upon ground speed for the final approach segment, and associated with the constant angle approach is also the need to be stabilized at an early enough point such that landing checklist is out of the way early enough, flight crew can positively then monitor the conduct of final approach. ”

“ What U.S. Airways is in the process of doing is creating an approach concept within their industry that says an approach is an approach is an approach, and it doesn't matter whether it's a precision approach or non-precision approach, if we've flown exactly the same way using a descent path, that is a final descent that goes right down to the runway threshold. ”

“ So, the definition of significant is difficult to come by, but where we drew our line is we said that in order for terrain to be on a chart, there needs to be at least one elevation that's 4,000 feet or greater above the airport in at least one planned view of the airport or if there's one elevation that's 2,000 feet above the airport within six miles, then once we do that, then every one of the contour lines, they start at the nearest 1,000 feet to the airport elevation, and then they are at 1,000-foot intervals all the way up to the top altitude that's depicted. ”

“ When we have an empty channel, many of these potential external sources of noise and unintended signals, which are normally too weak to be heard, can be heard, and it's fairly common when we test airborne flight tests, instrument landing systems, and we turn off the localizer or the glide scope that -- that we record on our instrumentation intermittent indications of flag and needle activity, and as a result, the aviation community relies on notices to airmen as a procedural means to advise everyone that the channel is empty. ”

“ I think certain times, there are political considerations that force our friends in Bill Henderson's shop to design procedures that we might not rather see, like greatly offset localizers at places like Washington National or the approach at Kennedy is one that sticks out. Everybody that is really not a very good instrument approach. ”

“ If I might diverge very slightly, Chairman, there is some work going on in another country, which is trying to enhance what I would call awareness of safety management systems, and there, they have already discovered that the most important factor on the safety performance of any organization is its management culture. ”

“ What we did is we found that the application of the area minimum altitude in many cases actually was higher than segment altitude, and we -- we were concerned that if a pilot flew the actual instrument approach procedure as published by the government, in some cases, the minimum safe altitudes were actually higher than those altitudes, and now you've put the pilot in a dilemma of which altitude you actually should be using, the one that's part of the instrument approach procedure published by the government or whether you ought to use the minimum safe altitudes. ”

“ Shame, shame, shame on any country who doesn't utilize the existing MSAW, the equipment's in place.
We're going to -- we're losing lives out there, and MSAW is a wonderful system. It's been bought, it's there, and the radar's been bought and paid for. It could be made to work very easily just with some determination.
I know there's a political problem. The -- you know, in some countries, the controller has no protection against -- if he makes an error, and it results in an airplane being piled in, he can be held -- charged with manslaughter. Pilots can be thrown in jail. ”

“ So, our computer graphic visual edits, as we create the chart, are kinds of things that are beyond which we talked about earlier that go into the database for those validation, and since we use the database for chart production, if we find an airway that actually has a misalignment in it, we find by drawing a straight line how much misalignment there's there, and the graphic placement from the database actually sticks it there, and this is done for every place throughout the world, and there are a number of geographical locations. ”

“ As we started to create some changes to what we wanted to put on the approach charts, we tried to make some decisions on which direction we were going to go. We have approximately 30,000 different instrument approach procedures that we publish at Jeppesen, and one of the things that we're very careful to do is to make sure that we do enough samples so that we have a method that will work every place.
One of our favorite sayings is one robin does not a spring make. You can't use one example and apply it to everything. ”

“ But, nevertheless, it's a very high proportion of the airplanes are equipped and flying with some form of ground proximity warning system. Some are very old and ancient and some are pretty new.
We've accumulated over 230 million departures probably worldwide. So, there's a lot of experience with this equipment, and in conjunction with minimum safe altitude warning system in the United States, because that really is very, very effective technology -- pieces of technology can reduce the risk, and we've lowered it from about .85 to .03 per million. ”

“ Lights up, please. One last question. You had talked about trying to collect, I guess, real world data from line operations, so that you could feed that back into the training arena, and I think you as a line pilot know, and I think the industry knows, that a lot of times, the collection of such data is feared by pilots, that management will use that for other purposes other than for training or education but more for punitive action. ”

“ I think all pilot associations know of the various schemes in existence whereby such data is collected on an anonymous basis. It is not associated with a particular pilot, and some operators have procedures whereby only the union representative can be given information from engineering, not flight crew management, to eventually contact an individual to seek further information.
Airline managements do not have access or should not have access to the individual themselves, except through pre-arranged procedures that the pilot associations are comfortable with. ”

“ As to constant rate descents, as a TERPS -- as a pilot, I'm all for them. As a TERPS guy, I just have to issue some caveats because often where we have our most difficult non-precision approaches, and this is not true of Guam, there's places a lot worse than Guam, the terrain along the intermediate and final approach segments, we have so much terrain, we can't even put an ILS in. ”

“ Modern simulator systems have good visual displays. When operating to an airport in the simulator database, under VFR good visual conditions, in mountainous terrain, it is very easy to take a vector that puts the airplane flying towards a potential conflict with the terrain. The briefing to the crew is let it happen, see what it looks like, and don't do anything until the ground proximity warning pull-up occurs. ”

“ Any place that it's a mandatory required piece of equipment, it would not be appropriate to put a second set of minimums because it would lead the pilot to believe that if that piece of equipment was failed in his airplane or absent in his airplane, that he could fly that approach, and that he or she would be in serious trouble if lost communications and tried to make a missed approach. ”

“ No glide scope has ever been installed.
So, it is common that pilots have to deal with either a glide scope that's been installed being temporarily out of service, or a glide scope that was never installed presenting an empty channel to every -- every airplane on approach, and therefore the aviation community again, as I said earlier, relies on procedural methods, such as notices to airmen and ATIS announcements, to advise pilots that -- that a particular navigational aid is out of service. ”