jsat loss of control - cast

JSAT Loss of Control

CAST Approved

Final Report

Loss of Control JSAT

Results and Analysis

Paul Russell, Jay Pardee Co-Chairs

December 15, 2000

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TABLE OF CONTENTS

I. EXECUTIVE SUMMARY 3ii. RESULTS AND ANALYSIS 11 A. Background Information 11 B. Purpose and Makeup of Subteams 11 C. Analysis Data Set 12 D. Description of the Analysis Process 13 E. Research Interventions 16III. RESEARCH RECOMMENDATIONS 18 A. Human Factors 19 B. Piloting Skill 19 C. Failure Analysis 20 D. Handling Qualities Criteria 20IV. COMPARISON TO PSM + ICR REPORT 24V. RECOMMENDATIONS 31 A. Design Issue Interventions 33 B. Training Interventions 35 C. Practices, Policies and Procedure Interventions 38 D. Data Interventions 39 E. Regulatory Role Interventions 39

F. Recommendation Summary 40VI. APPENDICES 43 APPENDIX A. Loss of control JSAT Charter 44 APPENDIX B: Team Member List 47 APPENDIX C: Synopsis of Data Set 52 APPENDIX D: Interventions Ranked by Overall Effectiveness 57 APPENDIX E: Research & Development Interventions 88 APPENDIX F: Non-Rated Interventions 91 APPENDIX G: Interventions Sorted by Number (IS#) 93 APPENDIX H: Intervention Grouping by Strategies 129 1. Design Intervention Strategies 129 2. Training Intervention Strategies 136 3. Practices, Policies and Procedures Intervention Strategies 144 4. Data Intervention Strategies 154 5. Regulatory Role Intervention Strategies 156 APPENDIX I: Master Problem Statement/Intervention Matrix 157 APPENDIX J: Problem Statement Frequency Matrix 219 APPENDIX K: Icing 239

APPENDIX A: LOSS OF CONTROL JSAT CHARTER

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I. EXECUTIVE SUMMARY

In September 1999, the Commercial Aviation Safety Team (CAST) chartered the Loss of

Control (LOC) Joint Safety Analysis Team (JSAT). CAST previously had determined that

loss of control, due to aircraft design, aircraft malfunction, human performance, and other

causes, was among the top three categories of fatal accidents in the United States and

elsewhere.

CAST chartered the JSAT to review and analyze data on loss-of-control accidents, then

develop and recommend interventions that will reduce the rate of loss-of-control accidents

around the world as part of CAST's goal to reduce the overall fatal accident rate by 80

percent by 2007. The JSAT analysis of loss of control was based on publicly available

source information, official accident reports from aviation safety investigative authorities in

several countries, and other studies related to loss of control.

Appendix A presents the LOC Charter. Appendix B lists the members of the JSAT and their

respective organizations. Appendix C presents a synopsis of the accident data.

In addition, in accordance with the charter from CAST, the JSAT reviewed the analysis and

findings of an earlier industry-government study, "Propulsion System Malfunction and

Inappropriate Crew Response" (PSM+ICR). The review was designed to ensure that the

JSAT had considered all mutually effective interventions. (See Section IV.)

After the JSAT began its work, CAST asked the team to analyze the effects of icing in

selected loss-of-control accidents. The JSAT analysis and resulting interventions related to

icing are included in Appendix K. The developed interventions will be forwarded to the

upcoming Weather JSAT.

The LOC JSAT used the JSAT process as directed by the charter. The process stipulates

that the JSAT will not address the feasibility or costs of implementing the interventions. This

report is intended for the Loss of Control Joint Safety Implementation Team (JSIT), which is

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responsible for assessing the feasibility of JSAT recommendations and developing any

appropriate implementation plans. This report summarizes the analysis and results of the

Loss of Control JSAT and presents five broadly based strategies to reduce loss-of-control

accidents:

• Design Issues

• Training

• Practices, Policies, and Procedures

• Data Collection and Analysis

• The Regulatory Role

The team recognizes that interventions are limited in their potential to bring about a change

unless they are based on a thorough understanding of the underlying causes. Accordingly,

a set of supporting research recommendations is presented separately in Section V.

The JSAT methodology combines detailed case studies, a high-level data analysis, and

expert judgement. The case studies employ an event-sequence analysis, while the high-

level approach involves statistical data and data from other sources. Based on these

different sources, the JSAT developed interventions that addressed specific case-study

accidents. Each intervention was rated for three characteristics: power; confidence; and

applicability (as described in Section IV, below). The JSAT then computed an "Overall

Effectiveness" (OE) score or ranking, ranging from 0 to 6. The complete list of interventions,

prioritized by OE scores, may be found in Appendix D. OE scores primarily reflect the

estimated effectiveness of each intervention in preventing the respective case-study

accidents against which they were rated. Appendix G lists all interventions from the Loss of

Control JSAT, sorted by intervention number.

The JSAT also included interventions that addressed organizational culture, systematic use of

digital flight data, no-blame internal reporting systems, etc. Such interventions may not produce

their full benefits by the 2007 target, or the analysis of past accidents may not adequately assess

the full potential of some interventions to break complex causal chains in future accidents.

Consequently, some recommended interventions, particularly those that address research and

development, were not assigned OE ratings. Instead of OE ratings, this JSAT prioritized the


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research interventions to reflect the team's assessment of whether the research should be

initiated in the near term or deferred to some future date.

The interventions that received the highest OE ratings provide the foundation for the

recommendations, each of which calls for several actions by airlines/operators, manufacturers,

regulators, or others. In addition, the recommended strategies include interventions that received

lower OE ratings.

All recommendations require the active participation of regulatory authorities. Such participation

may include developing technical standards, approving procedures, or overseeing

implementation. In addition to the regulators, many recommendations identify other members of

the aviation community that must take action if the recommendations are to be effectively

implemented. The recommendation strategies are presented with their constituent interventions

in a non-prioritized order.

The team analyzed the accident data set to develop interventions that would have worldwide

application. Full implementation of these recommendations will therefore involve manufacturers,

operators, air traffic service agencies and regulatory agencies throughout the world.

The following is a synopsis of the five broad strategies. These are built upon six interventions that

had OE scores of 4.0 or higher. Each of the five strategies, in turn, assumes that singular and

isolated interventions generally are less effective than are approaches that integrate related

interventions. Consequently, the five broad strategies include interventions that span the full

range of OEs (i.e., scores below 4.0), as discussed in Section IV.

1) Design Intervention Strategies

Design interventions encompass strategies ranging from developing and expanding new

technologies, such as flight envelope protection, to adapting and retrofitting older, proven

systems to existing aircraft. Additional interventions attempt to deal with aircraft and

systems certification. Team members expressed a great deal of concern that newer aircraft

and systems, certified under derivative criteria, are not required to comply with higher

standards of reliability and redundancy currently required of new designs. New technologies

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and existing technologies were also evaluated as to whether they should or could be

adapted to existing aircraft. The implementation of these concepts will be further evaluated

by the JSIT.

• New Technology

o Flight Envelope Protection (445)

• Existing Technology

o Displays (483,395,398)

o Automation Interface and Function

(533,501,16,408,412,413,424,472,485,515)

o Yaw Compensation (566)

o Stall Protection and Warning (380)

• Certification

o Derivative Certification (366)

o Expanded Flight Envelope (364,431,400)

2) Training Intervention Strategies

In general, training history was very poorly documented in most of the accident data

reviewed.. In most instances involving training issues, team members developed

interventions based upon their experiences with best practices, which have proven effective

in reducing or preventing accidents.

The training interventions focused primarily on preventing loss of control and regaining

control. Several major carriers have recently introduced upset recovery training. However,

the team felt that on a worldwide basis this continues to be a neglected area. The team also

felt that current regulations and training regimes which focus on "approach to stall"

inadequately prepare the pilots to deal with recovery from a full-stall condition.

Many of the accidents involved training issues related to automation. Pilots were confused

by the automation, did not understand or were not aware of what automation was doing or

how to control the automation. Once control was lost, pilots did not clearly understand how

to regain control of the aircraft through manual control, disabling the automation, or

reestablishing automated control.


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Pilot training was a topic in almost every accident analysis. There were two fundamental

issues involved:

• Current simulators are limited in their effectiveness to train pilots to recognize and

recover from a full stall.

• Pilots have not had adequate training to develop skills and confidence to recognize

and recover from aircraft upset.

Simulator data packages do not include data representing portions of the flight envelope,

including stall. This precludes realistic pilot training in the dynamics of stall and stall

recovery. The team recommends that the JSIT evaluate expansion of the flight envelope

data package and simulator capability in order to improve pilot training in the stall regime.

The team concluded that upset recovery training for pilots is essential to reduce the number

of loss-of-control accidents. The team believes that simulators can be used more effectively

to develop skills and confidence for pilots to recognize and recover from aircraft upset. The

team recommends that upset recovery training become a mandatory part of initial and

recurrent pilot training programs.

• Stall Recognition And Recovery (525, 384)

• Upset Recovery Training (357)

• Automation Training (486, 15)

• Instructor and Check Pilot Qualification and Training (535)

• Improved Training, Policies and Procedures (110, 7, 142, 157, 99)

• Simulators (546)

3) Practices, Policies, and Procedures Intervention Strategies

A large number of interventions deal with practices, policies, and procedures. Few of the

accident reports contained specific information regarding this topic area. The team

members had to rely on their experience to provide interventions that reflect the best

practices in the industry. The team recommends that accident investigation reports should

explicitly address practices, policies, and procedures.

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Standard Operating Procedures (SOP) either did not exist or were not followed in many

accidents. Assuming pilots do not intentionally violate existing SOPs, it is crucial to

understand the underlying cognitive processes contributing to procedural non-compliance.

Intervention 204 calls for important research aimed at understanding this issue.

In most accidents involving automation, there was an absence of an automation policy.

Pilots became confused about the automation and did not have any policy of monitoring or

disengaging that would have helped them prevent the accident. In many cases, airlines

have automation policies that include phrases like "Use the appropriate level of automation,"

but they provide no guidance or training as to how to decide what the appropriate level of

automation is for a given set of circumstances. This situation leads to pilot confusion and

inaction and contributes to automation-related accidents.

There were several cases where service bulletins had not been implemented or where they

had been implemented and there was no information provided to the pilots. There were also

several cases where the information provided by the manufacturer had not been

incorporated into the operating procedures of the airlines. The team recommends that the

JSIT identify and implement best practices for coordination between regulators,

manufacturers, and operators that ensures critical safety information is distributed and

implemented in a timely fashion to those who need it.

There continues to be an industry-wide problem of pairing minimally qualified pilots. It was

the opinion of the team that this issue needs continual oversight by both operators and

regulators.

• Standard Operating Procedures (99, 110, 142, 157, 397)

• Automation Policy (530, 561, 15)

• Integration of Manufacturer Procedures Into Flight Operations (431, 80, 400)

• Crew Qualifications (152)

• Currency and Accuracy of Information

• Service Bulletins (532, 98)

• Manuals (225)


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4) Data Intervention Strategies

There is a limited number of intervention strategies related to data collection. The analysis

of the team was complicated by the fact that many of the accident aircraft had no or limited

data recording available. In many of the accident aircraft, the data recorders were not

functioning or the data available was so limited that it was almost useless.

The accident report of USAir 427 included a recommendation from the NTSB that improved

quality Flight Data Recorders should be installed in all commercial aircraft (see intervention

576). That recommendation has not been implemented. It should be.

The team also recommended statutory support for ongoing analysis of data from nonvolatile

memory systems, such as FOQA or BASIS, and self-reporting programs, such as ASAP or

ASRS, to identify and eliminate problems before they result in accidents. These programs

need to be protected by statute to ensure that they can fulfill their purpose of sharing safety

data and identify precursors to accidents in a non-punitive atmosphere. (See interventions

361, 56, and 54.)

5) Regulatory Intervention Strategies

Almost every intervention assumed a regulatory role. Effective implementation of any

particular intervention will require active regulatory participation if not direct implementation

responsibility. The regulatory interventions encompass both the "rules" and the oversight

responsibility of the regulatory agencies on a global basis.

• Regulations, Rules, and Advisory Circulars

o Certification (366, 364, 431, 501, 413, 515)

o System Reliability (423)

o Training (525,357

• Oversight

o SOP (110, 157, 397, 408)

o Airline Operations (110, 80, 152)

o Currency and Accuracy of Information (98, 214, 225)

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The Loss of Control JSAT, as other JSATs have done, illustrates the ability of industry and

government to work together effectively. The Loss of Control JSAT recommends continuing

this joint activity. The team also recommends sharing this report with the commercial

aviation community.


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II. RESULTS AND ANALYSIS

A. Background Information

The three most common types of aviation accidents are Controlled Flight into Terrain (CFIT),

Approach and Landing, and Loss of Control (LOC). CAST previously chartered JSATs on

CFIT and approach and landing accidents. The CAST then chartered the Loss of Control

JSAT (Appendix A), as well as the Runway Incursion and Turbulence JSATs. This JSAT

analyzed data and official reports on loss-of-control accidents.

The JSAT defined loss of control to include significant, unintended departure of the aircraft

from controlled flight, the operational flight envelope, or usual flight attitudes, including

ground events. "Significant" implies an event that results in an accident or incident. This

definition excluded catastrophic explosions, CFIT, runway collisions, complete loss of thrust

that did not involve loss of control, and any other accident scenarios in which the crew

retained control.

Each year, about 2.8 fatal loss-of-control accidents occur worldwide, excluding the

Commonwealth of Independent States. Given current projections of growth in traffic, and

assuming no change in the rate of accidents, up to 5 fatal loss-of-control accidents could be

expected by 2010 unless the world aviation community develops and implements informed

interventions, thereby lowering the rate. Although aviation will remain the safest form of

transportation, an annual average of 5 fatal loss-of-control accidents will not be acceptable

to the industry or to the public.

B. Purpose and Makeup of Subteams

The LOC JSAT consisted of individuals representing a cross-section of the international

commercial aviation community. Co-chairs from the FAA and industry directed the team.

The team initially consisted of approximately 40 members but was supplemented with four to

six additional members to adequately address the icing-related loss-of-control accidents that

were added to the data set.

The JSAT included individuals from CAST member organizations who represented a broad

spectrum of aviation expertise, including human factors specialists, line pilots, aeronautical

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engineers, regulators, data experts, safety analysts, air traffic controllers, researchers and

maintenance experts. See Appendix B for the complete list of team members and

participants.

Due to the extent of the accident data set assigned to the LOC JSAT and the schedule that

the JSAT was to meet, the team was subdivided into three subteams. Each subteam

analyzed several loss-of-control accidents in accordance with the JSAT process. Each

subteam consisted of at least one representative from each of the member organizations.

The number of subteams was later expanded to four when CAST added several accidents

to the data set.

When a subteam needed a specific area of expertise (e.g., Air Traffic Control, Flight

Standards, etc.), an expert was “borrowed” from another team to lend assistance and input.

In addition, the team used outside resources as required. To ensure that each subteam

would have access to all available expertise, meetings were held at a common location.

C. Analysis Data Set

CAST guidance required the use of accident cases that were extensively documented and

data rich, including flight data and voice recorder records. Forty loss-of-control accidents

and incidents were considered as potential candidates for use; 24 were selected for case-

study analysis. The accidents represented a broad range of aircraft types, operations,

geographical areas, and environmental conditions. A synopsis of the accident data set is

provided in Appendix C.

Accident reports from the United States' National Transportation Safety Board, the United

Kingdom's Aviation Accident Investigation Bureau, the Transportation Safety Board of the

Netherlands, and other national authorities provided the "data-rich" information necessary to

conduct the JSAT’s analyses. The 24 reports enabled the team to identify complex

environments and chains of events that, in turn, offered numerous opportunities for

interventions to break those chains or at least to mitigate their consequences.


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The 24 cases provided an adequate sample with which to apply the CAST JSAT process.

Few case studies in any discipline are based on such a large data set.

D. Description of the Analysis Process

The Loss of Control JSAT followed the Process for Conducting Joint Safety Analysis Teams,

Revision B. Additional refinements were developed to improve the process step associated

with evaluating the effectiveness of interventions. These refinements were briefed to and

approved by the CAST before they were implemented. These process improvements were

based on experience gained from previous JSATs. The improvements were designed to

yield more accurate and reliable estimates of Intervention Power (P) and Applicability (A).

These changes did not affect the meaning or use of those factors. As part of the process

improvement, guidelines were developed to assist this JSAT and future teams in the

conduct of the analysis meetings.

Each of the four subteams cited in Section II was assigned a set of accident reports to

analyze. Subteams developed an event sequence spreadsheet for each of their assigned

accident reports. Spreadsheets included events needed to provide necessary context for

understanding the nature of the accident sequence. Events were then evaluated to

determine if they represented a "problem" involving hardware/software failure or human

execution errors, decisions, or procedural non-compliance.

If an event was considered contributory to the accident, then a statement describing why it

contributed to the accident was developed. The specific nature of the problem associated

with an event in the sequence was identified along with the factors, which could have

precipitated the problem.

These Contributing Factors were then restated, in more general terms, as Standard Problem

Statements in order to have relevance beyond the specific accident. The Standard Problem

Statements were then rated as described below.

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Potential interventions were developed to address each Standard Problem Statements. The

process followed by the LOC JSAT yielded approximately 200 new interventions. The

interventions were then rated as described below.

All interventions are listed in Appendices D, E, F, G, and H. Standard Problem Statements

used by the LOC JSAT are found in Appendix I. The frequency that each problem

statement was used and the accidents in which each was used is listed in Appendix J.

Ratings.

The following rating factors were developed to prioritize the interventions: Power (P);

Confidence (C); and Applicability (A). Overall Effectiveness (OE) is determined by the scores

assigned to "P," "C'" and "A."

Power. "Power" indicates how important a problem was to a particular accident and the degree

to which an intervention could have resolved the problem and break the chain of events in that

accident if the intervention worked as perfectly as could be hoped. However, some confusion

had developed over the practical meaning of Power. In practice, "P" sometimes was scored to

indicate the relative power that the targeted problem had played in the accident and, at other

times, to indicate the power of an intervention to resolve a specific problem and thereby break

the chain of events. As a result, in practice, "P" often failed to integrate the two concepts and,

instead, scored one side of the concept to the exclusion of the other.

In recognition of this confusion, the process was changed following the Approach and Landing

JSAT. The two factors within Power, outlined above, were partitioned into P1 and P2 so that

each could be rated separately, as follows.

P1 indicates the importance of the problem or contributing factor as a causal link in the

accident.

P2 indicates the ability of the rated intervention to mitigate the problem or contributing

factor.

.


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The 0-6 rating scales used to evaluate P1 and P2 were similar to those used for previous

ratings. The two scores then were combined arithmetically to produce a single Power rating.

This explicitly addressed the past confusion and, simultaneously, yielded a single Power score

that was conceptually equivalent to the Power rating as used by previous JSATs.

The change will be incorporated into revised process guidelines used by the LOC JSAT and will

be included in the Process for Conducting Joint Safety Analysis Teams (JSAT), Revision C. In

sum, P1 focuses overtly and exclusively on the problem or contributing factor, while P2 focuses

on the intervention.

Confidence . This factor indicates how strongly the team believed that everyone and

everything would perform as expected if the interventions were implemented. The

Confidence factor assesses the “real world,” where interventions are seldom perfect and do

not always have 100% of the desired effect.

Applicability. This factor indicates how frequently the problem(s) being addressed by the

specific intervention will continue to be present in future operations. The Applicability factor

provides a bridge from the specifics of the particular accident being analyzed to expected

future operations.

Overall Effectiveness.

The ratings of P, C and A were mathematically combined to yield an overall effectiveness

score (OE) in a range of 0 to 6 for each intervention. Appendix D lists the interventions

ranked by OE. For a detailed explanation of the process for rating factors and ranking the

interventions see the Process for Conducting Joint Safety Analysis Team, Revision C.

To facilitate the work of the JSIT and to provide readers of this report with easy access to

specific interventions of interest, the JSAT sorted all its proposed interventions in a number

of different ways. (See Appendices D through H.)

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E. Research Interventions

During the rating process, in accordance with the process handbook, those interventions,

that called for research, were not rated with OE scores. When the preliminary report was

presented to the CAST in September 2000, CAST requested that the JSAT prioritize the

research interventions, based on their potential to address the rated interventions or to

provide scientific knowledge that might form the basis of future interventions. The

prioritization was to be included in the final report. A subteam was formed to develop a

process for prioritizing the research interventions. The subteam then reported the results to

the entire JSAT.

Several alternative strategies were discussed and tested for prioritizing research

interventions. Because the outcomes of research cannot be anticipated, the subteam

decided on a simple voting scheme based on each subteam member’s overall assessment

of the importance of the research, as described above. For each research intervention,

each subteam member voted based on the following choice, with recognition of the scoring

of the associated problems and applicability ratings:

• Category A: The research should be initiated in the near term;

• Category B: The research should be deferred to some future date.

The underlying principle for this approach was that the degree of consensus could be used

to indicate the relative importance of research activities. This approach was based on the

wide variety of background and experience of the team members (e.g. researchers,

designers, pilots, and regulators). If most members felt the research addressed an

important problem and should be initiated in the near term, the project received high priority.

If most members of the team found research addressed a less significant safety problem or

should be deferred, the research received a low priority.

After the members voted on each research activity, a ratio was calculated for each activity,

as follows: number of votes for near-term initiation divided by the number of votes for

deferral. Activities then were rank-ordered based on the ratios. The resultant rank ordering

was divided into four groups.


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Priority 1: A/B > .66 (at least 2/3 of the members voted for Category A)

Priority 2: .65 >A/B > .5 (at least 1/2 of the members voted for Category A)

Priority 3: .49 > A/B > .33 (at least 1/3 of the members voted for Category A)

Priority 4: A/B < .33 (less than 1/3 of the members voted for Category A)

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III. RESEARCH RECOMMENDATIONS

Interventions aimed at further research fall into several broad areas: Modeling for Upset

Prevention and Recovery Training; Human Factors; Piloting Skill; Failure Analysis; and

Handling Qualities Criteria. Each of these areas is presented below in further detail with a

discussion of some relevant interventions. Several recommendations for further research on

icing conditions were also developed, and are included in the table below and in Appendix

K.

Modeling for Upset Recovery Prevention and Training

Several of the interventions address the need for upset recovery, stall and post-stall

recovery training. To accomplish this training, improved aerodynamic modeling near the

limits of the flight envelope (high angles of attack and/or sideslip) is necessary for

appropriate simulator fidelity. Aerodynamic data for these conditions can be acquired

through wind tunnel testing research that encompasses the potential flight envelope in a

loss-of-control situation. Determining how to best model such aerodynamics in a simulation

database (e.g., what level of fidelity and data resolution is required) is also an area that

needs to be studied. (See interventions 358, 384, 386, 451, and 475.)

The actual method of training is also an area of research that needs to be explored. The

two primary issues are:

• Adequacy of conventional training simulators with improved aerodynamic models to

support training objectives.

• Sufficiency of simulators' motion, visual and aural cues to model the potentially

highly dynamic motions of a loss-of-control scenario with its vestibular and

proprioceptive effects.

There are some suggestions that the most effective method of training is actual flight

experience under such conditions, e.g., through the use of aerobatic or other high-

performance aircraft. (See intervention 359.)


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In the area of upset prevention, research is recommended to develop systems which can

advise a flight crew of an impending loss-of-control situation, by providing a predictive

capability of future flight path given the current condition. In addition, there are interventions

focused on the development of automatic and manually activated recovery systems.

Improved aerodynamic modeling will also be a benefit to such efforts. (See intervention 245

and 471.)

A. Human Factors

Several human factors research issues emerged including understanding crew

preoccupation/overload, alerting, and interaction with automation; and crew misprioritization of

tasks. Research into understanding these phenomena and developing strategies to counteract

them is recommended. Development of a set of cues to help crews recognize loss of situational

awareness is also recommended. (See interventions 208, 379, 428, 448, and 572.)

Research is recommended to identify optimum ways to alert crews to be attentive to

potentially problematic situations such as inconsistencies between flight modes and aircraft

performance; aircraft status in critical situations; and proper annunciation of propulsion

system malfunctions, to name a few. Since flight crews ignore or disregard critical warnings

in some situations, research should also be conducted to understand this phenomenon and

develop solutions. (See interventions 244, 356, 385, 392, 425, 430 and 443.)

The incorporation of automation into the flight deck requires additional research into the

transition from automated flight to manual flight, and the interactions of flight crews with

automated systems, such as the need to keep crews alert in low-stimulation situations (e.g.,

long-haul flights in highly automated flight decks). (See interventions 406 and 426.)

B. Piloting Skill

Research is needed to define what constitutes "normal piloting skills." During aircraft

development, manufacturers must make assumptions about what can be handled by 'normal

piloting skills.' Research should be undertaken to determine if those assumptions are valid

for realistic airline operations. One method of adding objective structure to skill levels would

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be to study the potential for developing a multi-level pilot licensing and qualification system.

(See interventions 419 and 552.)

C. Failure Analysis

Modern aircraft consist of many complex systems that constantly interact with each other in

ways unforeseen in previous designs. Because conventional safety analyses may miss

latent or combination failures in such complex systems, research to determine the optimum

methods of conducting safety analyses in such an environment is recommended. (See

interventions 455 and 496.)

D. Handling Qualities Criteria

Similarly, modern aircraft possess extremely complex flight control and automated systems.

Because assessments of handling qualities are subjective and were developed for earlier-

generation aircraft, they may not be adequate to properly assess current aircraft in all

regions of the operating flight envelope, particularly in transitioning from automated to

manual flight modes. For these reasons, research is recommended to determine the

adequacy of current evaluation methods, and develop improved, more quantitative, handling

qualities acceptance criteria. (See intervention 550 and un-rated intervention 449.)

The following table contains the research interventions sorted by Priority Group:

IS# Research Intervention Strategy PriorityGroup

359To improve effectiveness of upset recovery training, research shouldidentify the most effective methodology for upset training. 1

386To support advanced maneuver training, manufacturers should developsimulator models that facilitate post stall recovery training (see 358). 1

419

Because manufacturers must make certain assumptions regarding whichfailures will be detected and handled by the pilot with "normal pilotingskills," research should be conducted to determine if these assumed skillsand knowledge are valid in realistic airline operations.

1

425

To enhance crew awareness of automation modes, research should beconducted to develop intelligent systems that will alert the flight crew toinconsistencies between the selected automated flight modes, aircraftperformance and current system status.

1


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426Research should be undertaken to determine how to keep crews alert inlow-stimulation environments (e.g., highly-automated flightdecks, long-haulflights)

1

499

To make flight crews aware of the possibility of airframe ice accretion,research should be conducted to develop reliable means of aircraft surfaceice detection, as well as ground and aircraft-based means of detection ofmeteorological icing conditions.

1

244To prevent plan continuation errors (e.g. press-on-itis), research should beconducted to determine the effectiveness of directive information systemsfor go-around situations.

2

362To enable further development of safe aircraft separation and operationalrequirements, research should be conducted to describe the dynamics andlocation of wake turbulence and environmentally generated turbulence.

2

385Because flight crews sometimes disregard flight deck warnings whichrequire immediate action, research should be conducted to understand thisphenomenon and develop appropriate solutions.

2

392In order to support pilot takeoff decision-making, research should beconducted to determine the effectiveness of alerting systems to identifysituations which warrant a rejected takeoff.

2

430Research should be conducted to determine the optimal way to provideflight crews with aircraft status recognition during critical situations. 2

455

Because latent and combination failures may be missed in failureanalyses, manufacturers and regulators should conduct research intoimproved methods for conducting safety analyses, to ensure reliableidentification of failures which, singly or in combination with other systemfailures, can result in accidents.

2

459

For a full understanding of aircraft performance and handling qualities inicing conditions, research should be conducted to define the effects of allice accretions, with particular emphasis on the roll effect due to ice-contaminated wings (intercycle or residual).

2

550

Since handling quality evaluations are subjective and subject to non-technical influences, the regulatory authorities, manufacturers, researchorganizations, and operators should work together to develop improved,quantitative, objective metrics and acceptance criteria to ensure safehandling qualities.

2

204Research should be conducted to better understand the underlyingreasons/causes for procedural noncompliance. 3

208208 Research should be conducted to understand and counteract thephenomenon of flight crew overload (e.g. why do flight crews ignoreGPWS warnings).

3

356Research should be conducted to develop an effective tactical decision-making model for flight crews in time critical situations. 3

379Since people are often unaware of their own confusion, research should beconducted to develop a set of cues to help flight crews and controllersidentify when they have lost situation awareness.

3

428Research should be conducted to develop ways to prevent inappropriatepreoccupation with trouble shooting following engine or other system 3

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failure to the exclusion of the major task of flying the airplane.

443To ensure the best technique for engine malfunction/failure annunciationand to minimize nuisance alerts, research should be conducted todetermine when, and how, to annunciate engine malfunctions/failures.

3

496To enable failure analysis which is based upon realistic levels of flight crewreliability, researchers should develop and validate models of human error. 3

509

To reduce the risk of encountering hazardous weather conditions (e.g.super-cooled large droplets (sld), thunderstorms, etc.) research must beconducted to develop methods for accurate prediction and identification ofthese conditions.

3

552To add structure to piloting skill levels, research should be conducted todetermine the efficacy and impact of a multi-level pilot licensing andqualification structure (e.g. analogous to apprentice, journeyman, master).

3

406

In order to minimize automated flight to manual transition effects, researchshould be conducted to determine the feasibility and desirability ofautomated flight/flight control system designs that eliminate the need forlarge flight control input at disengagement from ALIGN mode.

4

448To preclude trainee overload, research should be conducted to understandthe optimum workload level for effective flight training. 4

461To reduce the adverse effects of ice accretion roughness, the regulatorsand NASA should conduct research leading to improved ice protectiontechnologies.

4

471

Since many factors can make the identification of impending loss of controldifficult, research should be directed toward the development of systemsthat advise the flight crew that the aircraft is departing from a flight pathconsistent with the flight control inputs.

4

510To better understand the effects of super-cooled large droplets (sld), icingresearch should be conducted on ice protection system design andoperation in this weather phenomenon.

4

572Research should be conducted to improve understanding of how/whypilots misprioritize or become fixated upon concerns and tasks, and todevelop strategies to counteract this effect.

4


24


25

IV. COMPARISON TO PSM+ICR REPORT.

The JSAT analyzed 24 loss-of-control cases in great depth in order to document and gain a rich

understanding of complex causal chains, several of which involve power systems. Though 24 is

a very large number of accident case studies, the case-study approach inherently sacrifices the

statistical inferences that can be gained from analyzing a much more broadly based data set.

Conscious of this tradeoff, CAST directed the Loss of Control JSAT to review findings and

recommendations from the 1998 "Project Report of the AIA/AECMA Propulsion System

Malfunction Plus Inappropriate Crew Response (PSM+ICR) Workshop."

The PSM+ICR analysis was an 18-month effort that involved representation from government,

engine, aircraft and simulator manufacturers, air carriers, and pilot organizations. As implied by

its title, the PSM+ICR Workshop analyzed accidents and incidents involving propulsion system

malfunction and subsequent crew responses that may have been inappropriate for the

respective situations, which is one of several common scenarios in loss-of-control accidents.

As with comparable reviews by other JSATs of existing studies, the review of PSM+ICR

recommendations had two core objectives. First, since the PSM+ICR addressed one of the

elements in loss of control, CAST and the JSAT wished to assure themselves that the JSAT

did not overlook interventions related to propulsion systems. Secondly, CAST and the JSAT

wished to lend their support to recommendations from PSM+ICR where appropriate.

The two reports were different in scope and in team composition. PSM+ICR targeted issues

that constitute a significant but still singular type of loss-of-control accident. Consequently,

the PSM+ICR team was more dominated by professionals from various propulsion

disciplines than was the JSAT. Nevertheless, the recommendations from the two studies

proved to be very consistent.

The review indicated that the JSAT's recommendations correlated strongly to those in the

PSM+ICR report. The JSAT comprehensively covered 8 of the 9 PSM+ICR

recommendations. The remaining PSM+ICR recommendation addressed specific training

media (text and video). While the JSAT addressed training needs at some length, the JSAT

did not recommend specific training media.


26

Below is a detailed comparison of PSM+ICR recommendations and the JSAT interventions.

Each recommendation from PSM+ICR is quoted in full. The related JSAT interventions are

indented in order that readers may distinguish them easily from the PSM+ICR

recommendations.

PSM+ICR Recommendation A. The requirements of 14 CFR Parts 61 and 121 / JAR-OPS

/ JAR-FCL need to be enhanced for pilot training in powerplant failure recognition, the effect

of powerplant failure on airplane performance and controllability, and the subsequent control

of the airplane.

401. To ensure proper identification of engine malfunctions and avoidance of

possible loss of control, airline/operators should provide enhanced and more realistic

training for engine malfunctions, engine responses to control signal errors and the

appropriate aircrew actions.

427. To prevent inappropriate preoccupation with trouble shooting following engine

or other system failure, airline operators should enhance training and checking to

prioritize safe control of the airplane.

487. To minimize the occurrence of loss-of-control events, airline operators' training

programs should emphasize pattern recognition and skill-based procedures to cope

with time critical situations, rather than relying on knowledge based analysis.

PSM+ICR Recommendation B. The regulatory authorities should establish and implement

a rigorous “process” to ensure that the following occurs during the development of a pilot

training program:

• Identification of powerplant failure conditions that need to be trained.

• Preparation of training aids (Tools & Methods).

• Establishment of the appropriate means to conduct the training.

• Assurance that each pilot receives the appropriate training for both malfunction

recognition and proper response to it.

• Validation of training effectiveness, along with a feedback loop to improve / update

training.

27

401. To ensure proper identification of engine malfunctions and avoidance of

possible loss of control, airline/operators should provide enhanced and more realistic

training for engine malfunctions, engine responses to control signal errors and the

appropriate aircrew actions.

428. Research should be done to develop ways to prevent inappropriate

preoccupation with trouble shooting following engine or other system failure to the

exclusion of the major task of flying the airplane.

535. To ensure adequate instructor / check pilot qualifications, operators must

establish and maintain minimum line and instructor / check airman qualifications.

546. Ensure that flight crews are adequately trained in an appropriate level simulator

for the training being conducted (i.e. engine out, upset recovery, etc.) before being

assigned to the line. (See 153, 312)

PSM+ICR Recommendation C. The mandatory pilot training program associated with

simulated V1 engine failures in an airplane has caused a number of hull loss/fatal accidents.

The value of performing this training in the airplane should be reviewed. It is the Project

Group’s belief that this specific training could be better effected in simulators. Where

suitable simulators are not available, the airplane handling task could then be adequately

and much more safely trained at altitude where recovery can be safely accomplished.

While there are no directly correlating LOC JSAT interventions relative to simulated

V1 engine failures in an airplane, LOC 546 does recommend engine-out training in a

simulator.

546. Ensure that flight crews are adequately trained in an appropriate level simulator

for the training being conducted (i.e. engine out, upset recovery, etc.) before being

assigned to the line.


28

PSM+ICR Recommendation D. The use of flight idle on turboprop airplanes for simulated

engine failures or in the event of a malfunction should be reviewed by industry because of

the potential association with loss-of-control events if the engine is not shut down.

541. To reduce the risk of loss of control during flight with a propulsion system

malfunction in turboprop aircraft, if the engine failure procedure is not completed,

airline operators should review the consequences of the malfunctioning propulsion

system being placed in flight idle.

PSM+ICR Recommendation E. The aviation industry should undertake as a matter of high

priority the development of basic generic text and video training material on turboprop and

turbofan propulsion system malfunctions, recognition, procedures, and airplane effects.

The LOC JSAT developed a substantial number of training interventions, including

several that explicitly addressed engine and propulsion failure or malfunction.

However, the LOC team did not address specific media, as such an issue typically

would be addressed by a JSIT.

PSM+ICR Recommendation F. The regulatory authorities should establish a means to

ensure that the simulators used to support pilot training are equipped with the appropriate

realistic propulsion system malfunctions for the purpose of “recognition and appropriate

response training”. To this end, the industry should develop specifications and standards for

the simulation of propulsion system malfunctions.

413. To prevent negative transfer effects with flight critical systems, regulators

should establish requirements for standardization of flight deck information/controls

414. To reduce negative transfer effects during pilot transition to new aircraft, airline

operators should determine the potential for negative transfer of inappropriate pilot

actions and techniques on flight critical systems and overtrain to prevent their

occurrence.

29

438. To reduce the probability of accidents, operators should adopt operational risk

management techniques for non-standard flight operations and/or flights requiring

intensive training scenarios.

528. To provide optimal training (including propulsion system malfunctions) and to

minimize negative training, regulators, aircraft and simulator manufacturers and

operators should ensure that training devices replicate realistic failure scenarios,

aircraft performance and appropriate response.

PSM+ICR Recommendation G. A review of propulsion system instrumentation

requirements should be completed to determine if improved engine displays or methods can

be found to present engine information in a manner which would better help the pilot

recognize propulsion system malfunctions.

442. To avoid delay in the recognition of engine malfunction/failure, manufacturers

should develop and implement a direct aural and visual flight deck indication of

engine malfunction/failure. (Minor transients need not be annunciated.)

443. To ensure the best technique for engine malfunction/failure annunciation and

to minimize nuisance alerts, research should be conducted to determine when, and

how to annunciate engine malfunctions/failures.

472. Since certain engine control and autothrottle system failures can result in

undesirable asymmetry, manufacturers should redesign ATSs so that they

disconnect (with appropriate annunciation) when unable to achieve the commanded

thrust settings (analogous to autopilot disconnect logic).

PSM+ICR Recommendation H. It is recommended that the aviation industry sponsor

activity to develop appropriate human factors methodologies to study both annunciation and

training effectiveness for turboprop and turbofan propulsion system failures.

443. To ensure the best technique for engine malfunction/failure annunciation and to

minimize nuisance alerts, research should be conducted to determine when, and

how to annunciate engine malfunctions/failures.


30

PSM+ICR Recommendation I. Circumstances of negative transfer from previous training

or operations should be identified and their lessons learned should be communicated as

widely as possible within the industry.

413. To prevent negative transfer effects with flight critical systems, regulators

should establish requirements for standardization of flight deck information/controls

414. To reduce negative transfer effects during pilot transition to new aircraft, airline

operators should determine the potential for negative transfer of inappropriate pilot

actions and techniques on flight critical systems and overtrain to prevent their

occurrence.

31



32

V. RECOMMENDATIONS

These interventions ranged from a simple recommendation to develop and implement a policy

or procedure to providing flight envelope protection. The JSAT organized the interventions into

four broad categories, as follows.

• Rated Interventions

• Research Interventions

• Icing-related Interventions

• Nonrated Interventions

Where appropriate, the JSAT rated each intervention for P1, P2, C, and A. Those scores

produced an Overall Effectiveness rating. This process resulted in a list of rated

interventions shown in Appendix F. Additionally, the team developed a number of research-

related interventions. These were subjected to the rating process described in Section IV.

The results of the research and the application of the findings may alter the nature or priority

of other interventions. In addition, many of the research interventions were developed

specifically to augment or support other interventions.

The interventions ranked highest by their overall effectiveness ratings address some of the

most common underlying problems and contributing factors in loss-of-control accidents.

However, lower-ranked interventions, when combined with more powerful interventions that

address the same problem, often became a necessity or their effectiveness increased due

to the synergy offered by the broader strategy. Consequently, to improve the efficiency and

effectiveness of all interventions, the JSAT organized its interventions into related groupings

that constitute broad strategies for reducing the rate at which loss-of-control accidents

occur. Each strategy is built on, or organized around, those interventions with the highest

OE scores. These strategies constitute the JSAT’s recommendations.

The team developed groupings of related interventions. For instance, the top rated

intervention was number 445, "…manufacturers should develop and implement flight

envelope protection…" Flight envelope protection is related to 11 other rated design

interventions and several research interventions. Interventions with OEs of 4.0 or greater,

are shown with related interventions from the same group in this section.

33

Very few interventions stand alone in their effectiveness. Therefore, the JSAT further

recommends that the JSIT review the entire intervention set to identify synergistic

relationships between interventions from each strategy.

Similarly, the team developed but did not rate several interventions that addressed improved

on-board data recording and better routine use of such data. For example, intervention 576

recommends immediate implementation of NTSB recommendations to improve digital flight

data recorders (DFDR) and Cockpit Voice Recorders (CVR). This intervention was not rated

because the team could not determine the degree to which improved flight recorders would

reduce future accident rates. Nevertheless, the team felt strongly that the long-standing

NTSB recommendation needs to be implemented. The problem of poor data, inoperative

recorders, and limited data collection were pervasive in the data set. The JSIT should take

action to implement this intervention.

There was an underlying assumption that a regulatory role is required for almost all

interventions. Implementation of some interventions requires developing a new regulation,

enforcement of regulations, or oversight of operations by airlines, manufacturers, or air

traffic services. For example, intervention 445 does not include regulatory action, but

regulatory action is required to implement flight envelope protection. However, the JSAT

rating process yielded a low rating for the intervention providing regulatory oversight (345).

However, without intervention 345, intervention 445 and others cannot achieve their full

effectiveness.

After analysis of the interventions, their effectiveness and their synergistic potential in

various groupings, the JSAT makes the following recommendations to the CAST as the

highest leverage actions that can be taken at an industry level to reduce the number of loss

of control accidents.

The recommendations are presented as the highest rated interventions in each group. In

order to assist the JSIT, the team determined that the interventions could be grouped by

strategies. These are:

• Design Issues

• Training

• Practices, Policies, and Procedures


34

• Data Collection and Analysis

• Regulatory Role

In order to focus on the top-level interventions, the recommendations are arbitrarily limited to

those interventions rated 4.0 OE or above.

A. Design Interventions

The top two interventions were Design Interventions. Intervention 445 recommends

implementation of flight envelope protection. This reflects the team's view that while today's

aircraft, air traffic control system, and operating environment are becoming more complex,

pilot experience and skill levels appear to be decreasing. The implementation of flight

envelope protection should reduce loss of control accidents.

The team was also concerned that modern aircraft are being developed without a

requirement to reevaluate systems and components that were certified previously for

different aircraft. An example is the Boeing-737 New Generation aircraft that were certified

with the original rudder actuator. Intervention 366 was designed to address this certification

deficiency.

The top rated design interventions and their related interventions are presented below:

445. To help avoid loss of control, manufacturers should develop and implement flight

envelope protection. (e.g. bank/pitch angle limits, over-speed, angle of attack, load factor)

New Technology. (OE 4.6)

366. To protect aircraft against flight control malfunctions, manufacturers must design and

regulators must certificate, derivative aircraft and components to current applicable

certification requirements, i.e. single point failures, redundancy, and probability of failure.

(OE 4.2)

566. Manufacturers should incorporate an automatic yaw compensation to ensure that

adequate yaw control is provided. (OE 3.8)

35

364. To protect aircraft against loss of control, regulators should develop as soon as

possible, certification criteria, throughout the entire flight envelope, for crossover speeds and

maximum rudder side slips. (OE 3.5)

380. To reduce the risk of inadvertent entry into stall, manufacturers should develop and

implement stall protection features in all transport category airplanes, (e.g. stick pusher,

alpha protection). (OE 3.1)

253. To prevent loss of control, there should be redundancy and failure tolerance features

for all flight critical components, such as dual path design, fail operational redundant

systems, with fault annunciation. (OE 2.8)

159. Manufacturers should incorporate an "input rudder" indicator or automatic yaw

compensation to ensure that adequate yaw control is provided. (OE 2.1)

513 To preclude undesired flight control displacement manufacturers should design flight

controls so that the airplane does not experience uncommanded, adverse flight control

deflections that are beyond the control of the flight crew (throughout the flight envelope,

including aerodynamic stall). (OE 1.7)

565. Manufacturers should incorporate an "input rudder" indicator to ensure that adequate

yaw control is provided. (OE 1.5)

49. Regulators should establish criteria for, and manufacturers should evaluate and

improve, the reliability and failure tolerance of flight systems. (includes hardware, software

and human performance). (OE 1.0)

363. To enhance aircraft controllability in severe or greater turbulence conditions, regulators

and manufacturers should develop and implement certification criteria that consider effects

of turbulence, including automated flight capability and disconnect parameters. (OE 1.0)

389. To assist flight crews in responding to system malfunctions, manufacturers should

develop and airlines/operators should incorporate readily accessible flight crew procedures

for partial or total failure of flight critical systems. (OE 0.7)


36

544. To ensure that flight controls are available during critical flight phases or conditions,

manufacturers should design system overrides that are available to the flight crew to regain

manual control. (OE 0.5)

B. Training Interventions

The highest rated Training Intervention (525) recommended stall recognition and recovery

training. When all training was done in an aircraft, stall recognition and recovery were a

routine part of training. However, since most transport category training migrated to

simulators, training is now limited to "approaches to stall." In this condition, the aircraft is

not fully stalled. In many LOC accidents, the aircraft became fully stalled and pilots did not

recognize the stall or did not recover from the stall. Consequently, pilots should be trained

to recognize and recover from stall.

The second-highest ranked training intervention (357) recommends upset recovery training

for pilots. This intervention should be possible to implement in the near term and it should

provide a significant reduction in loss of control accidents.

The third intervention presented here (486) involves pilot interface with automated aircraft

and systems. The questions of "What is it doing?" and "Why is it doing that?" remain much

too prevalent in the accident data set. Pilots are often unaware they are losing control of the

automated aircraft and frequently do not understand how to regain control. This intervention

will involve obtaining or developing correct, useable information from manufacturers about

the capabilities and limitations of automated systems, and then fully incorporating that

information into training, policies and procedures.

Below are the three top-rated training interventions, with supporting interventions associated

with each.

525. To mandate stall recognition and recovery training, regulators must modify the

appropriate regulations. (OE 4.2)

37

357. To ensure crews have the adequate skills to recover from extreme attitude upsets,

regulators should require, and operators should immediately implement, initial and recurrent

upset recovery training. (OE 4.0)

486. Airlines/operators and manufacturers should train crews to understand the capabilities

and limitations of automated flight systems, the conditions which would cause the systems

to not function as the crew anticipates, and how to detect and recover from inadvertent

activation of automated flight modes. (OE 4.0)

546. Airlines/operators should ensure that flight crews are adequately trained in an

appropriate level simulator for the training being conducted (i.e. engine out, upset recovery,

etc.) before being assigned to the line. (OE 3.8)

384. Since it is possible to enter a stall, airlines/operators should develop and implement a

ground school and simulator training program to train pilots to handle post stall recovery as

part of advanced maneuver training. (OE 3.3)

15. Airlines/operators should ensure that their training/standardization programs instruct

when to disengage automated systems and fly manually. (OE 3.1)

165. Airlines/operators should provide training scenarios that match realistic situations (i.e.

stall recoveries during approach, in landing configuration at flight idle with the autopilot on

(in simulator)). (OE 2.8)

331. Airline operators and manufacturers will train crews to understand capabilities and

limitations of system, conditions which would cause the system to not function properly and

how to detect failure to deploy and recommend contingency actions. (OE 2.8)

358. To prevent negative transfer effects with flight critical systems, regulators should

establish requirements for standardization of flight deck information/controls. (OE 2.8)

502. To insure flight crews can identify possible upset conditions, airline/operators should

implement flight crew training programs that demonstrate the operation of a normally


38

functioning automated flight system under non-standard flight conditions (e.g. out of trim

airplane/contaminated wing). (OE 2.8)

520. To ensure flight crews have a comprehensive knowledge of the automation system(s)

functional operation, airlines/operators should ensure that their training /standardization

programs emphasize these skills. (OE 2.8)

522. Since it is possible to enter a stall, regulators should mandate the implementation of a



391. Because of the interaction between systems, manufacturers should develop alerting

systems that help pilots understand any common cause of multiple failure messages (OE

2.4)

456. To help ensure appropriate decision making, flight crews should be trained on the

impact of automation on CRM. (OE 2.4)

473. Due to increasing dependence on automation and the complexity of potential partial

system failures, airlines/operators should modify training programs to emphasize the use of

multiple data sources to confirm that the airplane and systems are performing as expected

and in accordance with the operational mode. (OE 1.8)

470. Since current airline training emphasizes recovery from approach to stall,

airline/operators should emphasize to air crews the importance of proper analysis and

response to incipient stall conditions (for example timely reduction in angle of attack). (OE

1.7)

432. To facilitate recovery from flight upsets, airlines/operators should clearly define, train

and check the specific PF/PNF upset recovery duties. (OE 1.1)

39

C. Practices, Policies, and Procedure Interventions

A large number of interventions were related to Practices, Policies, and Procedures. Only

intervention 99, which is a statement of "best practices," met the 4.0 OE criteria. Many of

the accident reports did not clearly address the issue of standard operating procedures.

However, the analysis of the data indicated that SOPs either had not been developed or

were not being followed. Many of the accident scenarios involved sequences of events that

could have been broken if the SOPs present in many major carriers had been in place and

had been followed. This issue has been cited by every JSAT completed to date.

99. Airlines/operators should ensure that clear, concise, accurate, appropriate standard

operating procedures are published and enforced. (OE 4.0)

110. Airlines/operators and regulators should ensure that their training/standardization and

monitoring programs emphasize the importance of adherence to standard operating

procedures and identify the rationale behind those procedures (OE 3.7)

225. Airlines/operators and regulators should ensure necessary manuals (operational &

maintenance) are complete, accurate, available and appropriately used. (OE 3.1)

542. To preclude over reliance on automation, airlines/operators and regulators should

create and/or clarify a definition of “appropriate levels of automation,” to include the need to

validate against other information sources and insure that the resulting definition is

published and included in all appropriate flight crew publications, manuals and training

programs. (OE 2.1)

469. To ensure clear understanding of flight crew tasking airlines/operators should develop

criteria specifying when transfer of control is necessary or appropriate. (OE 1.5)

Another troubling and persistent aspect of the accident analysis was crew failure to comply

with procedures. Intervention 204, though unrated, is critical to understanding why this

failure persists and, subsequently, to determining how the aviation community can intervene

to improve adherence to SOPs. This research would directly support intervention 99, which

has been recommended by every JSAT completed to date.


40

204 Research should be conducted to better understand the underlying reasons/causes for

procedural noncompliance.

D. Data Collection and Analysis Interventions

No Data Intervention was rated 4.0 OE or above largely because data, by itself, has little power

to prevent any particular accident. However, the analysis of data to prevent future accidents is

very powerful. Interventions 361 and 56 represent recommendations by the team to improve the

quality of data collection and to routinely analyze that data. In addition, the team recommends

that nonrated intervention 576 be implemented to improve the quality of on-board digital

recorders. The three data-related interventions, listed below, are mutually supportive of each

other.

361. To enhance the ability to analyze, identify and take corrective actions for preventing

accidents, regulators and operators should create a collection and analysis process which

utilizes all existing and future aircraft data collection systems, such as DFDR, FOQA, ASAP and

other nonvolatile memory systems. (OE 3.8)

56. Airlines/operators should implement Flight Operations Quality Assurance (FOQA) programs

to identify systemic procedural deviations and unsafe trends. (OE 3.7)

576. To improve the effectiveness of accident investigations and, in so doing, help prevent

future accidents, regulators should immediately implement NTSB recommendations to increase

the quantity and quality of survivable data recorded in both existing and future aircraft, and

manufacturers should improve the reliability of the recording equipment (DFDR, CVR).

(Combined from 27, 303, 360, 453, 462)

E. Regulatory Interventions

As stated before, the highest rated intervention (445) will require regulatory action for

implementation. However, the intervention included no regulatory requirement. Note, too,

41

that intervention 366 is repeated in this group because the language of the intervention

addressed both design and regulatory issues.

Interventions 525 and 357 were addressed in the Training Related Interventions section.

This demonstrates that most of the interventions will require regulatory action to be

successfully implemented. The top three regulatory interventions are listed below with their

respective supporting interventions.

366. To protect aircraft against flight control malfunctions, manufacturers must design and

regulators must certificate derivative aircraft and components to current applicable

certification requirements, i.e. single point failures, redundancy, and probability of failure.

(OE 4.2)

525. To mandate stall recognition and recovery training, regulators must modify the

appropriate regulations. (OE 4.2)

357. To ensure crews have adequate skills to recover from extreme attitude upsets,

regulators should require, and operators should immediately implement, initial and recurrent

upset recovery training. (OE 4.0)

358. To prevent negative transfer effects with flight critical systems, regulators should

establish requirements for standardization of flight deck information/controls. (OE 2.8)

522. Since it is possible to enter a stall, regulators should mandate the implementation of a



369. To provide adequate stall warning, regulators should require, and manufacturers

should develop, stall warning systems for new/derivative aircraft that provide accurate

information throughout the certificated flight regime. (OE 1.3)

F. Recommendation Summary


42

The recommendations stated above are built on interventions that were rated with on OE of 4.0

or greater. There are many reasons why any one intervention may not be highly rated. That

does not mean that any particular intervention has limited or no value. Rather, the highest-

ranking interventions are supported by related interventions that have lower OEs.

Similarly, many lower-rated interventions could significantly impact a particular type of aircraft,

area of operation, pilot population, or regulatory agency. The team recommends that members

of the commercial transport industry carefully review the entire list and evaluate implementing

the interventions in their particular segment of operations.

The JSAT also recognizes that regulatory involvement is critical to the safe operation of the

airline transport industry. Many accidents and incidents analyzed by the JSAT involved

inadequate or ineffective regulatory oversight. All States must properly organize, prioritize,

fund and staff the regulatory function to insure its competence and effectiveness. The JSAT

recommends that the JSIT carefully scrutinize the regulatory role in the effective

implementation of recommended interventions.

43



44

VI. APPENDICES

Appendix A: Loss Of Control JSAT Charter ........................................................ 44Appendix B: Team Member List .......................................................................... 47Appendix C: Synopsis Of Data Set ..................................................................... 52Appendix D: Interventions Ranked By Overall Effectiveness (OE) ..................... 57Appendix E: Research & Development Interventions.......................................... 88Appendix F: Non-Rated Interventions ................................................................. 91Appendix G: Interventions Sorted By Number (IS#) ............................................ 93Appendix H: Intervention Grouping By Strategy................................................ 129

1. Design Intervention Strategies................................................................... 1292. Training Intervention Strategies................................................................. 1363. Practices, Policies, and Procedures Intervention Strategies ..................... 1444. Data Intervention Strategies ...................................................................... 1545. Regulatory Role Intervention Strategies .................................................... 156

Appendix I: Master Problem Statement / Intervention Matrix ............................ 177 Appendix J: Problem Statement Frequency Mix…………………………………..219

Appendix K: Icing .............................................................................................. 2391. Icing Interventions ..................................................................................... 2402. Icing Research & Development Recommendations .................................. 241


45

Appendix A: Loss Of Control JSAT Charter

Loss of Control Joint Safety Analysis Team (JSAT) Charter

Team Sponsors. The Commercial Aviation Safety Team (CAST), which includes theaviation industry, FAA and NASA, DOD are the sponsors of this commercial aviation Loss ofControl Joint Safety Analysis Team.

Background. The members of CAST have agreed to work together to implement a datadriven, benefit focused, safety enhancement program designed to continuously improve oursafecommercial aviation system. The CAST has further agreed that cooperatively andselectively pursuing a critical few high leveraged safety intervention strategies willmaximize the safety benefit to the flying public through a focused application of industryand government resources. To achieve this goal, the CAST has agreed to charter a JointSafety Analysis Team (JSAT) to determine intervention strategies that will reduce thepotential for airplane accidents due to loss of control. Loss of control accidents are thesecond highest cause of passenger fatalities (1988-1997) in commercial aviation.

Objectives. To review and analyze data and make coordinated recommendations toimplement intervention strategies that will enhance commercial aviation safety by reducingthe number of loss of control accidents.

Team Tasks.

A. The team shall acquire publicly available data, including prior studies andanalyses. This will constitute the beginning point for review and analysis. Theteam will coordinate with the AIA/AECMA Project on Propulsion SystemMalfunction Plus Inappropriate Crew Response (PSM+ICR). The team will focusits analysis on aircraft currently operated under FAR 121 or equivalent.

B. The team shall conduct an in-depth analysis of selected loss of control accidentsand incidents and other relevant information, using the process outlined in theJSAT Recommended Process Report.

C. The team shall develop and prioritize safety intervention strategies that willreduce the potential for loss of control accidents. In addition to documenting itsanalysis results and recommended intervention strategies, the team shalldocument its assumptions regarding the amount and extent of data consideredand any changes made to the basic JSAT process. The team will build uponprevious JSAT problem statements and intervention strategies. Correlation of theproblems and interventions identified by the JSAT with available FOQA andpartnership program data is considered highly desirable.


46

Product. The deliverable is a report to the CAST documenting recommendations, including,assumptions used in the analysis and safety intervention strategies. In addition, the teamshall provide any recommended changes to the JSAT process.

Timing. The team will meet monthly for periods of approximately three days. It isexpected that the final team report will be delivered to the CAST prior to August 31, 2000.

Constraints. The team shall utilize the recommended JSAT process to develop safetyintervention strategies. The basic JSAT process can be modified by the team if necessary;however, the concept of building on the problem statements and intervention strategies ofprevious JSATs shall be adhered to.

Process. Following the basic JSAT process, each team member will have equal authorityand responsibility, and use their expertise, to develop and prioritize intervention strategies.In addition team members are expected to finish all of the homework assignments on time.

Membership. The team will include representatives with the appropriate technicalbackground provided by industry and government. The co-chairpersons of the JSATprocess shall provide a recommended team membership list to the CAST prior toSeptember 23, 1999.

Resources. The signatories agree to provide the financial, logistic and personnelresources to carry out this charter.

Approval of Charter:


47

Approval of Charter Continued:


48

Appendix B: Team Member List

Ann AzevedoRisk Analysis SpecialistEngine & Propeller DirectorateFederal Aviation Administration

Immanuel BarshiResearch PsychologistHuman Factors Research and Technology DivisionNASA Ames Research Center

Captain Gregory BlandAir Line Pilots Association

Tom BondChief, Icing BranchNASA Glenn Research Center

Steve BoydHuman Factors SpecialistAirplane and Flight Crew Interface BranchTransport Airplane DirectorateFederal Aviation Administration

Joe BrackenEngineering & Air SafetyAir Line Pilots Association

John BrooksSenior Safety AnalystAirplane Safety EngineeringBoeing Commercial Airplanes Group

Captain Rudy Canto, Jr.Director Flight Operations TechnicalAirbus North America

David C. CarbaughChief Pilot Flight Operations SafetyBoeing Commercial Airplanes Group

Captain Joseph ChronicTrans World Airlines

Captain Steve CumminsDirector of Internal EvaluationAmerican Trans Air Airlines

APPENDIX B: TEAM MEMBER LIST

49

Major Clark DavenportHuman Factors and Aircraft Mishap InvestigatorLife Sciences BranchHeadquarters, United States Air Force Safety Center

First Officer John A. DavidAllied Pilots Association

Jerald DavisFlight Safety ConsultantAirbus Industrie

Key DismukesChief Scientist of Human FactorsNASA Ames Research Center

Jeff DuvenProgram Manager, Transport Airplane DirectorateFederal Aviation Administration

Edward E. Garlick IIIQuality Assurance SpecialistEastern Region Air Traffic DivisionFederal Aviation Administration

Ir P.J. van der GeestNational Aerospace Laboratory NLRThe Netherlands

Gerard GuyotDirector, Aircraft Safety StrategiesEngineering DirectorateAirbus Industrie

John HickeyManager, Transport Airplane DirectorateFederal Aviation Administration

Eugene HillChief Scientific & Technical AdvisorEnvironmental IcingFederal Aviation Administration

Chuck HobbsSr. Director of Flight Standards and TrainingRegional Airline Association

Robert C. JonesAerospace EngineerFederal Aviation Administration


50

Win KarishFlight Standards Aviation Safety Inspector (Operations)Federal Aviation Administration

Captain David C. KeelingChief Technical PilotSouthwest Airlines

Major (Dr.) Raymond E. KingChief, Research BranchPrograms, Research, and Technology DivisionHeadquarters, United States Air Force Safety Center

Joe MarksteinerManager, Investigations & Accident PreventionCommercial Flight Safety OfficeGeneral Electric Aircraft Engines

Bob MatthewsTeam Leader, Safety Analysis TeamOffice of Accident InvestigationFederal Aviation Administration

Glenn W. MichaelAssistant Air Traffic Manager, Boston ARTCCFederal Aviation Administration

Kyle L. Olsen – Team LeaderManager, Continued Operational SafetyTransport Airplane DirectorateFederal Aviation Administration

Jay J. PardeeManager, Engine & Propeller DirectorateFederal Aviation Administration

Dick ParkerAssociate FellowEngine Failure and Aircraft Accident InvestigationsPratt & Whitney

Captain John C. PenneyAdvanced Maneuvers Program ManagerUnited Airlines

Decio PullinAeronautical Engineering Senior ManagerEmbraer


51

Lawrence RandallProgram AnalystAssistant Administrator for System SafetyFederal Aviation Administration

Thomas RatvaskyAerospace EngineerNASA Glenn Research Center

Hank ReedSafety AnalystAirplane Safety EngineeringBoeing Commercial Airplanes Group

Andrew ReehorstAerospace EngineerNASA Glenn Research Center

William J. RiekeChief, Aircraft Operations OfficeNASA Glenn Research Center

Matthew RileyDirector, Flight Operations-AmericasATR

Bill RoyceSenior Technical Pilot B777Boeing Commercial Airplanes Group

Paul D. RussellChief Engineer, Aviation System SafetyBoeing Commercial Airplanes Group

Gautam H. ShahAerospace Engineer, Flight Dynamics and ControlNASA Langley Research Center

Christopher S. ShefflerAirworthiness EngineerFAA-Designated Engineering Representative/Aircraft EnginesRolls-Royce Corporation

William D. Shontz, PhDAssociate Technical FellowHuman Factors EngineeringBoeing Commercial Airplanes Group

Corey StephensStaff EngineerEngineering & Accident Investigation


52

Air Line Pilots Association

Gerard M.G. TemmeCertification Test PilotJoint Aviation Authorities

Thomas ToulaManager, Air Carrier TrainingManager, Air Carrier OperationsFederal Aviation Administration

Captain Benny WhiteAir Line Pilots Association

John J. WhiteManager, Single Aircraft Accident Prevention ProjectAviation Safety Program OfficeNASA Langley Research Center

James E. WilbornAerodynamic Stability and Control EngineerBoeing Commercial Airplanes Group

David C. YeomanSystems Certification EngineerRockwell Collins

Keeton ZacharyManager, Seattle Aircraft Evaluation GroupFederal Aviation Administration

Facilitator

Michele A. PrebleManager, Executive Resource BranchFederal Aviation Administration

APPENDIX C: SYNOPSIS OF DATA SET

53

Appendix C: Synopsis Of Data Set

The following is a synopsis, based on the accident reports produced by investigativeauthorities, of each accident analyzed by the Loss of Control JSAT:

1. Sahara India Airlines, Boeing 737-200, March 8, 1994, IGI Airport, Delhi, India. Theaircraft was on a pilot training flight at the IGI Airport. After the sixth takeoff from a touchand go landing, the aircraft turned left after reaching about 400 feet. The aircraft continuedleft and crashed near the airport’s International Terminal. The aircraft disintegrated andburned. There were nine fatalities, including the four crewmembers and five groundpersonnel. There were four additional fire-related ground injuries.

2. China Airlines, Airbus A 300-622, February 16, 1998, Chiang Kai-shek InternationalAirport, Taipei.The aircraft was cleared to land on runway 05 after an uneventful flight from Ngurah RaiInternational Airport, Bali, Indonesia. The aircraft executed what appeared to the controllerto be a “go-around,” but he got no response from the crew when questioned. The aircraftwas not moving on the controller’s D-BRITE scope prior to impact. The aircraft crashed on aroad and five residences near the airport. The aircraft was destroyed and burned. Therewere 202 fatalities, including the 14 crewmembers, 182 passengers, and 6 residents on theground.

3. Northwest Airlines, Inc., McDonnell Douglas MD-82, August 16, 1987, DetroitMetropolitan Wayne County Airport, Romulus, Michigan.The aircraft crashed shortly after takeoff from runway 03 center. After takeoff, the aircraftrolled left and right about 35° in each direction. The aircraft collided with obstaclesnortheast of the runway and broke up as it slid across the ground and burned. There were156 fatalities, including the 6 crewmembers, 148 passengers, and 2 people on the ground.One passenger survived with serious injuries and 5 persons on the ground sustainedserious and minor injuries.

4. Atlantic Coast Airlines, BAe Jetstream 4101, January 7, 1994, Columbus, Ohio.The aircraft stalled and crashed 1.2 nm east of the airport while on an ILS approach.Excessively high airspeed and improper aircraft configuration led to an unstabilizedapproach. The crew later did not observe the airspeed decay during the final approach andthe aircraft stalled. The aircraft received substantial damage. There were five fatalities, twominor injuries, and one passenger was uninjured.

5. Simmons Airlines, d.b.a. American Eagle, Avions de Transport Regional ATR 72,October 31, 1994, Roselawn, Indiana.The aircraft crashed during a rapid descent after an uncommanded roll excursion. Theaircraft was in a holding pattern and was descending to a newly assigned altitude of 8,000feet when the initial roll excursion occurred. The loss of control was attributed to a suddenand unexpected aileron hinge movement reversal that occurred after a ridge of ice accretedbeyond the de-ice boots. The impact forces destroyed the aircraft. There were 68 fatalities,including the four crewmembers.

6. Comair Airlines, Inc., Embraer EMB 120RT, January 9. 1997, Monroe, Minnesota.The aircraft crashed during a rapid descent after an uncommanded roll excursion. The flightwas operating under instrument meteorological conditions and accumulated a thin, rough


54

accretion of ice on the lifting surfaces. Crew and aircraft certification procedures were citedin the investigation. Ground impact and the post accident fire destroyed the aircraft. Therewere 29 fatalities including the three crewmembers.

7. Thai Airways Company, Boeing 737-200, August 31,1987, near Phuket Airport,Thailand.The aircraft crashed into the Andaman Sea while maneuvering on approach to the PhuketAirport. Prior to the accident, there was a traffic sequencing confusion between the Thaiaircraft and another aircraft also approaching the airport. The other aircraft later observedthe Thai aircraft stall and spin into the water. The impact destroyed the aircraft. There were61 fatalities including the crewmembers.

8. Birgenair, Boeing 757-225, February 6, 1996, Gregario Luperion InternationalAirport, Puerto Plata, Dominican Republic.Minutes after takeoff, the aircraft crashed into the Atlantic Ocean about 14 nautical milesnortheast of the airport. There was confusion on takeoff between the pilots about anapparent inoperative airspeed indicator or pitot system. The pilots were attempting totroubleshoot the problem with circuit breakers and stalled the aircraft. Pitch attitude,airspeed, and thrust lever position varied until impact with the water. The aircraft wasdestroyed upon impact. There were 189 fatalities including the 13 crewmembers.

9. Airbus 310 Event. (Accident Deidentified)The aircraft crashed about two minutes after departure from the airport. The aircraft hadbegun experiencing a continuous engine thrust asymmetry during climb-out. The crewattempted to solve the thrust condition with autopilot engagement but was unsuccessful.The pilot-in-command did not properly diagnose the malfunction of the automatic thrustsystem and the copilot did not have sufficient time to recover. The aircraft was destroyed bythe impact. There were 60 fatalities including the 11 crewmembers.

10. Midwest Express Airlines, Inc., Douglas DC 9-14, September 6, 1985, General BillyMitchell Field, Milwaukee, Wisconsin.The aircraft crashed into an open field just past the departure end of the runway. During theinitial climb at about 450 feet above the ground, the aircraft experienced an uncontainedengine failure of the right engine. The aircraft rolled right to about 90°, entered anaccelerated stall and crashed. The ground impact and postcrash fire destroyed the aircraft.There were 31 fatalities including the 4 crewmembers.

11. Copa Airlines, Boeing 737-204, June 6, 1992, near Ticuti, Panama.The crew departed Tocumen International Airport and requested a left turn to avoid a largearea of weather near the airport. The aircraft climbed to and leveled at FL 250 and later withno unusual radio transmissions was observed by ground residents to descend in flames.The probable cause focused on an intermittent attitude indicator, night weather visibility, andcrew error. The impact and subsequent fire destroyed the aircraft. There were 47 fatalitiesincluding the 7 crewmembers.

12. China Eastern Airlines, McDonnell Douglas MD 11, April 6, 1993, about 950 nmSouth of Shemya, Alaska.The aircraft encountered an inadvertent in-flight slat deployment at cruise altitude. Theautopilot disconnected and the captain was manually controlling the aircraft when itprogressed through several violent pitch oscillations. The captain regained stabilized flightand diverted to Shemya AFB, Alaska. The aircraft did not receive external structural


55

damage, but the passenger cabin was substantially damaged. Of the 235 passengers and20 crewmembers aboard the aircraft, 2 passengers were fatally injured, 53 passengers and4 flight attendants received serious injuries, and 96 other passengers received minorinjuries.

13. TAM Brasil, Fokker 100, October 31,1996, San Paulo, Brazil.The aircraft crashed following an uncommanded deployment of the number two thrustreverser immediately after takeoff. The aircraft climbed to about 90 feet, entered a rightturn, and struck a building before crashing into a heavily populated neighborhood. Theground impact and postcrash fire destroyed the aircraft. There were 96 fatalities includingthe 6 crewmembers.

14. Atlantic Southeast Airlines, Inc., Embraer EMB 120RT, August 21,1995, Carrollton,Georgia.This accident was analyzed in depth by the Approach and Landing JSAT and, therefore,was deleted from the Loss of Control data set.

15. Federal Express Inc., McDonnell Douglas MD-11, July 31, 1997, NewarkInternational Airport, Newark, New Jersey.The aircraft crashed due to the Captain’s overcontrol of the aircraft during landing and hisfailure to execute a go-around from a destabilized flare. Issues discussed in the report ofthe accident were landing techniques, bounced landing recovery, unstabilized approachrecognition and decision making, and MD-11 handling characteristics. The ground impactand postcrash fire destroyed the aircraft. There were five minor injuries during the groundegress including the two crewmembers.

16. China Airlines, Airbus 300-622, April 26, 1994, Nagoya Airport, Japan.The aircraft was approaching Nagoya Airport for landing and crashed in the landing zoneclose to E1 taxiway of the airport. The copilot flying the aircraft accidentally triggered thethrust “GO” level during the approach and caused an abnormal trim condition to develop.The captain and copilot could not solve this condition and stalled the aircraft. The groundimpact and postcrash fire destroyed the aircraft. There were 264 fatalities including the 15crewmembers. Seven passengers were seriously injured.

17. Airborne Express Air, Inc, Douglas DC 8-63, December 22,1996, near Narrows,Virginia.The aircraft impacted mountainous terrain while on a post-modification functional evaluationflight. The crew was executing maneuvers as part of the evaluation flight includingapproach to stall and recovery. The aircraft entered a full stall and the pilot usedinappropriate control inputs in the recovery. The non-flying pilot-in-command failed torecognize, address, and correct these inappropriate inputs. Company procedures, aircraftsystems, and simulator training procedures were cited in the report. The ground impact andpostcrash fire destroyed the aircraft. There were three crewmember fatalities.

18. China Airlines, Boeing 747 SP-09, February 19, 1985, about 300 nm NW of SanFrancisco, California.The aircraft was at a cruise altitude of 41,000 feet when the loss of number 4 engine causedan in-flight upset. During the crew’s attempt to recover the engine, the aircraft rolled to theright, nosed over, and entered an uncontrollable descent. The captain was able to restorethe aircraft to stable flight at 9,500 feet, but the aircraft suffered major structural damage.


56

The aircraft landed safely at San Francisco International Airport. Two persons wereseriously injured during the upset and recovery.

19. British Midlands Airways, Ltd., Fokker F 27 Friendship, January 18, 1987, nearEast Midlands Airport, United Kingdom.The aircraft was engaged in crew training and crashed during the final stages of a simulatedasymmetric thrust instrument approach to land at East Midlands Airport. After the accident,one inch of ice was found on the leading edges of the aircraft’s wings and tail surfaces. Theaircraft suffered extensive damage in the ground impact. The three crewmembers on boardsustained serious injuries.

20. Airbus 310 Event. (Deidentified)The aircraft was being vectored for an ILS approach but was too fast and high for the properintercept and distance for the approach. The aircraft entered a steep dive and stalled. Thecrew recovered and performed a second approach with no further incidents. The aircraftlanded normally with no damage. There were no injuries to the 176 passengers and 11crewmembers

21. Air France, Boeing 747-200 Combi, December 2, 1985, Rio de Janeiro, Brazil.The aircraft landed normally and all four engines were retarded to idle. The reverse thrustlevers were placed in the interlock position, but number one engine reverser did not positioncorrectly. The throttle cable for number one engine separated and went to maximumforward thrust. The aircraft could not be controlled and veered off the runway. The aircraftwas severely damaged and considered a hull loss. There were no injuries to the 261passengers and 17 crewmembers.

22. Transavia Airlines, Boeing 757-2K2, December 24, 1997, Schiphol InternationalAirport, Amsterdam, Holland.The nose landing gear assembly collapsed on landing. The crash was attributed to the crewnot properly aligning the aircraft longitudinally with the runway before touchdown. Theaircraft was substantially damaged. There were no injuries to the 205 passengers or 8crewmembers.

23. USAir, Boeing 737-3B7, September 8, 1994, Aliquippa, Pennsylvania (near thePittsburgh International Airport).The aircraft crashed while maneuvering to land at the Pittsburgh Airport. The probablecause was determined to be the loss of control resulting from the movement of the ruddersurface to its blowdown limit. The rudder surface most likely deflected in the oppositedirection to that commanded by the pilots as a result of a jam in the main rudder powercontrol unit. The ground impact and postcrash fire destroyed the aircraft. There were 132fatalities including the 5 crewmembers.

24. Airbus A300-600 Accident (Deidentified).The aircraft experienced an in-flight upset while on descent. The upset was described as aslow deceleration after leveling off on the descent, followed by a continued deceleration in aturn and a subsequent asymmetric stall of both wings. This was followed by a recoveryinvolving secondary stalls and large oscillations. The final recovery was achieved throughincreased thrust and a nose down pitch attitude. The aircraft made an emergency landingand experienced minor damage. One passenger was seriously injured and one flightattendant received minor injuries during the upset. 163 others were not injured includingeight crewmembers.


57

25. Flagship Airlines Inc., BAe Jetsteam 3201, December 13, 1994, Raleigh-DurhamInternational Airport, Morrisville, North Carolina.The aircraft crashed while executing an ILS approach into Raleigh-Durham. The Captainmisinterpreted a momentary ignition light to be an engine failure and did not crosscheck theother engine instruments. The aircraft stalled when he attempted to go-around from a singleengine approach even though the other engine was operating normally. The ground impactand postcrash fire destroyed the aircraft. There were 15 fatalities including the 2crewmembers. Thirteen additional passengers received serious injuries.


58

Appendix D: Interventions Ranked By Overall Effectiveness (OE)

Rank IS# Intervention Strategy Power C A OE

1 445 445 To help avoid loss of control, manufacturersshould develop and implement flight envelopeprotection (e.g. bank / pitch angle limits,overspeed, angle of attack, load factor).

5.5 5 6 4.6

2 366 366 To protect aircraft against flight controlmalfunctions, manufacturers must design andregulators must certificate derivative aircraft andcomponents to current applicable certificationrequirements, i.e. single point failures,redundancy, and probability of failure.

6 5 5 4.2

3 525 525 To mandate stall recognition and recoverytraining, regulators must modify the appropriateregulations.

6 5 5 4.2

4 99 99 Airlines and operators should ensure thatclear, concise, accurate, and appropriatestandard operating procedures are published andenforced. (See 110.)

6 4 6 4

5 357 357 To ensure crews have the adequate skills torecover from extreme attitude upsets, regulatorsshould require, and operators should immediatelyimplement, initial and recurrent upset recoverytraining.

6 4 6 4

6 486 486 Airlines and operators and manufacturersshould train crews to understand the capabilitiesand limitations of automated flight systems, theconditions which would cause the systems to notfunction as the crew anticipates, and how todetect and recover from inadvertent activation ofautomated flight modes. (See 331.)

6 4 6 4

7 361 361 To enhance the ability to analyze, identifyand take corrective actions for preventingaccidents, regulators and operators should createa collection and analysis process which utilizes allexisting and future aircraft data collectionsystems, such as DFDR, FOQA, ASAP and othernonvolatile memory systems.

5.5 5 5 3.8

8 483 483 To ensure that the display of conflictingattitude information does not confuse or misleadthe flight crew, the attitude sensing and displaysystems should be designed so that invalidinformation is detected and clearly annunciated tothe flight crew and removed from display.

5.5 5 5 3.8

APPENDIX D: INTERVENTIONS RANKED BY OVERALL EFFECTIVENESS (OE)

59


9 532 532 To minimize the probability of accidents,operators should prioritize service bulletinimplementation using operational riskmanagement techniques to assess potentialoperational hazards, including aircraftmodification, etc. (See 98, 348.)

5.5 5 5 3.8

10 533 533 To prevent loss of control, manufacturersshould design automated systems to yield controlto manual inputs when those manual inputs are inconflict with the automated configuration.

5.5 5 5 3.8

11 535 535 To ensure adequate instructor / check pilotqualifications, operators must establish andmaintain minimum line and instructor / checkairman qualifications.

5.5 5 5 3.8

12 546 546 Airlines and operators should ensure thatflight crews are adequately trained in anappropriate level simulator for the training beingconducted (e.g. engine out, upset recovery, etc.)before being assigned to the line. (See 153, 312.)

5.5 5 5 3.8

13 566 566 Manufacturers should incorporate anautomatic yaw compensation to ensure thatadequate yaw control is provided.

5.5 5 5 3.8

14 56 56 Airlines and operators should implement FlightOperations Quality Assurance (FOQA) programsto identify systemic procedural deviations andunsafe trends. (See 54, 55.)

5.5 4 6 3.7

15 110 110 Airlines and operators and regulators shouldensure that their training, standardization, andmonitoring programs emphasize the importanceof adherence to standard operating proceduresand identify the rationale behind thoseprocedures. (See 99.)

5.5 4 6 3.7

16 530 530 To optimize pilot workload, airlines /operators policies should stress using theappropriate level of automation. (See 246.)

5.5 4 6 3.7

17 364 364 To protect aircraft against loss of control,regulators should develop, as soon as possible,certification criteria, throughout the entire flightenvelope, for crossover speeds and maximumrudder side slips. (See 431.)

5 5 5 3.5

18 423 423 To ensure that recurrent, intermittent failuresare not allowed to persist, regulators shouldrevise MEL dispatch requirements so that certainintermittent failures are considered to be fullfailures, if warranted by safety implications of thefailures and frequency of occurrence.

5 5 5 3.5


60


19 431 431 To assist flight crews in avoiding loss ofcontrol on existing aircraft, regulators andmanufacturers should evaluate the effects ofcrossover speeds and maximum rudder side slipthroughout the entire flight envelope anddisseminate the information to operators and flightcrews.

5 5 5 3.5

20 501 501 To assist flight crews in avoiding loss ofcontrol, manufacturers should develop, andregulators should require, automated flight systemauto-disconnect logic that does not disconnectwhen the automated flight system is properlyattempting to correct an abnormal flight situationor condition. (See 363.)

5 5 5 3.5

21 7 7 Airlines and operators should ensure that theirtraining and standardization programs emphasizereview of approach and missed approachprocedures. (See 329.)

6 4 5 3.3

22 16 16 To prevent mode confusion, manufacturersshould ensure that automated systems providethe flight crew with sufficient information(automation feedback).

5 4 6 3.3

23 80 80 Airlines and operators should verify, andregulators should check, that operators whocreate their own AOM's include all operationalprocedures prescribed by original equipmentmanufacturers Airplane Flight Manual (AFM).

6 4 5 3.3

24 152 152 Airlines and operators and regulators shouldraise standards (e.g. crew pairing, approachminimums, etc.) for flight crewmembers that meetminimum qualifications but have demonstratedlimited proficiency or competency. (See 151, 335,337.)

4.8 5 5 3.3

25 384 384 Since it is possible to enter a stall, airlines /operators should develop and implement aground school and simulator training program totrain pilots to handle post stall recovery as part ofadvanced maneuver training.

6 4 5 3.3

26 561 561 Airlines should maximize the use ofautomated landing systems consistent withmaintaining manual landing proficiency.

6 4 5 3.3

27 15 15 Airlines and operators should ensure that theirtraining and standardization programs instructwhen to disengage automated systems and flymanually. (See 246)

5.5 4 5 3.1


61


28 98 98 Airlines and operators and regulatory agenciesshould review procedures to ensure that designchanges (service bulletins) to flight criticalsystems are incorporated in a timely manner.

5.5 4 5 3.1

29 142 142 Airlines and operators should establishpolicies, parameters, and training to recognizeunstabilized approaches and other factors andimplement a go-around gate system. (See FSF -"defined gates" p. 193) (See 116, 123)

5.5 4 5 3.1

30 157 157 Airlines and operators, regulators, air trafficservice providers should establish policies orprograms to address rushed approaches,including elimination of rushed approaches,recognition and rejection of rushed approachesand training for those encountered.

5.5 4 5 3.1

31 214 214 Regulators should enforce timelyincorporation of appropriate manufacturers’recommendations. (See 98, 201)

5.5 4 5 3.1

32 225 225 Airlines and operators and regulators shouldensure necessary operational and maintenancemanuals are complete, accurate, available andappropriately used.

5.5 4 5 3.1

33 380 380 To reduce the risk of inadvertent entry intostall, manufacturers should develop andimplement stall protection features in all transportcategory airplanes (e.g. stick pusher, alphaprotection, etc.)

5.5 5 4 3.1

34 395 395 To ensure that the display of conflicting airdata information does not confuse or mislead theflight crew, the air data sensing and displaysystems should be designed so that invalidinformation is detected and clearly annunciated tothe flight crew, and removed from display.

5.5 5 4 3.1

35 397 397 To provide accurate wind information to flightcrews, regulators should ensure that weatherinformation providers and air traffic servicesemploy systems and procedures that will ensureaccurate measurement of wind data anddissemination of wind information for takeoff andlanding areas of the runways in use.

4.4 5 5 3.1

36 398 398 To provide real time accurate windcomponent information to flight crews, air trafficservices and manufacturers should implementreal time (automated) transmission and display ofsuch information in the most directly useableformat to the flight crew, during approach andlanding phase. (See 94.)

5.5 4 5 3.1


62


37 400 400 In order to promote safe crosswind landings,manufacturers will provide and airline operatorswill implement aircraft crosswind landinglimitations, including considerations for flightcontrol effectiveness and gust conditions.

5.5 4 5 3.1

38 408 408 To minimize undesirable effects of transitionto manual flight from ALIGN mode, regulatorsshould require that minimum altitudes andconditions be established for disengagement ofautomated systems when a manual landing isanticipated.

4.4 5 5 3.1

39 412 412 To avoid problems due to unexpected modechanges, automated flight system logic should bedesigned to be error tolerant or, at a minimumprovide an alert when the desired mode is inconflict with aircraft energy state.

5.5 4 5 3.1

40 413 413 To prevent negative transfer effects with flightcritical systems, regulators should establishrequirements for standardization of flight deckinformation and controls.

5.5 5 4 3.1

41 424 424 To enhance crew awareness of automationmodes, manufacturers should ensure that modechanges or disconnects, in the automatedsystems are annunciated in a way that is obviousto the flight crew.

5.5 5 4 3.1

42 472 472 Since certain engine control and automatedthrottle system failures can result in undesirableasymmetry, manufacturers should redesign ATS’sso that they disconnect (with appropriateannunciation) when unable to achieve thecommanded thrust settings (analogous toautopilot disconnect logic).

4.4 5 5 3.1

43 485 485 To preclude the accidental change of aircraftsystems status, manufacturers should designflight decks to minimize the potential forinadvertent activation or deactivation of aircraftsystems or unintended automated flight modechanges.

4.4 5 5 3.1

44 515 515 To warn of impending loss of control with theautomated flight system fully engaged,manufacturers should develop and regulatorsshould require annunciation of an airplane flightcondition which significantly differs from thatbeing commanded by the selected automatedflight system mode. (See 243.)

5.5 5 4 3.1

45 114 114 Airlines and operators should ensure thattheir training and standardization programsprovide sufficient training to ensure aircrewproficiency.

5.5 3 6 2.8


63


46 128 128 Airlines and operators and regulators shouldimplement a no blame safety reporting and datasharing system with appropriate protections fromlitigation and prosecution concerns.

5 4 5 2.8

47 147 147 Airlines and operators should require trainingand standardization programs, which teachsituation awareness. (The knowledge andunderstanding of the relevant elements of the pilotsurroundings, including aircraft systems, and thepilots intentions)

5.5 3 6 2.8

48 165 165 Airlines and operators should provide trainingscenarios that match realistic situations [i.e. stallrecoveries during approach, in landingconfiguration at flight idle with the autopilot on (insimulator)].

5 4 5 2.8

49 201 201 Regulators should develop adequateoversight as appropriate to ensure compliancewith regulations. (See 145, 146, 202, 345.)

5 4 5 2.8

50 253 253 To prevent loss of control, there should beredundant and failure tolerant features for all flightcritical components, such as dual-path design, failoperational redundant systems, with faultannunciation.

5 5 4 2.8

51 331 331 Airline operators and manufacturers will traincrews to understand capabilities and limitations ofsystem conditions, which would cause the systemto not function properly, and how to detect failureto deploy or activate and recommend contingencyactions.

5.5 3 6 2.8

52 358 358 To provide optimal upset recovery trainingand to minimize negative training, regulators,aircraft, and simulator manufacturers andoperators should ensure that training devicesreplicate aircraft performance and responsenecessary for effective training. (See 386, 475.)

5 4 5 2.8

53 365 365 To ensure pilot capability to maintain orregain control, regulators should require andoperators should implement training programsthat address crossover speed effects.

5 4 5 2.8


64


54 416 416 To provide improved flight crew situationawareness, manufacturers should provide a clearindication that predicts the future aircraft energystate and automated flight configuration if thecurrent course of action is continued. (E.g.,analogous to EGPWS mode that analyzes theairplane's descent rate vs. its terrain map, andtells the crew that a conflict will occur if theycontinue at that descent rate. The system wouldwarn the crew that, if they continue at the currentroll rate (for example), the plane will exceed theenvelope, or the autopilot will reach the limits ofits authority, etc.)

5.5 3 6 2.8

55 463 463 To avoid treating an incident as an isolatedoccurrence and to ensure on-going assessmentof aircraft specific loss of control problems, afocused safety or risk assessment of all accidentsand incidents should be conducted to determinethe need for immediate resolution. (See 254.)

5 4 5 2.8

56 490 490 In order to ensure that relevant information isshared during the pilot hiring process, airlinesshould implement and regulators require astorage and retrieval system that containspertinent standardized information on the qualityof airline pilot performance during training andservice. (Reference ‘Pilot Records ImprovementAct’ – FAA AC 120-68.)

5 4 5 2.8

57 502 502 To ensure flight crews can identify possibleupset conditions, airlines and operators shouldimplement flight crew training programs thatdemonstrate the operation of a normallyfunctioning automated flight system undernonstandard flight conditions (e.g. out of trimairplane or contaminated wing).

5 4 5 2.8

58 520 520 To ensure flight crews have a comprehensiveknowledge of the automation system(s) functionaloperation, Airlines and operators should ensurethat their training and standardization programsemphasize these skills.

5 4 5 2.8

59 527 527 To ensure that alerting and warning logicdoes not annunciate self-recovery functions oralerts that do not require pilot action, themanufacturer should design systems thatannunciate only when pilot action is required.

5 5 4 2.8


65


60 545 545 To provide the national airspace system withaccurate, real time in-flight weather conditions(automatic or manual), a system should bedeveloped and implemented to effectivelytransmit airborne weather related information toair traffic facilities.

5 4 5 2.8

61 79 79 Airlines and operators should implement areliable process to communicate information tothe flight crew that may affect flight or aircraftoperations.

6 4 4 2.7

62 305 305 Regulators should require airlines / operatorsto outfit aircraft with electronic checklists. Ifunable to install electronic checklists, usemechanical checklists or, at a minimum, developa process to reinforce challenge and responsechecklists.

4.8 4 5 2.7

63 407 407 To minimize pilot reaction requirementsduring transition from autocoupled to manual flightduring approach, regulators should require, andmanufacturers should design, automated flightsystems so that ALIGN mode need not beengaged when a manual landing is planned.

4.8 5 4 2.7

64 433 433 To preclude inadvertent entry into stallconditions during autopilot operation, regulatorsshould not permit and manufacturers should notdesign automated flight systems that will allow theautopilot to control the aircraft into a stalledcondition.

4.8 5 4 2.7

65 488 488 To facilitate recovery and attitude awareness,manufacturers should include adequateinstrumentation to optimize performance duringrecovery from unusual attitude.

4.8 4 5 2.7

66 522 522 Since it is possible to enter a stall, regulatorsshould mandate the implementation of a groundschool and simulator training program to trainpilots to handle post stall recovery as part ofadvanced maneuver training. (See 384.)

4.8 4 5 2.7

67 207 207 Airlines and operators should developprocedures to specify how transfer of control isformally accomplished.

5 3 6 2.5

68 257 257 To eliminate loopholes in crew restrequirements and to ensure adequate crew rest,regulators should clarify crew rest regulations.(See 31, 130, 203, 315, 316.)

3.8 4 6 2.5

69 93 93 Air Traffic service should provide real time(most current) radio communication of criticalairport and weather information.

4.4 4 5 2.4


66


70 121 121 Air Traffic service providers should implementworldwide surveillance radar (e.g. ADS/B).

4.4 4 5 2.4

71 218 218 Airlines and operators should conductsurveillance of contractor training programs foradequacy of training. (See 110, 202.)

5.5 4 4 2.4

72 314 314 Airlines and operators should developsimulator training scenarios that require flightcrews to learn multi-tasking abilities andappropriate prioritization abilities in concert withCRM skills. (See Red Flag LOFT scenarios.)

4.4 4 5 2.4

73 322 322 Airlines and operators should develop andimplement a ground school and simulator trainingprogram to train pilots to handle unusual attitudesituations, e.g. American Airlines AdvancedAircraft Maneuvering Program.

5.5 4 4 2.4

74 345 345 Ensure regulators have adequate funding,training and processes to accomplish theiroversight responsibilities. (See 201.)

4.4 4 5 2.4

75 372 372 To ensure that in-service problems arereliably assessed for their safety implications andcorrected, regulators, operators, andmanufacturers should develop and implement astandard set of criteria for determining whether ornot a problem is safety-related and for timelycorrective action.

5.5 4 4 2.4

76 374 374 To provide terminal area position informationin environments without radar, ATS providers andairplane manufacturers should implement terminalarea automatic dependent surveillance (ADS-B)(Traffic Information Services (TIS)).

4.4 4 5 2.4

77 381 381 To provide improved pilot awareness of theairplane's energy state, manufacturers shoulddevelop and incorporate more effective energymanagement monitoring and alerting systems.

5.5 4 4 2.4

78 391 391 Because of the interaction between systems,manufacturers should develop alerting systemsthat help pilots understand any common cause ofmultiple failure messages

4.4 4 5 2.4

79 401 401 To ensure proper identification of enginemalfunctions and avoidance of possible loss ofcontrol, airlines and operators should provideenhanced and more realistic training for enginemalfunctions, engine responses to control signalerrors, and the appropriate aircrew actions.

4.4 4 5 2.4


67


80 420 420 In order to assure that airline operationsdepartments understand the operationalimplications of dispatching with degradedsystems, manufacturers and operators shoulddevelop a method for providing such informationto crews, for MEL and other dispatchable failureconditions (including intermittent failures).

4.4 5 4 2.4

81 427 427 To prevent inappropriate preoccupation withtrouble shooting following engine or other systemfailure, airline operators should enhance trainingand checking to prioritize safe control of theaircraft.

4.8 3 6 2.4

82 456 456 To help ensure appropriate decision making,flight crews should be trained on the impact ofautomation on CRM.

4.8 3 6 2.4

83 521 521 To ensure airline / operator training programsprovide enhanced aircrew proficiency, regulatorsshould revise Part 121 (14 CFR part 121),Appendix F to raise the minimum standards. (See114)

4.4 4 5 2.4

84 531 531 To minimize the occurrence of loss of controlduring unstable approaches, manufacturersshould design and implement a system to detectunstable approaches and provide an automaticcallout to go around.

5.5 4 4 2.4

85 20 20 Airlines and operators should ensure thatcommand oversight training for captains isprovided during the upgrade process and inrecurrent training and first officer responsibility formonitoring are reviewed during recurrent training.

5.5 3 5 2.3

86 54 54 Airlines and operators should implement FlightOperations Quality Assurance (FOQA) programs.

5.5 3 5 2.3

87 82 82 Airlines and operators should clearly define,train and check the specific PF, PNF, and FEduties.

5.5 3 5 2.3

88 111 111 Airlines and operators should ensure thattheir training and standardization programsemphasize basic airmanship skills and knowledgeduring initial and recurrent training.

5.5 3 5 2.3

89 115 115 Airlines and operators should ensure thattheir training and standardization programsemphasize the dangers of rushed approaches.(See 13, 157.)

5.5 3 5 2.3

90 116 116 Airlines and operators should ensure thattheir training and standardization programsemphasize the dangers of high rate of descentand unstable approaches. (See 142.)

5.5 3 5 2.3


68


91 149 149 Manufacturers should install a HUD asstandard equipment. (See 85.)

5.5 3 5 2.3

92 328 328 Airlines and operators should ensure thatflight crews are trained to think in terms of "I willgo-around unless" rather than "I will land unless."Regulatory policy should support this approach.(See 142, 311.)

5.5 3 5 2.3

93 329 329 Airlines and operators should incorporate ininitial and recurrent training ways to recognizemultiple cues that will require go-around. Theseinclude CFIT training aid 2.1.9, FSF definition ofstabilized approach, risk assessment tool, andwind shear training aid.

5.5 3 5 2.3

94 383 383 To ensure adequate time margin betweenstall warning and actual stall, manufacturers andregulators should develop and implement stallwarning systems that account for various entryrates and conditions to stall.

5.5 3 5 2.3

95 438 438 To reduce the probability of accidents,operators should adopt operational riskmanagement techniques for nonstandard flightoperations and flights requiring intensive trainingscenarios.

5.5 3 5 2.3

96 464 464 To ensure proper identification of flight criticalissues, manufacturers, operators and regulatorsmust develop consistent criteria to properlyidentify and disseminate (in a timely manner,including manual revisions) flight safety criticalinformation.

5.5 3 5 2.3

97 45 45 Manufacturers should ensure that allimpending equipment failures or inappropriatesettings that may affect the safe operation of theflight are properly annunciated to the flight crewby use of dual-source sensing. (See 103, 138.)

5 4 4 2.2

98 153 153 Ensure that flight crews are adequatelytrained in a level D simulator for dynamiccharacteristics before assignment to the line. (See312.)

5 4 4 2.2

99 202 202 Airlines and operators should develop aquality assurance program to ensure compliancewith regulations. (See 145, 146, 201.)

4 4 5 2.2

100 245 245 To recover aircraft in unusual attitude,manufacturers should develop systems to returnaircraft to normal attitude with one pilot buttonpush (pilot initiated auto-recovery systems).

5 4 4 2.2


69


101 382 382 To provide improved pilot awareness ofairspeed, manufacturers should provide flightinstruments with more effective airspeed trendindications and alerting.

5 4 4 2.2

102 405 405 To enhance stability in the approach andlanding phase, airline operators should train pilotsto properly control the aircraft in the transitionfrom autocoupled or automated landingapproaches to manual control.

5 4 4 2.2

103 417 417 Because failures which result in yaw or rollupsets can be particularly difficult for crews tointerpret and successfully handle, manufacturersand operators should give such failures increasedscrutiny and higher priority for reporting.

4 5 4 2.2

104 450 450 To ensure the aircraft can be safely flown bypilots with normal skill levels, regulatoryauthorities should require that handling qualitytests and demonstrations intended to showcompliance with applicable regulations includerepresentative line pilots as test subjects.

5 4 4 2.2

105 528 528 To provide optimal training (includingpropulsion system malfunctions) and to minimizenegative training, regulators, aircraft andsimulator manufacturers and operators shouldensure that training devices replicate realisticfailure scenarios, aircraft performance andappropriate response. (See 358.)

5 4 4 2.2

106 13 13 Air Traffic service providers should enhanceATC training to emphasize the dangers of rushedapproaches and performance characteristics of jettransports. (See 115, 157)

5 3 5 2.1

107 23 23 Airlines and operators should ensure thatregularly scheduled recurrent training (e.g. LOFT)emphasizes crew cooperation and workingtogether to maximize safe operations. (See 308,314.)

5 3 5 2.1

108 24 24 Airlines and operators should implementprocedures to ensure appropriate crew pairing.(Reference FSF corporate crew scheduling andfatigue evaluation.)

5 3 5 2.1

109 25 25 Airlines and operators should establish a CRMtraining program and regulators should requireand ensure that the initial training is provided priorto line flying and require recurrent CRM training.(See 131, 132, 349.)

5 3 5 2.1

110 57 57 Airlines and operators, regulators, andmanufacturers should implement a programdesigned for sharing of safety related informationwithin the aviation community.

5 3 5 2.1


70


111 107 107 Airlines and operators should ensure thattheir CRM training and standardization programemphasizes the importance of the team concept.

5 3 5 2.1

112 112 112 Airlines and operators and regulators shouldensure that the frequency and effectiveness ofproficiency checks for simulated instrumentfailures (partial panel) are adequate.

5 3 5 2.1

113 124 124 Air Traffic service providers should implementa Quality Assurance program to ensureadherence to established procedures.

5 3 5 2.1

114 129 129 Regulators should establish criteria to ensureoperators overall quality assurance andcompliance procedures are effective rather thanreliance on spot checks of individual components.

5 3 5 2.1

115 159 159 Manufacturers should incorporate an "inputrudder" indicator or automatic yaw compensationto ensure that adequate yaw control is provided.

5 5 3 2.1

116 227 227 Airlines and operators should ensure thattheir training and standardization programemphasizes the benefits of inter-crew / companycommunications. (See 131.)

5 3 5 2.1

117 308 308 Airlines and operators should ensure theirformal CRM training is culturally appropriate andemphasizes the following management skills:decision making, workload management, crewcoordination, planning, communication, situationalawareness and advocacy. (IAW AC120-51b.)(See 133.)

5 3 5 2.1

118 325 325 Airlines and operators should emphasizeduring initial and recurrent training the importanceof maintaining systems status awareness duringabnormal events and hazardous approaches(goal to avoid tunnel vision and narrowedattention).

5 3 5 2.1

119 347 347 Parent airlines / operators should adopt aprogram to ensure the same level of safety inregional partners including, but not limited, torecruitment, training, operations, andmaintenance.

5 3 5 2.1

120 409 409 To enhance stability during the approach andlanding phase, airline operators should developand implement policies and procedures thataddress mixed mode flight(e. g., autothrottles in manual flight) with specificemphasis on pitch / thrust coupling and aircraftcontrol problems.

4.8 4 4 2.1


71


121 411 411 To reduce accidents during the landingphase, airline operators should establish criteriaand procedures and train flight crews to recognizeconditions that might require a rejected landing.

5 3 5 2.1

122 442 442 To avoid delay in the recognition of enginemalfunction or failure, manufacturers shoulddevelop and implement a direct aural and visualflight deck indication of engine malfunction orfailure. (Minor transients need not beannunciated.)

3 5 5 2.1

123 467 467 To reduce unstabilized approaches, air trafficquality assurance programs should regularlyevaluate Air Traffic Control System CommandCenter / Traffic Management Unit (ATCSCC /TMU's) to ensure traffic management programsand initiatives include all traffic elements (i.e.tower enroute clearance / enroute traffic), areimplemented properly, effectively utilized andpersonnel are adequately trained.

5 3 5 2.1

124 474 474 Since indications of sideslip may not beprominent and can be masked by roll effects,manufacturers should develop improved sideslipindications and alerting (e.g. similar to pitch limitindications for pitch / angle of attack).

5 3 5 2.1

125 484 484 To ensure adequate FO proficiency, airlines /operators should incorporate the operatingpractice of alternating PF and PNF duties(alternating legs and landings).

4.8 4 4 2.1

126 542 542 To preclude over-reliance on automation,airlines / operators and regulators should createand clarify a definition of “appropriate levels ofautomation,” to include the need to validateagainst other information sources and ensure thatthe resulting definition is published and includedin all appropriate flight crew publications, manualsand training programs.

5 3 5 2.1

127 548 548 In order to provide flight crews with engineout training on takeoff without visual outsidereference, regulators should require, andoperators should conduct, takeoff engine outtraining and evaluation during the portion of thetakeoff after rotation through initial climb.

5 3 5 2.1

128 553 553 Since performance calculations can havesignificant safety implications, regulatoryauthorities should ensure that pilot training andprocedures adequately address their meaningand use.

5 3 5 2.1


72


129 48 48 Airlines and operators and regulators shouldstrictly enforce flight and duty time limitations.

4 3 6 2

130 94 94 Implement real time (digital) transmission ofairport and weather information to the aircraft.

2.9 5 5 2

131 131 131 Airlines and operators should ensure thattheir training and standardization programemphasizes the importance of the team concept,cross cultural issues, evaluation of options andthe obligation of the FO to effectivelycommunicate any concerns (CRM). (See 237.)

4.8 3 5 2

132 373 373 To ensure that manufacturers and regulatorsare aware of recurrent problems (type andfrequency), manufacturers, regulators, andoperators should implement a reliable process forgathering and reporting safety-related problems.

4.4 4 4 2

133 415 415 To provide improved aircraft statusawareness, airlines / operators should enhancetraining to identify aircraft configuration and therepercussions of the aircraft's energy state.

4.8 3 5 2

134 437 437 To enhance the safety of functionalevaluation flights (FEF), regulators shouldestablish standards for critical aircraft handlingmaneuvers.

4.4 4 4 2

135 439 439 To ensure proper designation of pilotsconducting nonstandard flight operations (e.g.,Functional Evaluation Flights), regulation and/orguidance should be revised to clearly indicatepilot experience, pairing, and training levelsrequired.

4.4 4 4 2

136 163 163 Airlines and operators should ensure thattheir training and standardization programsaddress common perceptions that could lead tounsafe practices.

3.8 3 6 1.9

137 30 30 Airlines and operators should adopt the"delegated" approach to standard operatingprocedures (e.g. monitored approachprocedures).

4 4 4 1.8

138 64 64 Airlines and operators should ensure that theirtraining and standardization programs direct theflight crews to regularly cross check allinstrumentation.

5.5 2 6 1.8

139 151 151 Regulators should establish policies thatrequire additional monitoring of flightcrewmembers that have repeatedly failed checkrides. (See 152, 335, 337.)

4.4 3 5 1.8


73


140 223 223 Regulators should ensure POI’s are properlyqualified and trained to approve appropriatecompany operational procedures.

4.4 3 5 1.8

141 368 368 To enable pilots to develop situationawareness with respect to aircraft performancecapability, regulators should require andmanufacturers should provide angle of attackdisplay.

4.4 3 5 1.8

142 414 414 To reduce negative transfer effects duringpilot transition to new aircraft, airline operatorsshould determine the potential for negativetransfer of inappropriate pilot actions andtechniques on flight critical systems and over trainto prevent their occurrence.

5.5 3 4 1.8

143 473 473 Due to increasing dependence on automationand the complexity of potential partial systemfailures, airlines / operators should modify trainingprograms to emphasize the use of multiple datasources to confirm that the airplane and systemsare performing as expected and in accordancewith the operational mode.

4.4 3 5 1.8

144 491 491 To ensure adequate flight crew competency,airlines / operators should establish moreeffective pilot screening and Capt. upgradecriteria to identify candidates with demonstrableflying skill deficiencies. (See 335)

4.4 3 5 1.8

145 519 519 To ensure pilot proficiency in basicairmanship skills and knowledge, regulatorsshould require training and standardizationprograms that emphasize these subjects duringinitial and recurrent training. (See 111).

4.4 3 5 1.8

146 538 538 Airline / operators should train flight crews inteam decision-making skills, including the abilityto rapidly turn data into information and testconclusions. (See 314.)

4.4 3 5 1.8

147 543 543 In order to provide pilots with sufficientairplane performance margins to reduce exposureto potential upsets, regulators should requireairplane operation in a cruise flight envelope withat least 1.3g margin to buffet onset.

4.4 5 3 1.8

148 26 26 Airlines and operators should ensure that CRMtraining is provided prior to line flying.

5 3 4 1.7

149 113 113 Airlines and operators should ensure thattheir training and standardization programsemphasize the importance of adequate preflightplanning.

4 3 5 1.7


74


150 243 243 To prevent alerting overload, flight deckdesigns should consider smart alerting systemssuch as those with prioritization schemes orcancelable nuisance alerts.

5 4 3 1.7

151 370 370 To foster transfer of safety-relatedinformation, airplane and componentmanufacturers should participate in safety datasharing programs, (e.g. current Manufacturers'safety data sharing meetings).

5 3 4 1.7

152 393 393 To ensure system status awareness, airlines/ operators should ensure that their training andstandardization programs direct the flight crews touse all available tools to determine airplanesystem status. (See 47.)

5 3 4 1.7

153 402 402 To prevent a more serious event,manufacturers should revise product failureanalyses if service history reveals unexpectedconsequences or failure modes.

5 3 4 1.7

154 440 440 To ensure all aircraft meet currently acceptedminimum performance standards, regulatorsshould require warning systems that meetairworthiness standards.

3 5 4 1.7

155 447 447 In order to maintain adequate safety marginsduring flight training, operators should establishand regulatory agencies should require standardsfor conducting flight training which precludeoverloading the trainee.

5 3 4 1.7

156 454 454 Because latent and combination failures havebeen missed in failure analyses, manufacturersand regulators should conduct more intensiveverification of all safety analyses associated withsystems whose failures, singly or in combinationwith other system failures, can result in accidents.

5 3 4 1.7

157 470 470 Since current airline training emphasizesrecovery from approach to stall, airlines andoperators should emphasize to air crews theimportance of proper analysis and response toincipient stall conditions (for example timelyreduction in angle of attack).

5 3 4 1.7

158 475 475 Since simulators cannot adequately replicatethe motion cues associated with sideslip, theindustry should develop improved methods forsafely training pilots to recognize and respond toin-flight sideslip events. (See 358, 386.)

5 3 4 1.7


75


159 513 513 To preclude undesired flight controldisplacement manufacturers should design flightcontrols so that the airplane does not experienceuncommanded, adverse flight control deflectionsthat are beyond the control of the flight crew.(Throughout the flight envelope, includingaerodynamic stall.)

5 4 3 1.7

160 529 529 To avoid negative training, airline operatorsshould ensure that their training curriculumcorrelates with the AOM and other relevantmanuals.

5 3 4 1.7

161 537 537 To ensure proper intra-cockpitcommunications, operators must ensure that thelanguage used in the cockpit is compatible,understandable, and consistent among all flightdeck crewmembers.

3 4 5 1.7

162 540 540 To ensure completeness, avoid erroneousprocedures, and prevent misinterpretation,manufacturers and operators should ensure andregulatory agencies should check that theguidance and procedures in AOM's are complete,clear and correct.

5 3 4 1.7

163 14 14 Install aural warning devices on aircraft to alertflight crew of arrival at MDA/DH.

2.9 4 5 1.6

164 211 211 Airlines and operators should retrofitequipment to provide automatic altitude call outson final approach.

2.9 4 5 1.6

165 246 246 To reduce pilot overload, airlines’ andoperators’ policies should stress using theappropriate level of automation.

3.8 3 5 1.6

166 468 468 To ensure the highest quality of air trafficservices, regulators should establish policies thatrequire additional oversight and training of airtraffic controllers that repeatedly commitoperational errors.

2.9 4 5 1.6

167 480 480 To improve operational oversight, regulatorsshould institute processes for periodic review ofPOI’s to ensure that appropriate oversight isbeing conducted for the POI's assigned operators.

2.9 4 5 1.6

168 481 481 Because POI’s may be responsible foroversight of remote training activities, regulatorsshould ensure that POI’s have sufficientCertificate Holding District Office resources,including staff, to conduct appropriate oversightfor the POI's assigned operators.

2.9 4 5 1.6


76


169 536 536 To prevent reoccurrence of accidents andincidents, regulators, manufacturers, andoperators should expedite development andapplication of an effective risk managementcontinuing airworthiness assessment based uponprior incidents and disseminate the results. (See372, 373.)

3.8 3 5 1.6

170 539 539 To ensure procedural compliance,manufacturers should design and incorporate'smart' checklists that detect failures and providethe proper flight crew actions. (See 444.)

2.9 4 5 1.6

171 562 562 Airlines and operators should developprocesses to identify and thoroughly review(seeking "no technical objection" frommanufacturer, when appropriate) informal pilottechniques to ensure that they have nounacceptable unintended consequences.

3.8 3 5 1.6

172 564 564 To reduce the need for pilots to work aroundthe automation, manufacturers should ensure thatsystems designs and safety analyses considerthe full range of operations.

3.8 3 5 1.6

173 350 350 Airlines and operators shall ensure thatadequate approach briefings are conducted thatinclude descriptions of normal approach,abnormal conditions and the results of the riskassessment analysis. (See 300.)

4.4 3 4 1.5

174 371 371 To eliminate the potential safetyconsequences of system failures,manufacturers/operators should develop areliable process for identifying, prioritizing, andresolving the safety consequences of system andcomponent malfunctions throughout theoperational envelope.

4.4 4 3 1.5

175 387 387 To ensure that airplane systems function asdesigned, airlines and operators should developprocesses to ensure adherence to manufacturer'srecommended maintenance procedures.

4.4 3 4 1.5

176 421 421 Since intermittent failures can persist forunspecified periods of time without correction,operators should develop specific policies,procedures and guidance defining whendegraded systems or systems with intermittentproblems should be disabled, invoking theappropriate MEL requirements.

4.4 3 4 1.5

177 469 469 To ensure clear understanding of flight crewtasking airlines and operators should developcriteria specifying when transfer of control isnecessary or appropriate. (See 207.)

4.4 3 4 1.5


77


178 487 487 To minimize the occurrence of loss of controlevents, airline operators' training programs shouldemphasize pattern recognition and skill-basedprocedures to better handle time-criticalsituations, rather than relying on knowledge-based analysis.

4.4 3 4 1.5

179 507 507 To ensure that flight crews have allnecessary weather information prior to flight,airlines and operators should immediately reviewtheir system of weather information disseminationto ensure that all significant weather information isprovided for their route of flight.

4.4 4 3 1.5

180 565 565 Manufacturers should incorporate an "inputrudder" indicator to ensure that adequate yawcontrol is provided.

5.5 2 5 1.5

181 573 573 To preclude late descent clearances, AirTraffic Service should ensure that standardterminal arrival procedures are in place totransition from enroute altitudes to the instrumentapproach procedure.

4.4 3 4 1.5

182 17 17 Airlines and operators should ensure that theirtraining and standardization programs emphasizethe importance of all flight-related briefings. (See342.)

5 2 5 1.4

183 237 237 Airlines and operators should provideguidance to crew concerning evaluation of alloptions prior to decision making as part of CRMtraining. (See 25, 26, 131, 132, 133, 308.)

5 2 5 1.4

184 300 300 Airlines and operators should adopt,implement and train a risk assessment tool toenhance flight crew awareness of hazardsassociated with all approaches and airports. (Seerisk analysis tactical checklist)

5 2 5 1.4

185 316 316 Regulators should require airlines andoperators to train flight crews to recognize andcounteract acute and chronic fatigue. (See 31,130, 203, 257,315.)

3.4 3 5 1.4

186 489 489 In order to improve oversight of airlines,regulators should ensure their organizations(Flight Standards in the U.S.) are staffed toprovide adequate inspector coverage for allairlines, (including small airlines).

3.4 3 5 1.4

187 130 130 Regulators should account for realistic restscenarios when developing and implementingcrew rest requirements during travel segments.(See 31, 203, 257, 315, 316.)

3.8 2 6 1.3

188 228 228 Regulators should require airlines andoperators to modify their training to maximizebenefits of inter-crew / company communications.

5 3 3 1.3


78


189 251 251 To preserve the original intended level ofairworthiness, there should be a better definitionand classification of subsequent in-service majorand minor critical component changes. Thedefinition of critical component should be morespecific.

4 3 4 1.3

190 369 369 To provide adequate stall warning, regulatorsshould require and manufacturers shoulddevelop, stall warning systems for new andderivative aircraft that provide accurateinformation throughout the certificated flightregime.

3.8 4 3 1.3

191 403 403 To ensure clear communication, airlineoperators should train flight crews to emphasize ifaction is required when giving status reports.

4 3 4 1.3

192 479 479 To improve operational oversight, regulatorsshould establish selection criteria and appropriatetraining programs (e.g. training with carriers) toensure that POI’s responsible for air carrieroversight have appropriate knowledge andexperience to perform those functions.

3 4 4 1.3

193 526 526 To increase the number of available pilots,airlines should implement, and regulators shouldallow, a performance-based selection system thatexpands the eligible pilot pool beyond the currentarbitrary limits (e.g., age 60 rule, minimum flighttime) with an appropriate medical andpsychological evaluation.

3.8 3 4 1.3

194 559 559 To reduce the likelihood of hard landings,airlines and operators should develop trainingsyllabi with improved coverage of landings,including identification of and recovery fromunstabilized flares, high sink rates, and bouncedlandings.

4.8 2 5 1.3

195 21 21 Establish or enhance quality assurance checksand training to ensure that timely and accuratecommunication between controllers and flightcrews is occurring.

2.9 3 5 1.2

196 42 42 Airlines, operators, and air traffic serviceproviders should implement a monitoring programto ensure the consistent use of the ICAOphraseology.

2.9 3 5 1.2

197 96 96 Airlines and operators should ensure that theirtraining and standardization programs emphasizethe importance of adequate approach preparationand contingency review prior to commencing anapproach.

4.4 2 5 1.2


79


198 106 106 Air Traffic service providers should train andmonitor ATC adherence to establishedcommunications procedures including hear backproblems. (See 240.)

2.9 3 5 1.2

199 134 134 Airlines, operators, and regulators shouldensure check list designs, prioritize critical itemsas recommended by NASA study, and arrangeitems in a manner that enhances checklistimplementation.

4.8 3 3 1.2

200 342 342 Airlines and operators should establish anSOP to ensure that flight crews should not begintheir approach until adequate briefing iscompleted for the expected runway. (See 17.)

4.4 2 5 1.2

201 492 492 In order to ensure pilot medical fitness forduty, airlines, operators, and regulators shouldestablish a structured process for return to flightstatus after sick leave that includes medicalclearance.

2.9 3 5 1.2

202 495 495 To improve aircraft failure tolerance,manufacturers and regulators should conductfailure analyses for design and certification thatreflect realistic levels of flight crew reliability.

2.9 3 5 1.2

203 518 518 To ensure an adequate supply of qualifiedpilots, the aviation community should promoteinitiatives that screen youth for potential aviatorqualifications, skills, and aptitude. The industryshould identify and develop career paths forsuitable candidates and mentor their careergrowth as successful aviators.

2.7 4 4 1.2

204 36 36 Airlines and operators should establish andimplement the use of electronic checklists or otheraids to ensure completion of all checklist items.

2.7 3 5 1.1

205 141 141 Airlines and operators and regulators shouldrequire training and standardization programsinclude training regarding physiological effects onaircrew performance, (e.g. low blood sugar,fatigue, etc.).

3.4 2 6 1.1

206 143 143 Airlines and operators should, and regulatoryagencies must, encourage a culture thatenhances safety in their daily operations. (SafetyCulture.) (See 22, 63, 348.)

3.8 2 5 1.1

207 203 203 Airlines and operators should provide crewswith in-flight rest periods and adequate facilities.(See 31, 130, 315.)

3.4 2 6 1.1

208 242 242 To prevent excessive fatigue, airlines andoperators should consider circadian rhythm increw scheduling to compensate for the effects ofrhythm interruptions.

3.4 2 6 1.1


80


209 348 348 Airlines and operators should utilize a self-audit process (such as FSF ICARUSrecommendation), operational risk managementprograms and accident cost analysis toproactively identify and mitigate safety concerns.(See 318.)

3.8 2 5 1.1

210 349 349 Airlines and operators should ensure trainingfor instructors and check airmen include objectivecriteria to be used in evaluating crew CRMperformance. (See 25,131.)

3.8 2 5 1.1

211 375 375 To improve controller situation awareness, airtraffic service providers should ensure that theirtraining and standardization programs direct thatcontrollers use all available tools to establishaircraft position. (See 75.)

4 2 5 1.1

212 418 418 Because not all operators understand thesignificance of failures which may result in yawand roll upsets, manufacturers should provideairlines with more information regarding theairplane control implications of such failures.

3.4 3 4 1.1

213 432 432 To facilitate recovery from flight upsets,airlines and operators should clearly define, trainand check the specific PF and PNF upsetrecovery duties.

2.7 3 5 1.1

214 436 436 To ensure adequate stall warning, regulatorsshould mandate improved accuracy and integrityin the stall warning system (including aircraftcurrently in service).

3.8 5 2 1.1

215 452 452 Since handling qualities and performancemargins may be significantly different during highaltitude cruise, airlines and operators shouldensure that pilots receive adequate training andexperience in manual flying in this flight regime.

4.4 3 3 1.1

216 493 493 To reduce the risk of pilots' non-readiness forflying, airlines and operators should train pilots toperform self-audit medical and psychologicalassessments prior to flight duty.

2.7 3 5 1.1

217 523 523 To ensure that airline operation trainingdepartments accomplish their trainingresponsibilities, they must be adequately funded.

4 2 5 1.1

218 534 534 Airlines and operators should implementprocedures that call for an immediate recoverymaneuver following a warning that indicates animminent departure from normal flight envelope(e.g. stall warning, over-speed, etc.). (See 161.)

3.4 3 4 1.1


81


219 49 49 Regulators should establish criteria for, andmanufacturers should evaluate and improve, thereliability and failure tolerance of flight systems(includes hardware, software and humanperformance). (See 332.)

2.9 3 4 1

220 224 224 Airlines and operators should ensure that allairline operations include compliance withall/seasonal guidance from the OEM.

4.4 2 4 1

221 378 378 To preclude continued flight into an unsafeaircraft energy state, airlines and operatorsshould establish procedures for flight crews toestablish a safe, stabilized flight condition whensituational uncertainty exists and then advise ATCof intentions.

4.4 2 4 1

222 390 390 Because some partial system failures maynot be reliably observed, manufacturers shoulddevelop warning systems that alert the pilot tothose partial or total failures of flight criticalsystems and flight instruments.

4 3 3 1

223 451 451 To allow adequate training in manual flight,manufacturers should develop models to allowflight simulators to accurately represent theaircraft's stability and control characteristics for allregions of the flight envelope likely to beencountered during normal operations (i.e.operation within the AFM-approved flightenvelope with no failures affecting aerodynamicperformance).

4.4 4 2 1

224 482 482 To prevent inaction when the PF is confusedor unresponsive to an in-flight hazard, airlines andoperators should develop training and clear andexplicit procedures to define when and how thePNF (especially the FO) will take control of theairplane.

4.4 2 4 1

225 505 505 To ensure that safety related incidentinformation is shared between validating andcertificating authorities, regulators should developa system to review the terms of and complianceto bilateral airworthiness agreements.

4.4 4 2 1

226 506 506 To ensure that the airworthiness authoritiesknow and understand the importance ofcomplying with the international agreements,ICAO should distribute annual notices to theauthorities emphasizing the importance of mutualdistribution of continued airworthinessinformation.

4.4 4 2 1


82


227 560 560 Since geographic organization of inspectionresponsibilities can affect the quality andtimeliness of inspections conducted by supportingorganizations at remote locations, regulatorsshould ensure that these remote inspectors aremore accountable to the requesting certificateholding office. (CHDO/CMO.)

2.4 3 5 1

228 296 296 To mitigate confusion regarding ATCclearances, operators should develop proceduresto ensure flight crews query ATC wheneveruncertainty exists.

4 2 4 0.9

229 310 310 Regulators should not allow noise abatementprocedures that reduce the level of safety thatexisted prior to their implementation.

3.4 2 5 0.9

230 434 434 To enhance the safety of operations,regulatory agencies should develop adequateoversight to encourage the use of commonlyaccepted safe operating practices. (See 201.)

3.4 2 5 0.9

231 476 476 Since repair processes can significantly affectthe airworthiness of components, regulatorsshould require manufacturer concurrence on allmaintenance and repair procedures affectingcritical aircraft structures, components, orperformance.

2.7 3 4 0.9

232 524 524 Regulators should establish flight crewphraseology guidelines, and airlines andoperators should train and monitor flight crewcompliance with communication phraseologyguidelines. (See 88, 240.)

1.7 4 5 0.9

233 541 541 To reduce the risk of loss of control duringflight with a propulsion system malfunction inturboprop aircraft, if the engine failure procedureis not completed, airline operators should reviewthe consequences of the malfunctioningpropulsion system being placed in flight idle.

3.4 3 3 0.9

234 558 558 Since current ATC procedures can result innonstandard use of automated flight systems (e.g."slam dunk approaches"), air traffic serviceproviders and airplane manufacturers shoulddevelop and implement automated tools so thatATC clearances are integrated with and take intoaccount the performance of airplanes usingautomated flight systems (e.g. CTAS/FMSprogram). (See 557.)

1.7 4 5 0.9


83


235 569 569 Since hard landings are identified primarilybased on pilot subjective judgment and to ensurethat individual airplanes are inspected whennecessary, manufacturers should develop andregulatory authorities should require theimplementation of objective means to identify theoccurrence of a hard landing within anappropriate period of time.

1.3 5 5 0.9

236 28 28 Implement a system to automatically transmitATC instructions and information between theground controller and the aircraft.

2.4 3 4 0.8

237 123 123 Airlines and operators should implement atrue no-fault go around policy (learning vs.blame).

2.7 2 5 0.8

238 133 133 Airlines and operators training of captainsand chief pilots should include managementpractices that promote team building and effectivehuman relations (leadership training beyondcurrent CRM programs). (See 308.)

2.4 3 4 0.8

239 367 367 To provide necessary information to pilots,regulators should require and manufacturersshould develop, flight control position indicatingand alerting systems which will provide warningsfor critical aircraft flight control malfunctions (e.g.actual flight control position disagreement withcommanded position).

2.4 3 4 0.8

240 376 376 To improve aircrew awareness of othertraffic, manufacturers should install TCAS in allnew aircraft, airlines and operators should retrofitTCAS into the existing fleet and internationalregulators should require the installation and useof TCAS. (See 35.)

2.9 2 5 0.8

241 396 396 To ensure a standard level of safety at allairports, airport operators should adopt airportoperations procedures that are no less stringentthan ICAO recommendations.

3.4 2 4 0.8

242 422 422 To ensure constant visibility of knownintermittent failures, operators should developprocedures for continued reporting of andmaintenance actions to address unresolvedintermittent failures.

2.9 5 2 0.8

243 549 549 To prevent a blurring of flight crewresponsibilities when two captains are paired tofly a trip sequence, one of the pilots should bedesignated as the pilot-in-command for theduration of the trip pairing.

3.8 2 4 0.8


84


244 563 563 Manufacturers should provide airlines andoperators with training material designed toexplain to pilots how and why systems work theway they do.

2.9 2 5 0.8

245 567 567 To minimize potential negative safetyimplications of procedural changes, airlines andoperators should develop processes to review allproposed operating procedures in order touncover and evaluate potential unintendedconsequences.

2.9 2 5 0.8

246 22 22 Airlines and operators should encourage aculture that emphasizes safe arrivals over timelyarrivals. (See 63, 143.)

3 2 4 0.7

247 100 100 Airlines and operators should ensure thattheir training and standardization programsemphasize the importance of adhering toMDA/DH.

2.4 2 5 0.7

248 136 136 Airlines and operators should ensure thattheir training and standardization programsemphasize the importance of the sterile cockpitenvironment.

2.7 3 3 0.7

249 363 363 To enhance aircraft controllability in severe orgreater turbulence conditions, regulators andmanufacturers should develop and implementcertification criteria that consider effects ofturbulence, including automated flight capabilityand disconnect parameters.

2.4 2 5 0.7

250 389 389 To assist flight crews in responding to systemmalfunctions, manufacturers should develop andairlines and operators should incorporate readilyaccessible flight crew procedures for partial ortotal failure of flight critical systems.

4.4 2 3 0.7

251 477 477 To improve maintenance quality, regulatorsshould require that airlines and operators instituteprocesses for oversight of maintenance facilitiesthat maintain safety-critical parts, components, orsystems (e.g. Coordinating Agency for SupplierEvaluation (CASE) might be one type of programthat could provide an acceptable method ofcompliance).

1.6 3 5 0.7

252 478 478 To improve maintenance quality, regulatorsshould increase oversight of maintenancefacilities that maintain safety-critical parts,components, or systems.

1.7 3 5 0.7

253 547 547 In order to ensure that the certificationprocess is based solely on safety and compliancewith the regulations, certification should includean independent audit process to guard againstthe influence of nontechnical considerations.

4.4 2 3 0.7


85


254 556 556 To reduce pilot overload, airlines andoperators should develop standard operatingprocedures to help standardize the use of theappropriate level of automation for the operationand the airplane design. (See 246, 530.)

1.7 3 5 0.7

255 557 557 Since current ATC procedures can result innonstandard use of automated flight systems (e.g."slam dunk approaches"), air traffic serviceproviders should harmonize ATC procedures sothat they take into account the flightcharacteristics of modern airplanes andautomated flight system capability.

1.7 3 5 0.7

256 570 570 To ensure appropriate crew experiencelevels, regulatory authorities should requireprocedures to ensure appropriate crew pairing.(Ref. FSF Corporate Crew Scheduling andFatigue Evaluation.) (See 24.)

1.7 3 5 0.7

257 555 555 Because it is important that training reflectthe realities of line operations, airline trainingdepartments should review and modify, inconsultation with line pilots, training curricula toreflect realistic line operations scenarios andconditions.

1.7 3 5 0.7

258 95 95 Airlines and operators should establishprocedures for flight crews to review and crosscheck instructions, clearances, etc. to ensureconsistency with expected procedures orpractices.

3.4 2 3 0.6

259 105 105 Airlines and operators should train flightcrews on how flight delays upon departure orenroute (weather, maintenance, ATC, etc.) canaffect their subsequent decision-making relativeto the safe conduct of the flight.

3.4 2 3 0.6

260 162 162 Airline / operators should include in theirtraining programs the awareness of potentialsafety risks due to the complacency whenoperating at a very familiar airport (e.g. homebase).

2 2 5 0.6

261 240 240 To reduce the possibility of error, confusionand workload increase related to ATC clearances,regulators should require and operators ensurethat flight crews utilize proper phraseology andread backs. (See 88.)

2 2 5 0.6

262 241 241 To eliminate hear back errors, ATC shouldreexamine and implement improvements toaddress hear back problems. (See 240.)

2 2 5 0.6


86


263 574 574 To ensure accurate and safe flight release,airlines / operators should ensure that dispatchersare aware of and take into account aircraft andflight crew qualifications.

1.7 4 3 0.6

264 19 19 Airlines and operators should implement aprocedure to climb to a minimum safe altitudewhen position uncertainty exists by at least onecrewmember. Flight crew must advise ATC ofintentions.

2.4 2 4 0.5

265 78 78 Airlines, operators and regulators shouldimprove the availability, clarity, and prioritizationof NOTAM information.

2.7 2 3 0.5

266 88 88 Airlines and operators should train and monitorflight crew compliance with establishedcommunication phraseology guidelines.

1.6 3 4 0.5

267 122 122 Air Traffic service providers should implementtransmission of ATC instructions and information(between the ground and aircraft) via a computerlink as opposed to voice communications.

1.7 2 5 0.5

268 135 135 Airlines and operators and regulators shouldensure checklist design and implementation ofprocedures to promote effective crew coordinationand distribution of PF and PNF tasks. (See 82.)

3 2 3 0.5

269 297 297 To prevent CFIT, operators should developprocedures to ensure that flight crews do notdescend when confusion exists concerningaircraft position.

2.4 2 4 0.5

270 394 394 Because of increasing interactions betweensystems, manufacturers and trainingorganizations should develop new approaches forinstructing pilots in the interrelationships betweensystems.

3.4 1 5 0.5

271 429 429 To reduce the risk of flight with a structurallydamaged airplane, airline operators shouldinstitute procedures for a diversion to the closestsuitable airport following an upset event thatexceeds defined parameters.

2.7 2 3 0.5

272 435 435 To ensure that stall warning systems areproperly functioning, manufacturers shouldestablish appropriate inspection and calibrationprocedures.

2.9 3 2 0.5

273 544 544 To ensure that flight controls are availableduring critical flight phases or conditions,manufacturers should design system overridesthat are available to the flight crew to regainmanual control.

1.7 5 2 0.5

274 46 46 Airlines and operators should implementprocedures to increase flight crew awareness ofrecent aircraft maintenance actions.

2.4 2 3 0.4


87


275 52 52 Airlines and operators should ensure that theirtraining and standardization programs establishflight crew proficiency in the use of the FMSsystem.

1.6 2 4 0.4

276 410 410 To enhance safety in the airport environment,regulators and airport operators should developguidelines for minimizing the effects ofenvironmental factors on wind fields in theapproach and landing areas of the runways andwork with local authorities for implementation.

1.6 2 5 0.4

277 441 441 To avoid confusion, regulators/operatorsshould develop a consistent standard for stallspeed calculation.

1.7 4 2 0.4

278 554 554 Because it is important that training reflectthe realities of line operations, airline trainingdepartments should include instructors whoregularly fly in line operations.

1.6 2 5 0.4

279 571 571 To ensure the aircraft can be safely flown bypilots with normal skill levels, regulatoryauthorities should require that tests anddemonstrations intended to show compliance withapplicable regulations include representative linepilots performing representative line-typeoperations.

2 2 4 0.4

280 388 388 Airlines and operators should encourage aculture that emphasizes safe operations over on-time performance. (See 22.)

2 1 5 0.3

281 503 503 To alert the flight crew of flight control trimchanges, manufacturers should provide anappropriate level of aural annunciation.

3 4 1 0.3

282 517 517 To ensure an acceptable skill level of pilotsentering the aviation profession, the aviationcommunity should encourage the development ofand enrollment in aviation career trainingprograms.

1.5 2 4 0.3

283 12 12 Air traffic service providers should emphasizein ATC training the controllers' potential inassisting the flight crew in improving theirsituation awareness. (See 377.)

1.6 1 5 0.2

284 137 137 Manufacturers should ensure cockpit designthat does not interfere with or distract the flightcrew from executing their duties (e.g. rain in thecockpit, location of switches in cockpits).

2 2 2 0.2

285 575 575 To provide the flight crew with a morepositive indication of autopilot engagement ordisengagement, the manufacturer should developand provide an active and positive annunciation ofautopilot engage status which appears after flightcrew initiation of a go-around.

2 2 2 0.2


88


286 404 404 To enhance crew performance in theapproach and landing phase, airline operatorsshould train pilots to understand the limitations ofcomputed wind displays.

1.3 2 2 0.1

287 10 10 Air traffic service providers should train airtraffic controllers to use all available tools toestablish aircraft position (e.g. don't fixate on justDME).

1 1 1 0

288 108 108 Air traffic service providers should implementand/or review procedures to ensure ATC trainingdoes not create a hazard to flight operations.

0 1 0

289 514 514 Combined with 525 0

290 465 465 To reduce flight crew workload indownloading voice ATIS information, regulators,through consensus with the aviation community,should reexamine and limit the content of ATISbroadcasts.

0 3 5 0

291 466 466 To further improve the quality of weatherinformation provided to the flight crews, theregulators should implement recommendationsfrom the weather product working group of the1999 FAA In-flight Icing Operations Conference.

0 3 5 0

APPENDIX E: RESEARCH & DEVELOPMENT INTERVENTIONS

89

Appendix E: Research & Development Interventions

IS# Intervention Strategy Power Priority

204204 Research should be conducted to better understand theunderlying reasons and causes for proceduralnoncompliance.

R&D 3

208208 Research should be conducted to understand andcounteract the phenomenon of flight crew overload (e.g. whydo flight crews ignore GPWS warnings).

R&D 3

244244 To prevent plan continuation errors (e.g. press-on-itis),research should be conducted to determine the effectivenessof directive information systems for go-around situations.

R&D 2

356356 Research should be done to develop an effective tacticaldecision-making model for flight crews in time criticalsituations.

R&D 3

359359 To improve effectiveness of upset recovery training,research should identify the most effective methodology forupset training.

R&D 1

362

362 To enable further development of safe aircraft separationand operational requirements, research should be conductedto describe the dynamics and location of wake turbulenceand environmentally generated turbulence.

R&D 2

379

379 Since people are often unaware of their own confusion,research should be conducted to develop a set of cues tohelp flight crews and controllers identify when they have lostsituation awareness.

R&D 3

385

385 Because flight crews sometimes disregard flight deckwarnings which require immediate action, research should beconducted to understand this phenomena and developappropriate solutions.

R&D 2

386386 To support advanced maneuver training, manufacturersshould develop simulator models that facilitate post stallrecovery training. (See 358.)

R&D 1

392

392 In order to support pilot takeoff decision-making,research should be conducted to determine the effectivenessof altering systems to identify situations, which warrant arejected takeoff.

R&D 2

406

406 In order to minimize automated flight to manual transitioneffects, research should be conducted to determine thefeasibility and desirability of automated flight and flight controlsystems designs that eliminate the need for large flightcontrol input at disengagement from ALIGN mode.

R&D 4

419

419 Because manufacturers must make certain assumptionsregarding which failures will be detected and handled by thepilot with "normal piloting skills," research should beconducted to determine if these assumed skills andknowledge are valid in realistic airline operations.

R&D 1


90


425

425 To enhance crew awareness of automation modes,research should be conducted to develop intelligent systemsthat will alert the flight crew to inconsistencies between theselected automated flight modes, aircraft performance andcurrent system status.

R&D 1

426426 Research should be undertaken to determine how tokeep crews alert in low-stimulation environments (e.g.,highly-automated flight decks, long-haul flights).

R&D 1

428

428 Research should be done to develop ways to preventinappropriate preoccupation with trouble shooting followingengine or other system failure to the exclusion of the majortask of flying the airplane.

R&D 3

430430 Research should be conducted to determine the optimalway to provide flight crews with aircraft status recognitionduring critical situations.

R&D 2

443

443 To ensure the best technique for engine malfunction andfailure annunciation, and to minimize nuisance alerts,research should be conducted to determine when, and how,to annunciate engine malfunctions and failures.

R&D 3

448448 To preclude trainee overload, research should beconducted to understand the optimum workload level foreffective flight training.

R&D 4

455

455 Because latent and combination failures may be missedin failure analyses, manufacturers and regulators shouldconduct research into improved methods for conductingsafety analyses, to ensure reliable identification of failureswhich, singly or in combination with other system failures,can result in accidents.

R&D 2

459

459 For a full understanding of aircraft performance andhandling qualities in icing conditions, research should beconducted to define the effects of all ice accretions, withparticular emphasis on the roll effect due to ice contaminatedwings (intercycle or residual).

R&D 2

461461 To reduce the adverse effects of ice accretionroughness, the regulators and NASA should conductresearch leading to improved ice protection technologies.

R&D 4

471

471 Since many factors can make the identification ofimpending loss of control difficult, research should bedirected toward the development of systems that advise theflight crew that the aircraft is departing from a flight pathconsistent with the flight control inputs.

R&D 4

496496 To enable failure analysis which is based upon realisticlevels of flight crew reliability, researchers should developand validate models of human error.

R&D 3


91


499

499 To make flight crews aware of the possibility of airframeice accretion, research should be conducted to developreliable means of aircraft surface ice detection, as well asground and aircraft based means of detection ofmeteorological icing conditions.

R&D 1

509

509 To reduce the risk of encountering hazardous weatherconditions (e.g. sld, thunderstorms, etc.) research must beconducted to develop methods for accurate prediction andidentification of these conditions.

R&D 3

510510 To better understand the effects of sld icing researchshould be conducted on ice protection system design andoperation in this weather phenomena.

R&D 4

550

550 Since handling qualities evaluations are subjective andsubject to nontechnical influences, the regulatory authorities,manufacturers, research organizations, and operators shouldwork together to develop improved, quantitative, objectivemetrics and acceptance criteria to ensure safe handlingqualities.

R&D 2

552

552 To add structure to piloting skill levels, research shouldbe conducted to determine the efficacy and impact of a multi-level pilot licensing and qualification structure (e.g. analogousto apprentice, journeyman, master).

R&D 3

572

572 Research should be conducted to improveunderstanding of how and why pilots misprioritize or becomefixated upon concerns and tasks, and to develop strategies tocounteract this effect.

R&D 4

APPENDIX F: NON-RATED INTERVENTIONS

92

Appendix F: Non-Rated Interventions

The following interventions were not rated because they were superceded or combined withother interventions; would not have prevented the accident in question; are futureinvestments that would provide knowledge/technologies to help prevent accidents.

IS# Intervention Strategy Power

27 27 Airlines and operators should implement maintenance proceduresto ensure proper functioning of the CVR at all times. (Note: thisintervention was recorded as a potential intervention of futureaccidents, it would not have prevented the subject accidents.) (See576.)

NR

120 120 Airlines and operators should ensure procedures do not increasepilot workload during critical phases of flight.

NR

303 303 Regulators should implement the NTSB recommendations toincrease DFDR parameters (not rated). (See 576.)

NR

360 360 To improve the effectiveness of accident investigations, regulatorsshould immediately implement the NTSB recommendations toincrease the quantity and quality of survivable data recorded in bothexisting and future aircraft. (See 576.)

NR

377 377 Because pilots may be reluctant to ask for clarification ofclearances when uncertain, ATS providers should develop policies andtraining that encourages pilot queries when they (crew) are unsure ofclearances. (See 12.)

NR

444 444 To ensure procedural compliance, research should be conductedto develop 'smart' checklists which detect failures and provide theproper flight crew actions. (See 539.)

NR

449 449 In order to ensure adequate handling qualities in manual flight, inall regions of the flight envelope, regulators should review currentcertification requirements pertaining to aircraft stability to determine ifadditional rulemaking or advisory material development is warranted,especially to account for airplanes with new technologies affectinghandling qualities (e.g. "relaxed static stability"). [2-47]

NR

453 453 To help prevent future accidents, airlines and operators shouldimplement maintenance procedures to ensure proper functioning ofthe DFDR at all times. (Note: this intervention was recorded as apotential intervention of future accidents, it would not have preventedthe subject accidents.) (See 576.)

NR

458 458 To enhance the safety of all aircraft, regulators should ensure thatappropriate revised icing certification criteria apply to 14 CFR part 23,27 and 29 certificated aircraft in addition to 14 CFR part 25 aircraft.(Breakout for GA.)

NR

551 551. In order to develop “best business practices” throughout thecontinuum of certification, major design changes, and operating historyof aircraft types, industry and Government should conduct a joint,proactive, lessons-learned, review of the MD-11/MD-10 certificationprocess and operating history.

NR

APPENDIX F: NON-RATED INTERVENTIONS

93

IS# Intervention Strategy Power

568 568 Since the definition and reporting criteria for hard landings arepoorly defined and there have been several landings that haveresulted in MD-11 wing structural failures, regulatory authorities shouldrequire inspection of all MD-11s to ensure that unreported hardlandings have not resulted in structural damage.

NR

576 576 To improve the effectiveness of accident investigations and, in sodoing, help prevent future accidents, regulators should immediatelyimplement NTSB recommendations to increase the quantity andquality of survivable data recorded in both existing and future aircraft,and manufacturers should improve the reliability of the recordingequipment (DFDR, CVR). (Combined from 27, 303, 360, 453, 462.)

NR

APPENDIX G: INTERVENTIONS SORTED BY NUMBER (IS#)

94

Appendix G: Interventions Sorted By Number (IS#)


21 7 7 Airlines/operators should ensure that theirtraining/standardization programs emphasizereview of approach and missed approachprocedures. (See 329)

6 4 5 3.3

287 10 10 Air traffic service providers should train airtraffic controllers to use all available tools toestablish aircraft position (example: don't fixate onjust DME).

1 1 1 0

283 12 12 Air traffic service providers should emphasizein ATC training the controllers' potential inassisting the flight crew in improving theirsituation awareness. (See 377)

1.6 1 5 0.2

106 13 13 Air Traffic service providers should enhanceATC training to emphasize the dangers of rushedapproaches and performance characteristics of jettransports. (See 115, 157)

5 3 5 2.1

163 14 14 Install aural warning devices on aircraft to alertflight crew of arrival at MDA/DH.

2.9 4 5 1.6

27 15 15 Airlines/operators should ensure that theirtraining/standardization programs instruct when todisengage automated systems and fly manually.(See 246)

5.5 4 5 3.1

22 16 16 To prevent mode confusion, manufacturersshould ensure that automated systems providethe flight crew with sufficient information(automation feedback).

5 4 6 3.3

182 17 17 Airlines/operators should ensure that theirtraining/standardization programs emphasize theimportance of all flight-related briefings. (See342)

5 2 5 1.4

264 19 19 Airlines/operators should implement aprocedure to climb to a minimum safe altitudewhen position uncertainty exists by at least onecrewmember. Flight crew must advise ATC ofintentions.

2.4 2 4 0.5

85 20 20 Airlines/operators should ensure thatcommand oversight training for captains isprovided during the upgrade process and inrecurrent training and first officer responsibility formonitoring are reviewed during recurrent training.

5.5 3 5 2.3

195 21 21 Establish/enhance quality assurancechecks/training to ensure that timely and accuratecommunication between controllers and flightcrews is occurring.

2.9 3 5 1.2


95


246 22 22 Airlines/operators should encourage a culturethat emphasizes safe arrivals over timely arrivals.(See 63, 143)

3 2 4 0.7

107 23 23 Airlines/operators should ensure that regularlyscheduled recurrent training (e.g. LOFT)emphasizes crew cooperation and workingtogether to maximize safe operations. (See 308,314)

5 3 5 2.1

108 24 24 Airlines/operators should implementprocedures to ensure appropriate crew pairing.(reference FSF corporate crew scheduling andfatigue evaluation.)

5 3 5 2.1

109 25 25 Airlines/operators should establish a CRMtraining program and regulators should requireand ensure that the initial training is provided priorto line flying and require recurrent CRM training.(See 131, 132, 349)

5 3 5 2.1

148 26 26 Airlines/operators should ensure that CRMtraining is provided prior to line flying.

5 3 4 1.7

27 27 Airlines/operators should implementmaintenance procedures to ensure properfunctioning of the CVR at all times. (Note: thisintervention was recorded as a potentialintervention of future accidents, it would not haveprevented the subject accidents.) (See 576)

NR

236 28 28 Implement a system to automatically transmitATC instructions/information between the groundcontroller and the aircraft.

2.4 3 4 0.8

137 30 30 Airlines/operators should adopt the "delegated"approach to standard operating procedures. (e.g.monitored approach procedures)

4 4 4 1.8

204 36 36 Airlines/operators should establish andimplement the use of electronic checklists or otheraids to ensure completion of all checklist items.

2.7 3 5 1.1

196 42 42 Airlines/operators and air traffic serviceproviders should implement a monitoring programto ensure the consistent use of the ICAOphraseology.

2.9 3 5 1.2

97 45 45 Manufacturers should ensure that allimpending equipment failures or inappropriatesettings that may affect the safe operation of theflight are properly annunciated to the flight crewby use of dual source sensing. (See 103, 138)

5 4 4 2.2

274 46 46 Airlines/operators should implementprocedures to increase flight crew awareness ofrecent aircraft maintenance actions.

2.4 2 3 0.4


96


129 48 48 Airlines/operators and regulators should strictlyenforce flight/duty time limitations.

4 3 6 2

219 49 49 Regulators should establish criteria for, andmanufacturers should evaluate and improve, thereliability and failure tolerance of flight systems(includes hardware, software and humanperformance). (See 332)

2.9 3 4 1

275 52 52 Airlines/operators should ensure that theirtraining/standardization programs establish flightcrew proficiency in the use of the FMS system.

1.6 2 4 0.4

86 54 54 Airlines/operators should implement FlightOperations Quality Assurance (FOQA) programs.

5.5 3 5 2.3

14 56 56 Airlines/operators should implement FlightOperations Quality Assurance (FOQA) programsto identify systemic procedural deviations andunsafe trends. (See 54, 55)

5.5 4 6 3.7

110 57 57 Airlines/operators, regulators, andmanufacturers should implement a programdesigned for sharing of safety related informationwithin the aviation community.

5 3 5 2.1

138 64 64 Airlines/operators should ensure that theirtraining/standardization programs direct the flightcrews to regularly cross check all instrumentation.

5.5 2 6 1.8

265 78 78 Airlines/operators and regulators shouldimprove the availability, clarity, and prioritizationof NOTAM information.

2.7 2 3 0.5

61 79 79 Airlines/operators should implement a reliableprocess to communicate information to the flightcrew that may affect flight or aircraft operations.

6 4 4 2.7

23 80 80 Airlines/operators should verify, and regulatorsshould check, that operators who create their ownAOM's include all operational proceduresprescribed by original equipment manufacturers'Airplane Flight Manual (AFM).

6 4 5 3.3

87 82 82 Airlines/operators should clearly define, trainand check the specific PF/PNF/FE duties.

5.5 3 5 2.3

266 88 88 Airlines/operators should train and monitorflight crew compliance with establishedcommunication phraseology guidelines.

1.6 3 4 0.5

69 93 93 Air Traffic service should provide real time(most current) radio communication of criticalairport and weather information.

4.4 4 5 2.4

130 94 94 Implement real time (digital) transmission ofairport and weather information to the aircraft.

2.9 5 5 2

258 95 95 Airlines/operators should establish proceduresfor flight crews to review/cross check instructions,clearances, etc. to ensure consistency withexpected procedures or practices.

3.4 2 3 0.6


97


197 96 96 Airlines/operators should ensure that theirtraining/standardization programs emphasize theimportance of adequate approach preparationand contingency review prior to commencing anapproach.

4.4 2 5 1.2

28 98 98 Airlines/operators and regulatory agenciesshould review procedures to ensure that designchanges (service bulletins) to flight criticalsystems are incorporated in a timely manner.

5.5 4 5 3.1

4 99 99 Airlines/operators should ensure that clear,concise, accurate, appropriate standard operatingprocedures are published and enforced. (See110)

6 4 6 4

247 100 100 Airlines/operators should ensure that theirtraining/standardization programs emphasize theimportance of adhering to MDA/DH.

2.4 2 5 0.7

259 105 105 Airlines/operators should train flight crews onhow flight delays upon departure or enroute(weather, maintenance, ATC, etc.) can affect theirsubsequent decision-making relative to the safeconduct of the flight.

3.4 2 3 0.6

198 106 106 Air Traffic service providers should train andmonitor ATC adherence to establishedcommunications procedures including hear backproblems. (See 240)

2.9 3 5 1.2

111 107 107 Airlines/operators should ensure that theirCRM training/standardization programemphasizes the importance of the team concept.

5 3 5 2.1

288 108 108 Air traffic service providers should implementand/or review procedures to ensure ATC trainingdoes not create a hazard to flight operations.

0 1 0

15 110 110 Airlines/operators and regulators shouldensure that their training/standardization andmonitoring programs emphasize the importanceof adherence to standard operating proceduresand identify the rationale behind thoseprocedures. (See 99)

5.5 4 6 3.7

88 111 111 Airlines/operators should ensure that theirtraining/standardization programs emphasizebasic airmanship skills and knowledge duringinitial and recurrent training.

5.5 3 5 2.3

112 112 112 Airlines/operators and regulators shouldensure that the frequency and effectiveness ofproficiency checks for simulated instrumentfailures (partial panel) are adequate.

5 3 5 2.1

149 113 113 Airlines/operators should ensure that theirtraining/standardization programs emphasize theimportance of adequate preflight planning.

4 3 5 1.7


98


45 114 114 Airlines/operators should ensure that theirtraining/standardization programs providesufficient training to ensure aircrew proficiency.

5.5 3 6 2.8

89 115 115 Airlines/operators should ensure that theirtraining/standardization programs emphasize thedangers of rushed approaches. (See 13, 157)

5.5 3 5 2.3

90 116 116 Airlines/operators should ensure that theirtraining/standardization programs emphasize thedangers of high rate of descent and unstableapproaches. (See 142)

5.5 3 5 2.3

120 120 Airlines/operators should ensure proceduresdo not increase pilot workload during criticalphases of flight.

NR

70 121 121 Air Traffic service providers shouldimplement worldwide surveillance radar (example:ADS/B).

4.4 4 5 2.4

267 122 122 Air Traffic service providers shouldimplement transmission of ATCinstructions/information (between the ground andaircraft) via a computer link as opposed to voicecommunications.

1.7 2 5 0.5

237 123 123 Airlines/operators should implement a trueno-fault go around policy (learning vs. blame).

2.7 2 5 0.8

113 124 124 Air Traffic service providers should implementa Quality Assurance Program to ensureadherence to established procedures.

5 3 5 2.1

46 128 128 Airlines/operators and regulators shouldimplement a no-blame safety reporting and datasharing system with appropriate protections fromlitigation and prosecution concerns.

5 4 5 2.8

114 129 129 Regulators should establish criteria to ensureoperators overall quality assurance andcompliance procedures are effective rather thanreliance on spot checks of individual components.

5 3 5 2.1

187 130 130 Regulators should account for realistic restscenarios when developing and implementingcrew rest requirements during travel segments.(See 31, 203, 257, 315, 316)

3.8 2 6 1.3

131 131 131 Airlines/operators should ensure that theirtraining/standardization program emphasizes theimportance of the team concept, cross culturalissues, evaluation of options and the obligation ofthe FO to effectively communicate any concerns(CRM). (See 237)

4.8 3 5 2


99


238 133 133 Airlines/operators' training of captains andchief pilots should include management practicesthat promote team building and effective humanrelations (leadership training beyond current CRMprograms). (See 308)

2.4 3 4 0.8

199 134 134 Airlines/operators and regulators shouldensure check list designs, prioritize critical itemsas recommended by NASA study, and arrangeitems in a manner that enhances checklistimplementation.

4.8 3 3 1.2

268 135 135 Airlines/operators and regulators shouldensure checklist design and implementation ofprocedures to promote effective crew coordinationand distribution of PF and PNF tasks. (See 82)

3 2 3 0.5

248 136 136 Airlines/operators should ensure that theirtraining/standardization programs emphasize theimportance of the sterile cockpit environment.

2.7 3 3 0.7

284 137 137 Manufacturers should ensure cockpit designthat does not interfere with or distract the flightcrew from executing their duties (e.g. rain in thecockpit, location of switches in cockpits).

2 2 2 0.2

205 141 141 Airlines/operators and regulators shouldrequire training/standardization programs thatinclude training regarding physiological effects onaircrew performance, (e.g. low blood sugar,fatigue).

3.4 2 6 1.1

29 142 142 Airlines/operators should establish policies,parameters, and training to recognize unstabilizedapproaches and other factors and implement ago-around gate system. (See FSF - "definedgates" p. 193) (See 116, 123)

5.5 4 5 3.1

206 143 143 Airlines/operators should, and regulatoryagencies must, encourage a culture thatenhances safety in their daily operations. (SafetyCulture) (See 22, 63, 348)

3.8 2 5 1.1

47 147 147 Airlines/operators should requiretraining/standardization programs that teachsituation awareness. (The knowledge andunderstanding of the relevant elements of the pilotsurroundings, including aircraft systems, and thepilots' intentions)

5.5 3 6 2.8

91 149 149 Manufacturers should install a HUD asstandard equipment. (See 85)

5.5 3 5 2.3

139 151 151 Regulators should establish policies thatrequire additional monitoring of flightcrewmembers that have repeatedly failed checkrides. (See 152, 335, 337)

4.4 3 5 1.8


100


24 152 152 Airlines/operators and regulators should raisestandards (e.g. crew pairing, approach minimums,etc.) for flight crewmembers that meet minimumqualifications but have demonstrated limitedproficiency and/or competency. (See 151, 335,337)

4.8 5 5 3.3

98 153 153 Airlines/operators should ensure that flightcrews are adequately trained in a level Dsimulator for dynamic characteristics beforeassignment to the line. (See 312)

5 4 4 2.2

154 154 Airlines/operators should improve/increasetraining to increase awareness of icing effects onairplane type, including dynamic simulatortraining.

5.5 4 5 3.1

30 157 157 Airlines/operators, regulators, air trafficservice providers should establish policies orprograms to address rushed approaches,including elimination of rushed approaches,recognition and rejection of rushed approachesand training for those encountered.

5.5 4 5 3.1

115 159 159 Manufacturers should incorporate an "inputrudder" indicator or automatic yaw compensationto ensure that adequate yaw control is provided.

5 5 3 2.1

260 162 162 Airline/operators should include in theirtraining programs an awareness of potentialsafety risks due to crew complacency resultingfrom operating at a very familiar airport (e.g.home base).

2 2 5 0.6

136 163 163 Airlines/operators should ensure that theirtraining/standardization programs addresscommon perceptions that could lead to unsafepractices.

3.8 3 6 1.9

48 165 165 Airlines/operators should provide trainingscenarios that match realistic situations (i.e. stallrecoveries during approach, in landingconfiguration at flight idle with the autopilot on (insimulator).

5 4 5 2.8

49 201 201 Regulators should develop adequateoversight as appropriate to ensure compliancewith regulations. (See 145, 146, 202, 345)

5 4 5 2.8

99 202 202 Airlines/operators should develop a qualityassurance program to ensure compliance withregulations. (See 145, 146, 201)

4 4 5 2.2

207 203 203 Airlines/operators should provide crews within-flight rest periods and adequate facilities. (See31, 130, 315)

3.4 2 6 1.1

204 204 Research should be conducted to betterunderstand the underlying reasons/causes forprocedural noncompliance.

R&D


101


67 207 207 Airlines/operators should develop proceduresto specify how transfer of control is formallyaccomplished.

5 3 6 2.5

208 208 Research should be conducted to understandand counteract the phenomenon of flight crewoverload. (e.g. why do flight crews ignore GPWSwarnings)

R&D

164 211 211 Airlines/operators should retrofit equipment toprovide automatic altitude call outs on finalapproach.

2.9 4 5 1.6

31 214 214 Regulators should enforce timelyincorporation of appropriate manufacturers'recommendations. (See 98, 201)

5.5 4 5 3.1

71 218 218 Airlines/operators should conductsurveillance of contractor training programs foradequacy of training. (See 110, 202)

5.5 4 4 2.4

140 223 223 Regulators should ensure POI’s are properlyqualified and trained to approve appropriatecompany operational procedures.

4.4 3 5 1.8

220 224 224 Airlines/operators should ensure that allairline operations include compliance withall/seasonal guidance from the OEM.

4.4 2 4 1

32 225 225 Airlines/operators and regulators shouldensure necessary manuals (operational &maintenance) are complete, accurate, availableand appropriately used.

5.5 4 5 3.1

116 227 227 Airlines/operators should ensure that theirtraining/standardization programs emphasize thebenefits of inter-crew/company communications.(See 131)

5 3 5 2.1

188 228 228 Regulators should require airlines/operatorsto modify their training to maximize benefits ofinter-crew/company communications.

5 3 3 1.3

183 237 237 Airlines/operators should provide guidance tocrew concerning evaluation of all options prior todecision making as part of CRM training. (See25, 26, 131, 132, 133, 308)

5 2 5 1.4

261 240 240 To reduce the possibility of error, confusionand workload increase related to ATC clearances,regulators should require and operators ensure,that flight crews utilize proper phraseology andread backs. (See 88)

2 2 5 0.6

262 241 241 To eliminate hear back errors, ATC shouldreexamine and implement improvements toaddress hear back problems. (See 240)

2 2 5 0.6


102


208 242 242 To prevent excessive fatigue,airlines/operators should consider circadianrhythm in crew scheduling to compensate for theeffects of rhythm interruptions.

3.4 2 6 1.1

150 243 243 To prevent alerting overload, flight deckdesigns should consider smart alerting systemssuch as those with prioritization schemes orcancelable nuisance alerts.

5 4 3 1.7

244 244 To prevent plan continuation errors (e.g.press-on-itis), research should be conducted todetermine the effectiveness of directiveinformation systems for go-around situations.

R&D

100 245 245 To recover aircraft in unusual attitude,manufacturers should develop systems to returnaircraft to normal attitude with one pilot buttonpush (pilot initiated auto-recovery systems).

5 4 4 2.2

165 246 246 To reduce pilot overload, airlines/operatorspolicies should stress using the appropriate levelof automation.

3.8 3 5 1.6

189 251 251 To preserve the original intended level ofairworthiness, there should be a better definitionand classification of subsequent in-service majorand minor critical component changes. Thedefinition of critical component should be morespecific.

4 3 4 1.3

50 253 253 To prevent loss of control, there should beredundancy and failure tolerance features for allflight critical components, such as dual pathdesign, fail operational redundant systems, withfault annunciation.

5 5 4 2.8

68 257 257 To eliminate loopholes in crew restrequirements and to ensure adequate crew rest,regulators should clarify crew rest regulations.(See 31, 130, 203, 315, 316)

3.8 4 6 2.5

228 296 296 To mitigate confusion regarding ATCclearances, operators should develop proceduresto ensure flight crews query ATC wheneveruncertainty exists.

4 2 4 0.9

269 297 297 To prevent CFIT, operators should developprocedures to ensure that flight crews do notdescend when confusion exists concerningaircraft position.

2.4 2 4 0.5

184 300 300 Airlines/operators should adopt, implementand train a risk assessment tool to enhance flightcrew awareness of hazards associated with allapproaches and airports (see risk analysis tacticalchecklist).

5 2 5 1.4


103


303 303 Regulators should implement the NTSBrecommendations to increase DFDR parameters(not rated). (See 576)

NR

62 305 305 Regulators should require airlines/operatorsto outfit aircraft with electronic checklists. Ifunable to install electronic checklists, mechanicalchecklists should be used. At a minimum, aprocess to reinforce challenge and responsechecklists should be developed.

4.8 4 5 2.7

117 308 308 Airlines/operators should ensure their formalCRM training is culturally appropriate andemphasizes the following management skills:decision making, workload management, crewcoordination, planning, communication, situationalawareness and advocacy. (IAW AC120-51b).(See 133)

5 3 5 2.1

229 310 310 Regulators should not allow the use of noiseabatement procedures that reduce the level ofsafety that existed prior to their implementation.

3.4 2 5 0.9

72 314 314 Airlines/operators should develop simulatortraining scenarios that require flight crews to learnmulti-tasking abilities and appropriate prioritizationabilities in concert with CRM skills (see Red FlagLOFT scenarios).

4.4 4 5 2.4

185 316 316 Regulators should require airline/operators totrain flight crews to recognize and counteractacute and chronic fatigue. (See 31, 130, 203,257,315)

3.4 3 5 1.4

73 322 322 Airlines/operators should develop andimplement a ground school and simulator trainingprogram to train pilots to handle unusual attitudesituations, e.g. American Airlines AdvancedAircraft Maneuvering Program.

5.5 4 4 2.4

118 325 325 Airline/operators should emphasize duringinitial and recurrent training the importance ofmaintaining systems status awareness duringnon-normal events and hazardous approaches(goal to avoid tunnel vision/narrowed attention).

5 3 5 2.1

92 328 328 Airlines/operators should ensure that flightcrews are trained to think in terms of "I will go-around unless" rather than "I will land unless."Regulatory policy should support this approach.(See 142, 311)

5.5 3 5 2.3

93 329 329 Airlines/operators should incorporate in initialand recurrent training ways to recognize multiplecues that will require go-around. These includeCFIT training aid 2.1.9, FSF definition of stabilizedapproach, risk assessment tool, and wind sheartraining aid.

5.5 3 5 2.3


104


51 331 331 Airline operators and manufacturers will traincrews to understand capabilities and limitations ofsystem, conditions which would cause the systemto function improperly and how to detect failure todeploy/activate and recommend contingencyactions.

5.5 3 6 2.8

200 342 342 Airlines/operators should establish an SOP toensure that flight crews do not begin theirapproach until adequate briefing is completed forthe expected runway. (See 17)

4.4 2 5 1.2

74 345 345 Regulators should ensure that they haveadequate funding, training and processes toaccomplish their oversight responsibilities. (See201)

4.4 4 5 2.4

119 347 347 Parent airlines/operators should adopt aprogram to ensure the same level of safety inregional partners including, but not limited, torecruitment, training, operations andmaintenance.

5 3 5 2.1

209 348 348 Airlines/operators should utilize a self-auditprocess (such as FSF ICARUS recommendation),operational risk management programs andaccident cost analysis to proactively identify andmitigate safety concerns. (See 318)

3.8 2 5 1.1

210 349 349 Airlines/operators should ensure training forinstructors and check airmen includes objectivecriteria to be used in evaluating crew CRMperformance. (See 25,131)

3.8 2 5 1.1

173 350 350 Airlines/operators shall ensure that adequateapproach briefings that include descriptions ofnormal approach, non-normal conditions and theresults of the risk assessment analysis areconducted. (See 300)

4.4 3 4 1.5

356 356 Research should be conducted to develop aneffective tactical decision-making model for flightcrews in time-critical situations.

R&D

5 357 357 To ensure crews have the adequate skills torecover from extreme attitude upsets, regulatorsshould require, and operators should immediatelyimplement, initial and recurrent upset recoverytraining.

6 4 6 4

52 358 358 To provide optimal upset recovery trainingand to minimize negative training, regulators,aircraft and simulator manufacturers andoperators should ensure that training devicesreplicate aircraft performance and responsenecessary for effective training. (See 386, 475)

5 4 5 2.8


105


359 359 To improve effectiveness of upset recoverytraining, research should identify the mosteffective methodology for upset training.

R&D

360 360 To improve the effectiveness of accidentinvestigations, regulators should immediatelyimplement the NTSB recommendations toincrease the quantity and quality of survivabledata recorded in both existing and future aircraft.(See 576)

NR

7 361 361 To enhance the ability to analyze, identifyand take corrective actions for preventingaccidents, regulators and operators should createa collection and analysis process that utilizes allexisting and future aircraft data collection systems(such as DFDR, FOQA, ASAP and other non-volatile memory systems).

5.5 5 5 3.8

362 362 To enable further development of safe aircraftseparation and operational requirements,research should be conducted to describe thedynamics and location of wake turbulence andenvironmentally generated turbulence.

R&D

249 363 363 To enhance aircraft controllability in severe orgreater turbulence conditions, regulators andmanufacturers should develop and implementcertification criteria that consider effects ofturbulence, including automated flight capabilityand disconnect parameters.

2.4 2 5 0.7

17 364 364 To protect aircraft against loss of control,regulators should develop as soon as possible,certification criteria, throughout the entire flightenvelope, for crossover speeds and maximumrudder side slips. (see 431)

5 5 5 3.5

53 365 365 To ensure pilot capability to maintain orregain control, regulators should require andoperators should implement, training programsthat address crossover speed effects.

5 4 5 2.8

2 366 366 To protect aircraft against flight controlmalfunctions, manufacturers must design andregulators must certificate, derivative aircraft andcomponents to current applicable certificationrequirements, i.e. single point failures,redundancy, and probability of failure.

6 5 5 4.2

239 367 367 To provide necessary information to pilots,regulators should require and manufacturersshould develop, flight control position indicatingand alerting systems which will provide warningsfor critical aircraft flight control malfunctions, e.g.,actual flight control position disagreement withcommanded position.

2.4 3 4 0.8


106


141 368 368 To enable pilots to develop situationawareness with respect to aircraft performancecapability, regulators should require andmanufacturers should provide angle of attackdisplay.

4.4 3 5 1.8

190 369 369 To provide adequate stall warning, regulatorsshould require and manufacturers shoulddevelop, stall warning systems for new/derivativeaircraft that provide accurate informationthroughout the certificated flight regime.

3.8 4 3 1.3

151 370 370 To foster transfer of safety-relatedinformation, airplane and componentmanufacturers should participate in safety datasharing programs, (e.g. current Manufacturers'safety data sharing meetings).

5 3 4 1.7

174 371 371 To eliminate the potential safetyconsequences of system failures,manufacturers/operators should develop areliable process for identifying, prioritizing, andresolving the safety consequences of system andcomponent malfunctions throughout theoperational envelope.

4.4 4 3 1.5

75 372 372 To ensure that in-service problems arereliably assessed for their safety implications andcorrected, regulators, operators, andmanufacturers should develop and implement astandard set of criteria for determining if aproblem is safety-related and for provide fortimely corrective action.

5.5 4 4 2.4

132 373 373 To ensure that manufacturers and regulatorsare aware of recurrent problems (type andfrequency), manufacturers, regulators andoperators should implement a reliable process forgathering and reporting safety-related problems.

4.4 4 4 2

76 374 374 To provide terminal area position informationin non-radar environments, ATS providers andairplane manufacturers should implement terminalarea automatic dependent surveillance (ADS-B)(Traffic Information Services (TIS))

4.4 4 5 2.4

211 375 375 To improve controller situation awareness, airtraffic service providers should ensure that theirtraining/standardization programs directcontrollers to use all available tools to establishaircraft position. (See 75)

4 2 5 1.1


107


240 376 376 To improve aircrew awareness of othertraffic, manufacturers should install TCAS in allnew aircraft, airlines/operators should retrofitTCAS into the existing fleet and internationalregulators should require the installation and useof TCAS. (See 35)

2.9 2 5 0.8

377 377 Because pilots may be reluctant to ask forclarification of clearances when uncertain, ATSproviders should develop policies and training thatencourages pilot queries when they (crew) areunsure of clearances. (See 12)

NR

221 378 378 To preclude continued flight into an unsafeaircraft energy state, airlines/operators shouldestablish procedures for flight crews to establish asafe, stabilized flight condition when situationaluncertainty exists and THEN advise ATC ofintentions.

4.4 2 4 1

379 379 Since people are often unaware of their ownconfusion, research should be conducted todevelop a set of cues to help flight crews andcontrollers identify when they have lost situationawareness.

R&D

33 380 380 To reduce the risk of inadvertent entry intostall, manufacturers should develop andimplement stall protection features in all transportcategory airplanes, (e.g. stick pusher, alphaprotection)

5.5 5 4 3.1

77 381 381 To provide improved pilot awareness of theairplane's energy state, manufacturers shoulddevelop and incorporate more effective energymanagement monitoring and alerting systems.

5.5 4 4 2.4

101 382 382 To provide improved pilot awareness ofairspeed, manufacturers should provide flightinstruments with more effective airspeed trendindications and alerting.

5 4 4 2.2

94 383 383 To ensure adequate time margin betweenstall warning and actual stall, manufacturers andregulators should develop and implement stallwarning systems that account for various entryrates/conditions to stall.

5.5 3 5 2.3

25 384 384 Since it is possible to enter a stall,airlines/operators should develop and implementa ground school and simulator training program totrain pilots to handle post stall recovery as part ofadvanced maneuver training.

6 4 5 3.3


108


385 385 Because flight crews sometimes disregardflight deck warnings which require immediateaction, research in understanding this phenomenaand developing appropriate solutions should beconducted.

R&D

386 386 To support advanced maneuver training,manufacturers should develop simulator modelsthat facilitate post stall recovery training (see358).

R&D

175 387 387 To ensure that airplane systems function asdesigned, airlines/operators should developprocesses to ensure adherence to manufacturer'srecommended maintenance procedures.

4.4 3 4 1.5

280 388 388 Airlines/operators should encourage aculture that emphasizes safe operations over on-time performance (see 22)

2 1 5 0.3

250 389 389 To assist flight crews in responding to systemmalfunctions, manufacturers should develop andairlines/operators should incorporate readilyaccessible flight crew procedures for partial ortotal failure of flight critical systems.

4.4 2 3 0.7

222 390 390 Because some partial system failures maynot be reliably observed, manufacturers shoulddevelop warning systems that alert the pilot tothose partial/total failures of flight critical systemsand flight instruments.

4 3 3 1

78 391 391 Because of the interaction between systems,manufacturers should develop alerting systemsthat help pilots understand any common cause ofmultiple failure messages

4.4 4 5 2.4

392 392 In order to support pilot takeoff decision-making, research should be conducted todetermine the effectiveness of altering systems toidentify situations that warrant a rejected takeoff.

R&D

152 393 393 To ensure system status awareness,airlines/operators should ensure that theirtraining/standardization programs direct the flightcrews to use all available tools to determineairplane system status. (See 47)

5 3 4 1.7

270 394 394 Because of increasing interactions betweensystems, manufacturers and trainingorganizations should develop new approaches forinstructing pilots in the interrelationships betweensystems.

3.4 1 5 0.5


109


34 395 395 To ensure that the display of conflicting airdata information does not confuse or mislead theflight crew, the air data sensing and displaysystems should be designed so that invalidinformation is detected and clearly annunciated tothe flight crew and/or removed from display.

5.5 5 4 3.1

241 396 396 To ensure a standard level of safety at allairports, airport operators should adopt airportoperations procedures that are no less stringentthan ICAO recommendations.

3.4 2 4 0.8

35 397 397 To provide accurate wind information to flightcrews, regulators should ensure that weatherinformation providers and Air Traffic servicesemploy systems and procedures which willensure accurate measurement of wind data anddissemination of wind information for takeoff andlanding areas of the runways in use.

4.4 5 5 3.1

36 398 398 To provide real-time accurate windcomponent information to flight crews, Air Trafficservices and manufacturers should implementreal time (automated) transmission/display ofsuch information in the most directly useableformat to the flight crew, during approach andlanding phase. (See 94)

5.5 4 5 3.1

37 400 400 In order to promote safe crosswind landings,manufacturers will provide and airline operatorswill implement aircraft crosswind landinglimitations, including considerations for flightcontrol effectiveness and gust conditions.

5.5 4 5 3.1

79 401 401 To ensure proper identification of enginemalfunctions and avoidance of possible loss ofcontrol, airline/operators should provide enhancedand more realistic training for enginemalfunctions, engine responses to control signalerrors and the appropriate aircrew actions.

4.4 4 5 2.4

153 402 402 To prevent a more serious event,manufacturers should revise product failureanalyses if service history reveals unexpectedconsequences or failure modes.

5 3 4 1.7

191 403 403 To ensure clear communication, airlineoperators should train flight crews to emphasize ifaction is required when giving status reports.

4 3 4 1.3

286 404 404 To enhance crew performance in theapproach and landing phase, airline operatorsshould train pilots to understand the limitations ofcomputed wind displays.

1.3 2 2 0.1


110


102 405 405 To enhance stability in the approach andlanding phase, airline operators should train pilotsto properly control the aircraft in the transitionfrom autocoupled/autoland approaches to manualcontrol.

5 4 4 2.2

406 406 In order to minimize automated flight tomanual transition effects, research should beconducted to determine the feasibility anddesirability of automated flight/flight controlsystems designs that eliminate the need for largeflight control input at disengagement from ALIGNmode.

R&D

63 407 407 To minimize pilot reaction requirementsduring transition from autocoupled to manual flightduring approach, regulators should require, andmanufacturers should design, automated flightsystems so that ALIGN mode need not beengaged when a manual landing is planned.

4.8 5 4 2.7

38 408 408 To minimize undesirable effects of transitionto manual flight from ALIGN mode, regulatorsshould require that minimum altitudes andconditions be established for disengagement ofautomated systems when a manual landing isanticipated.

4.4 5 5 3.1

120 409 409 To enhance stability during the approach andlanding phase, airline operators should developand implement policies and procedures thataddress mixed mode flight (e. g., autothrottles inmanual flight) with specific emphasis onpitch/thrust coupling and aircraft control problems.

4.8 4 4 2.1

276 410 410 To enhance safety in the airport environment,regulators and airport operators should developguidelines for minimizing the effects ofenvironmental factors on wind fields in theapproach and landing areas of the runways andwork with local authorities to ensureimplementation.

1.6 2 5 0.4

121 411 411 To reduce accidents during the landingphase, airline operators should establish criteriaand procedures and train flight crews to recognizeconditions that might require a rejected landing.

5 3 5 2.1

39 412 412 To avoid problems due to unexpected modechanges, automated flight system logic should bedesigned to be error tolerant or, at a minimum,provide an alert when the desired mode is inconflict with aircraft energy state.

5.5 4 5 3.1


111


40 413 413 To prevent negative transfer effects in flight-critical systems, regulators should establishrequirements for standardization of flight deckinformation/controls.

5.5 5 4 3.1

142 414 414 To reduce negative transfer effects duringpilot transition to new aircraft, airline operatorsshould determine the potential for negativetransfer of inappropriate pilot actions andtechniques on flight critical systems and over-trainto prevent their occurrence.

5.5 3 4 1.8

133 415 415 To provide improved aircraft statusawareness, airline/operators should enhancetraining to identify aircraft configuration and therepercussions of the aircraft's energy state.

4.8 3 5 2

54 416 416 To provide improved flight crew situationawareness, manufacturers should provide a clearindication that predicts the future aircraft energystate and/or automated flight configuration if thecurrent course of action is continued. This isanalogous to EGPWS mode that analyzes theairplane's descent rate vs. its terrain map, andtells the crew that a conflict will occur if theycontinue at that descent rate. For example, thesystem would warn the crew that, if they continueat the current roll rate, the plane will exceed theenvelope, or the autopilot will reach the limits ofits authority, etc.)

5.5 3 6 2.8

103 417 417 Because failures which result in yaw/rollupsets can be particularly difficult for crews tointerpret and successfully handle, manufacturersand operators should give such failures increasedscrutiny and higher priority for reporting.

4 5 4 2.2

212 418 418 Because not all operators understand thesignificance of failures that may result in yaw/rollupsets, manufacturers should provide airlines withmore information regarding the airplane controlimplications of such failures.

3.4 3 4 1.1

419 419 Because manufacturers must make certainassumptions regarding which failures will bedetected and handled by the pilot with "normalpiloting skills," research should be conducted todetermine if these assumed skills and knowledgeare valid in realistic airline operations.

R&D


112


80 420 420 In order to assure that airline operationsdepartments understand the operationalimplications of dispatching with degradedsystems, manufacturers and operators shoulddevelop a method for providing such informationto crews, for MEL and other dispatchable failureconditions (including intermittent failures).

4.4 5 4

176 421 421 Since intermittent failures can persist forunspecified periods of time without correction,operators should develop specific policies,procedures and guidance defining whendegraded systems or systems with intermittentproblems should be disabled, invoking theappropriate MEL requirements.

4.4 3 4 1.5

242 422 422 To ensure constant visibility of knownintermittent failures, operators should developprocedures for continued reporting of andmaintenance actions to address unresolvedintermittent failures.

2.9 5 2 0.8

18 423 423 To ensure that recurrent, intermittent failuresare not allowed to persist, regulators shouldrevise MEL dispatch requirements so that certainintermittent failures are considered to be fullfailures, if warranted by safety implications of thefailures and frequency of occurrence.

5 5 5 3.5

41 424 424 To enhance crew awareness of automationmodes, manufacturers should ensure that modechanges or disconnects, in the automatedsystems are annunciated in a way that is obviousto the flight crew.

5.5 5 4 3.1

425 425 To enhance crew awareness of automationmodes, research should be conducted to developintelligent systems that will alert the flight crew toinconsistencies between the selected automatedflight modes, aircraft performance and currentsystem status.

R&D

426 426 Research should be undertaken to determinehow to keep crews alert in low-stimulationenvironments (e.g., highly-automated flight decks,long-haul flights)

R&D

81 427 427 To prevent inappropriate preoccupation withtrouble shooting following engine or other systemfailure, airline operators should enhance trainingand checking to prioritize safe control of theaircraft.

4.8 3 6 2.4


113


428 428 Research should be done to develop ways toprevent inappropriate preoccupation with troubleshooting following engine or other system failureto the exclusion of the major task of flying theairplane.

R&D

271 429 429 To reduce the risk of flight with a structurallydamaged airplane, airline operators shouldinstitute procedures for a diversion to the closestsuitable airport following an upset event thatexceeds defined parameters.

2.7 2 3 0.5

430 430 Research should be conducted to determinethe optimal way to provide flight crews withaircraft status recognition during critical situations.

R&D

19 431 431 To assist flight crews in avoiding loss ofcontrol on existing aircraft, regulators andmanufacturers should evaluate the effects ofcrossover speeds and maximum rudder side slipthroughout the entire flight envelope anddisseminate the information to operators and flightcrews.

5 5 5 3.5

213 432 432 To facilitate recovery from flight upsets,airlines/operators should clearly define, train andcheck the specific PF/PNF upset recovery duties.

2.7 3 5 1.1

64 433 433 To preclude inadvertent entry into stallconditions during autopilot operation, regulatorsshould not permit, and manufacturers should notdesign, automated flight systems that will allowthe autopilot to control the aircraft into a stalledcondition.

4.8 5 4 2.7

230 434 434 To enhance the safety of operations,regulatory agencies should develop adequateoversight to encourage the use of commonlyaccepted safe operating practices. (See 201)

3.4 2 5 0.9

272 435 435 To ensure stall warning systems are properlyfunctioning, manufacturers should establishappropriate inspection and calibration procedures.

2.9 3 2 0.5

214 436 436 To ensure adequate stall warning, regulatorsshould mandate improved accuracy and integrityin the stall warning system (including aircraftcurrently in service).

3.8 5 2 1.1

134 437 437 To enhance the safety of functionalevaluation flights (FEF), regulators shouldestablish standards for critical aircraft handlingmaneuvers.

4.4 4 4 2

95 438 438 To reduce the probability of accidents,operators should adopt operational riskmanagement techniques for non-standard flightoperations and/or flights requiring intensivetraining scenarios.

5.5 3 5 2.3


114


135 439 439 To ensure proper designation of pilotsconducting non-standard flight operations (e.g.,Functional Evaluation Flights), regulation and/orguidance should be revised to clearly indicatepilot experience, pairing, and training levelsrequired.

4.4 4 4 2

154 440 440 To ensure all aircraft meet currently acceptedminimum performance standards, regulatorsshould require warning systems that meetairworthiness standards.

3 5 4 1.7

277 441 441 To avoid confusion, regulators/operatorsshould develop a consistent standard for stallspeed calculation.

1.7 4 2 0.4

122 442 442 To avoid delay in the recognition of enginemalfunction/failure, manufacturers should developand implement a direct aural and visual flight deckindication of engine malfunction/failure. (Minortransients need not be annunciated.)

3 5 5 2.1

443 443 To ensure the best technique for enginemalfunction/failure annunciation and to minimizenuisance alerts, research should be conducted todetermine when and how to annunciate enginemalfunctions/failures.

R&D

444 444 To ensure procedural compliance, researchshould be conducted to develop 'smart' checklistswhich detect failures and provide the proper flightcrew actions. (See 539)

NR

1 445 445 To help avoid loss of control, manufacturersshould develop and implement flight envelopeprotection. (e.g. bank/pitch angle limits, over-speed, angle of attack, load factor)

5.5 5 6 4.6

446 446 To decrease the probability of ice buildup,manufacturers should design and install a systemthat automatically detects and sheds ice fromflight-critical surfaces.

4 4 3 1.3

155 447 447 In order to maintain adequate safety marginsduring flight training, operators should establishand regulatory agencies should require standardsfor conducting flight training which precludeoverloading the trainee.

5 3 4 1.7

448 448 To preclude trainee overload, researchshould be conducted to understand the optimumworkload level for effective flight training.

R&D


115


449 449 In order to ensure adequate handlingqualities in manual flight, in all regions of the flightenvelope, regulators should review currentcertification requirements pertaining to aircraftstability to determine if additional rulemaking oradvisory material development is warranted. Thisis especially important for airplanes with newtechnologies affecting handling qualities (e.g."relaxed static stability"). [2-47]

NR

104 450 450 To ensure the aircraft can be safely flown bypilots with normal skill levels, regulatoryauthorities should require that handling qualitytests and demonstrations intended to showcompliance with applicable regulations includerepresentative line pilots as test subjects.

5 4 4 2.2

223 451 451 To ensure adequate training in manual flight,manufacturers should develop models that permitflight simulators to accurately represent theaircraft's stability and control characteristics for allregions of the flight envelope likely to beencountered during normal operations (i.e.Operation within the AFM-approved flightenvelope with no failures affecting aerodynamicperformance).

4.4 4 2 1

215 452 452 Since handling qualities and performancemargins may be significantly different during highaltitude cruise, airlines/operators should ensurethat pilots receive adequate training andexperience in manual flying in this flight regime.

4.4 3 3 1.1

453 453 To help prevent future accidents,airlines/operators should implement maintenanceprocedures to ensure proper functioning of theDFDR at all times. (Note: this intervention wasrecorded as a potential intervention of futureaccidents, it would not have prevented the subjectaccidents.) (See 576)

NR

156 454 454 Because latent and combination failures havebeen missed in failure analyses, manufacturersand regulators should conduct more intensiveverification of all safety analyses associated withsystems whose failures, singly or in combinationwith other system failures, can result in accidents.

5 3 4 1.7

455 455 Because latent and combination failures maybe missed in failure analyses, manufacturers andregulators should conduct research into improvedmethods for conducting safety analyses, toensure reliable identification of failures which,singly or in combination with other systemfailures, can result in accidents.

R&D


116


82 456 456 To help ensure appropriate decision making,flight crews should be trained on the impact ofautomation on CRM.

4.8 3 6 2.4

457 457 To ensure full protection throughout the icingenvelope, regulators / manufacturers shouldexpand icing certification criteria to include iceaccretions due to residual, intercycle, delayedactivation and system malfunction to ensure thaticing protection equipment and/or proceduresprovide full operational envelope coverage. (See459, 516)

5.5 5 6 4.6

458 458 To enhance the safety of all aircraft,regulators should ensure that appropriate revisedicing certification criteria apply to FAR Part 23, 27and 29 certificated aircraft in addition to FAR Part25 aircraft. (Breakout for GA)

NR

459 459 For a full understanding of aircraftperformance and handling qualities in icingconditions, research should be conducted todefine the effects of all ice accretions, withparticular emphasis on the roll effect due to icecontaminated wings (intercycle or residual). (See457, 516.)

R&D

460 460 To ensure a better understanding, by aircrews, of appropriate procedures for use of iceprotection systems, operators, manufacturers andregulators should expedite the modification oftraining programs and distribution of media, toinclude ice bridging and deicing boot operation.

5.5 4 4 2.4

461 461 To reduce the adverse effects of ice accretionroughness, regulators and NASA should conductresearch leading to improved ice protectiontechnologies.

R&D

462 462 To enhance the ability to analyze, identifyand take corrective actions to prevent accidents,manufacturers should include, and regulatorsshould require, the recording of ice detection /protection system state on the flight datarecorder. (FAR 121 requires recording of icedetection) (See 576)

NR

55 463 463 To avoid treating an incident as an isolatedoccurrence and to ensure on-going assessmentof aircraft specific loss of control problems, afocused safety or risk assessment of all accidentsand incidents should be conducted to determinethe need for immediate resolution. (See 254)

5 4 5 2.8


117


96 464 464 To ensure proper identification of flight criticalissues, manufacturers, operators and regulatorsmust develop consistent criteria to properlyidentify and disseminate (in a timely manner,including manual revisions) flight safety criticalinformation.

5.5 3 5 2.3

290 465 465 To reduce flight crew workload indownloading voice ATIS information, regulators,through consensus with the aviation community,should reexamine and limit the content of ATISbroadcasts.

0 3 5 0

291 466 466 To further improve the quality of weatherinformation provided to the flight crews, theregulators should implement recommendationsfrom the weather product working group of the1999 FAA In-flight Icing Operations Conference.

0 3 5 0

123 467 467 To reduce unstabilized approaches, air trafficquality assurance programs should regularlyevaluate Air Traffic Control System CommandCenter / Traffic Management Unit (ATCSCC /TMU's) to ensure traffic management programsand initiatives include all traffic elements (i.e.tower enroute clearance / enroute traffic), areproperly implemented, effectively utilized, andpersonnel are adequately trained.

5 3 5 2.1

166 468 468 To ensure the highest quality of air trafficservices, regulators should establish policies thatrequire additional oversight and training of airtraffic controllers that repeatedly commitoperational errors.

2.9 4 5 1.6

177 469 469 To ensure clear understanding of flight crewtasking, airlines/operators should develop criteriaspecifying when transfer of control is necessary orappropriate. (See 207)

4.4 3 4 1.5

157 470 470 Since current airline training emphasizesrecovery from approach to stall, airline/operatorsshould emphasize to air crews the importance ofproper analysis and response to incipient stallconditions (for example timely reduction in angleof attack).

5 3 4 1.7

471 471 Since many factors can make theidentification of impending loss of control difficult,research should be directed toward thedevelopment of systems that advise the flightcrew that the aircraft is departing from a flightpath consistent with the flight control inputs.

R&D


118


42 472 472 Since certain engine control and automatedthrottle system failures can result in undesirableasymmetry, manufacturers should redesign ATS’sso that they disconnect (with appropriateannunciation) when unable to achieve thecommanded thrust settings (analogous toautopilot disconnect logic).

4.4 5 5 3.1

143 473 473 Due to increasing dependence on automationand the complexity of potential partial systemfailures, airlines/operators should modify trainingprograms to emphasize the use of multiple datasources to confirm that the airplane and systemsare performing as expected and in accordancewith the operational mode.

4.4 3 5 1.8

124 474 474 Since indications of sideslip may not beprominent and can be masked by roll effects,manufacturers should develop improved sideslipindications and/or alerting (e.g. similar to pitchlimit indications for pitch / angle of attack).

5 3 5 2.1

158 475 475 Since simulators cannot adequately replicatethe motion cues associated with sideslip, theindustry should develop improved methods forsafely training pilots to recognize and respond toin-flight sideslip events. (See 358, 386)

5 3 4 1.7

231 476 476 Since repair processes can significantly affectthe airworthiness of components, regulatorsshould require manufacturer concurrence on allmaintenance and repair procedures affectingcritical aircraft structures, components, orperformance.

2.7 3 4 0.9

251 477 477 To improve maintenance quality, regulatorsshould require that airlines/operators instituteprocesses for oversight of maintenance facilitiesthat maintain safety-critical parts, components, orsystems (e.g. CASE (Coordinating Agency forSupplier Evaluation) might be one type ofprogram that could provide an acceptable methodof compliance).

1.6 3 5 0.7

252 478 478 To improve maintenance quality, regulatorsshould increase oversight of maintenancefacilities that maintain safety-critical parts,components, or systems.

1.7 3 5 0.7

192 479 479 To improve operational oversight, regulatorsshould establish selection criteria and appropriatetraining programs (e.g. training with carriers) toensure that POI’s responsible for air carrieroversight have appropriate knowledge andexperience to perform those functions.

3 4 4 1.3


119


167 480 480 To improve operational oversight, regulatorsshould institute processes for periodic review ofPOI’s to ensure that appropriate oversight isbeing conducted for the POI's assigned operators.

2.9 4 5 1.6

168 481 481 Because POI’s may be responsible foroversight of remote training activities, regulatorsshould ensure that POI’s have sufficientCertificate Holding District Office resources,including staff, to conduct appropriate oversightfor the POI's assigned operators.

2.9 4 5 1.6

224 482 482 To prevent inaction when the PF is confusedor unresponsive to an in-flight hazard,airlines/operators should develop and train clearand explicit procedures to define when/how thePNF (especially the F/O) will take control of theairplane.

4.4 2 4 1

8 483 483 To ensure that the display of conflictingattitude information does not confuse or misleadthe flight crew, the attitude sensing and displaysystems should be designed so that invalidinformation is detected and clearly annunciated tothe flight crew and/or removed from display.

5.5 5 5 3.8

125 484 484 To ensure adequate FO proficiency,airlines/operators should incorporate theoperating practice of alternating PF/PNF duties(alternating legs and landings).

4.8 4 4 2.1

43 485 485 To preclude the accidental change of aircraftsystems status, manufacturers should designflight decks to minimize the potential forinadvertent activation/deactivation of aircraftsystems and/or unintended automated flight modechanges.

4.4 5 5 3.1

6 486 486 Airlines/operators and manufacturers shouldtrain crews to understand the capabilities andlimitations of automated flight systems, theconditions which would cause the systems to notfunction as the crew anticipates, and how todetect and recover from inadvertent activation ofautomated flight modes (see 331).

6 4 6 4

178 487 487 To minimize the occurrence of loss of controlevents, airline operators' training programs shouldemphasize pattern recognition and skill-basedprocedures to better handle time-criticalsituations, rather than relying on knowledge-based analysis.

4.4 3 4 1.5

65 488 488 To facilitate recovery and attitude awareness,manufacturers should include adequateinstrumentation to optimize performance duringrecovery from unusual attitude.

4.8 4 5 2.7


120


186 489 489 In order to improve oversight of airlines,regulators should ensure their organizations(Flight Standards in the USA) are staffed toprovide adequate inspector coverage for allairlines, (including small airlines).

3.4 3 5 1.4

56 490 490 In order to ensure that relevant information isshared during the pilot hiring process, airlinesshould implement and regulators require astorage and retrieval system that containspertinent standardized information on the qualityof airline pilot performance during training andservice. (Reference ‘Pilot Records ImprovementAct’ – FAA AC 120-68)

5 4 5 2.8

144 491 491 To ensure adequate flight crew competency,airlines/operators should establish more effectivepilot screening and Captain upgrade criteria toidentify candidates with demonstrable flying skilldeficiencies. (See 335)

4.4 3 5 1.8

201 492 492 In order to ensure pilot medical fitness forduty, airlines/operators/regulators shouldestablish a structured process for return to flightstatus after sick leave that includes medicalclearance.

2.9 3 5 1.2

216 493 493 To reduce the risk of pilots' non-readiness forflying, airlines/operators should train pilots toperform self-audit medical and psychologicalassessments prior to flight duty.

2.7 3 5 1.1

202 495 495 To improve aircraft failure tolerance,manufacturers and regulators should conductfailure analyses for design and certification thatreflect realistic levels of flight crew reliability.

2.9 3 5 1.2

496 496 To enable failure analysis based uponrealistic levels of flight crew reliability, researchersshould develop and validate models of humanerror.

R&D

497 497 To minimize exposure to flight operations inicing conditions, air traffic service providersshould initially and periodically train controllers onthe hazards / impacts of icing on aircraftperformance when holding or vectoring aircraft tothe final approach course in areas of known orreported icing conditions.

5 3 5 2.1

498 498 To ensure safe operating speeds in icingconditions, regulators shall require that minimumsafe operating speeds in icing conditions bepublished in the aircraft flight manual (section 1)for all aircraft operating configurations.

6 4 4 2.7


121


499 499 To make flight crews aware of the possibilityof airframe ice accretion, research should beconducted to develop reliable means of aircraftsurface ice detection, as well as ground andaircraft based means of detection ofmeteorological icing conditions.

R&D

499 499 To make flight crews aware of the possibilityof airframe ice accretion, research should beconducted to develop reliable means of aircraftsurface ice detection, as well as ground andaircraft based means of detection ofmeteorological icing conditions.

R&D

500 500 To ensure that flight crews initiate correct in-flight icing procedures, regulators should requireinstallation of an ice detection system thatprovides annunciation to alert the crew to respondappropriately to the icing hazard. (ref 243)

5 4 5 2.8

20 501 501 To assist flight crews in avoiding loss ofcontrol, manufacturers should develop andregulators should require automated flight systemauto-disconnect logic which does not disconnectwhen the automated flight system is properlyattempting to correct an abnormal flightsituation/condition. (See 363) 363)

5 5 5 3.5

57 502 502 To ensure flight crews can identify possibleupset conditions, airline/operators shouldimplement flight crew training programs thatdemonstrate the operation of a normallyfunctioning automated flight system under non-standard flight conditions (e.g. out of trimairplane/contaminated wing).

5 4 5 2.8

281 503 503 To alert the flight crew of flight control trimchanges, manufacturers should provide anappropriate level of aural annunciation.

3 4 1 0.3

504 504 To provide more tactile cues to flight crewson turboprop aircraft in icing conditions,airlines/operators should develop SOP’s callingfor flight crews to disengage autopilot duringmaneuvering, when workload permits

4.4 4 3 1.5

225 505 505 To ensure that safety related incidentinformation is shared between validating andcertificating authorities, regulators should developa system to review the terms of and complianceto bilateral airworthiness agreements.

4.4 4 2 1


122


226 506 506 To ensure that the airworthiness authoritiesknow and understand the importance ofcomplying with international agreements, ICAOshould distribute annual notices to the authoritiesemphasizing the importance of mutual distributionof continued airworthiness information.

4.4 4 2 1

179 507 507 To ensure that flight crews have allnecessary weather information prior to flight,airlines/operators should immediately review theirsystem of weather information dissemination toensure that all significant weather information isprovided for their route of flight.

4.4 4 3 1.5

508 508 To ensure that flight crews have and use allnecessary weather information, airlines/operatorsshall train flight crews and airline dispatchers onthe importance of reviewing weather informationfor potential in-flight icing.

4.4 4 3 1.5

509 509 To reduce the risk of encountering hazardousweather conditions (e.g. super-cooled largedroplets (sld), thunderstorms, etc.) research mustbe conducted to develop methods for accurateprediction and identification of these conditions.

R&D

510 510 To better understand the effects of super-cooled large droplets (sld) icing research shouldbe conducted on ice protection system designand operation in this weather phenomena.

R&D

511 511 To reduce the number of hazardous icingencounters and to keep air traffic apprised ofcurrent weather conditions, regulators shouldrecommend that flight crews report all icingconditions to air traffic control and be required toreport the occurrence of moderate to severe icingconditions. (ref. FAR 91.183)

5 4 5 2.8

159 513 513 To preclude undesired flight controldisplacement, manufacturers should design flightcontrols so that the airplane does not experienceuncommanded, adverse flight control deflectionsthat are beyond the control of the flight crew.(throughout the flight envelope, includingaerodynamic stall)

5 4 3 1.7

289 514 514 Combined with 525 0

44 515 515 To warn of impending loss of control with theautomated flight system fully engaged,manufacturers should develop, and regulatorsshould require, annunciation of an airplane flightcondition which significantly differs from thatbeing commanded by the selected automatedflight system mode. (ref 243)

5.5 5 4 3.1


123


516 516 To ensure full protection throughout theoperational envelope, regulators/ manufacturersshould expand icing certification criteria to includeperformance and handling qualities testing whichconsiders ice accretions due to residual icing,intercycle icing, delayed system activation and/orsystem malfunction. (See 457, 459)

5.5 5 6 4.6

282 517 517 To ensure an acceptable skill level of pilotsentering the aviation profession, the aviationcommunity should encourage the development ofand enrollment in aviation career trainingprograms.

1.5 2 4 0.3

203 518 518 To ensure an adequate supply of qualifiedpilots, the aviation community should promoteinitiatives that screen youth for potential aviatorqualifications, skills, and aptitude. The industryshould identify and develop career paths forsuitable candidates and mentor their careergrowth as successful aviators.

2.7 4 4 1.2

145 519 519 To ensure pilot proficiency in basicairmanship skills and knowledge, regulatorsshould require training/standardization programsthat emphasize these subjects during initial andrecurrent training. (See 111)

4.4 3 5 1.8

58 520 520 To ensure flight crews have a comprehensiveknowledge of the automation system(s) functionaloperation, airlines/operators should ensure thattheir training /standardization programsemphasize these skills.

5 4 5 2.8

83 521 521 To ensure airline/operator training programsprovide enhanced aircrew proficiency, regulatorsshould revise FAR Part 121, Appendix F, to raisethe minimum standards. (See 114)

4.4 4 5 2.4

66 522 522 Since it is possible to enter a stall, regulatorsshould mandate the implementation of groundschool and simulator training program to trainpilots to handle post stall recovery as part ofadvanced maneuver training. (See 384)

4.8 4 5 2.7

217 523 523 To ensure that airline operation trainingdepartments accomplish their trainingresponsibilities, they must be adequately funded.

4 2 5 1.1

232 524 524 Regulators should establish flight crewphraseology guidelines and airlines/operatorsshould train and monitor flight crew compliancewith communication phraseology guidelines.(See 88, 240)

1.7 4 5 0.9

3 525 525 To mandate stall recognition and recoverytraining, regulators must modify the appropriateregulations.

6 5 5 4.2


124


193 526 526 To increase the number of available pilots,airlines should implement, and regulators shouldallow, a performance-based selection system thatexpands the eligible pilot pool beyond the currentarbitrary limits (e.g., age 60 rule, minimum flighttime) with an appropriate medical/psychologicalevaluation.

3.8 3 4 1.3

59 527 527 To ensure that alerting and warning logicdoes not annunciate self-recovery functions oralerts that do not require pilot action, themanufacturer should design systems thatannunciate only when pilot action is required.

5 5 4 2.8

105 528 528 To provide optimal training (includingpropulsion system malfunctions) and to minimizenegative training, regulators, aircraft andsimulator manufacturers and operators shouldensure that training devices replicate realisticfailure scenarios, aircraft performance andappropriate response. (See 358)

5 4 4 2.2

160 529 529 To avoid negative training, airline operatorsshould ensure that their training curriculumcorrelates with the AOM and other relevantmanuals.

5 3 4 1.7

16 530 530 To optimize pilot workload, airlines/operatorspolicies should stress using the appropriate levelof automation. (See 246)

5.5 4 6 3.7

84 531 531 To minimize the occurrence of loss of controlduring unstable approaches, manufacturersshould design and implement a system to detectunstable approaches and provide an automaticcallout to go around.

5.5 4 4 2.4

9 532 532 To minimize the probability of accidents,operators should prioritize service bulletinimplementation using operational riskmanagement techniques to assess potentialoperational hazards, including aircraftmodification, etc.. (See 98, 348)

5.5 5 5 3.8

10 533 533 To prevent loss of control, manufacturersshould design automated systems to yield controlto manual inputs when those manual inputs are inconflict with the automated configuration.

5.5 5 5 3.8

218 534 534 Airlines/operators should implementprocedures that call for an immediate recoverymaneuver following a warning that indicates animminent departure from normal flight envelope(e.g. stall warning, over-speed). (See 161)

3.4 3 4 1.1


125


11 535 535 To ensure adequate instructor/check pilotqualifications, operators must establish andmaintain minimum line and instructor / checkairman qualifications.

5.5 5 5 3.8

169 536 536 To prevent reoccurrence of accidents andincidents, regulators / manufacturers / operatorsshould expedite development and application ofan effective risk management continuingairworthiness assessment based upon priorincidents and disseminate the results. (See 372,373)

3.8 3 5 1.6

161 537 537 To ensure proper intra-cockpitcommunications, operators must ensure that thelanguage used in the cockpit is compatible,understandable and consistent among all flightdeck crewmembers.

3 4 5 1.7

146 538 538 Airline/operators should train flight crews inteam decision-making skills, including the abilityto rapidly turn data into information and testconclusions. (See 314)

4.4 3 5 1.8

170 539 539 To ensure procedural compliance,manufacturers should design and incorporate'smart' checklists that detect failures and providethe proper flight crew actions. (See 444)

2.9 4 5 1.6

162 540 540 To ensure completeness, avoid erroneousprocedures and prevent misinterpretation,manufacturers/operators should ensure andregulatory agencies should check that theguidance and procedures in AOM's are complete,clear and correct.

5 3 4 1.7

233 541 541 To reduce the risk of loss of control duringflight with a propulsion system malfunction inturboprop aircraft, if the engine failure procedureis not completed, airline operators should reviewthe consequences of the malfunctioningpropulsion system being placed in flight idle.

3.4 3 3 0.9

126 542 542 To preclude over-reliance on automation,airlines/operators and regulators should createand/or clarify a definition of “appropriate levels ofautomation,” to include the need to validateagainst other information sources and ensure thatthe resulting definition is published and includedin all appropriate flight crew publications, manualsand training programs.

5 3 5 2.1

147 543 543 In order to provide pilots with sufficientairplane performance margins to reduce exposureto potential upsets, regulators should requireairplane operation in a cruise flight envelope withat least 1.3g margin to buffet onset.

4.4 5 3 1.8


126


273 544 544 To ensure that flight controls are availableduring critical flight phases or conditions,manufacturers should design system overridesthat are available to the flight crew to regainmanual control.

1.7 5 2 0.5

60 545 545 To provide the national airspace system withaccurate, real-time in-flight weather conditions(automatic or manual), a system should bedeveloped and implemented to effectivelytransmit airborne weather related information toair traffic facilities.

5 4 5 2.8

12 546 546 Airlines/operators should ensure that flightcrews are adequately trained in an appropriatelevel simulator for the training being conducted(i.e. engine out, upset recovery, etc.) before beingassigned to the line. (See 153, 312)

5.5 5 5 3.8

253 547 547 In order to ensure that the certificationprocess is based solely on safety and compliancewith the regulations, certification should includean independent audit process to guard againstthe influence of non-technical considerations.

4.4 2 3 0.7

127 548 548 In order to provide flight crews with engineout training on takeoff without visual outsidereference, regulators should require, andoperators should conduct, takeoff engine outtraining and evaluation during the portion of thetakeoff after rotation through initial climb.

5 3 5 2.1

243 549 549 To prevent a blurring of flight crewresponsibilities when two captains are paired tofly a trip sequence, one of the pilots should bedesignated as the pilot-in-command for theduration of the trip pairing.

3.8 2 4 0.8

550 550 Since handling qualities evaluations aresubjective and subject to non-technicalinfluences, the regulatory authorities,manufacturers, research organizations, andoperators should work together to developimproved, quantitative, objective metrics andacceptance criteria to ensure safe handlingqualities.

R&D

551 551. In order to develop “best business practices”throughout the continuum of certification, majordesign changes, and operating history of aircrafttypes, industry and Government should conduct ajoint, proactive, lessons-learned, review of theMD-11/MD-10 certification process and operatinghistory.

NR


127


552 552 To add structure to piloting skill levels,research should be conducted to determine theefficacy and impact of a multi-level pilot licensingand qualification structure (e.g. analogous toapprentice, journeyman, master).

R&D

128 553 553 Since performance calculations can havesignificant safety implications, regulatoryauthorities should ensure that pilot training andprocedures adequately address their meaningand use.

5 3 5 2.1

278 554 554 Because it is important that training reflectthe realities of line operations, airline trainingdepartments should include instructors whoregularly fly in line operations.

1.6 2 5 0.4

257 555 555 Because it is important that training reflectthe realities of line operations, airline trainingdepartments should review and modify, inconsultation with line pilots, training curricula toreflect realistic line operations scenarios andconditions.

1.7 3 5 0.7

254 556 556 To reduce pilot overload, airlines/operatorsshould develop standard operating procedures tohelp standardize the use of the appropriate levelof automation for the operation and the airplanedesign (See 246, 530).

1.7 3 5 0.7

255 557 557 Since current ATC procedures can result innon-standard use of automated flight systems(e.g. "slam dunk approaches"), air traffic serviceproviders should harmonize ATC procedures sothat they take into account the flightcharacteristics of modern airplanes andautomated flight system capability.

1.7 3 5 0.7

234 558 558 Since current ATC procedures can result innon-standard use of automated flight systems(e.g. "slam dunk approaches"), air traffic serviceproviders and airplane manufacturers shoulddevelop and implement automated tools so thatATC clearances are integrated with and take intoaccount the performance of airplanes usingautomated flight systems (e.g. CTAS/FMSprogram). (See 557)

1.7 4 5 0.9

194 559 559 To reduce the likelihood of hard landings,airlines/operators should develop training syllabiwith improved coverage of landings, includingidentification of and recovery from unstabilizedflares, high sink rates, and bounced landings.

4.8 2 5 1.3


128


227 560 560 Since geographic organization of inspectionresponsibilities can affect the quality/timeliness ofinspections conducted by supportingorganizations at remote locations, regulatorsshould ensure that these remote inspectors aremore accountable to the requesting certificateholding office.(CHDO/CMO)

2.4 3 5 1

26 561 561 Airlines should maximize the use of autolandsystems consistent with maintaining manuallanding proficiency.

6 4 5 3.3

171 562 562 Airlines/operators should develop processesto identify and thoroughly review (seeking "notechnical objection" from manufacturer, whenappropriate) informal pilot techniques to ensurethat they have no unacceptable unintendedconsequences.

3.8 3 5 1.6

244 563 563 Manufacturers should provideairlines/operators with training material designedto explain to pilots how and why systems work theway they do.

2.9 2 5 0.8

172 564 564 To reduce the need for pilots to work aroundthe automation, manufacturers should ensure thatsystems designs and safety analyses considerthe full range of operations.

3.8 3 5 1.6

180 565 565 Manufacturers should incorporate an "inputrudder" indicator to ensure that adequate yawcontrol is provided.

5.5 2 5 1.5

13 566 566 Manufacturers should incorporate anautomatic yaw compensation to ensure thatadequate yaw control is provided.

5.5 5 5 3.8

245 567 567 To minimize potential negative safetyimplications of procedural changes,airlines/operators should develop processes toreview all proposed operating procedures in orderto uncover and evaluate potential unintendedconsequences.

2.9 2 5 0.8

568 568 Since the definition and reporting criteria forhard landings are poorly defined and there havebeen several landings that have resulted in MD-11 wing structural failures, regulatory authoritiesshould require inspection of all MD-11s to ensurethat unreported hard landings have not resulted instructural damage.

NR


129


235 569 569 Since hard landings are identified primarilybased on pilot subjective judgment, and to ensurethat individual airplanes are inspected whennecessary, manufacturers should develop, andregulatory authorities should require, theimplementation of objective means to identify theoccurrence of a hard landing within anappropriate period of time.

1.3 5 5 0.9

256 570 570 To ensure appropriate crew experiencelevels, regulatory authorities should requireprocedures to ensure appropriate crew pairing.(ref FSF Corporate Crew Scheduling and FatigueEvaluation) (see 24)

1.7 3 5 0.7

279 571 571 To ensure the aircraft can be safely flown bypilots with normal skill levels, regulatoryauthorities should require that tests anddemonstrations intended to show compliance withapplicable regulations include representative linepilots performing representative line-typeoperations.

2 2 4 0.4

572 572 Research should be conducted to improveunderstanding of how/why pilots misprioritize orbecome fixated upon concerns and tasks, and todevelop strategies to counteract this effect.

R&D

181 573 573 To preclude late descent clearances, AirTraffic Service should ensure that standardterminal arrival procedures are in place totransition from enroute altitudes to the instrumentapproach procedure.

4.4 3 4 1.5

263 574 574 To ensure accurate and safe flight release,airlines / operators should ensure that dispatchersare aware of and take into account aircraft andflight crew qualifications.

1.7 4 3 0.6

285 575 575 To provide the flight crew with a morepositive indication of autopilot engagement /disengagement, the manufacturer should developand provide an active and positive annunciation ofautopilot engage status which appears after flightcrew initiation of a go-around.

2 2 2 0.2

576 576 To improve the effectiveness of accidentinvestigations and, in so doing, help preventfuture accidents, regulators should immediatelyimplement NTSB recommendations to increasethe quantity and quality of survivable datarecorded on both existing and future aircraft.Manufacturers also should improve the reliabilityof the recording equipment (DFDR, CVR).(Combined from 27, 303, 360, 453, 462)

NR

APPENDIX H: INTERVENTION GROUPING BY STRATEGY

130

Appendix H: Intervention Grouping By Strategy

1. Design Intervention Strategies

Rank IS# Intervention Strategy

ExistingA/C

and/orRetrofit

New

1 445

445 To help avoid loss of control, manufacturers shoulddevelop and implement flight envelope protection. (e.g.bank/pitch angle limits, over-speed, angle of attack, loadfactor)

Yes

2 366

366 To protect aircraft against flight control malfunctions,manufacturers must design and regulators must certificatederivative aircraft and components to current applicablecertification requirements, i.e. single point failures,redundancy, and probability of failure.

Y

8 483

483 To ensure that the display of conflicting attitudeinformation does not confuse or mislead the flightcrew, theattitude sensing and display systems should be designedso that invalid information is detected and clearlyannunciated to the flight crew and/or removed fromdisplay.

Maybe Y

10 533

533 To prevent loss of control, manufacturers shoulddesign automated systems to yield control to manualinputs when those manual inputs are in conflict with theautomated configuration.

M Y

13 566566 Manufacturers should incorporate an automatic yawcompensation to ensure that adequate yaw control isprovided.

Y

17 364

364 To protect aircraft against loss of control, regulatorsshould develop as soon as possible, certification criteria,throughout the entire flight envelope, for crossover speedsand maximum rudder side slips. (see 431)

Y

20 501

501 To warn of impending loss of control, manufacturersshould develop and regulators should require autoflightsystem auto-disconnect logic which does not disconnectwhen the autoflight system is properly attempting to correctan abnormal flight situation / condition. (ref 363)

M Y

22 1616 To prevent mode confusion, manufacturers shouldensure that automated systems provide the flight crew withsufficient information (automation feedback).

M

33 380

380 To reduce the risk of inadvertent entry into stall,manufacturers should develop and implement stallprotection features in all transport category airplanes, (e.g.stick pusher, alpha protection)

Y


131


ExistingA/C

and/orRetrofit

New

34 395

395 To ensure that the display of conflicting air datainformation does not confuse or mislead the flightcrew, theair data sensing and display systems should be designedso that invalid information is detected and clearlyannunciated to the flight crew and/or removed fromdisplay.

36 398

398 To provide real time accurate wind componentinformation to flight crews, air traffic services andmanufacturers should implement real time (automated)transmission/display of such information in the mostdirectly useable format to the flight crew, during approachand landing phase. (See 94)

Y Y

37 400

400 In order to promote safe crosswind landings,manufacturers will provide and airline operators willimplement aircraft crosswind landing limitations, includingconsiderations for flight control effectiveness and gustconditions.

Y

38 408

408 To minimize undesirable effects of transition to manualflight from ALIGN mode, regulators should require thatminimum altitudes and conditions be established fordisengagement of automated systems when a manuallanding is anticipated.

39 412

412 To avoid problems due to unexpected mode changes,automated flight system logic should be designed to beerror tolerant or, at a minimum provide an alert when thedesired mode is in conflict with aircraft energy state.

Y

40 413413 To prevent negative transfer effects with flight criticalsystems, regulators should establish requirements forstandardization of flight deck information/controls.

M Y

41 424

424 To enhance crew awareness of automation modes,manufacturers should ensure that mode changes ordisconnects, in the automated systems are annunciated ina way that is obvious to the flight crew.

M Y

42 472

472 Since certain engine control and autothrottle systemfailures can result in undesirable asymmetry,manufacturers should redesign ATSs so that theydisconnect (with appropriate annunciation) when unable toachieve the commanded thrust settings (analogous toautopilot disconnect logic).

M

43 485

485 To preclude the accidental change of aircraft systemsstatus, manufacturers should design flight decks tominimize the potential for inadvertentactivation/deactivation of aircraft systems and/orunintended autoflight mode changes.

M Y


132


ExistingA/C

and/orRetrofit

New

44 515

515 To warn of impending loss of control with the autoflightsystem fully engaged, manufacturers should develop andregulators should require annunciation of an airplane flightcondition which significantly differs from that beingcommanded by the selected autoflight system mode. (ref243)

M Y

50 253

253 To prevent loss of control, there should be redundancyand failure tolerance features for all flight criticalcomponents, such as dual path design, fail operationalredundant systems, with fault annunciation.

52 358

358 To provide optimal upset recovery training and tominimize negative training, regulators, aircraft andsimulator manufacturers and operators should ensure thattraining devices replicate aircraft performance andresponse necessary for effective training. (See 386, 475)

Y

54 416

416 To provide improved flight crew situation awareness,manufacturers should provide a clear indication thatpredicts the future aircraft energy state and/or autoflightconfiguration if the current course of action is continued(i.e., analogous to EGPWS mode that analyzes theairplane's descent rate vs. its terrain map, and tells thecrew that a conflict will occur if they continue at thatdescent rate. The system would warn the crew that, if theycontinue at the current roll rate (for example), the plane willexceed the envelope, or the autopilot will reach the limitsof its authority, etc.)

60 527

527 To ensure that alerting and warning logic does notannunciate self-recovery functions or alerts that do notrequire pilot action, the manufacturer should designsystems that annunciate only when pilot action is required.

61 545

545 To provide the national airspace system withaccurate, realtime inflight weather conditions (automatic ormanual), a system should be developed and implementedto effectively transmit airborne weather related informationto air traffic facilities.

63 305

305 Regulators should require airlines/operators to outfitaircraft with electronic checklists. If unable to installelectronic checklists, use mechanical checklists or, at aminimum, develop a process to reinforce challenge andresponse checklists.

Y

64 407

407 To minimize pilot reaction requirements duringtransition from autocoupled to manual flight duringapproach, regulators should require, and manufacturersshould design, autoflight systems so that ALIGN modeneed not be engaged when a manual landing is planned.


133


ExistingA/C

and/orRetrofit

New

65 433

433 To preclude inadvertent entry into stall conditionsduring autopilot operation, regulators should not permitand manufacturers should not design autoflight systemsthat will allow the autopilot to control the aircraft into astalled condition.

66 488

488 To facilitate recovery and attitude awareness,manufacturers should include adequate instrumentation tooptimize performance during recovery from unusualattitude.

71 121121 Air Traffic service providers should implementworldwide surveillance radar (example: ADS/B).

77 374

374 To provide terminal area position information in non-radar environments, ATS providers and airplanemanufacturers should implement terminal area automaticdependent surveillance (ADS-B) (Traffic InformationServices (TIS))

78 381

381 To provide improved pilot awareness of the airplane'senergy state, manufacturers should develop andincorporate more effective energy management monitoringand alerting systems.

79 391

391 Because of the interaction between systems,manufacturers should develop alerting systems that helppilots understand any common cause of multiple failuremessages

85 531

531 To minimize the occurrence of loss of control duringunstable approaches, manufacturers should design andimplement a system to detect unstable approaches andprovide an automatic callout to go around.

92 149149 Manufacturers should install a HUD as standardequipment. (See 85) Y

95 383

383 To ensure adequate time margin between stallwarning and actual stall, manufacturers and regulatorsshould develop and implement stall warning systems thataccount for various entry rates/conditions to stall.

98 45

45 Manufacturers should ensure that all impendingequipment failures or inappropriate settings that may affectthe safe operation of the flight are properly annunciated tothe flight crew by use of dual source sensing. (See 103,138)

101 245

245 To recover aircraft in unusual attitude, manufacturersshould develop systems to return aircraft to normal attitudewith one pilot button push (pilot initiated auto-recoverysystems).

102 382382 To provide improved pilot awareness of airspeed,manufacturers should provide flight instruments with moreeffective airspeed trend indications and alerting.


134


ExistingA/C

and/orRetrofit

New

106 528

528 To provide optimal training (including propulsionsystem malfunctions) and to minimize negative training,regulators, aircraft and simulator manufacturers andoperators should ensure that training devices replicaterealistic failure scenarios, aircraft performance andappropriate response. (See 358)

Y

116 159159 Manufacturers should incorporate an "input rudder"indicator or automatic yaw compensation to ensure thatadequate yaw control is provided.

Y

123 442

442 To avoid delay in the recognition of enginemalfunction/failure, manufacturers should develop andimplement a direct aural and visual flight deck indication ofengine malfunction/failure. (Minor transients need not beannunciated.)

125 474

474 Since indications of sideslip may not be prominent andcan be masked by roll effects, manufacturers shoulddevelop improved sideslip indications and/or alerting (e.g.similar to pitch limit indications for pitch / angle of attack).

131 9494 Implement real time (digital) transmission of airport andweather information to the aircraft. Y

142 368

368 To enable pilots to develop situation awareness withrespect to aircraft performance capability, regulatorsshould require and manufacturers should provide angle ofattack display.

Y

151 243243 To prevent alerting overload, flight deck designsshould consider smart alerting systems such as those withprioritization schemes or cancelable nuisance alerts.

160 513

513 To preclude undesired flight control displacementmanufacturers should design flight controls so that theairplane does not experience uncommanded, adverseflight control deflections that are beyond the control of theflightcrew. (throughout the flight envelope, includingaerodynamic stall)

164 1414 Install aural warning devices on aircraft to alertflightcrew of arrival at MDA/DH. Y

172 539

539 To ensure procedural compliance, manufacturersshould design and incorporate 'smart' checklists that detectfailures and provide the proper flight crew actions. (See444)

Y

174 564

564 To reduce the need for pilots to work around theautomation, manufacturers should ensure that systemsdesigns and safety analyses consider the full range ofoperations.

182 565565 Manufacturers should incorporate an "input rudder"indicator to ensure that adequate yaw control is provided.


135


ExistingA/C

and/orRetrofit

New

192 369

369 To provide adequate stall warning, regulators shouldrequire and manufacturers should develop, stall warningsystems for new/derivative aircraft that provide accurateinformation throughout the certificated flight regime.

216 436436 To ensure adequate stall warning, regulators shouldmandate improved accuracy and integrity in the stallwarning system (including aircraft currently in service).

221 49

49 Regulators should establish criteria for, andmanufacturers should evaluate and improve, the reliabilityand failure tolerance of flight systems. (includes hardware,software and human performance). (See 332)

224 390

390 Because some partial system failures may not bereliably observed, manufacturers should develop warningsystems that alert the pilot to those partial/total failures offlight critical systems and flight instruments.

225 451

451 To allow adequate training in manual flight,manufacturers should develop models to allow flightsimulators to accurately represent the aircraft's stabilityand control characteristics for all regions of the flightenvelope likely to be encountered during normaloperations (i.e. Operation within the AFM-approved flightenvelope with no failures affecting aerodynamicperformance).

Y

237 558

558 Since current ATC procedures can result in non-standard use of autoflight systems (e.g. "slam dunkapproaches"), air traffic service providers and airplanemanufacturers should develop and implement automatedtools so that ATC clearances are integrated with and takeinto account the performance of airplanes using autoflightsystems (e.g. CTAS/FMS program). (See 557)

239 2828 Implement a system to automatically transmit ATCinstructions/information between the ground controller andthe aircraft.

242 367

367 To provide necessary information to pilots, regulatorsshould require and manufacturers should develop, flightcontrol position indicating and alerting systems which willprovide warnings for critical aircraft flight controlmalfunctions, e.g., actual flight control positiondisagreement with commanded position.

243 376

376 To improve aircrew awareness of other traffic,manufacturers should install TCAS in all new aircraft,airlines/operators should retrofit TCAS into the existingfleet and international regulators should require theinstallation and use of TCAS. (See 35)

Y


136


ExistingA/C

and/orRetrofit

New

252 363

363 To enhance aircraft controllability in severe or greaterturbulence conditions, regulators and manufacturersshould develop and implement certification criteria thatconsider effects of turbulence, including autoflightcapability and disconnect parameters.

253 389

389 To assist flight crews in responding to systemmalfunctions, manufacturers should develop andairlines/operators should incorporate readily accessibleflight crew procedures for partial or total failure of flightcritical systems.

270 122

122 Air Traffic service providers should implementtransmission of ATC instructions/information (between theground and aircraft) via a computer link as opposed tovoice communications.

276 544

544 To ensure that flight controls are available duringcritical flight phases or conditions, manufacturers shoulddesign system overrides that are available to the flightcrewto regain manual control.

284 503503 To alert the flightcrew of flight control trim changes,manufacturers should provide an appropriate level of auralannunciation.

Y

287 137

137 Manufacturers should ensure cockpit design that doesnot interfere with or distract the flight crew from executingtheir duties (e.g. rain in the cockpit, location of switches incockpits).

288 575

575 To provide the flightcrew with a more positiveindication of autopilot engagement / disengagement, themanufacturer should develop and provide an active andpositive annunciation of autopilot engage status whichappears after flightcrew initiation of a go-around.

Y


137

2. Training Intervention Strategies


3 525525 To mandate stall recognition and recovery training, regulatorsmust modify the approprate regulations.

5 357357 To ensure crews have the adequate skills to recover from extremeattitude upsets, regulators should require, and operators shouldimmediately implement, initial and recurrent upset recovery training.

6 486

486 Airlines/operators and manufacturers should train crews tounderstand the capabilities and limitations of automated flight systems,the conditions which would cause the systems to not function as thecrew anticipates, and how to detect and recover from inadvertentactivation of autoflight modes (see 331).

11 535535 To ensure adequate instructor / check pilot qualifications,operators must establish and maintain minimum line and instructor /check airman qualifications.

12 546

546 Airlines/operators should ensure that flight crews are adequatelytrained in an appropriate level simulator for the training beingconducted (i.e. engine out, upset recovery, etc.) before being assignedto the line. (See 153, 312)

15 110

110 Airlines/operators and regulators should ensure that theirtraining/standardization and monitoring programs emphasize theimportance of adherence to standard operating procedures andidentify the rationale behind those procedures. (See 99)

21 77 Airlines/operators should ensure that their training/standardizationprograms emphasize review of approach and missed approachprocedures. (See 329)

25 384

384 Since it is possible to enter a stall, airlines/operators shoulddevelop and implement a ground school and simulator trainingprogram to train pilots to handle post stall recovery as part ofadvanced maneuver training.

27 1515 Airlines/operators should ensure that their training/standardizationprograms instruct when to disengage automated systems and flymanually. (See 246)

29 142

142 Airlines/operators should establish policies, parameters, andtraining to recognize unstabilized approaches and other factors andimplement a go-around gate system. (See FSF - "defined gates" p.193) (See 116, 123)

30 157

157 Airlines/operators, regulators, air traffic service providers shouldestablish policies or programs to address rushed approaches,including elimination of rushed approaches, recognition and rejectionof rushed approaches and training for those encountered.

45 114114 Airlines/operators should ensure that their training/standardizationprograms provide sufficient training to ensure aircrew proficiency.


138


47 147

147 Airlines/operators should require training/standardizationprograms, which teach situation awareness. (The knowledge andunderstanding of the relevant elements of the pilot surroundings,including aircraft systems, and the pilots intentions)

48 165165 Airlines/operators should provide training scenarios that matchrealistic situations (i.e. stall recoveries during approach, in landingconfiguration at flight idle with the autopilot on (in simulator).

51 331

331 Airline operators and manufacturers will train crews to understandcapabilities and limitations of system, conditions which would causethe system to not function properly and how to detect failure todeploy/activate and recommend contingency actions.

52 358

358 To provide optimal upset recovery training and to minimizenegative training, regulators, aircraft and simulator manufacturers andoperators should ensure that training devices replicate aircraftperformance and response necessary for effective training. (See 386,475)

53 365365 To ensure pilot capability to maintain or regain control, regulatorsshould require and operators should implement training programswhich address crossover speed effects.

58 502

502 To ensure flight crews can identify possible upset conditions,airline/operators should implement flight crew training programs thatdemonstrate the operation of a normally functioning autoflight systemunder non-standard flight conditions (e.g. out of trimairplane/contaminated wing).

59 520

520 To ensure flight crews have a comprehensive knowledge of theautomation system(s) functional operation, airlines/operators shouldensure that their training /standardization programs emphasize theseskills.

67 522

522 Since it is possible to enter a stall, regulators should mandate theimplementation of a ground school and simulator training program totrain pilots to handle post stall recovery as part of advanced maneuvertraining. (See 384)

73 314

314 Airlines/operators should develop simulator training scenarios thatrequire flight crews to learn multi-tasking abilities and appropriateprioritization abilities in concert with CRM skills (see Red Flag LOFTscenarios).

74 322

322 Airlines/operators should develop and implement a ground schooland simulator training program to train pilots to handle unusual attitudesituations, e.g. American Airlines Advanced Aircraft ManeuveringProgram.

80 401

401 To ensure proper identification of engine malfunctions andavoidance of possible loss of control, airline/operators should provideenhanced and more realistic training for engine malfunctions, engineresponses to control signal errors and the appropriate aircrew actions.

82 427427 To prevent inappropriate preoccupation with trouble shootingfollowing engine or other system failure, airline operators shouldenhance training and checking to prioritize safe control of the aircraft.


139


83 456456 To help ensure appropriate decision making, flight crews shouldbe trained on the impact of automation on CRM.

86 20

20 Airlines/operators should ensure that command oversight trainingfor captains is provided during the upgrade process and in recurrenttraining and first officer responsibility for monitoring are reviewedduring recurrent training.

88 8282 Airlines/operators should clearly define, train and check the specificPF/PNF/FE duties.

89 111111 Airlines/operators should ensure that their training/standardizationprograms emphasize basic airmanship skills and knowledge duringinitial and recurrent training.

90 115115 Airlines/operators should ensure that their training/standardizationprograms emphasize the dangers of rushed approaches. (See 13,157)

91 116116 Airlines/operators should ensure that their training/standardizationprograms emphasize the dangers of high rate of descent and unstableapproaches. (See 142)

93 328

328 Airlines/operators should ensure that flight crews are trained tothink in terms of "I will go-around unless" rather than "I will landunless." Regulatory policy should support this approach. (See 142,311)

94 329

329 Airlines/operators should incorporate in initial and recurrenttraining ways to recognize multiple cues that will require go-around.These include CFIT training aid 2.1.9, FSF definition of stabilizedapproach, risk assessment tool, and windshear training aid.

99 153153 Ensure that flight crews are adequately trained in a level Dsimulator for dynamic characteristics before assignment to the line.(See 312)

103 405405 To enhance stability in the approach and landing phase, airlineoperators should train pilots to properly control the aircraft in thetransition from autocoupled/autoland approaches to manual control.

106 528

528 To provide optimal training (including propulsion systemmalfunctions) and to minimize negative training, regulators, aircraftand simulator manufacturers and operators should ensure that trainingdevices replicate realistic failure scenarios, aircraft performance andappropriate response. (See 358)

107 1313 Air Traffic service providers should enhance ATC training toemphasize the dangers of rushed approaches and performancecharacteristics of jet transports. (See 115, 157)

108 2323 Airlines/operators should ensure that regularly scheduled recurrenttraining (e.g. LOFT) emphasizes crew cooperation and workingtogether to maximize safe operations. (See 308, 314)

110 25

25 Airlines/operators should establish a CRM training program andregulators should require and ensure that the initial training is providedprior to line flying and require recurrent CRM training. (See 131, 132,349)


140


112 107107 Airlines/operators should ensure that their CRMtraining/standardization program emphasizes the importance of theteam concept.

113 112112 Airlines/operators and regulators should ensure that the frequencyand effectiveness of proficiency checks for simulated instrumentfailures (partial panel) are adequate.

118 308

308 Airlines/operators should ensure their formal CRM training isculturally appropriate and emphasizes the following managementskills: decision making, workload management, crew coordination,planning, communication, situational awareness and advocacy. (IAWAC120-51b). (See 133)

119 325

325 Airline/operators should emphasize during initial and recurrenttraining the importance of maintaining systems status awarenessduring non-normal events and hazardous approaches (goal to avoidtunnel vision/narrowed attention).

122 411411 To reduce accidents during the landing phase, airline operatorsshould establish criteria and procedures and train flight crews torecognize conditions which might require a rejected landing.

124 467

467 To reduce unstabilized approaches, air traffic quality assuranceprograms should regularly evaluate Air Traffic Control SystemCommand Center / Traffic Management Unit (ATCSCC / TMU's) toensure traffic management programs and initiatives include all trafficelements (i.e. tower enroute clearance / enroute traffic), areimplemented properly, effectively utilized and personnel areadequately trained.

128 548

548 In order to provide flight crews with engine out training on takeoffwithout visual outside reference, regulators should require, andoperators should conduct, takeoff engine out training and evaluationduring the portion of the takeoff after rotation through initial climb.

129 553553 Since performance calculations can have significant safetyimplications, regulatory authorities should ensure that pilot training andprocedures adequately address their meaning and use.

132 131

131 Airlines/operators should ensure that their training/standardizationprogram emphasizes the importance of the team concept, crosscultural issues, evaluation of options and the obligation of the FO toeffectively communicate any concerns (CRM). (See 237)

134 415415 To provide improved aircraft status awareness, airline/operatorsshould enhance training to identify aircraft configuration and therepercussions of the aircraft's energy state.

137 163163 Airlines/operators should ensure that their training/standardizationprograms address common perceptions that could lead to unsafepractices.

139 6464 Airlines/operators should ensure that their training/standardizationprograms direct the flight crews to regularly cross check allinstrumentation.

141 223223 Regulators should ensure POIs are properly qualified and trainedto approve appropriate company operational procedures.


141


143 414

414 To reduce negative transfer effects during pilot transition to newaircraft, airline operators should determine the potential for negativetransfer of inappropriate pilot actions and techniques on flight criticalsystems and overtrain to prevent their occurrence.

144 473

473 Due to increasing dependence on automation and the complexityof potential partial system failures, airlines/operators should modifytraining programs to emphasize the use of multiple data sources toconfirm that the airplane and systems are performing as expected andin accordance with the operational mode.

146 519

519 To ensure pilot proficiency in basic airmanship skills andknowledge, regulators should require training/standardizationprograms that emphasize these subjects during initial and recurrenttraining. (See 111)

147 538538 Airline/operators should train flight crews in team decision-makingskills, including the ability to rapidly turn data into information and testconclusions. (See 314)

149 2626 Airlines/operators should ensure that CRM training is provided priorto line flying.

150 113113 Airlines/operators should ensure that their training/standardizationprograms emphasize the importance of adequate preflight planning.

153 393

393 To ensure system status awareness, airlines/operators shouldensure that their training/standardization programs direct the flightcrews to use all available tools to determine airplane system status.(See 47)

156 447

447 In order to maintain adequate safety margins during flighttraining, operators should establish and regulatory agencies shouldrequire standards for conducting flight training which precludeoverloading the trainee.

158 470

470 Since current airline training emphasizes recovery from approachto stall, airline/operators should emphasize to air crews the importanceof proper analysis and response to incipient stall conditions (forexample timely reduction in angle of attack).

159 475

475 Since simulators cannot adequately replicate the motion cuesassociated with sideslip, the industry should develop improvedmethods for safely training pilots to recognize and respond to inflightsideslip events. (See 358, 386)

161 529529 To avoid negative training, airline operators should ensure thattheir training curriculum correlates with the AOM and other relevantmanuals.

168 468468 To ensure the highest quality of air traffic services, regulatorsshould establish policies that require additional oversight and trainingof air traffic controllers that repeatedly commit operational errors.

180 487

487 To minimize the occurrence of loss of control events, airlineoperators' training programs should emphasize pattern recognition andskill-based procedures to better handle time-critical situations, ratherthan relying on knowledge- based analysis.


142


184 1717 Airlines/operators should ensure that their training/standardizationprograms emphasize the importance of all flight-related briefings.(See 342)

185 237237 Airlines/operators should provide guidance to crew concerningevaluation of all options prior to decision making as part of CRMtraining. (See 25, 26, 131, 132, 133, 308)

186 300

300 Airlines/operators should adopt, implement and train a riskassessment tool to enhance flight crew awareness of hazardsassociated with all approaches and airports (see risk analysis tacticalchecklist).

187 316316 Regulators should require airline/operators to train flight crews torecognize and counteract acute and chronic fatigue. (See 31, 130,203, 257,315)

190 228228 Regulators should require airlines/operators to modify theirtraining to maximize benefits of inter-crew/company communications.

193 403403 To ensure clear communication, airline operators should trainflightcrews to emphasize if action is required when giving statusreports.

194 479

479 To improve operational oversight, regulators should establishselection criteria and appropriate training programs (e.g. training withcarriers) to ensure that POIs responsible for air carrier oversight haveappropriate knowledge and experience to perform those functions.

196 559

559 To reduce the likelihood of hard landings, airlines/operatorsshould develop training syllabi with improved coverage of landings,including identification of and recovery from unstabilized flares, highsink rates, and bounced landings.

197 2121 Establish/enhance quality assurance checks/training to ensure thattimely and accurate communication between controllers and flightcrews is occurring.

199 9696 Airlines/operators should ensure that their training/standardizationprograms emphasize the importance of adequate approachpreparation and contingency review prior to commencing an approach.

200 106106 Air Traffic service providers should train and monitor ATCadherence to established communications procedures includinghearback problems. (See 240)

207 141

141 Airlines/operators and regulators should requiretraining/standardization programs include training regardingphysiological effects on aircrew performance, (e.g. low blood sugar,fatigue).

212 349349 Airlines/operators should ensure training for instructors and checkairmen include objective criteria to be used in evaluating crew CRMperformance. (See 25,131)

213 375

375 To improve controller situation awareness, air traffic serviceproviders should ensure that their training/standardization programsdirect that controllers use all available tools to establish aircraftposition. (See 75)


143


215 432432 To facilitate recovery from flight upsets, airlines/operators shouldclearly define, train and check the specific PF/PNF upset recoveryduties.

217 452

452 Since handling qualities and performance margins may besignificantly different during high altitude cruise, airlines/operatorsshould ensure that pilots receive adequate training and experience inmanual flying in this flight regime.

218 493493 To reduce the risk of pilots' non-readiness for flying,airlines/operators should train pilots to perform self-audit medical andpsychological assessments prior to flight duty.

226 482

482 To prevent inaction when the PF is confused or unresponsive toan in-flight hazard, airlines/operators should develop and train clearand explicit procedures to define when/how the PNF (especially theF/O) will take control of the airplane.

235 524524 Regulators should establish flightcrew phraseology guidelines andairlines/operators should train and monitor flight crew compliance withcommunication phraseology guidelines. (See 88, 240)

241 133

133 Airlines/operators training of captains and chief pilots shouldinclude management practices that promote team building andeffective human relations (leadership training beyond current CRMprograms). (See 308)

250 100100 Airlines/operators should ensure that their training/standardizationprograms emphasize the importance of adhering to MDA/DH.

251 136136 Airlines/operators should ensure that their training/standardizationprograms emphasize the importance of the sterile cockpitenvironment.

262 105

105 Airlines/operators should train flight crews on how flight delaysupon departure or enroute (weather, maintenance, ATC, etc.) canaffect their subsequent decision-making relative to the safe conduct ofthe flight.

263 162162 Airline/operators should include in their training programs theawareness of potential safety risks due to the complacency whenoperating at a very familiar airport (e.g. home base).

269 8888 Airlines/operators should train and monitor flight crew compliancewith established communication phraseology guidelines.

273 394

394 Because of increasing interactions between systems,manufacturers and training organizations should develop newapproaches for instructing pilots in the interrelationships betweensystems.

278 5252 Airlines/operators should ensure that their training/standardizationprograms establish flight crew proficiency in the use of the FMSsystem.

286 1212 Air traffic service providers should emphasize in ATC training thecontrollers' potential in assisting the flight crew in improving theirsituation awareness.


144


289 404404 To enhance crew performance in the approach and landingphase, airline operators should train pilots to understand the limitationsof computed wind displays.

290 1010 Air traffic service providers should train air traffic controllers to useall available tools to establish aircraft position (example: don't fixate onjust DME).

292 514514 Combined with 525


145

3. Practices, Policies, and Procedures Intervention Strategies


4 9999 Airlines/operators should ensure that clear, concise, accurate,appropriate standard operating procedures are published andenforced. (See 110)

9 532

532 To minimize the probability of accidents, operators shouldprioritize service bulletin implementation using operational riskmanagement techniques to assess potential operational hazards,including aircraft modification, etc.. (See 98, 348)

15 110

110 Airlines/operators and regulators should ensure that theirtraining/standardization and monitoring programs emphasize theimportance of adherence to standard operating procedures andidentify the rationale behind those procedures. (See 99)

16 530530 To optimize pilot workload, airlines/operators policies shouldstress using the appropriate level of automation. (See 246)

19 431

431 To assist flight crews in avoiding loss of control on existingaircraft, regulators and manufacturers should evaluate the effects ofcrossover speeds and maximum rudder side slip throughout the entireflight envelope and disseminate the information to operators and flightcrews.

23 80

80 Airlines/operators should verify, and regulators should check, thatoperators who create their own AOM's include all operationalprocedures prescribed by original equipment manufacturers AirplaneFlight Manual (AFM).

24 152

152 Airlines/operators and regulators should raise standards (e.g.crew pairing, approach minimums, etc.) for flight crewmembers thatmeet minimum qualifications but have demonstrated limitedproficiency and/or competency. (See 151, 335, 337)

26 561561 Airlines should maximize the use of autoland systems consistentwith maintaining manual landing proficiency.

27 1515 Airlines/operators should ensure that their training/standardizationprograms instruct when to disengage automated systems and flymanually. (See 246)

28 9898 Airlines/operators and regulatory agencies should reviewprocedures to ensure that design changes (service bulletins) to flightcritical systems are incorporated in a timely manner.

29 142

142 Airlines/operators should establish policies, parameters, andtraining to recognize unstabilized approaches and other factors andimplement a go-around gate system. (See FSF - "defined gates" p.193) (See 116, 123)

30 157

157 Airlines/operators, regulators, air traffic service providers shouldestablish policies or programs to address rushed approaches,including elimination of rushed approaches, recognition and rejectionof rushed approaches and training for those encountered.


146


32 225225 Airlines/operators and regulators should ensure necessarymanuals (operational & maintenance) are complete, accurate,available and appropriately used.

35 397

397 To provide accurate wind information to flight crews, regulatorsshould ensure that weather information providers and air trafficservices employ systems and procedures which will ensure accuratemeasurement of wind data and dissemination of wind information fortakeoff and landing areas of the runways in use.

37 400

400 In order to promote safe crosswind landings, manufacturers willprovide and airline operators will implement aircraft crosswind landinglimitations, including considerations for flight control effectiveness andgust conditions.

62 7979 Airlines/operators should implement a reliable process tocommunicate information to the flight crew that may affect flight oraircraft operations.

68 207207 Airlines/operators should develop procedures to specify howtransfer of control is formally accomplished.

70 9393 Air Traffic service should provide real time (most current) radiocommunication of critical airport and weather information.

72 218218 Airlines/operators should conduct surveillance of contractortraining programs for adequacy of training. (See 110, 202)

81 420

420 In order to assure that airline operations depts. understand theoperational implications of dispatching with degraded systems,manufacturers and operators should develop a method for providingsuch information to crews, for MEL and other dispatchable failureconditions (including intermittent failures).

88 8282 Airlines/operators should clearly define, train and check the specificPF/PNF/FE duties.

93 328

328 Airlines/operators should ensure that flight crews are trained tothink in terms of "I will go-around unless" rather than "I will landunless." Regulatory policy should support this approach. (See 142,311)

96 438438 To reduce the probability of accidents, operators should adoptoperational risk management techniques for non-standard flightoperations and/or flights requiring intensive training scenarios.

97 464

464 To ensure proper identification of flight critical issues,manufacturers, operators and regulators must develop consistentcriteria to properly identify and disseminate (in a timely manner,including manual revisions) flight safety critical information.

100 202202 Airlines/operators should develop a quality assurance program toensure compliance with regulations. (See 145, 146, 201)

104 417

417 Because failures which result in yaw/roll upsets can be particularlydifficult for crews to interpret and successfully handle, manufacturersand operators should give such failures increased scrutiny and higherpriority for reporting.


147


109 2424 Airlines/operators should implement procedures to ensureappropriate crew pairing. (reference FSF corporate crew schedulingand fatigue evaluation.)

114 124124 Air Traffic service providers should implement a QualityAssurance program to ensure adherence to established procedures.

117 227227 Airlines/operators should ensure that their training/standardizationprogram emphasizes the benefits of inter-crew/companycommunications. (See 131)

120 347347 Parent airlines/operators should adopt a program to ensure thesame level of safety in regional partners including, but not limited, torecruitment, training, operations and maintenance.

121 409

409 To enhance stability during the approach and landing phase,airline operators should develop and implement policies andprocedures that address mixed mode flight (e. g., autothrottles inmanual flight) with specific emphasis on pitch/thrust coupling andaircraft control problems.

122 411411 To reduce accidents during the landing phase, airline operatorsshould establish criteria and procedures and train flight crews torecognize conditions which might require a rejected landing.

124 467

467 To reduce unstabilized approaches, air traffic quality assuranceprograms should regularly evaluate Air Traffic Control SystemCommand Center / Traffic Management Unit (ATCSCC / TMU's) toensure traffic management programs and initiatives include all trafficelements (i.e. tower enroute clearance / enroute traffic), areimplemented properly, effectively utilized and personnel areadequately trained.

126 484484 To ensure adequate FO proficiency, airlines/operators shouldincorporate the operating practice of alternating PF/PNF duties(alternating legs and landings).

127 542

542 To preclude over-reliance on automation, airlines/operators andregulators should create and/or clarify a definition of “appropriatelevels of automation,” to include the need to validate against otherinformation sources and ensure that the resulting definition ispublished and included in all appropriate flight crew publications,manuals and training programs.

129 553553 Since performance calculations can have significant safetyimplications, regulatory authorities should ensure that pilot training andprocedures adequately address their meaning and use.

130 4848 Airlines/operators and regulators should strictly enforce flight/dutytime limitations.

133 373

373 To ensure that manufacturers and regulators are aware ofrecurrent problems (type and frequency), manufacturers, regulatorsand operators should implement a reliable process for gathering andreporting safety-related problems.


148


136 439

439 To ensure proper designation of pilots conducting non-standardflight operations (e.g., Functional Evaluation Flights), regulation and/orguidance should be revised to clearly indicate pilot experience, pairing,and training levels required.

138 3030 Airlines/operators should adopt the "delegated" approach tostandard operating procedures. (e.g. monitored approach procedures)

140 151151 Regulators should establish policies that require additionalmonitoring of flight crewmembers that have repeatedly failed checkrides. (See 152, 335, 337)

145 491

491 To ensure adequate flight crew competency, airlines/operatorsshould establish more effective pilot screening and Capt. upgradecriteria to identify candidates with demonstrable flying skilldeficiencies. (See 335)

154 402402 To prevent a more serious event, manufacturers should reviseproduct failure analyses if service history reveals unexpectedconsequences or failure modes.

157 454

454 Because latent and combination failures have been missed infailure analyses, manufacturers and regulators should conduct moreintensive verification of all safety analyses associated with systemswhose failures, singly or in combination with other system failures, canresult in accidents.

162 537537 To ensure proper intra-cockpit communications, operators mustensure that the language used in the cockpit is compatible,understandable and consistent among all flight deck crewmembers.

163 540

540 To ensure completeness, avoid erroneous procedures andprevent misinterpretation, manufacturers/operators should ensure andregulatory agencies should check that the guidance and procedures inAOM's are complete, clear and correct.

165 211211 Airlines/operators should retrofit equipment to provide automaticaltitude callouts on final approach.

166 246246 To reduce pilot overload, airlines/operators policies should stressusing the appropriate level of automation.

167 463

463 To avoid treating an incident as an isolated occurrence and toensure on-going assessment of aircraft specific loss of controlproblems, a focused safety or risk assessment of all accidents andincidents should be conducted to determine the need for immediateresolution. (See 254)

168 468468 To ensure the highest quality of air traffic services, regulatorsshould establish policies that require additional oversight and trainingof air traffic controllers that repeatedly commit operational errors.

169 480480 To improve operational oversight, regulators should instituteprocesses for periodic review of POIs to ensure that appropriateoversight is being conducted for the POI's assigned operators.

170 481

481 Because POIs may be responsible for oversight of remote trainingactivities, regulators should ensure that POIs have sufficient CertificateHolding District Office resources, including staff, to conductappropriate oversight for the POI's assigned operators.


149


173 562

562 Airlines/operators should develop processes to identify andthoroughly review (seeking "no technical objection" from manufacturer,when appropriate) informal pilot techniques to ensure that they haveno unacceptable unintended consequences.

175 350

350 Airlines/operators shall ensure that adequate approach briefingsare conducted that include descriptions of normal approach, non-normal conditions and the results of the risk assessment analysis.(See 300)

176 371

371 To eliminate the potential safety consequences of system failures,manufacturers/operators should develop a reliable process foridentifying, prioritizing, and resolving the safety consequences ofsystem and component malfunctions throughout the operationalenvelope.

177 387387 To ensure that airplane systems function as designed,airlines/operators should develop processes to ensure adherence tomanufacturer's recommended maintenance procedures.

178 421

421 Since intermittent failures can persist for unspecified periods oftime without correction, operators should develop specific policies,procedures and guidance defining when degraded systems or systemswith intermittent problems should be disabled, invoking the appropriateMEL requirements.

179 469469 To ensure clear understanding of flight crew taskingairlines/operators should develop criteria specifying when transfer ofcontrol is necessary or appropriate. (See 207)

181 507

507 To ensure that flightcrews have all necessary weather informationprior to flight, airlines/operators should immediately review theirsystem of weather information dissemination to ensure that allsignificant weather information is provided for their route of flight.

183 573573 To preclude late descent clearances, Air Traffic Service shouldensure that standard terminal arrival procedures are in place totransition from enroute altitudes to the instrument approach procedure.

184 1717 Airlines/operators should ensure that their training/standardizationprograms emphasize the importance of all flight-related briefings.(See 342)

185 237237 Airlines/operators should provide guidance to crew concerningevaluation of all options prior to decision making as part of CRMtraining. (See 25, 26, 131, 132, 133, 308)

186 300

300 Airlines/operators should adopt, implement and train a riskassessment tool to enhance flight crew awareness of hazardsassociated with all approaches and airports (see risk analysis tacticalchecklist).

191 251

251 To preserve the original intended level of airworthiness, thereshould be a better definition and classification of subsequent in-servicemajor and minor critical component changes. The definition of criticalcomponent should be more specific.


150


195 526

526 To increase the number of available pilots, airlines shouldimplement, and regulators should allow, a performance-basedselection system that expands the eligible pilot pool beyond thecurrent arbitrary limits (e.g., age 60 rule, minimum flight time) with anappropriate medical/psychological evaluation.

198 4242 Airlines/operators and air traffic service providers should implementa monitoring program to ensure the consistent use of the ICAOphraseology.

200 106106 Air Traffic service providers should train and monitor ATCadherence to established communications procedures includinghearback problems. (See 240)

201 134134 Airlines/operators and regulators should ensure check listdesigns, prioritize critical items as recommended by NASA study, andarrange items in a manner that enhances checklist implementation.

202 342342 Airlines/operators should establish an SOP to ensure that flightcrews should not begin their approach until adequate briefing iscompleted for the expected runway. (See 17)

203 492492 In order to ensure pilot medical fitness for duty,airlines/operators/regulators should establish a structured process forreturn to flight status after sick leave that includes medical clearance.

204 495495 To improve aircraft failure tolerance, manufacturers and regulatorsshould conduct failure analyses for design and certification that reflectrealistic levels of flightcrew reliability.

205 518

518 To ensure an adequate supply of qualified pilots, the aviationcommunity should promote initiatives that screen youth for potentialaviator qualifications, skills, and aptitude. The industry should identifyand develop career paths for suitable candidates and mentor theircareer growth as successful aviators.

206 3636 Airlines/operators should establish and implement the use ofelectronic checklists or other aids to ensure completion of all checklistitems.

208 143143 Airlines/operators should, and regulatory agencies must,encourage a culture that enhances safety in their daily operations.(Safety Culture) (See 22, 63, 348)

209 203203 Airlines/operators should provide crews with inflight rest periodsand adequate facilities. (See 31, 130, 315)

210 242242 To prevent excessive fatigue, airlines/operators should considercircadian rhythm in crew scheduling to compensate for the effects ofrhythm interruptions.

211 348

348 Airlines/operators should utilize a self-audit process (such as FSFICARUS recommendation), operational risk management programsand accident cost analysis to proactively identify and mitigate safetyconcerns. (See 318)

212 349349 Airlines/operators should ensure training for instructors and checkairmen include objective criteria to be used in evaluating crew CRMperformance. (See 25,131)


151


213 375

375 To improve controller situation awareness, air traffic serviceproviders should ensure that their training/standardization programsdirect that controllers use all available tools to establish aircraftposition. (See 75)

215 432432 To facilitate recovery from flight upsets, airlines/operators shouldclearly define, train and check the specific PF/PNF upset recoveryduties.

218 493493 To reduce the risk of pilots' non-readiness for flying,airlines/operators should train pilots to perform self-audit medical andpsychological assessments prior to flight duty.

219 523523 To ensure that airline operation training departments accomplishtheir training responsibilities, they must be adequately funded.

220 534

534 Airlines/operators should implement procedures that call for animmediate recovery maneuver following a warning that indicates animminent departure from normal flight envelope (e.g. stall warning,over-speed). (See 161)

222 224224 Airlines/operators should ensure that all airline operations includecompliance with all/seasonal guidance from the OEM.

223 378

378 To preclude continued flight into an unsafe aircraft energy state,Airlines/operators should establish procedures for flight crews toestablish a safe, stabilized flight condition when situational uncertaintyexists and THEN advise ATC of intentions.

226 482

482 To prevent inaction when the PF is confused or unresponsive toan in-flight hazard, airlines/operators should develop and train clearand explicit procedures to define when/how the PNF (especially theF/O) will take control of the airplane.

228 506

506 To ensure that the airworthiness authorities know and understandthe importance of complying with the international agreements, ICAOshould distribute annual notices to the authorities emphasizing theimportance of mutual distribution of continued airworthinessinformation.

229 536

536 To prevent reoccurrence of accidents and incidents, regulators /manufacturers / operators should expedite development andapplication of an effective risk management continuing airworthinessassessment based upon prior incidents and disseminate the results.(See 372, 373)

230 560

560 Since geographic organization of inspection responsibilities canaffect the quality/timeliness of inspections conducted by supportingorganizations at remote locations, regulators should ensure that theseremote inspectors are more accountable to the requesting certificateholding office.(CHDO/CMO)

231 296296 To mitigate confusion regarding ATC clearances, operatorsshould develop procedures to ensure flight crews query ATCwhenever uncertainty exists.

232 310310 Regulators should not allow noise abatement procedures thatreduce the level of safety that existed prior to their implementation.


152


233 434434 To enhance the safety of operations, regulatory agencies shoulddevelop adequate oversight to encourage the use of commonlyaccepted safe operating practices. (See 201)

234 476

476 Since repair processes can significantly affect the airworthiness ofcomponents, regulators should require manufacturer concurrence onall maintenance and repair procedures affecting critical aircraftstructures, components, or performance.

236 541

541 To reduce the risk of loss of control during flight with a propulsionsystem malfunction in turboprop aircraft, if the engine failure procedureis not completed, airline operators should review the consequences ofthe malfunctioning propulsion system being placed in flight idle.

238 569

569 Since hard landings are identified primarily based on pilotsubjective judgment and to ensure that individual airplanes areinspected when necessary, manufacturers should develop andregulatory authorities should require the implementation of objectivemeans to identify the occurrence of a hard landing within anappropriate period of time.

240 123123 Airlines/operators should implement a true no-fault go aroundpolicy (learning vs. blame).

241 133

133 Airlines/operators training of captains and chief pilots shouldinclude management practices that promote team building andeffective human relations (leadership training beyond current CRMprograms). (See 308)

244 396396 To ensure a standard level of safety at all airports, airportoperators should adopt airport operations procedures that are no lessstringent than ICAO recommendations.

245 422422 To ensure constant visibility of known intermittent failures,operators should develop procedures for continued reporting of andmaintenance actions to address unresolved intermittent failures.

246 549549 To prevent a blurring of flight crew responsibilities when twocaptains are paired to fly a trip sequence, one of the pilots should bedesignated as the pilot-in-command for the duration of the trip pairing.

247 563563 Manufacturers should provide airlines/operators with trainingmaterial designed to explain to pilots how and why systems work theway they do.

248 567

567 To minimize potential negative safety implications of proceduralchanges, airlines/operators should develop processes to review allproposed operating procedures in order to uncover and evaluatepotential unintended consequences.

249 2222 Airlines/operators should encourage a culture that emphasizes safearrivals over timely arrivals. (See 63, 143)

253 389

389 To assist flight crews in responding to system malfunctions,manufacturers should develop and airlines/operators shouldincorporate readily accessible flight crew procedures for partial or totalfailure of flight critical systems.


153


254 477

477 To improve maintenance quality, regulators should require thatairlines/operators institute processes for oversight of maintenancefacilities that maintain safety-critical parts, components, or systems(e.g. CASE (Coordinating Agency for Supplier Evaluation) might beone type of program that could provide an acceptable method ofcompliance).

256 547

547 In order to ensure that the certification process is based solely onsafety and compliance with the regulations, certification should includean independent audit process to guard against the influence of non-technical considerations.

257 556

556 To reduce pilot overload, airlines/operators should developstandard operating procedures to help standardize the use of theappropriate level of automation for the operation and the airplanedesign (See 246, 530).

258 557

557 Since current ATC procedures can result in non-standard use ofautoflight systems (e.g. "slam dunk approaches"), air traffic serviceproviders should harmonize ATC procedures so that they take intoaccount the flight characteristics of modern airplanes and autoflightsystem capability.

259 570

570 To ensure appropriate crew experience levels, regulatoryauthorities should require procedures to ensure appropriate crewpairing. (ref FSF Corporate Crew Scheduling and Fatigue Evalution)(see 24)

260 555

555 Because it is important that training reflect the realities of lineoperations, airline training departments should review and modify, inconsultation with line pilots, training curricula to reflect realistic lineoperations scenarios and conditions.

261 9595 Airlines/operators should establish procedures for flight crews toreview/cross check instructions, clearances, etc. to ensure consistencywith expected procedures or practices.

264 240

240 To reduce the possibility of error, confusion and workloadincrease related to ATC clearances, regulators should require andoperators ensure that flight crews utilize proper phraseology andreadbacks. (See 88)

265 241241 To eliminate hearback errors, ATC should reexamine andimplement improvements to address hearback problems. (See 240)

266 574574 To ensure accurate and safe flight release, airlines / operatorsshould ensure that dispatchers are aware of and take into accountaircraft and flightcrew qualifications.

267 1919 Airlines/operators should implement a procedure to climb to aminimum safe altitude when position uncertainty exists by at least onecrewmember. Flight crew must advise ATC of intentions.

268 7878 Airlines/operators and regulators should improve the availability,clarity, and prioritization of NOTAM information.

270 122122 Air Traffic service providers should implement transmission ofATC instructions/information (between the ground and aircraft) via acomputer link as opposed to voice communications.


154


271 135135 Airlines/operators and regulators should ensure checklist designand implementation of procedures to promote effective crewcoordination and distribution of PF and PNF tasks. (See 82)

272 297297 To prevent CFIT, operators should develop procedures to ensurethat flight crews do not descend when confusion exists concerningaircraft position.

273 394

394 Because of increasing interactions between systems,manufacturers and training organizations should develop newapproaches for instructing pilots in the interrelationships betweensystems.

274 429

429 To reduce the risk of flight with a structurally damaged airplane,airline operators should institute procedures for a diversion to theclosest suitable airport following an upset event that exceeds definedparameters.

275 435435 To ensure stall warning systems are properly functioning,manufacturers should establish appropriate inspection and calibrationprocedures.

277 4646 Airlines/operators should implement procedures to increaseflightcrew awareness of recent aircraft maintenance actions.

279 410

410 To enhance safety in the airport environment, regulators andairport operators should develop guidelines for minimizing the effectsof environmental factors on windfields in the approach and landingareas of the runways and work with local authorities forimplemenetation.

280 441441 To avoid confusion, regulators/operators should develop aconsistent standard for stall speed calculation.

281 554554 Because it is important that training reflect the realities of lineoperations, airline training departments should include instructors whoregularly fly in line operations.

283 388388 Airlines/operators should encourage a culture that emphasizessafe operations over on-time performance (see 22)

285 517517 To ensure an acceptable skill level of pilots entering the aviationprofession, the aviation community should encourage the developmentof and enrollment in aviation career training programs.

291 108108 Air traffic service providers should implement and/or reviewprocedures to ensure ATC training does not create a hazard to flightoperations.


155

4. Data Intervention Strategies


7 361

361 To enhance the ability to analyze, identify and take correctiveactions for preventing accidents, regulators and operators shouldcreate a collection and analysis process which utilizes all existing andfuture aircraft data collection systems, such as DFDR, FOQA, ASAPand other non-volatile memory systems.

14 5656 Airlines/operators should implement Flight Operations QualityAssurance (FOQA) programs to identify systemic proceduraldeviations and unsafe trends. (See 54, 55)

46 128128 Airlines/operators and regulators should implement a no blamesafety reporting and data sharing system with appropriate protectionsfrom litigation and prosecution concerns.

55 463

463 To avoid treating an incident as an isolated occurrence and toensure on-going assessment of aircraft specific loss of controlproblems, a focused safety or risk assessment of all accidents andincidents should be conducted to determine the need for immediateresolution. (See 254)

56 490

490 In order to ensure that relevant information is shared during thepilot hiring process, airlines should implement and regulators require astorage and retrieval system that contains pertinent standardizedinformation on the quality of airline pilot performance during trainingand service. (Reference ‘Pilot Records Improvement Act’ – FAA AC120-68)

76 372

372 To ensure that in-service problems are reliably assessed for theirsafety implications and corrected, regulators, operators, andmanufacturers should develop and implement a standard set of criteriafor determining whether or not a problem is safety-related and fortimely corrective action.

87 5454 Airlines/operators should implement Flight Operations QualityAssurance (FOQA) programs.

104 417

417 Because failures which result in yaw/roll upsets can be particularlydifficult for crews to interpret and successfully handle, manufacturersand operators should give such failures increased scrutiny and higherpriority for reporting.

111 5757 Airlines/operators, regulators, and manufacturers should implementa program designed for sharing of safety related information within theaviation community.

133 373


152 370370 To foster transfer of safety-related information, airplane andcomponent manufacturers should participate in safety data sharingprograms, (e.g. current Manufacturers' safety data sharing meetings).


156


154 402402 To prevent a more serious event, manufacturers should reviseproduct failure analyses if service history reveals unexpectedconsequences or failure modes.

171 536


214 418

418 Because not all operators understand the significance of failureswhich may result in yaw/roll upsets, manufacturers should provideairlines with more information regarding the airplane controlimplications of such failures.

227 505

505 To ensure that safety related incident information is sharedbetween validating and certificating authorities, regulators shoulddevelop a system to review the terms of and compliance to bilateralairworthiness agreements.

229 536



157

5. Regulatory Role Intervention Strategies


56 490

490 In order to ensure that relevant information is shared during thepilot hiring process, airlines should implement and regulators require astorage and retrieval system that contains pertinent standardizedinformation on the quality of airline pilot performance during trainingand service. (Reference ‘Pilot Records Improvement Act’ – FAA AC120-68)

76 372

372 To ensure that in-service problems are reliably assessed for theirsafety implications and corrected, regulators, operators, andmanufacturers should develop and implement a standard set of criteriafor determining whether or not a problem is safety-related and fortimely corrective action.

133 373


171 536


227 505

505 To ensure that safety related incident information is sharedbetween validating and certificating authorities, regulators shoulddevelop a system to review the terms of and compliance to bilateralairworthiness agreements.

229 536


APPENDIX I: MASTER PROBLEM STATEMENT / INTERVENTION MATRIX

159

2 FLIGHTCREW – SOP –Failure of the flight crewto provide completeresponses (callbacks,position reports, etc.)using standardphraseology inaccordance withestablished procedures(FAA, ICAO, Company,etc.)

21 Establish/enhance qualityassurance checks/training toensure that timely and accuratecommunication betweencontrollers and flight crews isoccurring. (OE 1.2)

42 Airlines/operators and airtraffic service providers shouldimplement a monitoringprogram to ensure theconsistent use of the ICAOphraseology. (OE 1.2)

88 Airlines/operators shouldtrain and monitor flight crewcompliance with establishedcommunication phraseologyguidelines. (OE 0.5)

110 Airlines/operators andregulators should ensure thattheir training/standardizationand monitoring programsemphasize the importance ofadherence to standardoperating procedures andidentify the rationale behindthose procedures. (See 99)(OE 3.7)

204 Research should beconducted to better understandthe underlying reasons/causesfor procedural noncompliance.(OE NR)

240 To reduce the possibility oferror, confusion and workloadincrease related to ATCclearances, regulators shouldrequire and operators ensurethat flight crews utilize properphraseology and readbacks.(See 88) (OE 0.6)

2 Cont. 524 Regulators shouldestablish flightcrewphraseology guidelines andairlines/operators should trainand monitor flight crewcompliance withcommunication phraseologyguidelines. (See 88, 240) (OE0.9)

5 AIR TRAFFICSYSTEM/FLIGHTCREW– Inability of air trafficcontrol and theflightcrew to effectivelycommunicate.

28 Implement a system toautomatically transmit ATCinstructions/informationbetween the ground controllerand the aircraft. (OE 0.8)

6 AIR TRAFFIC SYSTEM –Failure of air trafficcontrol to provideinstructions/information/clearances usingstandard phraseologyin accordance withappropriate regulatorydirectives.



106 Air Traffic service providersshould train and monitor ATCadherence to establishedcommunications proceduresincluding hearback problems.(See 240) (OE 1.2)

124 Air Traffic service providersshould implement a QualityAssurance program to ensureadherence to establishedprocedures. (OE 2.1)


241 To eliminate hearbackerrors, ATC should reexamineand implement improvementsto address hearback problems.(See 240) (OE 0.6)

7 AIR TRAFFIC SYSTEM –Inadequate situationawareness (horizontal).Failure of air trafficcontrol to correctlyidentify aircraft positionover the ground

121 Air Traffic serviceproviders should implementworldwide surveillance radar(example: ADS/B). (OE 2.4)

374 To provide terminal areaposition information in non-radar environments, ATSproviders and airplanemanufacturers shouldimplement terminal areaautomatic dependentsurveillance (ADS-B) (TrafficInformation Services (TIS))(OE 2.4)


160

8 AIR TRAFFIC SYSTEM –Failure of air trafficcontrol to followestablished procedures(SOP).

13 Air Traffic service providersshould enhance ATC training toemphasize the dangers ofrushed approaches andperformance characteristics ofjet transports. (See 115, 157)(OE 2.1)

93 Air Traffic service shouldprovide real time (most current)radio communication of criticalairport and weatherinformation. (OE 2.4)



157 Airlines/operators,regulators, air traffic serviceproviders should establishpolicies or programs to addressrushed approaches, includingelimination of rushedapproaches, recognition andrejection of rushed approachesand training for thoseencountered. (OE 3.1)


8 Cont. 497 To minimize exposure toflight operations in icingconditions, air traffic serviceproviders should initially andperiodically train controllers onthe hazards / impacts of icingon aircraft performance whenholding or vectoring aircraft tothe final approach course inareas of known or reportedicing conditions. (OE 2.1)

10 FLIGHTCREW – SOP –Failure of flight crew tofollow establishedprocedures (SOP).

7 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize review ofapproach and missed approachprocedures. (See 329) (OE3.3)

23 Airlines/operators shouldensure that regularly scheduledrecurrent training (e.g. LOFT)emphasizes crew cooperationand working together tomaximize safe operations.(See 308, 314) (OE 2.1)

36 Airlines/operators shouldestablish and implement theuse of electronic checklists orother aids to ensure completionof all checklist items. (OE 1.1)

56 Airlines/operators shouldimplement Flight OperationsQuality Assurance (FOQA)programs to identify systemicprocedural deviations andunsafe trends. (See 54, 55)(OE 3.7)

82 Airlines/operators shouldclearly define, train and checkthe specific PF/PNF/FE duties.(OE 2.3)

99 Airlines/operators shouldensure that clear, concise,accurate, appropriate standardoperating procedures arepublished and enforced. (See110) (OE 4.0)

10Cont.


131 Airlines/operators shouldensure that theirtraining/standardizationprogram emphasizes theimportance of the teamconcept, cross cultural issues,evaluation of options and theobligation of the FO toeffectively communicate anyconcerns (CRM). (See 237)(OE 2.0)


305 Regulators should requireairlines/operators to outfitaircraft with electronicchecklists. If unable to installelectronic checklists, usemechanical checklists or, at aminimum, develop a process toreinforce challenge andresponse checklists. (OE 2.7)

539 To ensure proceduralcompliance, manufacturersshould design and incorporate'smart' checklists that detectfailures and provide the properflight crew actions. (See 444)(OE 1.6)

11 FLIGHTCREW –Inadequate situationawareness (vertical).Failure of flight crew tocorrectly identifyaircraft height aboveground.

14 Install aural warning deviceson aircraft to alert flightcrew ofarrival at MDA/DH. (OE 1.6)

19 Airlines/operators shouldimplement a procedure to climbto a minimum safe altitudewhen position uncertaintyexists by at least onecrewmember. Flight crew mustadvise ATC of intentions. (OE0.5)

100 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize theimportance of adhering toMDA/DH. (OE 0.7)

116 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize thedangers of high rate of descentand unstable approaches.(See 142) (OE 2.3)

142 Airlines/operators shouldestablish policies, parameters,and training to recognizeunstabilized approaches andother factors and implement ago-around gate system. (SeeFSF - "defined gates" p. 193)(See 116, 123) (OE 3.1)

211 Airlines/operators shouldretrofit equipment to provideautomatic altitude callouts onfinal approach. (OE 1.6)

11Cont.

297 To prevent CFIT, operatorsshould develop procedures toensure that flight crews do notdescend when confusion existsconcerning aircraft position.(OE 0.5)

342 Airlines/operators shouldestablish an SOP to ensurethat flight crews should notbegin their approach untiladequate briefing is completedfor the expected runway. (See17) (OE 1.2)


161

12 FLIGHTCREW –Inadequate situationawareness (horizontal).Failure of flight crew tocorrectly identifyaircraft position overthe ground.

244 To prevent plancontinuation errors (e.g. press-on-itis), research should beconducted to determine theeffectiveness of directiveinformation systems for go-around situations . (OE NR)

297 To prevent CFIT, operatorsshould develop procedures toensure that flight crews do notdescend when confusion existsconcerning aircraft position.(OE 0.5)

300 Airlines/operators shouldadopt, implement and train arisk assessment tool toenhance flight crew awarenessof hazards associated with allapproaches and airports (seerisk analysis tactical checklist).(OE 1.4)

308 Airlines/operators shouldensure their formal CRMtraining is culturally appropriateand emphasizes the followingmanagement skills: decisionmaking, workloadmanagement, crewcoordination, planning,communication, situationalawareness and advocacy. (IAWAC120-51b). (See 133) (OE2.1)


13 FLIGHTCREW – Flightcrew misinterpretedinstrument presentationand failed to crosscheck other availableinstruments

64 Airlines/operators shouldensure that theirtraining/standardizationprograms direct the flight crewsto regularly cross check allinstrumentation. (OE 1.8)

112 Airlines/operators andregulators should ensure thatthe frequency andeffectiveness of proficiencychecks for simulated instrumentfailures (partial panel) areadequate. (OE 2.1)

325 Airline/operators shouldemphasize during initial andrecurrent training theimportance of maintainingsystems status awarenessduring non-normal events andhazardous approaches (goal toavoid tunnel vision/narrowedattention). (OE 2.1)

390 Because some partialsystem failures may not bereliably observed,manufacturers should developwarning systems that alert thepilot to those partial/totalfailures of flight critical systemsand flight instruments. (OE1.0)

391 Because of the interactionbetween systems,manufacturers should developalerting systems that help pilotsunderstand any common causeof multiple failure messages.(OE 2.4)

393 To ensure system statusawareness, airlines/operatorsshould ensure that theirtraining/standardizationprograms direct the flight crewsto use all available tools todetermine airplane systemstatus. (See 47) (OE 1.7)

13Cont.

445 To help avoid loss ofcontrol, manufacturers shoulddevelop and implement flightenvelope protection. (e.g.bank/pitch angle limits, over-speed, angle of attack, loadfactor) (OE 4.6)

14 AIRCRAFT EQUIPMENT– EQUIPMENT FAILURE– Failure of instrumentand/or warning systemduring critical phase offlight (e.g. takeoff,approach, landing,approach to stall, etc.)

45 Manufacturers shouldensure that all impendingequipment failures orinappropriate settings that mayaffect the safe operation of theflight are properly annunciatedto the flight crew by use of dualsource sensing. (See 103,138) (OE 2.2)

49 Regulators should establishcriteria for, and manufacturersshould evaluate and improve,the reliability and failuretolerance of flight systems.(includes hardware, softwareand human performance). (See332) (OE 1.0)

253 To prevent loss of control,there should be redundancyand failure tolerance featuresfor all flight critical components,such as dual path design, failoperational redundant systems,with fault annunciation. (OE2.8)

371 To eliminate the potentialsafety consequences of systemfailures,manufacturers/operatorsshould develop a reliableprocess for identifying,prioritizing, and resolving thesafety consequences of systemand component malfunctionsthroughout the operationalenvelope. (OE 1.5)

436 To ensure adequate stallwarning, regulators shouldmandate improved accuracyand integrity in the stall warningsystem (including aircraftcurrently in service). (OE 1.1)

454 Because latent andcombination failures have beenmissed in failure analyses,manufacturers and regulatorsshould conduct more intensiveverification of all safetyanalyses associated withsystems whose failures, singlyor in combination with othersystem failures, can result inaccidents. (OE 1.7)

14Cont.

455 Because latent andcombination failures may bemissed in failure analyses,manufacturers and regulatorsshould conduct research intoimproved methods forconducting safety analyses, toensure reliable identification offailures which, singly or incombination with other systemfailures, can result in accidents.(OE NR)


162

16 FLIGHTCREW – CRM –Lack of CRM training orfailure to follow CRMpractices.

25 Airlines/operators shouldestablish a CRM trainingprogram and regulators shouldrequire and insure that theinitial training is provided priorto line flying and requirerecurrent CRM training. (See131, 132, 349) (OE 2.1)

26 Airlines/operators shouldensure that CRM training isprovided prior to line flying.(OE 1.7)

94 Implement real time (digital)transmission of airport andweather information to theaircraft. (OE 2.0)

107 Airlines/operators shouldensure that their CRMtraining/standardizationprogram emphasizes theimportance of the teamconcept. (OE 2.1)


133 Airlines/operators trainingof captains and chief pilotsshould include managementpractices that promote teambuilding and effective humanrelations (leadership trainingbeyond current CRMprograms). (See 308) (OE 0.8)

16Cont.


314 Airlines/operators shoulddevelop simulator trainingscenarios that require flightcrews to learn multi-taskingabilities and appropriateprioritization abilities in concertwith CRM skills (see Red FlagLOFT scenarios). (OE 2.4)

349 Airlines/operators shouldensure training for instructorsand check airmen includeobjective criteria to be used inevaluating crew CRMperformance. (See 25,131)(OE 1.1)

17 AIRLINES/OPERATORS– SOP – Failure of theairline/operator toprovide adequatestandard operatingprocedures (SOP) thataddress situations andenvironments that theflight crews operate in.

30 Airlines/operators shouldadopt the "delegated" approachto standard operatingprocedures. (e.g. monitoredapproach procedures). (OE1.8)




141 Airlines/operators andregulators should requiretraining/standardizationprograms include trainingregarding physiological effectson aircrew performance, (e.g.low blood sugar, fatigue). (OE1.1)

316 Regulators should requireairline/operators to train flightcrews to recognize andcounteract acute and chronicfatigue. (See 31, 130, 203,257,315) (OE 1.4)

17Cont.

389 To assist flight crews inresponding to systemmalfunctions, manufacturersshould develop andairlines/operators shouldincorporate readily accessibleflight crew procedures forpartial or total failure of flightcritical systems. (OE 0.7)



400 In order to promote safecrosswind landings,manufacturers will provide andairline operators will implementaircraft crosswind landinglimitations, includingconsiderations for flight controleffectiveness and gustconditions. (OE 3.1)

19 FLIGHTCREW – Lack ofbasic piloting skills orknowledge required tosuccessfully perform aflight maneuver or aprocedure orunderstand itsconsequences.

54 Airlines/operators shouldimplement FlightOperationsQuality Assurance(FOQA) programs. (OE 2.3)




111 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize basicairmanship skills andknowledge during initial andrecurrent training. (OE 2.3)

114 Airlines/operators shouldensure that theirtraining/standardizationprograms provide sufficienttraining to ensure aircrewproficiency. (OE 2.8)


163

19Cont.

147 Airlines/operators shouldrequire training/standardizationprograms, which teach situationawareness. (The knowledgeand understanding of therelevant elements of the pilotsurroundings, including aircraftsystems, and the pilotsintentions)

149 Manufacturers shouldinstall a HUD as standardequipment. (See 85) (OE 2.3)

159 Manufacturers shouldincorporate an "input rudder"indicator or automatic yawcompensation to ensure thatadequate yaw control isprovided. (OE 2.1)

331 Airline operators andmanufacturers will train crewsto understand capabilities andlimitations of system, conditionswhich would cause the systemto not function properly andhow to detect failure todeploy/activate andrecommend contingencyactions. (OE 2.8)

357 To insure crews have theadequate skills to recover fromextreme attitude upsets,regulators should require, andoperators should immediatelyimplement, initial and recurrentupset recovery training. (OE4.0)

358 To provide optimal upsetrecovery training and tominimize negative training,regulators, aircraft andsimulator manufacturers andoperators should insure thattraining devices replicateaircraft performance andresponse necessary foreffective training. (See 386,475) (OE 2.8)

19Cont.

359 To improve effectivenessof upset recovery training,research should identify themost effective methodology forupset training. (OE NR)

384 Since it is possible to entera stall, airlines/operators shoulddevelop and implement aground school and simulatortraining program to train pilotsto handle post stall recovery aspart of advanced maneuvertraining. (OE 3.3)

474 Since indications ofsideslip may not be prominentand can be masked by rolleffects, manufacturers shoulddevelop improved sideslipindications and/or alerting (e.g.similar to pitch limit indicationsfor pitch / angle of attack). (OE2.1)

475 Since simulators cannotadequately replicate the motioncues associated with sideslip,the industry should developimproved methods for safelytraining pilots to recognize andrespond to inflight sideslipevents. (See 358, 386) (OE1.7)

484 To ensure adequate FOproficiency, airlines/operatorsshould incorporate theoperating practice of alternatingPF/PNF duties (alternating legsand landings). (OE 2.1)

490 In order to ensure thatrelevant information is sharedduring the pilot hiring process,airlines should implement andregulators require a storageand retrieval system thatcontains pertinent standardizedinformation on the quality ofairline pilot performance duringtraining and service.(Reference ‘Pilot RecordsImprovement Act’ – FAA AC120-68) (OE 2.8)

19Cont.

559 To reduce the likelihood ofhard landings,airlines/operators shoulddevelop training syllabi withimproved coverage of landings,including identification of andrecovery from unstabilizedflares, high sink rates, andbounced landings. (OE 1.3)

561 Airlines should maximizethe use of autoland systemsconsistent with maintainingmanual landing proficiency.(OE 3.3)

568 Since the definition andreporting criteria for hardlandings are poorly defined andthere have been severallandings that have resulted inMD-11 wing structural failures,regulatory authorities shouldrequire inspection of all MD-11sto ensure that unreported hardlandings have not resulted instructural damage. (OE NR)

20 AIRLINES/OPERATORS– TRAINING –Airline/operator trainingfailed to adequatelyaddress operationalrequirements necessaryfor the flight crew tosafely operate theairplane

15 Airlines/operators shouldensure that theirtraining/standardizationprograms instruct when todisengage automated systemsand fly manually. (See 246)(OE 3.1)







164

20Cont.

143 Airlines/operators should,and regulatory agencies must,encourage a culture thatenhances safety in their dailyoperations. (Safety Culture)(See 22, 63, 348) (OE 1.1)

246 To reduce pilot overload,airlines/operators policiesshould stress using theappropriate level of automation.(OE 1.6)

328 Airlines/operators shouldensure that flight crews aretrained to think in terms of "Iwill go-around unless" ratherthan "I will land unless."Regulatory policy shouldsupport this approach. (See142, 311) (OE 2.3)

329 Airlines/operators shouldincorporate in initial andrecurrent training ways torecognize multiple cues that willrequire go-around. Theseinclude CFIT training aid 2.1.9,FSF definition of stabilizedapproach, risk assessment tool,and windshear training aid.(OE 2.3)



20Cont.


365 To ensure pilot capabilityto maintain or regain control,regulators should require andoperators should implementtraining programs whichaddress crossover speedeffects. (OE 2.8)

405 To enhance stability in theapproach and landing phase,airline operators should trainpilots to properly control theaircraft in the transition fromautocoupled/autolandapproaches to manual control.(OE 2.2)

409 To enhance stability duringthe approach and landingphase, airline operators shoulddevelop and implement policiesand procedures that addressmixed mode flight (e. g.,autothrottles in manual flight)with specific emphasis onpitch/thrust coupling andaircraft control problems. (OE2.1)

452 Since handling qualitiesand performance margins maybe significantly different duringhigh altitude cruise,airlines/operators shouldensure that pilots receiveadequate training andexperience in manual flying inthis flight regime. (OE 1.1)

529 To avoid negative training,airline operators should ensurethat their training curriculumcorrelates with the AOM andother relevant manuals. (OE1.7)

20Cont.

548 In order to provide flightcrews with engine out trainingon takeoff without visualoutside reference, regulatorsshould require, and operatorsshould conduct, takeoff engineout training and evaluationduring the portion of the takeoffafter rotation through initialclimb. (OE 2.1)

21 FLIGHTCREW – Flightcrew disregard of, orfailure to recognizecues to terminatecurrent course of actionor maneuver (“PRESS-ON-ITUS").

22 Airlines/operators shouldencourage a culture thatemphasizes safe arrivals overtimely arrivals. (See 63, 143)(OE 0.7)


96 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize theimportance of adequateapproach preparation andcontingency review prior tocommencing an approach.(OE 1.2)

105 Airlines/operators shouldtrain flight crews on how flightdelays upon departure orenroute (weather,maintenance, ATC, etc.) canaffect their subsequentdecision-making relative to thesafe conduct of the flight. (OE0.6)

115 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize thedangers of rushed approaches.(See 13, 157) (OE 2.3)

162 Airline/operators shouldinclude in their trainingprograms the awareness ofpotential safety risks due to thecomplacency when operating ata very familiar airport (e.g.home base). (OE 0.6)

21Cont.

244 To prevent plancontinuation errors (e.g. press-on-itis), research should beconducted to develop directiveinformation systems for go-around situations . (OE NR)



429 To reduce the risk of flightwith a structurally damagedairplane, airline operatorsshould institute procedures fora diversion to the closestsuitable airport following anupset event that exceedsdefined parameters. (OE 0.5)


165

22 FLIGHTCREW – PilotNot Flying (PNF) failedto perform monitoringfunction and other PNFresponsibilities




403 To ensure clearcommunication, airlineoperators should trainflightcrews to emphasize ifaction is required when givingstatus reports. (OE 1.3)

23 FLIGHTCREW – Flightcrew intentionaldisregard of and failureto respond to flightdeckwarning







23Cont.

208 Research should beconducted to understand andcounteract the phenomenon offlight crew overload. (e.g. whydo flight crews ignore GPWSwarnings) (OE NR)

378 To preclude continuedflight into an unsafe aircraftenergy state, Airlines/operatorsshould establish procedures forflight crews to establish a safe,stabilized flight condition whensituational uncertainty existsand THEN advise ATC ofintentions. (OE 1.0)

24 FLIGHTCREW/AIRLINES/OPERATORS –Disregard ofaeromedical factors(fatigue, sleep cycles,medications, alcohol,etc.)

48 Airlines/operators andregulators should strictlyenforce flight/duty timelimitations. (OE 2.0)

130 Regulators should accountfor realistic rest scenarios whendeveloping and implementingcrew rest requirements duringtravel segments. (See 31,203, 257, 315, 316) (OE 1.3)


203 Airlines/operators shouldprovide crews with inflight restperiods and adequate facilities.(See 31, 130, 315) (OE 1.1)

242 To prevent excessivefatigue, airlines/operatorsshould consider circadianrhythm in crew scheduling tocompensate for the effects ofrhythm interruptions. (OE 1.1)

257 To eliminate loopholes increw rest requirements and toensure adequate crew rest,regulators should clarify crewrest regulations. (See 31, 130,203, 315, 316) (OE 2.5)

24Cont.


388 Airlines/operators shouldencourage a culture thatemphasizes safe operationsover on-time performance (see22) (OE 0.3)

493 To reduce the risk of pilots'non-readiness for flying,airlines/operators should trainpilots to perform self-auditmedical and psychologicalassessments prior to flight duty.(OE 1.1)

26 AIRCRAFT EQUIPMENT– CVR not fullyfunctional during theaccident (for futureaccident prevention).

27 Airlines/operators shouldimplement maintenanceprocedures to ensure properfunctioning of the CVR at alltimes. (Note: this interventionwas recorded as a potentialintervention of future accidents,it would not have prevented thesubject accidents.) (OE NR)


166

28 AIR TRAFFIC SYSTEM –INFRASTRUCTURE –The air traffic systemlacked equipment thatmight have helpedprevent the accident(DME, radar, etc.)

10 Air traffic service providersshould train air trafficcontrollers to use all availabletools to establish aircraftposition (example: don't fixateon just DME). (OE 0)

12 Air traffic service providersshould emphasize in ATCtraining the controllers' potentialin assisting the flight crew inimproving their situationawareness. (OE 0.2)

121 Air Traffic serviceproviders should implementworldwide surveillance radar(example: ADS/B). (OE 2.4)


374 To provide terminal areaposition information in non-radar environments, ATSproviders and airplanemanufacturers shouldimplement terminal areaautomatic dependentsurveillance (ADS-B) (TrafficInformation Services (TIS))(OE 2.4)

30 AIR TRAFFIC SYSTEM –Inadequate situationawareness (vertical).Failure of air trafficcontrol to correctlyidentify aircraft heightabove the ground.

108 Air traffic service providersshould implement and/orreview procedures to ensureATC training does not create ahazard to flight operations.(OE 0)

31 FLIGHTCREW –Preoccupation withautomated systems(FMS) to the exclusionof alternative navigationsystems

52 Airlines/operators shouldensure that theirtraining/standardizationprograms establish flight crewproficiency in the use of theFMS system. (OE 0.4)


520 To ensure flight crewshave a comprehensiveknowledge of the automationsystem(s) functional operation,airlines/operators shouldensure that their training/standardization programsemphasize these skills. (OE2.8)

542 To preclude over-relianceon automation,airlines/operators andregulators should create and/orclarify a definition of“appropriate levels ofautomation,” to include theneed to validate against otherinformation sources and insurethat the resulting definition ispublished and included in allappropriate flight crewpublications, manuals andtraining programs. (OE 2.1)

32 AIRLINES/OPERATORS– SOP – Failure of orinadequateairline/operatorprocedures fordisseminating flight-critical informationwithin the organization.

79 Airlines/operators shouldimplement a reliable process tocommunicate information to theflight crew that may affect flightor aircraft operations. (OE 2.7)

80 Airlines/operators shouldverify, and regulators shouldcheck, that operators whocreate their own AOM's includeall operational proceduresprescribed by originalequipment manufacturersAirplane Flight Manual (AFM).(OE 3.3)


225 Airlines/operators andregulators should ensurenecessary manuals(operational & maintenance)are complete, accurate,available and appropriatelyused. (OE 3.1)

498 To ensure safe operatingspeeds in icing conditions,regulators shall require thatminimum safe operatingspeeds in icing conditions bepublished in the aircraft flightmanual (section 1) for allaircraft operatingconfigurations. (OE 2.7)

507 To ensure that flightcrewshave all necessary weatherinformation prior to flight,airlines/operators shouldimmediately review theirsystem of weather informationdissemination to ensure that allsignificant weather informationis provided for their route offlight. (OE 1.5)

32Cont.

508 To ensure that flight crewshave and use all necessaryweather information,airlines/operators shall trainflightcrews and airlinedispatchers on the importanceof reviewing weatherinformation for potential in-flighticing. (OE 1.5)

509 To reduce the risk ofencountering hazardousweather conditions (e.g. super-cooled large droplets (sld),thunderstorms, etc.) researchmust be conducted to developmethods for accurate predictionand identification of theseconditions. (OE NR)


167

33 AIR TRAFFIC SYSTEM –Failure of, orinadequate air trafficsystem procedures fordisseminating flight-critical information.


34 FLIGHTCREW – Failureof captain to exercisecommand authority.

20 Airlines/operators shouldensure that command oversighttraining for captains is providedduring the upgrade processand in recurrent training andfirst officer responsibility formonitoring are reviewed duringrecurrent training. (OE 2.3)




356 Research should be doneto develop an effective tacticaldecision-making model for flightcrews in time critical situations.(OE NR)

38 FLIGHTCREW – Flightcrew preoccupationwith inappropriate tasksor failure to correctlyprioritize the criticaltasks under timeconstraints.







38Cont.







38Cont.


376 To improve aircrewawareness of other traffic,manufacturers should installTCAS in all new aircraft,airlines/operators should retrofitTCAS into the existing fleet andinternational regulators shouldrequire the installation and useof TCAS. (See 35) (OE 0.8)

426 Research should beundertaken to determine how tokeep crews alert in low-stimulation environments (e.g.,highly-automated flightdecks,long-haul flights). (OE NR)

427 To prevent inappropriatepreoccupation with troubleshooting following engine orother system failure, airlineoperators should enhancetraining and checking toprioritize safe control of theaircraft. (OE 2.4)

428 Research should be doneto develop ways to preventinappropriate preoccupationwith trouble shooting followingengine or other system failureto the exclusion of the majortask of flying the airplane. (OENR)

434 To enhance the safety ofoperations, regulatory agenciesshould develop adequateoversight to encourage the useof commonly accepted safeoperating practices. (See 201)(OE 0.9)


168

38Cont.

538 Airline/operators shouldtrain flight crews in teamdecision-making skills,including the ability to rapidlyturn data into information andtest conclusions. (See 314)(OE 1.8)

572 Research should beconducted to improveunderstanding of how/whypilots misprioritize or becomefixated upon concerns andtasks, and to develop strategiesto counteract this effect. (OENR)

39 MANUFACTURERS –DESIGN – Design noterror tolerant. Systemdesign does not provideadequate redundancy tocounteract errors oralerting of the effects oferrors.

45 Manufacturers shouldensure that all impendingequipment failures orinappropriate settings that mayaffect the safe operation of theflight are properly annunciatedto the flight crew by use of dualsource sensing. (See 103,138) (OE 2.2)

412 To avoid problems due tounexpected mode changes,automated flight system logicshould be designed to be errortolerant or, at a minimumprovide an alert when thedesired mode is in conflict withaircraft energy state. (OE 3.1)

416 To provide improved flightcrew situation awareness,manufacturers should provide aclear indication that predicts thefuture aircraft energy stateand/or autoflight configuration ifthe current course of action iscontinued (i.e., analogous toEGPWS mode that analyzesthe airplane's descent rate vs.its terrain map, and tells thecrew that a conflict will occur ifthey continue at that descentrate. The system would warnthe crew that, if they continueat the current roll rate (forexample), the plane will exceedthe envelope, or the autopilotwill reach the limits of itsauthority, etc.) (OE 2.8)

424 To enhance crewawareness of automationmodes, manufacturers shouldensure that mode changes ordisconnects, in the automatedsystems are annunciated in away that is obvious to the flightcrew. (OE 3.1)

430 Research should beconducted to determine theoptimal way to provideflightcrews with aircraft statusrecognition during criticalsituations. (OE NR)

433 To preclude inadvertententry into stall conditions duringautopilot operation, regulatorsshould not permit andmanufacturers should notdesign autoflight systems thatwill allow the autopilot to controlthe aircraft into a stalledcondition. (OE 2.7)

39Cont.

446 To decrease theprobability of ice buildup,manufacturers should designand install a system thatautomatically detects andsheds ice from flight-criticalsurfaces. (OE 1.3)

483 To ensure that the displayof conflicting attitudeinformation does not confuse ormislead the flightcrew, theattitude sensing and displaysystems should be designed sothat invalid information isdetected and clearlyannunciated to the flight crewand/or removed from display.(OE 3.8)

485 To preclude the accidentalchange of aircraft systemsstatus, manufacturers shoulddesign flight decks to minimizethe potential for inadvertentactivation/deactivation ofaircraft systems and/orunintended autoflight modechanges. (OE 3.1)

533 To prevent loss of control,manufacturers should designautomated systems to yieldcontrol to manual inputs whenthose manual inputs are inconflict with the automatedconfiguration. (OE 3.8)

42 FLIGHTCREW – Failureof the flight crew torecognize and takeappropriate action tomitigate combinationsof circumstantialfactors, hazards, and/ornon-normal systemconditions.


147 Airlines/operators shouldrequire training/standardizationprograms which teach situationawareness. (the knowledgeand understanding of therelevant elements of the pilotsurroundings, including aircraftsystems, and the pilot'sintentions)

154 Airlines/operators shouldimprove/increase training toincrease awareness of icingeffects on airplane typeincluding dynamic simulatortraining. (OE 3.1)

163 Airlines/operators shouldensure that theirtraining/standardizationprograms address commonperceptions that could lead tounsafe practices. (OE 1.9)




169

42Cont.







42Cont.


401 To ensure properidentification of enginemalfunctions and avoidance ofpossible loss of control,airline/operators should provideenhanced and more realistictraining for enginemalfunctions, engine responsesto control signal errors and theappropriate aircrew actions.(OE 2.4)


415 To provide improvedaircraft status awareness,airline/operators shouldenhance training to identifyaircraft configuration and therepercussions of the aircraft'senergy state. (OE 2.0)


424 To enhance crewawareness of automationmodes, manufacturers shouldensure that mode changes ordisconnects, in the automatedsystems are annunciated in away that is obvious to the flightcrew. (OE 3.1)

42Cont.

425 To enhance crewawareness of automationmodes, research should beconducted to develop intelligentsystems that will alert the flightcrew to inconsistenciesbetween the selectedautomated flight modes, aircraftperformance and currentsystem status. (OE NR)

438 To reduce the probability ofaccidents, operators shouldadopt operational riskmanagement techniques fornon-standard flight operationsand/or flights requiringintensive training scenarios.(OE 2.3)

442 To avoid delay in therecognition of enginemalfunction/failure,manufacturers should developand implement a direct auraland visual flight deck indicationof engine malfunction/failure.(Minor transients need not beannunciated.) (OE 2.1)

443 To ensure the besttechnique for enginemalfunction/failure annunciationand to minimize nuisancealerts, research should beconducted to determine when,and how, to annunciate enginemalfunctions/failures . (OE NR)

549 To prevent a blurring offlight crew responsibilities whentwo captains are paired to fly atrip sequence, one of the pilotsshould be designated as thepilot-in-command for theduration of the trip pairing. (OE0.8)

43 FLIGHTCREW – Flightcrew failure torecognize andcounteractcomplacency that mayexist when operating athome aerodrome.(“HOME AERODROMECOMPLACENCY”)



170

44 FLIGHTCREW – Flightcrew failure torecognize and correctunstable approach.







44Cont.





531 To minimize theoccurrence of loss of controlduring unstable approaches,manufacturers should designand implement a system todetect unstable approachesand provide an automaticcallout to go around. (OE 2.4)

45 FLIGHTCREW - Failureof the flight crew tounderstand the impactof inoperative ordegraded aircraftsystems on aircraftperformance (e.g. dueto maintenanceactions).


553 Since performancecalculations can havesignificant safety implications,regulatory authorities shouldensure that pilot training andprocedures adequately addresstheir meaning and use. (OE2.1)

46 AIR TRAFFIC SYSTEM –Air traffic systemprocedures that maycompromise safety orincrease flight crewworkload (e.g. noiseabatement procedures,slam dunk approaches,inappropriate taxiroutes during lowvisibility operations,etc.).




310 Regulators should notallow noise abatementprocedures that reduce thelevel of safety that existed priorto their implementation. (OE0.9)

47 FLIGHTCREW – Flightcrew failure to maintainaircraft systems statusawareness.


147 Airlines/operators shouldrequire training/standardizationprograms, which teach situationawareness. (The knowledgeand understanding of therelevant elements of the pilotsurroundings, including aircraftsystems, and the pilotsintentions)




379 Since people are oftenunaware of their ownconfusion, research should beconducted to develop a set ofcues to help flight crews andcontrollers identify when theyhave lost situation awareness.(OE NR)


171

47Cont.





48 AIRLINES/OPERATORS– Airline/operator lackof stabilized approachcriteria and mandatorygo-around/rejectedlanding policy.



411 To reduce accidents duringthe landing phase, airlineoperators should establishcriteria and procedures andtrain flight crews to recognizeconditions which might requirea rejected landing. (OE 2.1)

50 AIRLINES/OPERATORS– Airline/operator failedto effectively correctknown procedural non-compliance issues.


51 AIRLINES/OPERATORS– Airline/operator failedto correct systemiccomplacency and non-standard conduct withinthe company.


52 REGULATORS –Ineffective oversight ofprocedural non-compliance

12 Air traffic service providersshould emphasize in ATCtraining the controllers' potentialin assisting the flight crew inimproving their situationawareness. (OE 0.2)



345 Ensure regulators haveadequate funding, training andprocesses to accomplish theiroversight responsibilities. (See201) (OE 2.4)


172

54 AIR TRAFFICSYSTEM/FLIGHTCREW– Flight crew actions orinactions contributed toincreased workload(e.g. missed checklistitems causing a rushedapproach).




147 Airlines/operators shouldrequire training/standardizationprograms which teach situationawareness. (the knowledgeand understanding of therelevant elements of the pilotsurroundings, including aircraftsystems, and the pilotsintentions)


296 To mitigate confusionregarding ATC clearances,operators should developprocedures to ensure flightcrews query ATC wheneveruncertainty exists. (OE 0.9)

54Cont.



377 Because pilots may bereluctant to ask for clarificationof clearances when uncertain,ATS providers should developpolicies and training thatencourages pilot queries whenthey are unsure of clearances.(OE NR)


379 Since people are oftenunaware of their ownconfusion, research should beconducted to develop a set ofcues to help flight crews andcontrollers identify when theyhave lost situation awareness.(OE NR)

573 To preclude late descentclearances, Air Traffic Serviceshould ensure that standardterminal arrival procedures arein place to transition fromenroute altitudes to theinstrument approachprocedure. (OE 1.5)

55 AIRLINES/OPERATORS– Airline/operatorpolicies burdened flightcrew with non-flightrelated tasks (e.g.paperworkrequirements whileflying; communicationswith dispatch and/or airtraffic control requestsfor info not related tosafe flight and landing).


56 MANUFACTURERS/AIRLINES/OPERATORS –Failure ofmanufacturers andairlines/operators toappropriately prioritizechecklist items toensure critical itemsreceive properemphasis.


134 Airlines/operators andregulators should ensure checklist designs, prioritize criticalitems as recommended byNASA study, and arrange itemsin a manner that enhanceschecklist implementation. (OE1.2)


444 To ensure proceduralcompliance, research shouldbe conducted to develop 'smart'checklists which detect failuresand provide the proper flightcrew actions. (OE NR)

57 MANUFACTURERS –DESIGN – Systemdesign was notappropriate forconditionsencountered.


137 Manufacturers shouldensure cockpit design that doesnot interfere with or distract theflight crew from executing theirduties (e.g. rain in the cockpit,location of switches incockpits). (OE 0.2)

364 To protect aircraft againstloss of control, regulatorsshould develop as soon aspossible, certification criteria,throughout the entire flightenvelope, for crossover speedsand maximum rudder sideslips. (see 431) (OE 3.5)

368 To enable pilots to developsituation awareness withrespect to aircraft performancecapability, regulators shouldrequire and manufacturersshould provide angle of attackdisplay. (OE 1.8)

369 To provide adequate stallwarning, regulators shouldrequire and manufacturersshould develop, stall warningsystems for new/derivativeaircraft that provide accurateinformation throughout thecertificated flight regime. (OE1.3)



173

57Cont.

383 To ensure adequate timemargin between stall warningand actual stall, manufacturersand regulators should developand implement stall warningsystems that account forvarious entry rates/conditionsto stall. (OE 2.3)

398 To provide real timeaccurate wind componentinformation to flight crews, airtraffic services andmanufacturers shouldimplement real time(automated)transmission/display of suchinformation in the most directlyuseable format to the flightcrew, during approach andlanding phase. (See 94) (OE3.1)

404 To enhance crewperformance in the approachand landing phase, airlineoperators should train pilots tounderstand the limitations ofcomputed wind displays. (OE0.1)

406 In order to minimizeautoflight to manual transitioneffects, research should beconducted to determine thefeasibility and desirability ofautoflight/flight control systemsdesigns that eliminate the needfor large flight control input atdisengagement from ALIGNmode. (OE NR)

407 To minimize pilot reactionrequirements during transitionfrom autocoupled to manualflight during approach,regulators should require, andmanufacturers should design,autoflight systems so thatALIGN mode need not beengaged when a manuallanding is planned. (OE 2.7)


57Cont.


431 To assist flight crews inavoiding loss of control onexisting aircraft, regulators andmanufacturers should evaluatethe effects of crossover speedsand maximum rudder side slipthroughout the entire flightenvelope and disseminate theinformation to operators andflight crews. (OE 3.5)

436 To ensure adequate stallwarning, regulators shouldmandate improved accuracyand integrity in the stall warningsystem (including aircraftcurrently in service). (OE 1.1)

446 To decrease theprobability of ice buildup,manufacturers should designand install a system thatautomatically detects andsheds ice from flight-criticalsurfaces. (OE 1.3)

495 To improve aircraft failuretolerance, manufacturers andregulators should conductfailure analyses for design andcertification that reflect realisticlevels of flightcrew reliability.(OE 1.2)


100 REGULATORS –Insufficient regulatoryoversight of air carrieroperations includingmanagement andtraining practices.



201 Regulators should developadequate oversight asappropriate to ensurecompliance with regulations.(See 145, 146, 202, 345) (OE2.8)

202 Airlines/operators shoulddevelop a quality assuranceprogram to ensure compliancewith regulations. (See 145,146, 201) (OE 2.2)

214 Regulators should enforcetimely incorporation ofappropriate manufacturersrecommendations. (See 98,201) (OE 3.1)

223 Regulators should ensurePOIs are properly qualified andtrained to approve appropriatecompany operationalprocedures. (OE 1.8)

100Cont.


345 Ensure regulators haveadequate funding, training andprocesses to accomplish theiroversight responsibilities. (See201) (OE 2.4)

347 Parent airlines/operatorsshould adopt a program toensure the same level of safetyin regional partners including,but not limited, to recruitment,training, operations andmaintenance. (OE 2.1)

434 To enhance the safety ofoperations, regulatory agenciesshould develop adequateoversight to encourage the useof commonly accepted safeoperating practices. (See 201)(OE 0.9)

480 To improve operationaloversight, regulators shouldinstitute processes for periodicreview of POIs to ensure thatappropriate oversight is beingconducted for the POI'sassigned operators. (OE 1.6)

481 Because POIs may beresponsible for oversight ofremote training activities,regulators should ensure thatPOIs have sufficient CertificateHolding District Officeresources, including staff, toconduct appropriate oversightfor the POI's assignedoperators. (OE 1.6)


174

100Cont.

489 In order to improveoversight of airlines, regulatorsshould ensure theirorganizations (Flight Standardsin the USA) are staffed toprovide adequate inspectorcoverage for all airlines,(including small airlines). (OE1.4)

560 Since geographicorganization of inspectionresponsibilities can affect thequality/timeliness of inspectionsconducted by supportingorganizations at remotelocations, regulators shouldensure that these remoteinspectors are moreaccountable to the requestingcertificate holdingoffice.(CHDO/CMO) (OE 1.0)

101 AIRLINES/OPERATORS– MAINTENANCE – Theairline/operator culturedid not reflect aproactive approach tomaintain systems fullyoperational in a timelymanner.


372 To ensure that in-serviceproblems are reliably assessedfor their safety implications andcorrected, regulators,operators, and manufacturersshould develop and implementa standard set of criteria fordetermining whether or not aproblem is safety-related andfor timely corrective action.(OE 2.4)

387 To ensure that airplanesystems function as designed,airlines/operators shoulddevelop processes to ensureadherence to manufacturer'srecommended maintenanceprocedures. (OE 1.5)

388 Airlines/operators shouldencourage a culture thatemphasizes safe operationsover on-time performance (see22) (OE 0.3)

420 In order to assure thatairline operations departmentsunderstand the operationalimplications of dispatching withdegraded systems,manufacturers and operatorsshould develop a method forproviding such information tocrews, for MEL and otherdispatchable failure conditions(including intermittent failures).(OE 2.4)

102 FLIGHTCREW –Inadequateplanning/briefing by theflight crew.


17 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize theimportance of all flight-relatedbriefings. (See 342) (OE 1.4)

95 Airlines/operators shouldestablish procedures for flightcrews to review/cross checkinstructions, clearances, etc. toensure consistency withexpected procedures orpractices. (OE 0.6)




103 AIR TRAFFIC SYSTEM –Inadequate weatherinformation provided tothe flight crew by airtraffic services.





175

104 AIRLINES/OPERATORS/REGULATORS – SOP –Lack of airline operatorprocedures and lack ofregulations to identifyflight crew that are"qualified" but whohave a history oftest/check ride failureand demonstratedweaknesses.


151 Regulators shouldestablish policies that requireadditional monitoring of flightcrewmembers that haverepeatedly failed check rides.(See 152, 335, 337) (OE 1.8)

152 Airlines/operators andregulators should raisestandards (e.g. crew pairing,approach minimums, etc.) forflight crewmembers that meetminimum qualifications buthave demonstrated limitedproficiency and/or competency.(See 151, 335, 337) (OE 3.3)

347 Parent airlines/operatorsshould adopt a program toensure the same level of safetyin regional partners including,but not limited, to recruitment,training, operations andmaintenance. (OE 2.1)

105 AIRLINES/OPERATORS– SOP – Lack of airlineoperatorpolicies/procedures toprevent pairinginexperienced pilotstogether (total time,time in type, etc.).

24 Airlines/operators shouldimplement procedures toensure appropriate crewpairing. (reference FSFcorporate crew scheduling andfatigue evaluation.) (OE 2.1)


106 FLIGHTCREW – Flightcrew failure torecognize the state ofthe airplane (speed,energy state, powersetting, pitch attitude,relevant elements of thepilot surroundings,including aircraftsystems and the pilotsintentions).





147 Airlines/operators shouldrequire training/standardizationprograms, which teach situationawareness. (The knowledgeand understanding of therelevant elements of the pilotsurroundings, including aircraftsystems, and the pilotsintentions). (OE 2.8)


106Cont.







106Cont.


381 To provide improved pilotawareness of the airplane'senergy state, manufacturersshould develop and incorporatemore effective energymanagement monitoring andalerting systems. (OE 2.4)






176

106Cont.






472 Since certain enginecontrol and autothrottle systemfailures can result inundesirable asymmetry,manufacturers should redesignATSs so that they disconnect(with appropriate annunciation)when unable to achieve thecommanded thrust settings(analogous to autopilotdisconnect logic). (OE 3.1)

106Cont.

473 Due to increasingdependence on automation andthe complexity of potentialpartial system failures,airlines/operators shouldmodify training programs toemphasize the use of multipledata sources to confirm that theairplane and systems areperforming as expected and inaccordance with theoperational mode. (OE 1.8)

474 Since indications ofsideslip may not be prominentand can be masked by rolleffects, manufacturers shoulddevelop improved sideslipindications and/or alerting (e.g.similar to pitch limit indicationsfor pitch / angle of attack). (OE2.1)

475 Since simulators cannotadequately replicate the motioncues associated with sideslip,the industry should developimproved methods for safelytraining pilots to recognize andrespond to inflight sideslipevents. (See 358, 386) (OE1.7)

515 To warn of impending lossof control with the autoflightsystem fully engaged,manufacturers should developand regulators should requireannunciation of an airplaneflight condition whichsignificantly differs from thatbeing commanded by theselected autoflight systemmode. (ref 243) (OE 3.1)


565 Manufacturers shouldincorporate an "input rudder"indicator to ensure thatadequate yaw control isprovided. (OE 1.5)

106Cont.

566 Manufacturers shouldincorporate an automatic yawcompensation to ensure thatadequate yaw control isprovided. (OE 3.8)

107 FLIGHTCREW – Flightcrew failure to use allavailable informationresources.








177

107Cont.




469 To ensure clearunderstanding of flight crewtasking airlines/operatorsshould develop criteriaspecifying when transfer ofcontrol is necessary orappropriate. (See 207) (OE1.5)

128 526 To increase the number ofavailable pilots, airlines shouldimplement, and regulatorsshould allow, a performance-based selection system thatexpands the eligible pilot poolbeyond the current arbitrarylimits (e.g., age 60 rule,minimum flight time) with anappropriatemedical/psychologicalevaluation. (OE 1.3)

204 FLIGHTCREW –Flightcrew notadequately prepared forthe task (inadequatebriefing, inadequateassessment of weatherfactors and/or notmentally prepared).

17 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize theimportance of all flight-relatedbriefings. (See 342) (OE 1.4)


113 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize theimportance of adequatepreflight planning. (OE 1.7)



135 Airlines/operators andregulators should ensurechecklist design andimplementation of proceduresto promote effective crewcoordination and distribution ofPF and PNF tasks. (See 82)(OE 0.5)

204Cont.



350 Airlines/operators shallensure that adequate approachbriefings are conducted thatinclude descriptions of normalapproach, non-normalconditions and the results ofthe risk assessment analysis.(See 300) (OE 1.5)



447 In order to maintainadequate safety margins duringflight training, operators shouldestablish and regulatoryagencies should requirestandards for conducting flighttraining which precludeoverloading the trainee. (OE1.7)


178

204Cont.

448 To preclude traineeoverload, research should beconducted to understand theoptimum workload level foreffective flight training. (OENR)

206 FLIGHTCREW –Flightcrew failure torespond to and/orprocess the flight deckwarning.







206Cont.


243 To prevent alertingoverload, flight deck designsshould consider smart alertingsystems such as those withprioritization schemes orcancelable nuisance alerts.(OE 1.7)


380 To reduce the risk ofinadvertent entry into stall,manufacturers should developand implement stall protectionfeatures in all transportcategory airplanes, (e.g. stickpusher, alpha protection). (OE3.1)

385 Because flight crewssometimes disregard flight deckwarnings which requireimmediate action, researchshould be conducted tounderstand this phenomenaand develop appropriatesolutions. (OE NR)

207 FLIGHTCREW –Flightcrew failure to usethe appropriate level ofautomation to reduceworkload andcomplexity in flightdeck.


16 To prevent mode confusion,manufacturers should ensurethat automated systemsprovide the flight crew withsufficient information(automation feedback). (OE3.3)


530 To optimize pilot workload,airlines/operators policiesshould stress using theappropriate level of automation.(See 246) (OE 3.7)

556 To reduce pilot overload,airlines/operators shoulddevelop standard operatingprocedures to help standardizethe use of the appropriate levelof automation for the operationand the airplane design (See246, 530). (OE 0.7)

557 Since current ATCprocedures can result in non-standard use of autoflightsystems (e.g. "slam dunkapproaches"), air traffic serviceproviders should harmonizeATC procedures so that theytake into account the flightcharacteristics of modernairplanes and autoflight systemcapability. (OE 0.7)

207Cont.

558 Since current ATCprocedures can result in non-standard use of autoflightsystems (e.g. "slam dunkapproaches"), air traffic serviceproviders and airplanemanufacturers should developand implement automated toolsso that ATC clearances areintegrated with and take intoaccount the performance ofairplanes using autoflightsystems (e.g. CTAS/FMSprogram). (See 557) (OE 0.9)


179

301 AIRLINES/OPERATORS/MANUFACTURERS –Recommendedoperational proceduresare inconsistent and/ornot reconciled.






224 Airlines/operators shouldensure that all airlineoperations include compliancewith all/seasonal guidance fromthe OEM. (OE 1.0)

301Cont.


303 FLIGHTCREW – Failureto process and interpretavailable relevant data.







303Cont.







303Cont.








180

303Cont.



442 To avoid delay in therecognition of enginemalfunction/failure,manufacturers should developand implement a direct auraland visual flight deck indicationof engine malfunction/failure.(Minor transients need not beannunciated.) (OE 2.1)

443 To ensure the besttechnique for enginemalfunction/failure annunciationand to minimize nuisancealerts, research should beconducted to determine when,and how, to annunciate enginemalfunctions/failures . (OE NR)



303Cont.

553 Since performancecalculations can havesignificant safety implications,regulatory authorities shouldensure that pilot training andprocedures adequately addresstheir meaning and use. (OE2.1)

400 AIRLINES/OPERATORS– TRAINING –Inadequate flightcrewtraining due toeconomic/culturalpressures.




523 To ensure that airlineoperation training departmentsaccomplish their trainingresponsibilities, they must beadequately funded. (OE 1.1)

535 To ensure adequateinstructor / check pilotqualifications, operators mustestablish and maintainminimum line and instructor /check airman qualifications.(OE 3.8)

401 AIRLINES/OPERATORS– Airline/operatorstandards failed toensure adequateinstructor/check airmanqualifications(proficiency/skill) priorto conducting training.(see 20)




218 Airlines/operators shouldconduct surveillance ofcontractor training programs foradequacy of training. (See110, 202) (OE 2.4)



181

402 AIRLINES/OPERATORS– TRAINING –Flightcrew inadequatelyprepared for the typeoperation or level oftraining conducted.






404 FLIGHTCREW – SOP –Failure to followprocedures – notannouncing transfer ofcontrol. (see 10)

207 Airlines/operators shoulddevelop procedures to specifyhow transfer of control isformally accomplished. (OE2.5)

406 AIR TRAFFIC SYSTEM –Failure to follow IFRseparation andclearance procedures(SOP). (see 8)


407 AIR TRAFFIC SYSTEM –Inadequate situationawareness (horizontal).Failure to requestand/or correctlyinterpret appropriateaircraft positioninformation (see 7)

375 To improve controllersituation awareness, air trafficservice providers shouldensure that theirtraining/standardizationprograms direct that controllersuse all available tools toestablish aircraft position. (See75) (OE 1.1)

408 AIR TRAFFIC SYSTEM –Failure to followposition reportingprocedures by notrequesting appropriateaircraft positioninformation.(SOP) (see8, 406)

375 To improve controllersituation awareness, air trafficservice providers shouldensure that theirtraining/standardizationprograms direct that controllersuse all available tools toestablish aircraft position. (See75) (OE 1.1)

409 AIR TRAFFIC SYSTEM –Failure to follow propersequencing procedures.(see 8)


410 AIR TRAFFICSYSTEM/FLIGHTCREW– Inadequatecommunications due toblockage of radiotransmission. (see 5)

122 Air Traffic serviceproviders should implementtransmission of ATCinstructions/information(between the ground andaircraft) via a computer link asopposed to voicecommunications. (OE 0.5)


182

411 FLIGHTCREW – Failureto monitor aircraftenergy state due to self-induced highworkload/confusion(see 106)





381 To provide improved pilotawareness of the airplane'senergy state, manufacturersshould develop and incorporatemore effective energymanagement monitoring andalerting systems. (OE 2.4)

382 To provide improved pilotawareness of airspeed,manufacturers should provideflight instruments with moreeffective airspeed trendindications and alerting. (OE2.2)

411Cont.







411Cont.



412 FLIGHTCREW – Failureto follow the "approachto stall" procedures(see 10)




165 Airlines/operators shouldprovide training scenarios thatmatch realistic situations (i.e.stall recoveries duringapproach, in landingconfiguration at flight idle withthe autopilot on (in simulator).(OE 2.8)

525 To mandate stallrecognition and recoverytraining, regulators must modifythe appropriate regulations.(OE 4.2)

534 Airlines/operators shouldimplement procedures that callfor an immediate recoverymaneuver following a warningthat indicates an imminentdeparture from normal flightenvelope (e.g. stall warning,over-speed). (See 161) (OE1.1)


183

413 FLIGHTCREW – Notprepared for post stallrecovery task. (see 204)

245 To recover aircraft inunusual attitude, manufacturersshould develop systems toreturn aircraft to normal attitudewith one pilot button push (pilotinitiated auto-recoverysystems). (OE 2.2)

322 Airlines/operators shoulddevelop and implement aground school and simulatortraining program to train pilotsto handle unusual attitudesituations, e.g. AmericanAirlines Advanced AircraftManeuvering Program. (OE2.4)





413Cont.

386 To support advancedmaneuver training,manufacturers should developsimulator models that faciliatepost stall recovery training (see358). (OE NR)

414 AIRLINES/OPERATORS– TRAINING – Trainingfailed to adequatelydevelop firstofficer/captain pilotingskills. (see 20)




415 REGULATORS –Inadequate oversight ofairline/operator checkpilotselection/qualifications.


416 AIRLINES/OPERATORS– TRAINING – Non-compliance withregulations (training)(see 40)

129 Regulators shouldestablish criteria to ensureoperators overall qualityassurance and complianceprocedures are effective ratherthan reliance on spot checks ofindividual components. (OE2.1)


348 Airlines/operators shouldutilize a self-audit process(such as FSF ICARUSrecommendation), operationalrisk management programsand accident cost analysis toproactively identify and mitigatesafety concerns. (See 318)(OE 1.1)

419 AIRLINES/OPERATORS– TRAINING – Failure ofthe airline/operators toprovide adequatetraining to ensurecompliance with SOP.(see 10)








184

419Cont.




420 REGULATORS –Regulatory oversightfailed to insureairline/manufactureprocedures wereconsistent andreconciled. (see 301)





421 FLIGHTCREW –Increased workload incockpit due to use ofmulti-language phrases.

537 To ensure proper intra-cockpit communications,operators must ensure that thelanguage used in the cockpit iscompatible, understandableand consistent among all flightdeck crewmembers. (OE 1.7)

422 AIRLINES/OPERATORS– TRAINING –Airline/operator trainingfailed to adequatelyaddress methods torecover fromunexpected autoflightmode changes.



456 To help ensure appropriatedecision making, flight crewsshould be trained on the impactof automation on CRM. (OE2.4)

486 Airlines/operators andmanufacturers should traincrews to understand thecapabilities and limitations ofautomated flight systems, theconditions which would causethe systems to not function asthe crew anticipates, and howto detect and recover frominadvertent activation ofautoflight modes (see 331).(OE 4.0)

423 MANUFACTURERS –DESIGN – Lack ofintuitive clarity(transparency) of howto change autoflightmodes.


425 To enhance crewawareness of automationmodes, research should beconducted to develop intelligentsystems that will alert the flightcrew to inconsistenciesbetween the selectedautomated flight modes, aircraftperformance and currentsystem status. (OE NR)

486 Airlines/operators andmanufacturers should traincrews to understand thecapabilities and limitations ofautomated flight systems, theconditions which would causethe systems to not function asthe crew anticipates, and howto detect and recover frominadvertent activation ofautoflight modes (see 331).(OE 4.0)


185

424 AIRLINES/OPERATORS– Lack of a mandatorygo-around policy forunanticipated modechanges duringapproach. (see 48)

123 Airlines/operators shouldimplement a true no-fault goaround policy (learning vs.blame). (OE 0.8)



425 REGULATORS/AIRLINES/OPERATORS – CRM –Lack of culturallyappropriate CRMtraining.



523 To ensure that airlineoperation training departmentsaccomplish their trainingresponsibilities, they must beadequately funded. (OE 1.1)

426 AIRLINES/OPERATORS– Airline/operator didnot adequately evaluatethe safety aspects ofservice bulletins.

98 Airlines/operators andregulatory agencies shouldreview procedures to ensurethat design changes (servicebulletins) to flight criticalsystems are incorporated in atimely manner. (OE 3.1)

532 To minimize the probabilityof accidents, operators shouldprioritize service bulletinimplementation usingoperational risk managementtechniques to assess potentialoperational hazards, includingaircraft modification, etc.. (See98, 348) (OE 3.8)

427 MANUFACTURERS/REGULATORS – Did notproperly assign servicebulletin (SB) category toreflect the level ofoperational urgency.


428 AIRLINES/OPERATORS– Operationalprocedures and trainingdid not adequatelyreduce the requirementfor knowledge-basedsolutions. (Rule-basedrather than knowledge-based)

487 To minimize theoccurrence of loss of controlevents, airline operators'training programs shouldemphasize pattern recognitionand skill-based procedures tobetter handle time-criticalsituations, rather than relyingon knowledge- based analysis.(OE 1.5)


186

429 FLIGHTCREW –Inappropriate crewresponse during criticalflight regime orsituation. (see 10)







429Cont.



395 To ensure that the displayof conflicting air datainformation does not confuse ormislead the flightcrew, theattitude sensing and displaysystems should be designed sothat invalid information isdetected and clearlyannunciated to the flight crewand/or removed from display.(OE 3.1)




429Cont.

432 To facilitate recovery fromflight upsets, airlines/operatorsshould clearly define, train andcheck the specific PF/PNFupset recovery duties. (OE1.1)

470 Since current airlinetraining emphasizes recoveryfrom approach to stall,airline/operators shouldemphasize to air crews theimportance of proper analysisand response to incipient stallconditions (for example timelyreduction in angle of attack).(OE 1.7)

482 To prevent inaction whenthe PF is confused orunresponsive to an in-flighthazard, airlines/operatorsshould develop and train clearand explicit procedures todefine when/how the PNF(especially the F/O) will takecontrol of the airplane. (OE1.0)

430 FLIGHTCREW – CRM –Lack of communicationskills.





227 Airlines/operators shouldensure that theirtraining/standardizationprogram emphasizes thebenefits of inter-crew/companycommunications. (See 131)(OE 2.1)

228 Regulators should requireairlines/operators to modifytheir training to maximizebenefits of inter-crew/companycommunications. (OE 1.3)

430Cont.

237 Airlines/operators shouldprovide guidance to crewconcerning evaluation of alloptions prior to decision makingas part of CRM training. (See25, 26, 131, 132, 133, 308)(OE 1.4)





187

431 FLIGHTCREW – CRM –Lack of crewcoordination skills .







431Cont.





432 FLIGHTCREW – CRM –Lack of workloadmanagement skills.





120 Airlines/operators shouldensure procedures do notincrease pilot workload duringcritical phases of flight. (OENR)


432Cont.






433 FLIGHTCREW – CRM –Lack of planning skills.

556 To reduce pilot overload,airlines/operators should

develop standard operatingprocedures to help standardizethe use of the appropriate levelof automation for the operationand the airplane design (See

246, 530). (OE 0.7)


188

434 FLIGHTCREW – CRM– Lack of decisionmaking skills.







434Cont.





435 FLIGHTCREW –Failure to understandtheoperation/limitations ofAutomation Mode(s)







437 FLIGHTCREW –Inappropriateuse/reliance onautomation to recoverthe airplane fromunusual attitude orunusual in-flightsituations.





439 AIRLINES/OPERATORS - Airline/operatorfailed to ensure thatpre-flight maintenanceprocedures wereaccomplished.



189

440 MANUFACTURERS –Failure to provide anon-normal/emergencyprocedure for a knownfailure condition.

389 To assist flight crews inresponding to systemmalfunctions, manufacturersshould develop andairlines/operators shouldincorporate readily accessibleflight crew procedures forpartial or total failure of flightcritical systems. (OE 0.7)

441 FLIGHTCREW – SOP– Failure to properlyconfirm system statusprior to responding tochecklist challenge(see 106)

392 In order to support pilottakeoff decision-making,research should be conductedto determine the effectivenessof alerting systems to identifysituations which warrant arejected takeoff. (OE NR)

442 MANUFACTURERS –DESIGN – Aircraftdesign allowed thedisplay of misleadinginformation withoutappropriateannunciation. (see 57)


483 To ensure that the displayof conflicting attitudeinformation does not confuse ormislead the flightcrew, theattitude sensing and displaysystems should be designed sothat invalid information isdetected and clearlyannunciated to the flight crewand/or removed from display.(OE 3.8)

443 AIRLINES/OPERATORS – TRAINING –Failure to ensureadequate andstandardized trainingfor their pilots. (see419)



218 Airlines/operators shouldconduct surveillance ofcontractor training programs foradequacy of training. (See110, 202) (OE 2.4)


444 MANUFACTURERS/AIRLINES/OPERATORS – Safetyassessment methodsdo not adequatelyidentify the operationalsafety consequencesof system failureconditions.



417 Because failures whichresult in yaw/roll upsets can beparticularly difficult for crews tointerpret and successfullyhandle, manufacturers andoperators should give suchfailures increased scrutiny andhigher priority for reporting.(OE 2.2)

418 Because not all operatorsunderstand the significance offailures which may result inyaw/roll upsets, manufacturersshould provide airlines withmore information regarding theairplane control implications ofsuch failures . (OE 1.1)

419 Because manufacturersmust make certain assumptionsregarding which failures will bedetected and handled by thepilot with "normal piloting skills,"research should be conductedto determine if these assumedskills and knowledge are validin realistic airline operations.(OE NR)


190

445 MANUFACTURERS –Failure of, orinadequateprocedures fordisseminating safetyinformation betweenmanufacturers. (see32)

57 Airlines/operators,regulators, and manufacturersshould implement a programdesigned for sharing of safetyrelated information within theaviation community. (OE 2.1)

370 To foster transfer of safety-related information, airplaneand component manufacturersshould participate in safety datasharing programs, (e.g. currentManufacturers' safety datasharing meetings). (OE 1.7)

446 AIRLINES/OPERATORS – Failure to disableautomation systemswith known problems.(see 207)

421 Since intermittent failurescan persist for unspecifiedperiods of time withoutcorrection, operators shoulddevelop specific policies,procedures and guidancedefining when degradedsystems or systems withintermittent problems should bedisabled, invoking theappropriate MEL requirements.(OE 1.5)

447 AIRLINES/OPERATORS – Over reliance oncrew procedures towork aroundunresolved intermittentairplane failureconditions.

423 To ensure that recurrent,intermittent failures are notallowed to persist, regulatorsshould revise MEL dispatchrequirements so that certainintermittent failures areconsidered to be full failures, ifwarranted by safetyimplications of the failures andfrequency of occurrence. (OE3.5)

448 REGULATORS – Lackof a formalized systemfor threat freereporting of safety-related incidents fromoperators tomanufacturers.

No interventions cited

449 MANUFACTURERS –Lack of a reliableprocess forreviewing/revisingsystem safetyassessments basedon field data collectedafter certification.



373 To ensure thatmanufacturers and regulatorsare aware of recurrentproblems (type and frequency),manufacturers, regulators andoperators should implement areliable process for gatheringand reporting safety-relatedproblems. (OE 2.0)

402 To prevent a more seriousevent, manufacturers shouldrevise product failure analysesif service history revealsunexpected consequences orfailure modes. (OE 1.7)


191

450 AIRLINES/OPERATORS – MAINTENANCE– Airline/operator doesnot provide a loggingprocess that requiresflight crews to reportrecurring events.

422 To ensure constantvisibility of known intermittentfailures, operators shoulddevelop procedures forcontinued reporting of andmaintenance actions toaddress unresolved intermittentfailures. (OE 0.8)

451 AIRLINES/OPERATORS – Failure toaddress the problemsassociated with theflight crew transitionfrom Eastern builtaircraft to Westernbuilt airplanes.

471 Since many factors canmake the identification ofimpending loss of controldifficult, research should bedirected toward thedevelopment of systems thatadvise the flight crew that theaircraft is departing from a flightpath consistent with the flightcontrol inputs. (OE NR)

565 Manufacturers shouldincorporate an "input rudder"indicator to ensure thatadequate yaw control isprovided. (OE 1.5)

566 Manufacturers shouldincorporate an automatic yawcompensation to ensure thatadequate yaw control isprovided. (OE 3.8)

453 FLIGHTCREW – PilotFlying (PF) failed toperform monitoringfunction and/or otherPF responsibilities.(see 22)




454 MANUFACTURERS –Failed to recommendappropriate aircraftsystems calibrationintervals.

435 To ensure stall warningsystems are properlyfunctioning, manufacturersshould establish appropriateinspection and calibrationprocedures. (OE 0.5)

455 AIRLINES/OPERATORS – Kept and/orentered inadequatelyprepared aircraft intoservice due toeconomic pressures.


456 REGULATORS –Inadequateregulation/guidanceestablishing minimumconditions for criticalaircraft handlingmaneuvers. (See 582)


408 To minimize undesirableeffects of transition to manualflight from ALIGN mode,regulators should require thatminimum altitudes andconditions be established fordisengagement of automatedsystems when a manuallanding is anticipated. (OE3.1)

437 To enhance the safety offunctional evaluation flights(FEF), regulators shouldestablish standards for criticalaircraft handling maneuvers.(OE 2.0)

439 To ensure properdesignation of pilots conductingnon-standard flight operations(e.g., Functional EvaluationFlights), regulation and/orguidance should be revised toclearly indicate pilotexperience, pairing, andtraining levels required. (OE2.0)


192

457 FLIGHTCREW – Lackof upset recovery(Advanced Maneuver)skills and knowledge.



322 Airlines/operators shoulddevelop and implement aground school and simulatortraining program to train pilotsto handle unusual attitudesituations, e.g. AmericanAirlines Advanced AircraftManeuvering Program. (OE2.4)




457Cont.




458 SIMULATOR/AIRCRAFTMANUFACTURERS –Lack of simulatorfidelity andaerodynamic modelsthat adequatelysupport upsetrecovery (AdvancedManeuver) training.





459 FLIGHTCREW –Failure to recognizethe performanceeffects of iceaccumulation on theaircraft.




460 To ensure a betterunderstanding, by air crews, ofappropriate procedures for useof ice protection systems,operators, manufacturers andregulators should expedite themodification of trainingprograms and distribution ofmedia, to include ice bridgingand deicing boot operation.(OE 2.4)

460 MANUFACTURERS –DESIGN – Failure toprovide adequateinstrumentation tooptimize performanceduring recovery fromunusual attitude.

488 To facilitate recovery andattitude awareness,manufacturers should includeadequate instrumentation tooptimize performance duringrecovery from unusual attitude.(OE 2.7)


193

461 MANUFACTURERS –DESIGN – Previouslycertificated designsmay not meet currentminimum performancestandards.

366 To protect aircraft againstflight control malfunctions,manufacturers must design andregulators must certificatederivative aircraft andcomponents to currentapplicable certificationrequirements, i.e. single pointfailures, redundancy, andprobability of failure. (OE 4.2)

440 To ensure all aircraft meetcurrently accepted minimumperformance standards,regulators should requirewarning systems that meetairworthiness standards. (OE1.7)

462 REGULATORS/AIRLINES/OPERATORS –Lack of consistentdefined method ofcalculating stall speed.

441 To avoid confusion,regulators/operators shoulddevelop a consistent standardfor stall speed calculation. (OE0.4)

464 REGULATORS – Highrisk maneuverspermitted duringtraining due toregulatoryrequirement/lack ofrequirement. (see 490)

546 Airlines/operators shouldensure that flight crews areadequately trained in anappropriate level simulator forthe training being conducted(i.e. engine out, upset recovery,etc.) before being assigned tothe line. (See 153, 312) (OE3.8)

465 REPAIR FACILITY –MAINTENANCE –Failure to developadequate repair andinspection procedures.



251 To preserve the originalintended level of airworthiness,there should be a betterdefinition and classification ofsubsequent in-service majorand minor critical componentchanges. The definition ofcritical component should bemore specific. (OE 1.3)

476 Since repair processes cansignificantly affect theairworthiness of components,regulators should requiremanufacturer concurrence onall maintenance and repairprocedures affecting criticalaircraft structures, components,or performance. (OE 0.9)

466 REPAIR FACILITY –MAINTENANCE –Failure tofollow/superviseestablished repair andinspection procedures.



467 AIRLINES/OPERATORS – MAINTENANCE– Insufficientairline/operatoroversight of contractrepair facilityoperations includingmanagement andtraining practices. (refsps 100, 2-53)

477 To improve maintenancequality, regulators shouldrequire that airlines/operatorsinstitute processes for oversightof maintenance facilities thatmaintain safety-critical parts,components, or systems (e.g.CASE (Coordinating Agency forSupplier Evaluation) might beone type of program that couldprovide an acceptable methodof compliance). (OE 0.7)


194

468 REGULATORS –Insufficient regulatoryoversight of repairfacility operations,including managementand training practices.(see 100)

478 To improve maintenancequality, regulators shouldincrease oversight ofmaintenance facilities thatmaintain safety-critical parts,components, or systems. (OE0.7)

469 REGULATORS – Lackof a reliable processfor reviewing/revisingsafety decisions basedon field data collectedafter certification. (see449, 2-53, 536)


536 To prevent reoccurrence ofaccidents and incidents,regulators / manufacturers /operators should expeditedevelopment and application ofan effective risk managementcontinuing airworthinessassessment based upon priorincidents and disseminate theresults. (See 372, 373) (OE1.6)

569 Since hard landings areidentified primarily based onpilot subjective judgment and toensure that individual airplanesare inspected when necessary,manufacturers should developand regulatory authoritiesshould require theimplementation of objectivemeans to identify theoccurrence of a hard landingwithin an appropriate period oftime. (OE NR)

470 REGULATORS – Lackof appropriateknowledge andexperience necessaryfor PrincipalOperations Inspector(POI) to perform aircarrier oversightfunction. (see 19)

479 To improve operationaloversight, regulators shouldestablish selection criteria andappropriate training programs(e.g. training with carriers) toensure that POIs responsiblefor air carrier oversight haveappropriate knowledge andexperience to perform thosefunctions. (OE 1.3)

471 MANUFACTURERS/REGULATORS –Limited flight datarecording capabilityhampersunderstanding ofaccident sequence.(For future accidentprevention (see 26)

303 Regulators shouldimplement the NTSBrecommendations to increaseDFDR parameters (not rated).(OE NR)

361 To enhance the ability toanalyze, identify and takecorrective actions forpreventing accidents,regulators and operatorsshould create a collection andanalysis process which utilizesall existing and future aircraftdata collection systems, suchas DFDR, FOQA, ASAP andother non-volatile memorysystems. (OE 3.8)

472 REGULATORS/MANUFACTURERS –DESIGN – Stick-shaker system fails toprovide adequate timemargin betweenactivation and stall inan accelerated stallcondition.



195

473 REGULATORS –Regulator failed toidentify need fortraining in recognitionand recovery fromunusual flightregimes/attitudes.(see 437, 457, 458)





474 MANUFACTURERS –DESIGN – Inadequateconsideration of thehuman factors aspectsof failure recognitionand/or annunciation.

527 To ensure that alerting andwarning logic does notannunciate self-recoveryfunctions or alerts that do notrequire pilot action, themanufacturer should designsystems that annunciate onlywhen pilot action is required.(OE 2.8)

475 MANUFACTURERS/AIRLINES/OPERATORS – TRAINING –Inadequate trainingmaterials relating tomodern propulsionsystem malfunctionrecognition.

540 To ensure completeness,avoid erroneous proceduresand prevent misinterpretation,manufacturers/operatorsshould ensure and regulatoryagencies should check that theguidance and procedures inAOM's are complete, clear andcorrect. (OE 1.7)

477 AIRLINES/OPERATORS – TRAINING –Inadequate use ofavailable trainingmaterial related tomodern propulsionsystem malfunctionrecognition.

528 To provide optimal training(including propulsion systemmalfunctions) and to minimizenegative training, regulators,aircraft and simulatormanufacturers and operatorsshould ensure that trainingdevices replicate realisticfailure scenarios, aircraftperformance and appropriateresponse. (See 358) (OE 2.2)

479 SIMULATORMANUFACTURERS –Lack of realisticsimulation ofpropulsion systemmalfunction andaircraft response.



196

481 REGULATORS –Failure to requirerealism in simulatorrepresentation ofpropulsion systemmalfunction.


483 MANUFACTURERS –DESIGN – Cockpitindicators alert forthresholds(exceedances), butonly provide passiveindication of trends(See 520)

481 Because POIs may beresponsible for oversight ofremote training activities,regulators should ensure thatPOIs have sufficient CertificateHolding District Officeresources, including staff, toconduct appropriate oversightfor the POI's assignedoperators. (OE 1.6)

487 AIRLINES/OPERATORS – TRAINING –Training programfailed to recognize andoffset negativetransfer.

414 To reduce negativetransfer effects during pilottransition to new aircraft, airlineoperators should determine thepotential for negative transfer ofinappropriate pilot actions andtechniques on flight criticalsystems and overtrain toprevent their occurrence. (OE1.8)

491 AIRLINES/OPERATORS – MAINTENANCE– Failure to ensurepertinent maintenancehistory is madeavailable to the crew.

46 Airlines/operators shouldimplement procedures toincrease flightcrew awarenessof recent aircraft maintenanceactions. (OE 0.4)

492 MANUFACTURERS –DESIGN – Decreasedcrew vigilance due tomodern flight deckautomation and low-stimulationenvironment.




426 Research should beundertaken to determine how tokeep crews alert in low-stimulation environments (e.g.,highly-automated flightdecks,long-haul flights). (OE NR)

493 AIRLINES/OPERATORS – Operatinglimitations are lessstringent than ICAOrecommendations.

396 To ensure a standard levelof safety at all airports, airportoperators should adopt airportoperations procedures that areno less stringent than ICAOrecommendations. (OE 0.8)


197

494 AIRLINES/OPERATORS – Airline/operatordid not adequatelyevaluate the safetyaspect of NOTAMS.

78 Airlines/operators andregulators should improve theavailability, clarity, andprioritization of NOTAMinformation. (OE 0.5)

95 Airlines/operators shouldestablish procedures for flightcrews to review/cross checkinstructions, clearances, etc. toensure consistency withexpected procedures orpractices. (OE 0.6)

495 AIR TRAFFICSYSTEM – Accurateweather informationnot available to FlightCrews and air trafficsystem.


397 To provide accurate windinformation to flight crews,regulators should insure thatweather information providersand air traffic services employsystems and procedures whichwill insure accuratemeasurement of wind data anddissemination of windinformation for takeoff andlanding areas of the runways inuse. (OE 3.1)


496 MANUFACTURERS –DESIGN – Runwaywind information notpresented in cockpitdisplays as headwindand crosswindcomponents.


497 REGULATORS/AIRPORT OPERATORS –Inadequateprecautions takenregarding effects ofterrain, obstructions,and buildingplacement on windconditions on runway.(see 564)

410 To enhance safety in theairport environment, regulatorsand airport operators shoulddevelop guidelines forminimizing the effects ofenvironmental factors onwindfields in the approach andlanding areas of the runwaysand work with local authoritiesfor implementation. (OE 0.4)

498 MANUFACTURERS –DESIGN – Noannunciation providedto flight crew whenoperating in a non-standard flightinstrumentconfiguration



198

499 REGULATORS –Inadequate regulatoryoversight ofairline/operatorchecklist/procedureschanges.


500 AVIATIONCOMMUNITY – Lackof experienced/skilledpilots due to limitedaviation career trainingprograms.

517 To ensure an acceptableskill level of pilots entering theaviation profession, the aviationcommunity should encouragethe development of andenrollment in aviation careertraining programs. (OE 0.3)

501 AVIATIONCOMMUNITY – Lackof experienced/skilledpilots due to highcosts of aviation pilottraining andexperienceacquisition.

518 To ensure an adequatesupply of qualified pilots, theaviation community shouldpromote initiatives that screenyouth for potential aviatorqualifications, skills, andaptitude. The industry shouldidentify and develop careerpaths for suitable candidatesand mentor their career growthas successful aviators. (OE1.2)

502 AIRLINES/OPERATORS –Inexperienced/juniorpilots able totransition/upgrade tonew equipment due toeconomicpressures/contractsthat preclude moreexperienced/seniorpilots from upgrading.


503 REGULATORS –Current regulationsallowinexperienced/juniorpilots totransition/upgrade tonew equipment due toeconomicpressures/contractsthat precludeexperienced/seniorpilots from upgrading.

519 To ensure pilot proficiencyin basic airmanship skills andknowledge, regulators shouldrequire training/standardizationprograms that emphasize thesesubjects during initial andrecurrent training. (See 111)(OE 1.8)

521 To ensure airline/operatortraining programs provideenhanced aircrew proficiency,regulators should revise FARPart 121, Appendix F to raisethe minimum standards. (See114) (OE 2.4)


199

504 AIRLINES/OPERATORS/REGULATORS –TRAINING – Lack of asimulator limited thelevel of flightcrewtraining that could beprovided in a giventime period and thetraining syllabus didnot compensate forthis loss of trainingeffectiveness.

153 Ensure that flight crews areadequately trained in a level Dsimulator for dynamiccharacteristics beforeassignment to the line. (See312) (OE 2.2)




505 REGULATORS –Regulators failed todisseminate pertinentflight safetyinformation.



464 To ensure properidentification of flight criticalissues, manufacturers,operators and regulators mustdevelop consistent criteria toproperly identify anddisseminate (in a timelymanner, including manualrevisions) flight safety criticalinformation. (OE 2.3)

536 To prevent reoccurrence ofaccidents and incidents,regulators / manufacturers /operators should expeditedevelopment and application ofan effective risk managementcontinuing airworthinessassessment based upon priorincidents and disseminate theresults. (See 372, 373) (OE1.6)

506 REGULATORS – Lackof adequateregulations to preventpairing inexperiencedpilots. (total time, timein type, etc.).


552 To add structure to pilotingskill levels, research should beconducted to determine theefficacy and impact of a multi-level pilot licensing andqualification structure (e.g.analogous to apprentice,journeyman, master). (OE NR)

570 To ensure appropriatecrew experience levels,regulatory authorities shouldrequire procedures to ensureappropriate crew pairing. (refFSF Corporate CrewScheduling and FatigueEvalution) (see 24) (OE 0.7)

507 MANUFACTURERS –DESIGN – Failure toprovide adequateaudible/visualannunciation to theflightcrew of trimchange/travel.

503 To alert the flightcrew offlight control trim changes,manufacturers should providean appropriate level of auralannunciation. (OE 0.3)


508 REGULATORS/OPERATORS – Failure torequire/maintain sterilecockpit environmentduring critical flightregimes.

136 Airlines/operators shouldensure that theirtraining/standardizationprograms emphasize theimportance of the sterile cockpitenvironment. (OE 0.7)


200

509 AIR TRAFFICSYSTEM – Failure toprovide proper radarvectoring to theinstrument approach.


510 AIRLINES/OPERATORS – TRAINING –Training does notcover range ofpossible events thatcould lead to loss ofcontrol on the ground.



511 REPAIR FACILITY –MAINTENANCE –Use of part notapproved by themanufacturer.



512 MANUFACTURERS –DESIGN – Improperassessment of failuremodes and effectsanalyses.


402 To prevent a more seriousevent, manufacturers shouldrevise product failure analysesif service history revealsunexpected consequences orfailure modes. (OE 1.7)

513 FLIGHTCREW –Flight Engineer (FE)failed to performmonitoring functionand other FEresponsibilities.


243 To prevent alertingoverload, flight deck designsshould consider smart alertingsystems such as those withprioritization schemes orcancelable nuisance alerts.(OE 1.7)


514 MANUFACTURERS –DESIGN – Alerts notprovided to indicatewhen pilot flightcontrol inputs areinhibited due todesign.




201

515 REGULATORS –Failure to require datarecording capabilitysufficient tounderstand accidentsequence. (For futureaccident prevention )(see 471)

360 To improve theeffectiveness of accidentinvestigations, regulatorsshould immediately implementthe NTSB recommendations toincrease the quantity andquality of survivable datarecorded in both existing andfuture aircraft. (refer to 303.)(OE NR)

516 AVIATIONCOMMUNITY – Somecharacteristics andeffects of waketurbulence not fullyunderstood.

362 To enable furtherdevelopment of safe aircraftseparation and operationalrequirements, research shouldbe conducted to describe thedynamics and location of waketurbulence and environmentallygenerated turbulence. (OENR)

517 REGULATORS –Certification criteria donot adequatelyaddress effects ofexternal influences(wake turbulence,gusts) on aircraftcontrollability.

363 To enhance aircraftcontrollability in severe orgreater turbulence conditions,regulators and manufacturersshould develop and implementcertification criteria thatconsider effects of turbulence,including autoflight capabilityand disconnect parameters.(OE 0.7)

518 REGULATORS/MANUFACTURERS – Flightcontrol authority undercrossover conditionswas not adequatelyaddressed duringcertification.

364 To protect aircraft againstloss of control, regulatorsshould develop as soon aspossible, certification criteria,throughout the entire flightenvelope, for crossover speedsand maximum rudder sideslips. (see 431) (OE 3.5)

431 To assist flight crews inavoiding loss of control onexisting aircraft, regulators andmanufacturers should evaluatethe effects of crossover speedsand maximum rudder side slipthroughout the entire flightenvelope and disseminate theinformation to operators andflight crews. (OE 3.5)

519 MANUFACTURERS –DESIGN – Systemdesign does notprovide adequateredundancy tocircumventmalfunction. (notmalfunction tolerant)

366 To protect aircraft againstflight control malfunctions,manufacturers must design andregulators must certificatederivative aircraft andcomponents to currentapplicable certificationrequirements, i.e. single pointfailures, redundancy, andprobability of failure. (OE 4.2)


202

520 MANUFACTURERS –DESIGN – Designdoes not providesufficient trendinformation to permitthe flight crew toanalyze/understandconditionsencountered. (See483)


521 MANUFACTURERS –DESIGN – Does notprovide alerting of aflight criticalmalfunction.

367 To provide necessaryinformation to pilots, regulatorsshould require andmanufacturers should develop,flight control position indicatingand alerting systems which willprovide warnings for criticalaircraft flight controlmalfunctions, e.g., actual flightcontrol position disagreementwith commanded position. (OE0.8)


394 Because of increasinginteractions between systems,manufacturers and trainingorganizations should developnew approaches for instructingpilots in the interrelationshipsbetween systems. (OE 0.5)

522 MANUFACTURERS/REGULATORS –DESIGN – Insufficientappreciation ofimplications of newtechnologyapplications mergedwith older/existingdesign (e.g., RelaxedStatic Stability (RSS),Longitudinal StabilityAugmentation System(LSAS).

419 Because manufacturersmust make certain assumptionsregarding which failures will bedetected and handled by thepilot with "normal piloting skills,"research should be conductedto determine if these assumedskills and knowledge are validin realistic airline operations.(OE NR)

449 In order to ensureadequate handling qualities inmanual flight, in all regions ofthe flight envelope, regulatorsshould review currentcertification requirementspertaining to aircraft stability todetermine if additionalrulemaking or advisory materialdevelopment is warranted,especially to account forairplanes with newtechnologies affecting handlingqualities (e.g. "relaxed staticstability"). (OE NR)

450 To ensure the aircraft canbe safely flown by pilots withnormal skill levels, regulatoryauthorities should require thathandling quality tests anddemonstrations intended toshow compliance withapplicable regulations includerepresentative line pilots as testsubjects. (OE 2.2)

543 In order to provide pilotswith sufficient airplaneperformance margins to reduceexposure to potential upsets,regulators should requireairplane operation in a cruiseflight envelope with at least1.3g margin to buffet onset.(OE 1.8)

547 In order to ensure that thecertification process is basedsolely on safety andcompliance with theregulations, certification shouldinclude an independent auditprocess to guard against theinfluence of non-technicalconsiderations. (OE 0.7)

550 Since handling qualitiesevaluations are subjective andsubject to non-technicalinfluences, the regulatoryauthorities, manufacturers,research organizations, andoperators should work togetherto develop improved,quantitative, objective metricsand acceptance criteria toensure safe handling qualities.(OE NR)

523 MANUFACTURERS/REGULATORS –DESIGN – Aircraftdesign allowed criticalflight controls to bemoved inadvertentlyand inappropriately.

No interventions cited(no interventions have beendeveloped regarding the flaphandle/quadrant designbecause the problem is uniqueto the MD-11 and the entireMD-11 fleet has been retrofittedto eliminate the problems.)


203

524 SIMULATOR/AIRCRAFTMANUFACTURERS –Lack of realisticsimulation of aircrafthandlingcharacteristics likely tobe encountered duringnormal operations.(see 458)

451 To allow adequate trainingin manual flight, manufacturersshould develop models to allowflight simulators to accuratelyrepresent the aircraft's stabilityand control characteristics forall regions of the flight envelopelikely to be encountered duringnormal operations (i.e.Operation within the AFM-approved flight envelope withno failures affectingaerodynamic performance).(OE 1.0)

526 MANUFACTURERS/REGULATORS –DESIGN – Lack ofreliable process forperforming systemfault analysis duringoriginal design orsubsequentmodification.

454 Because latent andcombination failures have beenmissed in failure analyses,manufacturers and regulatorsshould conduct more intensiveverification of all safetyanalyses associated withsystems whose failures, singlyor in combination with othersystem failures, can result inaccidents. (OE 1.7)

455 Because latent andcombination failures may bemissed in failure analyses,manufacturers and regulatorsshould conduct research intoimproved methods forconducting safety analyses, toensure reliable identification offailures which, singly or incombination with other systemfailures, can result in accidents.(OE NR)

527 MANUFACTURERS/REGULATORS –DESIGN – Designdoes not comply withcertification standards.


528 MANUFACTURERS –DESIGN – Failure toprovide warning offlight critical systemunsafe status .(see14)


529 FLIGHTCREW – Lackof communications.Failure to adequatelydifferentiate itemsrequiring action fromitems that areinformative.

403 To ensure clearcommunication, airlineoperators should trainflightcrews to emphasize ifaction is required when givingstatus reports. (OE 1.3)


204

531 REGULATORS –Failure to evaluateand/or establishrequirements forstandardization offlight deckinformation/controls toprevent negativetransfer effects onflight critical systems.

413 To prevent negativetransfer effects with flightcritical systems, regulatorsshould establish requirementsfor standardization of flightdeck information/controls. (OE3.1)

532 AIRLINES/OPERATORS – TRAINING –Improper, incomplete,and/or inadequatetraining.


534 FLIGHTCREW –Failure to refuseclearance that is inconflict with desiredaircraft energy stateand/or standardoperating procedures.


535 MANUFACTURERS –DESIGN – Multi-function computerinternal logicprecluded flight controlusage at a criticaltime.

544 To ensure that flightcontrols are available duringcritical flight phases orconditions, manufacturersshould design system overridesthat are available to theflightcrew to regain manualcontrol. (OE 0.5)

536 REGULATORS –Insufficient analysis ofprevious incidents andlack of availableincident information tothe operators due tolack of oversight onthe part of theregulator(s). (see 32,469, 505)

57 Airlines/operators,regulators, and manufacturersshould implement a programdesigned for sharing of safetyrelated information within theaviation community. (OE 2.1)

128 Airlines/operators andregulators should implement ano blame safety reporting anddata sharing system withappropriate protections fromlitigation and prosecutionconcerns. (OE 2.8)

360 To improve theeffectiveness of accidentinvestigations, regulatorsshould immediately implementthe NTSB recommendations toincrease the quantity andquality of survivable datarecorded in both existing andfuture aircraft. (refer to 303.)(OE NR)

361 To enhance the ability toanalyze, identify and takecorrective actions forpreventing accidents,regulators and operatorsshould create a collection andanalysis process which utilizesall existing and future aircraftdata collection systems, suchas DFDR, FOQA, ASAP andother non-volatile memorysystems. (OE 3.8)

370 To foster transfer of safety-related information, airplaneand component manufacturersshould participate in safety datasharing programs, (e.g. currentManufacturers' safety datasharing meetings). (OE 1.7)



205

536Cont.

373 To ensure thatmanufacturers and regulatorsare aware of recurrentproblems (type and frequency),manufacturers, regulators andoperators should implement areliable process for gatheringand reporting safety-relatedproblems. (OE 2.0)

462 To enhance the ability toanalyze, identify and takecorrective actions forpreventing accidents,manufacturers should includeand regulators should requirethe recording of ice detection /protection system state on theflight data recorder. (FAR 121requires recording of icedetection) (OE NR)

463 To avoid treating anincident as an isolatedoccurrence and to ensure on-going assessment of aircraftspecific loss of controlproblems, regulators,airlines/operators shouldconduct a focused safety or riskassessment of all accidentsand incidents to determine theneed for immediate resolution.(See 254) (OE 2.8)

537 REGULATORS –Known critical flightsafety information notavailable to theflightcrew due to thefailure of theregulators to ensurethat the informationwas disseminated.



538 REGULATORS –Timely flight safetyinformation was notshared between thevalidating authorityand certificatingauthority due to a lackof compliance with theterms of the bi-lateralairworthinessagreement.

505 To ensure that safetyrelated incident information isshared between validating andcertificating authorities,regulators should develop asystem to review the terms ofand compliance to bilateralairworthiness agreements. (OE1.0)

506 To ensure that theairworthiness authorities knowand understand the importanceof complying with theinternational agreements, ICAOshould distribute annual noticesto the authorities emphasizingthe importance of mutualdistribution of continuedairworthiness information. (OE1.0)

539 REGULATORS –Insufficient icingcertificationrequirements toensure safe flightthroughout theatmospheric icing andexpected operationalenvironment.

457 To ensure full protectionthroughout the icing envelope,regulators / manufacturersshould expand icingcertification criteria to includeice accretions due to residual,intercycle, delayed activationand system malfunction toensure that icing protectionequipment and/or proceduresprovide full operationalenvelope coverage. (See 459,516) (OE 4.6)

458 To enhance the safety ofall aircraft, regulators shouldensure that appropriate revisedicing certification criteria applyto FAR Part 23, 27 and 29certificated aircraft in additionto FAR Part 25 aircraft. (OENR)

459 For a full understanding ofaircraft performance andhandling qualities in icingconditions, research should beconducted to define the effectsof all ice accretions, withparticular emphasis on the rolleffect due to ice contaminatedwings (intercycle orresidual).(See 457, 516) (OENR)

516 To ensure full protectionthroughout the operationalenvelope, regulators /manufacturers should expandicing certification criteria toinclude performance andhandling qualities testing whichconsiders ice accretions due toresidual icing, intercycle icing,delayed system activationand/or system malfunction.(See 457, 459) (OE 4.6)


206

540 AIR TRAFFICSYSTEM – Ineffectiveuse of trafficmanagementprograms by Air TrafficControl SystemCommand Center /Traffic ManagementUnit due to lack ofcomprehensiveworking knowledge ofthe trafficmanagement program.

467 To reduce unstabilizedapproaches, air traffic qualityassurance programs shouldregularly evaluate Air TrafficControl System CommandCenter / Traffic ManagementUnit (ATCSCC / TMU's) toensure traffic managementprograms and initiatives includeall traffic elements(i.e. towerenroute clearance / enroutetraffic), are implementedproperly, effectively utilized andpersonnel are adequatelytrained. (OE 2.1)

541 FLIGHTCREW –Distracting cockpitactivities due to lack ofcockpit disciplineresulted in inattentionto aircraft andenvironment.

20 Airlines/operators shouldensure that command oversighttraining for captains is providedduring the upgrade processand in recurrent training andfirst officer responsibility formonitoring are reviewed duringrecurrent training. (OE 2.3)

542 MANUFACTURERS/REGULATORS – Somenormally encounteredoperationalconfigurations, inicing, not addressedduring airworthinesscertification.




543 FLIGHTCREW –Flightcrew failure torecognize theseriousness of iceaccumulation and it'saffect on aircraftperformance andcontrollability.



499 To make flightcrewsaware of the possibility ofairframe ice accretion, researchshould be conducted todevelop reliable means ofaircraft surface ice detection,as well as ground and aircraftbased means of detection ofmeteorological icing conditions.(OE NR)

500 To ensure that flightcrewsinitiate correct in-flight icingprocedures, the regulatorsshould require installation of icedetection system that providesannunciation that alerts thecrew to respond appropriatelyto the icing hazard. (ref 243)(OE 2.8)

510 To better understand theeffects of super-cooled largedroplets (sld) icing researchshould be conducted on iceprotection system design andoperation in this weatherphenomena. (OE NR)


207

544 MANUFACTURERS –DESIGN – Autoflightdesign masks theonset of slowlydeveloping adverseflight controlconditions and doesnot provide adequatecues to aid flightcrewsituational awareness.

501 To assist flight crews inavoiding loss of control,manufacturers should developand regulators should requireautoflight system auto-disconnect logic which does notdisconnect when the autoflightsystem is properly attemptingto correct an abnormal flightsituation/condition. (ref 363)(OE 3.5)

502 To insure flight crews canidentify possible upsetconditions, airline/operatorsshould implement flight crewtraining programs thatdemonstrate the operation of anormally functioning autoflightsystem under non-standardflight conditions (e.g. out of trimairplane/contaminated wing).(OE 2.8)


546 MANUFACTURERS –DESIGN – Iceprotection systemdesign was notappropriate forconditionsencountered.


547 MANUFACTURERS –DESIGN – Autopilotlimit logic caused thesystem to disconnectwhile the autoflightsystem was stillapplying propercontrol inputs.





409 To enhance stability duringthe approach and landingphase, airline operators shoulddevelop and implement policiesand procedures that addressmixed mode flight (e. g.,autothrottles in manual flight)with specific emphasis onpitch/thrust coupling andaircraft control problems. (OE2.1)


547Cont.

504 To provide more tactilecues to flightcrews onturboprop aircraft in icingconditions, airlines/operatorsshould develop SOP’s callingfor flightcrews to disengageautopilot during maneuvering,when workload permits. (OE1.5)


575 To provide the flightcrewwith a more positive indicationof autopilot engagement /disengagement, themanufacturer should developand provide an active andpositive annunciation ofautopilot engage status whichappears after flightcrewinitiation of a go-around. (OE0.2)


208

548 REGULATORS –Current practical teststandardsoveremphasizeminimum altitude lossduring approach tostall recovery that maylead to a negativetraining transfer for astalled wing recovery.







549 AIRLINES/OPERATORS – Failure toconsider humanfactors in checklistdesign.




550 REGULATORS –Regulationsinadequate to ensureproper flight crewproficiency for the typeof operations beingconducted.

519 To ensure pilot proficiencyin basic airmanship skills andknowledge, regulators shouldrequire training/standardizationprograms that emphasize thesesubjects during initial andrecurrent training. (See 111)(OE 1.8)

551 REGULATORS – Lackof regulatoryrequirements for poststall recognition andrecovery training.





522 Since it is possible to entera stall, regulators shouldmandate the implementation ofa ground school and simulatortraining program to train pilotsto handle post stall recovery aspart of advanced maneuvertraining. (See 384) (OE 2.7)

525 To mandate stallrecognition and recoverytraining, regulators must modifythe appropriate regulations.(OE 4.2)

552 AIRLINES/OPERATORS – TRAINING –Failure to provide poststall recognition andrecovery training.



209

553 FLIGHTCREW –TRAINING – Failure toproperly interpretcues/indications ofmain wing stall versustail plane stall due toinadequate trainingand experience.


554 REGULATORS/MANUFACTURERS –DESIGN – Aircraftdesign andcertification failureanalyses do notadequately addressthe potential forflightcrew error orinaction.

49 Regulators should establishcriteria for, and manufacturersshould evaluate and improve,the reliability and failuretolerance of flight systems.(includes hardware, softwareand human performance). (See332) (OE 1.0)

495 To improve aircraft failuretolerance, manufacturers andregulators should conductfailure analyses for design andcertification that reflect realisticlevels of flightcrew reliability.(OE 1.2)

496 To enable failure analysiswhich is based upon realisticlevels of flightcrew reliability,researchers should developand validate models of humanerror. (OE NR)

555 REGULATORS – Icingroughness onprotected surfacesduring normaloperation in icing isnot defined forcertification.




458 To decrease theprobability of ice buildup,manufacturers should designand install a system thatautomatically detects andsheds ice from flight-criticalsurfaces. (OE NR)

556 AVIATIONCOMMUNITY –Misunderstanding andmisinformation aboutthe existence of icebridging is prevalentwithin the aviationcommunity.


461 To reduce the adverseeffects of ice accretionroughness, the regulators andNASA should conduct researchleading to improved iceprotection technologies. (OENR)

499 To make flightcrewsaware of the possibility ofairframe ice accretion, researchshould be conducted todevelop reliable means ofaircraft surface ice detection,as well as ground and aircraftbased means of detection ofmeteorological icing conditions.(OE NR)


210

557 AVIATIONCOMMUNITY –Characteristics andeffects of ice accretionon aircraftperformance not fullyunderstood.



558 AIRLINES/OPERATORS/REGULATORS –Failure of orinadequateairline/operatorprocess to determinethe criticality ofoperationalinformation and toidentify the properdistribution method toaddress theinformation.



464 To ensure properidentification of flight criticalissues, manufacturers,operators and regulators mustdevelop consistent criteria toproperly identify anddisseminate (in a timelymanner, including manualrevisions) flight safety criticalinformation. (OE 2.3)

559 AIRLINES/OPERATORS – MAINTENANCE– Failure of orinadequateprocedures for themaintenance andreplacement ofairframe components.


560 REGULATORS –Requirements forATIS to have allunpublished NOTAMinformation places anexcessive burden onthe voice broadcast.


122 Air Traffic serviceproviders should implementtransmission of ATCinstructions/information(between the ground andaircraft) via a computer link asopposed to voicecommunications. (OE 0.5)

465 To reduce flight crewworkload in downloading voiceATIS information regulators,through consensus with theaviation community, shouldreexamine and limit the contentof ATIS broadcasts. (OE NR)

466 To further improve thequality of weather informationprovided to the flight crews, theregulators should implementrecommendations from theweather product working groupof the 1999 FAA Inflight IcingOperations Conference. (OENR)

561 AIR TRAFFICSYSTEM – Air trafficsystem practices thatmay compromisesafety or increaseflight crew workload(see 46)








211

561Cont.


467 To reduce unstabilizedapproaches, air traffic qualityassurance programs shouldregularly evaluate Air TrafficControl System CommandCenter / Traffic ManagementUnit (ATCSCC / TMU's) toensure traffic managementprograms and initiatives includeall traffic elements (i.e. towerenroute clearance / enroutetraffic), are implementedproperly, effectively utilized andpersonnel are adequatelytrained. (OE 2.1)

468 To ensure the highestquality of air traffic services,regulators should establishpolicies that require additionaloversight and training of airtraffic controllers thatrepeatedly commit operationalerrors. (OE 1.6)

497 To minimize exposure toflight operations in icingconditions, air traffic serviceproviders should initially andperiodically train controllers onthe hazards / impacts of icingon aircraft performance whenholding or vectoring aircraft tothe final approach course inareas of known or reportedicing conditions. (OE 2.1)

562 AVIATIONCOMMUNITY – Lackof informationavailable regarding theeffects of delayedpneumatic bootoperation in icingconditions.




563 AIRLINES/OPERATORS – TRAINING –Approach to stalltraining inadequatelyaddresses pre-stallaudible and tactilecues.





564 AIRCRAFTEQUIPMENT – FDRnot fully functionalduring the accident(for future accidentprevention)

453 To help prevent futureaccidents, airlines/operatorsshould implement maintenanceprocedures to ensure properfunctioning of the DFDR at alltimes. (Note: this interventionwas recorded as a potentialintervention of future accidents,it would not have prevented thesubject accidents.) (OE NR)


212

566 AIRLINES/OPERATORS – TRAINING –Failure to provideadequate training fordistinguishing betweenmain wing stall versustail plane stall.


567 AIR TRAFFICSYSTEM - Failure tofollow verticalseparation procedures(SOP) (ref SPS 8, 30)


568 MANUFACTURERS/REGULATORS – Stallwarning systems arenot designed andcertified to account fora sufficiently widerange of entryconditions.



569 MANUFACTURERS/AIRLINES/OPERATORS –


423 To ensure that recurrent,intermittent failures are notallowed to persist, regulatorsshould revise MEL dispatchrequirements so that certainintermittent failures areconsidered to be full failures, ifwarranted by safetyimplications of the failures andfrequency of occurrence. (OE3.5)

570 Economic andoperational pressuresconflict with safetyconsiderations




213

571 AIRLINES/OPERATORS/REGULATORS –Lack of objective no-fault reporting andsharing of pertinentstandardizedinformation on pilotperformance,qualification, andsafety history.

491 To ensure adequate flightcrew competency,airlines/operators shouldestablish more effective pilotscreening and Capt. upgradecriteria to identify candidateswith demonstrable flying skilldeficiencies. (See 335) (OE1.8)

572 AIRLINES/OPERATORS – Selectionprocess for initial hireand upgrades allowedthe hiring and upgradeof unqualified pilots


573 AIRLINES/OPERATORS – Failure tomaintain allrelevant/requiredtraining records.


574 AIRLINES/OPERATORS – Lack of safetyculture thatencourages threat-freereporting of safetyinformation (includingrepeated errors andpoor performance)within the airline.

492 In order to ensure pilotmedical fitness for duty,airlines/operators/regulatorsshould establish a structuredprocess for return to flightstatus after sick leave thatincludes medical clearance.(OE 1.2)

575 AIRLINES/OPERATORS/REGULATORS –Failure to requirestructured return toduty requirementsafter sick leave. (i.e.medical clearance).

529 To avoid negative training,airline operators should ensurethat their training curriculumcorrelates with the AOM andother relevant manuals. (OE1.7)


214

576 AIRLINES/OPERATORS – Training notconsistent with theairline operationsmanual.

482 To prevent inaction whenthe PF is confused orunresponsive to an in-flighthazard, airlines/operatorsshould develop and train clearand explicit procedures todefine when/how the PNF(especially the F/O) will takecontrol of the airplane. (OE1.0)

577 FLIGHTCREW –Failure of first officerto take control of theaircraft when it is clearthat the captain is notperformingadequately.



578 AIRCRAFTEQUIPMENT -Autopilot design doesnot warn ofinappropriate aircraftresponse to autopilotinput (i.e. roll inputversus a/p command,etc) or approachingautopilot control limits.



579 AIRLINES/OPERATORS – Failure of orinadequateprocedures for themaintenance andreplacement of enginecontrols.


511 To reduce the number ofhazardous icing encountersand to keep air traffic apprisedof current weather conditions,regulators should recommendthat flight crews report all icingconditions to air traffic controland be required to report theoccurrence of moderate tosevere icing conditions. (ref.FAR 91.183) (OE 2.8)

545 To provide the nationalairspace system with accurate,realtime inflight weatherconditions (automatic ormanual), a system should bedeveloped and implemented toeffectively transmit airborneweather related information toair traffic facilities. (OE 2.8)

580 AIR TRAFFICSYSTEM – Lack ofawareness on the partof the controllers ofexisting weatherconditions at altituderesulted in aninadvertent hold inhazardous weatherconditions.



215

581 REGULATORS –Failure to provideadequate oversight ofoperator training todistinguish betweenvarious stall onsettriggers (see 566)


582 REGULATORS – Lackof sufficiently objectivehandling qualitiescriteria in certificationrequirements (See456)

450 To ensure the aircraft canbe safely flown by pilots withnormal skill levels, regulatoryauthorities should require thathandling quality tests anddemonstrations intended toshow compliance withapplicable regulations includerepresentative line pilots as testsubjects. (OE 2.2)

550 Since handling qualitiesevaluations are subjective andsubject to non-technicalinfluences, the regulatoryauthorities, manufacturers,research organizations, andoperators should work togetherto develop improved,quantitative, objective metricsand acceptance criteria toensure safe handling qualities.(OE NR)

571 To ensure the aircraft canbe safely flown by pilots withnormal skill levels, regulatoryauthorities should require thattests and demonstrationsintended to show compliancewith applicable regulationsinclude representative linepilots performing representativeline-type operations. (OE NR)

551. In order to develop “bestbusiness practices” throughoutthe continuum of certification,major design changes, andoperating history of aircrafttypes, industry andGovernment should conduct ajoint, proactive, lessons-learned, review of the MD-11/MD-10 certification processand operating history.

583 AIRLINES/OPERATORS – TRAININGTraining environmentand practices not fullyaligned with lineoperations.

554 Because it is important thattraining reflect the realities ofline operations, airline trainingdepartments should includeinstructors who regularly fly inline operations. (OE NR)

555 Because it is important thattraining reflect the realities ofline operations, airline trainingdepartments should review andmodify, in consultation with linepilots, training curricula toreflect realistic line operationsscenarios and conditions. (OENR)

585 AIRLINES/OPERATORS – Use of flight idlefollowing propulsionsystem malfunction ona turboprop airplanecan result in increaseddrag and possible lossof control (if theengine is not shutdown and thepropeller is notfeathered)

541 To reduce the risk of lossof control during flight with apropulsion system malfunctionin turboprop aircraft, if theengine failure procedure is notcompleted, airline operatorsshould review theconsequences of themalfunctioning propulsionsystem being placed in flightidle. (OE 0.9)

586 AIRLINEOPERATORS/MANUFACTURERS – Correctprocedural informationon the use ofpneumatic boots wasnot disseminated tothe operators.

540 To ensure completeness,avoid erroneous proceduresand prevent misinterpretation,manufacturers/operatorsshould ensure and regulatoryagencies should check that theguidance and procedures inAOM's are complete, clear andcorrect. (OE 1.7)


216

587 REGULATORS -Inadequate aircraftcertification criteria.Gusts not consideredin crosswindlimitations.


588 FLIGHTCREW - Overreliance on automationduring critical phase offlight due toautomationdependency





589 AIRLINEOPERATIONS /REGULATORS – Lackof common industrystandards andguidelines in aircraftangle of attack / lowairspeed indicatorsystem design,equipage and training


369 To provide adequate stallwarning, regulators shouldrequire and manufacturersshould develop, stall warningsystems for new/derivativeaircraft that provide accurateinformation throughout thecertificated flight regime. (OE1.3)

382 To provide improved pilotawareness of airspeed,manufacturers should provideflight instruments with moreeffective airspeed trendindications and alerting. (OE2.2)


590 REGULATOR -Regulators failed toadequately identifytraining requirementsthat include engine outtraining in the initialtakeoff climb phase.



217

591 FLIGHT CREW –Pilot’s excessiveattention to factorsthat wereinconsequential to thecompletion of a safeflight let them toexecute a moredifficult, non-standardprocedure/pilotingtechnique than waswarranted byconditions.

572 Research should beconducted to improveunderstanding of how/whypilots misprioritize or becomefixated upon concerns andtasks, and to develop strategiesto counteract this effect. (OENR)

592 MANUFACTURER –DESIGN – Automatedsystems designs arebased on a limited setof assumptions whichdo not cover all routineoperations.


562 Airlines/operators shoulddevelop processes to identifyand thoroughly review (seeking"no technical objection" frommanufacturer, whenappropriate) informal pilottechniques to ensure that theyhave no unacceptableunintended consequences.(OE 1.6)

564 To reduce the need forpilots to work around theautomation, manufacturersshould ensure that systemsdesigns and safety analysesconsider the full range ofoperations. (OE 1.6)

593 MANUFACTURER –Failed to providesufficientdocumentation and/ortraining regarding adesign feature oroperationalcharacteristic.

563 Manufacturers shouldprovide airlines/operators withtraining material designed toexplain to pilots how and whysystems work the way they do.(OE 0.8)

594 AIRLINE/OPERATOR– Failure of companyto realize theunintendedconsequences of newflight operationspolicies.

567 To minimize potentialnegative safety implications ofprocedural changes,airlines/operators shoulddevelop processes to review allproposed operating proceduresin order to uncover andevaluate potential unintendedconsequences. (OE 0.8)

595 MANUFACTURERS –DESIGN – Lack of apowered controlsystem alloweduncommanded controldeflections and highrecovery forces.



513 To preclude undesiredflight control displacementmanufacturers should designflight controls so that theairplane does not experienceuncommanded, adverse flightcontrol deflections that arebeyond the control of theflightcrew. (throughout the flightenvelope, includingaerodynamic stall). (OE 1.7)



218

708 AIR TRAFFICSYSTEM – ControlJudgment (AnticipatedSeparation). Failureto correctly anticipateseparation.





709 AIR TRAFFICSYSTEM – ControlJudgment.(Prioritization). Failureto correctly prioritizecontrol actions.







709Cont.




219

716 AIR TRAFFICSYSTEM –Communications/Practices/ProceduresIncreased Flight CrewWorkload During aCritical Phase. ATCpractices/procedurescaused a disruption increw activities andcontributed to anincreased flight crewworkload during acritical phase of flight.







716Cont.







220


APPENDIX J: PROBLEM STATEMENT FREQUENCY MATRIX

221

Appendix J: Problem Statement Frequency Matrix

1 2 3 4 5 6 7 8 9 10 11 12 13 15 16 17 18 19 20 21 22 23 24 25

Pro

ble

mN

o.

Problem

Sah

ara

Indi

aB

737

Chi

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300

Nor

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Det

roit

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272

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365

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Mid

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Chi

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402

F-1

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MD

-11

Chi

na A

/LA

300

AB

X A

ir D

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8 Chi

na A

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747

Brit

ish

Mid

land

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OM

A31

0

Air

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agle

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tream

32

To

tal

2 FLIGHTCREW – SOP – Failure of the flightcrew to provide complete responses(callbacks, position reports, etc.) usingstandard phraseology in accordance withestablished procedures (FAA, ICAO,Company, etc.)

1 1 1 3

5 AIR TRAFFIC SYSTEM/FLIGHTCREW –Inability of air traffic control and the flightcrewto effectively communicate.

1 1

6 AIR TRAFFIC SYSTEM – Failure of air trafficcontrol to provideinstructions/information/clearances usingstandard phraseology in accordance withappropriate regulatory directives.

1 1 1 1 4

7 AIR TRAFFIC SYSTEM – Inadequatesituation awareness (horizontal). Failure ofair traffic control to correctly identify aircraftposition over the ground

1 1

8 AIR TRAFFIC SYSTEM – Failure of air trafficcontrol to follow established procedures(SOP).

1 1 1 1 1 5

10 FLIGHTCREW – SOP – Failure of flight crewto follow established procedures (SOP). 1 1 1 1 1 1 1 1 8

11 FLIGHTCREW – Inadequate situationawareness (vertical). Failure of flight crew tocorrectly identify aircraft height aboveground.

1 1 2

12 FLIGHTCREW – Inadequate situationawareness (horizontal). Failure of flight crewto correctly identify aircraft position over theground.

1 1

13 FLIGHTCREW – Flight crew misinterpretedinstrument presentation and failed to crosscheck other available instruments

1 1 1 1 1 1 6

14 AIRCRAFT EQUIPMENT – EQUIPMENTFAILURE – Failure of instrument and/orwarning system during critical phase of flight(e.g. takeoff, approach, landing, approach tostall, etc.)

1 1 1 3


222

1 2 3 4 5 6 7 8 9 10 11 12 13 15 16 17 18 19 20 21 22 23 24 25

Pro

ble

mN

o.

Problem

Sah

ara

Indi

aB

737

Chi

na A

/LA

300

Nor

thw

est

Det

roit

A30

0A

CA

J41

00

Sim

mon

sA

TR

-72

Com

air 3

272

Thai

365

Birg

enai

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757

A31

0B

ucha

rest

Mid

wes

tE

xpre

ss

Cop

a B

737

Chi

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aste

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D-1

1

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402

F-1

00Fe

dex

MD

-11

Chi

na A

/LA

300

AB

X A

ir D

C-

8 Chi

na A

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747

Brit

ish

Mid

land

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16 FLIGHTCREW – CRM – Lack of CRMtraining or failure to follow CRM practices. 1 1 1 1 1 5

17 AIRLINES/OPERATORS – SOP – Failure ofthe airline/operator to provide adequatestandard operating procedures (SOP) thataddress situations and environments that theflight crews operate in.

1 1 1 1 1 1 1 7

19 FLIGHTCREW – Lack of basic piloting skillsor knowledge required to successfullyperform a flight maneuver or a procedure orunderstand its consequences.

1 1 1 1 1 1 1 7

20 AIRLINES/OPERATORS – TRAINING –Airline/operator training failed to adequatelyaddress operational requirements necessaryfor the flight crew to safely operate theairplane

1 1 1 1 1 1 1 1 1 1 10

21 FLIGHTCREW – Flight crew disregard of, orfailure to recognize cues to terminate currentcourse of action or maneuver (“PRESS-ON-ITUS").

1 1 1 1 1 5

22 FLIGHTCREW – Pilot Not Flying (PNF) failedto perform monitoring function and other PNFresponsibilities

1 1 1 1 4

23 FLIGHTCREW – Flight crew intentionaldisregard of and failure to respond toflightdeck warning

1 1 2

24 FLIGHTCREW/AIRLINES/OPERATORS –Disregard of aeromedical factors (fatigue,sleep cycles, medications, alcohol, etc.)

1 1 1 1 1 5

26 AIRCRAFT EQUIPMENT – CVR not fullyfunctional during the accident (for futureaccident prevention).

1 1 2

28 AIR TRAFFIC SYSTEM – INFRASTRUCTURE– The air traffic system lacked equipment thatmight have helped prevent the accident (DME,radar, etc.)

1 1 2

30 AIR TRAFFIC SYSTEM – Inadequatesituation awareness (vertical). Failure of airtraffic control to correctly identify aircraftheight above the ground.

1 1

31 FLIGHTCREW – Preoccupation withautomated systems (FMS) to the exclusion ofalternative navigation systems

1 1


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32 AIRLINES/OPERATORS – SOP – Failure ofor inadequate airline/operator procedures fordisseminating flight-critical information withinthe organization.

1 1 1 1 1 5

33 AIR TRAFFIC SYSTEM – Failure of, orinadequate air traffic system procedures fordisseminating flight-critical information.

1 1

34 FLIGHTCREW – Failure of captain toexercise command authority. 1 1 1 1 1 1 6

38 FLIGHTCREW – Flight crew preoccupationwith inappropriate tasks or failure to correctlyprioritize the critical tasks under timeconstraints.

1 1 1 1 1 1 1 7

39 MANUFACTURERS – DESIGN – Design noterror tolerant. System design does notprovide adequate redundancy to counteracterrors or alerting of the effects of errors.

1 1 1 1 1 1 1 7

42 FLIGHTCREW – Failure of the flight crew torecognize and take appropriate action tomitigate combinations of circumstantialfactors, hazards, and/or non-normal systemconditions.

1 1 1 1 1 1 1 1 1 1 1 11

43 FLIGHTCREW – Flight crew failure torecognize and counteract complacency thatmay exist when operating at homeaerodrome. (“HOME AERODROMECOMPLACENCY”)

1 1

44 FLIGHTCREW – Flight crew failure torecognize and correct unstable approach. 1 1 1 1 4

45 FLIGHTCREW - Failure of the flight crew tounderstand the impact of inoperative ordegraded aircraft systems on aircraftperformance (e.g. due to maintenanceactions).

1 1 2

46 AIR TRAFFIC SYSTEM – Air traffic systemprocedures that may compromise safety orincrease flight crew workload (e.g. noiseabatement procedures, slam dunkapproaches, inappropriate taxi routes duringlow visibility operations, etc.).

1 1 1 3

47 FLIGHTCREW – Flight crew failure tomaintain aircraft systems status awareness. 1 1 1 1 1 1 6

48 AIRLINES/OPERATORS – Airline/operatorlack of stabilized approach criteria andmandatory go-around/rejected landing policy.

1 1 2


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50 AIRLINES/OPERATORS – Airline/operatorfailed to effectively correct known proceduralnon-compliance issues.

1 1

51 AIRLINES/OPERATORS – Airline/operatorfailed to correct systemic complacency andnon-standard conduct within the company.

1 1

52 REGULATORS – Ineffective oversight ofprocedural non-compliance 1 1

54 AIR TRAFFIC SYSTEM/FLIGHTCREW –Flight crew actions or inactions contributed toincreased workload (e.g. missed checklistitems causing a rushed approach).

1 1 1 3

55 AIRLINES/OPERATORS – Airline/operatorpolicies burdened flight crew with non-flightrelated tasks (e.g. paperwork requirementswhile flying; communications with dispatchand/or air traffic control requests for info notrelated to safe flight and landing).

1 1

56 MANUFACTURERS/AIRLINES/OPERATORS – Failure of manufacturers andairlines/operators to appropriately prioritizechecklist items to ensure critical itemsreceive proper emphasis.

1 1

57 MANUFACTURERS – DESIGN – Systemdesign was not appropriate for conditionsencountered.

1 1 1 1 1 1 1 1 1 9

100 REGULATORS – Insufficient regulatoryoversight of air carrier operations includingmanagement and training practices.

1 1 1 1 1 1 1 7

101 AIRLINES/OPERATORS – MAINTENANCE– The airline/operator culture did not reflect aproactive approach to maintain systems fullyoperational in a timely manner.

1 1 2

102 FLIGHTCREW – Inadequateplanning/briefing by the flight crew. 1 1

103 AIR TRAFFIC SYSTEM – Inadequateweather information provided to the flightcrew by air traffic services.

1 1 1 1 4

104 AIRLINES/OPERATORS/REGULATORS –SOP – Lack of airline operator proceduresand lack of regulations to identify flight crewthat are "qualified" but who have a history oftest/check ride failure and demonstratedweaknesses.

1 1 2


225

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105 AIRLINES/OPERATORS – SOP – Lack ofairline operator policies/procedures toprevent pairing inexperienced pilots together(total time, time in type, etc.).

1 1 2

106 FLIGHTCREW – Flight crew failure torecognize the state of the airplane (speed,energy state, power setting, pitch attitude,relevant elements of the pilot surroundings,including aircraft systems and the pilotsintentions).

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 17

107 FLIGHTCREW – Flight crew failure to use allavailable information resources. 1 1 1 1 4

204 FLIGHTCREW – Flightcrew not adequatelyprepared for the task (inadequate briefing,inadequate assessment of weather factorsand/or not mentally prepared).

1 1 1 1 4

206 FLIGHTCREW – Flightcrew failure torespond to and/or process the flight deckwarning.

1 1 1 1 5

207 FLIGHTCREW – Flightcrew failure to use theappropriate level of automation to reduceworkload and complexity in flight deck.

1 1 1 1 4

301 AIRLINES/OPERATORS/MANUFACTURERS – Recommended operational proceduresare inconsistent and/or not reconciled.

1 1 1 3

303 FLIGHTCREW – Failure to process andinterpret available relevant data. 1 1 1 1 1 1 1 1 1 1 1

0400 AIRLINES/OPERATORS – TRAINING –

Inadequate flightcrew training due toeconomic/cultural pressures.

1 1 1 3

401 AIRLINES/OPERATORS – Airline/operatorstandards failed to ensure adequateinstructor/check airman qualifications(proficiency/skill) prior to conducting training.(see 20)

1 1

402 AIRLINES/OPERATORS – TRAINING –Flightcrew inadequately prepared for the typeoperation or level of training conducted.

1 1 1 3

404 FLIGHTCREW – SOP – Failure to followprocedures – not announcing transfer ofcontrol. (see 10)

1 1


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406 AIR TRAFFIC SYSTEM – Failure to followIFR separation and clearance procedures(SOP). (see 8)

1 1

407 AIR TRAFFIC SYSTEM – Inadequatesituation awareness (horizontal). Failure torequest and/or correctly interpret appropriateaircraft position information (see 7)

1 1

408 AIR TRAFFIC SYSTEM – Failure to followposition reporting procedures by notrequesting appropriate aircraft positioninformation.(SOP) (see 8, 406)

1 1

409 AIR TRAFFIC SYSTEM – Failure to followproper sequencing procedures. (see 8) 1 1

410 AIR TRAFFIC SYSTEM/FLIGHTCREW –Inadequate communications due to blockageof radio transmission. (see 5)

1 1

411 FLIGHTCREW – Failure to monitor aircraftenergy state due to self-induced highworkload/confusion (see 106)

1 1 1 1 4

412 FLIGHTCREW – Failure to follow the"approach to stall" procedures (see 10) 1 1 1 1 4

413 FLIGHTCREW – Not prepared for post stallrecovery task. (see 204) 1 1 1 1 1 1 6

414 AIRLINES/OPERATORS – TRAINING –Training failed to adequately develop firstofficer/captain piloting skills. (see 20)

1 1 2

415 REGULATORS – Inadequate oversight ofairline/operator check pilotselection/qualifications.

1 1

416 AIRLINES/OPERATORS – TRAINING –Non-compliance with regulations (training)(see 40)

1 1

419 AIRLINES/OPERATORS – TRAINING –Failure of the airline/operators to provideadequate training to ensure compliance withSOP. (see 10)

1 1

420 REGULATORS – Regulatory oversight failedto insure airline/manufacture procedureswere consistent and reconciled. (see 301)

1 1 2

421 FLIGHTCREW – Increased workload incockpit due to use of multi-language phrases. 1 1


227

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422 AIRLINES/OPERATORS – TRAINING –Airline/operator training failed to adequatelyaddress methods to recover from unexpectedautoflight mode changes.

1 1 2

423 MANUFACTURERS – DESIGN – Lack ofintuitive clarity (transparency) of how tochange autoflight modes.

1 1

424 AIRLINES/OPERATORS – Lack of amandatory go-around policy for unanticipatedmode changes during approach. (see 48)

1 1

425 REGULATORS/AIRLINES/OPERATORS –CRM – Lack of culturally appropriate CRMtraining.

1 1 2

426 AIRLINES/OPERATORS – Airline/operatordid not adequately evaluate the safetyaspects of service bulletins.

1 1

427 MANUFACTURERS/REGULATORS – Didnot properly assign service bulletin (SB)category to reflect the level of operationalurgency.

1 1

428 AIRLINES/OPERATORS – Operationalprocedures and training did not adequatelyreduce the requirement for knowledge-basedsolutions. (Rule-based rather thanknowledge-based)

1 1

429 FLIGHTCREW – Inappropriate crewresponse during critical flight regime orsituation. (see 10)

1 1 1 1 1 1 1 1 8

430 FLIGHTCREW – CRM – Lack ofcommunication skills. 1 1 2

431 FLIGHTCREW – CRM – Lack of crewcoordination skills . 1 1 1 1 1 1 6

432 FLIGHTCREW – CRM – Lack of workloadmanagement skills. 1 1 1 1 1 5

433 FLIGHTCREW – CRM – Lack of planningskills. 1 1

434 FLIGHTCREW – CRM – Lack of decisionmaking skills. 1 1

435 FLIGHTCREW – Failure to understand theoperation/limitations of Automation Mode(s) 1 1 2

437 FLIGHTCREW – Inappropriate use/relianceon automation to recover the airplane fromunusual attitude or unusual in-flightsituations.

1 1 2


228

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439 AIRLINES/OPERATORS - Airline/operatorfailed to ensure that pre-flight maintenanceprocedures were accomplished.

1 1

440 MANUFACTURERS – Failure to provide anon-normal/emergency procedure for aknown failure condition.

1 1 2

441 FLIGHTCREW – SOP – Failure to properlyconfirm system status prior to responding tochecklist challenge (see 106)

1 1

442 MANUFACTURERS – DESIGN – Aircraftdesign allowed the display of misleadinginformation without appropriate annunciation.(see 57)

1 1 2

443 AIRLINES/OPERATORS – TRAINING –Failure to ensure adequate and standardizedtraining for their pilots. (see 419)

1 1 2

444 MANUFACTURERS/AIRLINES/OPERATORS – Safety assessment methods do notadequately identify the operational safetyconsequences of system failure conditions.

1 1 1 3

445 MANUFACTURERS – Failure of, orinadequate procedures for disseminatingsafety information between manufacturers.(see 32)

1 1

446 AIRLINES/OPERATORS – Failure to disableautomation systems with known problems.(see 207)

1 1

447 AIRLINES/OPERATORS – Over reliance oncrew procedures to work around unresolvedintermittent airplane failure conditions.

1 1

448 REGULATORS – Lack of a formalizedsystem for threat free reporting of safety-related incidents from operators tomanufacturers.

1 1

449 MANUFACTURERS – Lack of a reliableprocess for reviewing/revising system safetyassessments based on field data collectedafter certification.

1 1 1 1 4

450 AIRLINES/OPERATORS – MAINTENANCE– Airline/operator does not provide a loggingprocess that requires flight crews to reportrecurring events.

1 1


229

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451 AIRLINES/OPERATORS – Failure toaddress the problems associated with theflight crew transition from Eastern builtaircraft to Western built airplanes.

1 1

453 FLIGHTCREW – Pilot Flying (PF) failed toperform monitoring function and/or other PFresponsibilities. (see 22)

1 1 1 1 1 5

454 MANUFACTURERS – Failed to recommendappropriate aircraft systems calibrationintervals.

1 1

455 AIRLINES/OPERATORS – Kept and/orentered inadequately prepared aircraft intoservice due to economic pressures.

1 1

456 REGULATORS – Inadequateregulation/guidance establishing minimumconditions for critical aircraft handlingmaneuvers. (See 582)

1 1 2

457 FLIGHTCREW – Lack of upset recovery(Advanced Maneuver) skills and knowledge. 1 1 1 1 1 1 1 7

458 SIMULATOR/AIRCRAFTMANUFACTURERS – Lack of simulatorfidelity and aerodynamic models thatadequately support upset recovery(Advanced Maneuver) training.

1 1 1 1 4

459 FLIGHTCREW – Failure to recognize theperformance effects of ice accumulation onthe aircraft.

1 1 1 3

460 MANUFACTURERS – DESIGN – Failure toprovide adequate instrumentation to optimizeperformance during recovery from unusualattitude.

1 1

461 MANUFACTURERS – DESIGN – Previouslycertificated designs may not meet currentminimum performance standards.

1 1 2

462 REGULATORS/AIRLINES/OPERATORS –Lack of consistent defined method ofcalculating stall speed.

1 1

464 REGULATORS – High risk maneuverspermitted during training due to regulatoryrequirement/lack of requirement. (see 490)

1 1

465 REPAIR FACILITY – MAINTENANCE –Failure to develop adequate repair andinspection procedures.

1 1 2


230

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466 REPAIR FACILITY – MAINTENANCE –Failure to follow/supervise established repairand inspection procedures.

1 1 2

467 AIRLINES/OPERATORS – MAINTENANCE– Insufficient airline/operator oversight ofcontract repair facility operations includingmanagement and training practices. (ref sps100, 2-53)

1 1

468 REGULATORS – Insufficient regulatoryoversight of repair facility operations,including management and training practices.(see 100)

1 1

469 REGULATORS – Lack of a reliable processfor reviewing/revising safety decisions basedon field data collected after certification. (see449, 2-53, 536)

1 1 1 1 4

470 REGULATORS – Lack of appropriateknowledge and experience necessary forPrincipal Operations Inspector (POI) toperform air carrier oversight function. (see19)

1 1

471 MANUFACTURERS/REGULATORS –Limited flight data recording capabilityhampers understanding of accidentsequence. (For future accident prevention(see 26)

1 1 2

472 REGULATORS/MANUFACTURERS –DESIGN – Stick-shaker system fails toprovide adequate time margin betweenactivation and stall in an accelerated stallcondition.

1 1

473 REGULATORS – Regulator failed to identifyneed for training in recognition and recoveryfrom unusual flight regimes/attitudes. (see437, 457, 458)

1 1 1 1 4

474 MANUFACTURERS – DESIGN – Inadequateconsideration of the human factors aspectsof failure recognition and/or annunciation.

1 1

475 MANUFACTURERS/AIRLINES/OPERATORS – TRAINING – Inadequate trainingmaterials relating to modern propulsionsystem malfunction recognition.

1 1

477 REGULATORS – Failure to establishstandards/requirements for propulsionsystem malfunction recognition training.

1 1


231

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479 SIMULATOR MANUFACTURERS – Lack ofrealistic simulation of propulsion systemmalfunction and aircraft response.

1 1

481 REGULATORS – Failure to require realism insimulator representation of propulsionsystem malfunction.

1 1

483 MANUFACTURERS – DESIGN – Cockpitindicators alert for thresholds (exceedances),but only provide passive indication of trends

1 1

487 AIRLINES/OPERATORS – TRAINING –Training program failed to recognize andoffset negative transfer.

1 1 2

491 AIRLINES/OPERATORS – MAINTENANCE– Failure to ensure pertinent maintenancehistory is made available to the crew.

1 1

492 MANUFACTURERS – DESIGN – Decreasedcrew vigilance due to modern flight deckautomation and low-stimulation environment.

1 1

493 AIRLINES/OPERATORS – Operatinglimitations are less stringent than ICAOrecommendations.

1 1

494 AIRLINES/OPERATORS – Airline/operatordid not adequately evaluate the safety aspectof NOTAMS.

1 1

495 AIR TRAFFIC SYSTEM – Accurate weatherinformation not available to Flight Crews andair traffic system.

1 1

496 MANUFACTURERS – DESIGN – Runwaywind information not presented in cockpitdisplays as headwind and crosswindcomponents.

1 1

497 REGULATORS/AIRPORT OPERATORS –Inadequate precautions taken regardingeffects of terrain, obstructions, and buildingplacement on wind conditions on runway.(see 564)

1 1

498 MANUFACTURERS – DESIGN – Noannunciation provided to flight crew whenoperating in a non-standard flight instrumentconfiguration

1

499 REGULATORS – Inadequate regulatoryoversight of airline/operatorchecklist/procedures changes.

1 1


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500 AVIATION COMMUNITY – Lack ofexperienced/skilled pilots due to limitedaviation career training programs.

1 1

501 AVIATION COMMUNITY – Lack ofexperienced/skilled pilots due to high costs ofaviation pilot training and experienceacquisition.

1 1

502 AIRLINES/OPERATORS –Inexperienced/junior pilots able totransition/upgrade to new equipment due toeconomic pressures/contracts that precludemore experienced/senior pilots fromupgrading.

1 1

503 REGULATORS – Current regulations allowinexperienced/junior pilots totransition/upgrade to new equipment due toeconomic pressures/contracts that precludeexperienced/senior pilots from upgrading.

1 1

504 AIRLINES/OPERATORS/REGULATORS –TRAINING – Lack of a simulator limited thelevel of flightcrew training that could beprovided in a given time period and thetraining syllabus did not compensate for thisloss of training effectiveness.

1 1

505 REGULATORS – Regulators failed todisseminate pertinent flight safetyinformation.

1 1 2

506 REGULATORS – Lack of adequateregulations to prevent pairing inexperiencedpilots. (total time, time in type, etc.).

1 1 2

507 MANUFACTURERS – DESIGN – Failure toprovide adequate audible/visual annunciationto the flightcrew of trim change/travel.

1 1 2

508 REGULATORS/OPERATORS – Failure torequire/maintain sterile cockpit environmentduring critical flight regimes.

1 1

509 AIR TRAFFIC SYSTEM – Failure to provideproper radar vectoring to the instrumentapproach.

1 1

510 AIRLINES/OPERATORS – TRAINING –Training does not cover range of possibleevents that could lead to loss of control onthe ground.

1 1

511 REPAIR FACILITY – MAINTENANCE – Useof part not approved by the manufacturer. 1 1


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512 MANUFACTURERS – DESIGN – Improperassessment of failure modes and effectsanalyses.

1 1

513 FLIGHTCREW – Flight Engineer (FE) failedto perform monitoring function and other FEresponsibilities.

1 1

514 MANUFACTURERS – DESIGN – Alerts notprovided to indicate when pilot flight controlinputs are inhibited due to design.

1 1

515 REGULATORS – Failure to require datarecording capability sufficient to understandaccident sequence. (For future accidentprevention ) (see 471)

1 1

516 AVIATION COMMUNITY – Somecharacteristics and effects of waketurbulence not fully understood.

1 1

517 REGULATORS – Certification criteria do notadequately address effects of externalinfluences (wake turbulence, gusts) onaircraft controllability.

1 1

518 REGULATORS/MANUFACTURERS – Flightcontrol authority under crossover conditionswas not adequately addressed duringcertification.

1 1

519 MANUFACTURERS – DESIGN – Systemdesign does not provide adequateredundancy to circumvent malfunction. (notmalfunction tolerant)

1 1

520 MANUFACTURERS – DESIGN – Designdoes not provide sufficient trend informationto permit the flight crew toanalyze/understand conditions encountered.(See 483)

1 1

521 MANUFACTURERS – DESIGN – Does notprovide alerting of a flight critical malfunction. 1 1 2

522 MANUFACTURERS/REGULATORS –DESIGN – Insufficient appreciation ofimplications of new technology applicationsmerged with older/existing design (e.g.,Relaxed Static Stability (RSS), LongitudinalStability Augmentation System (LSAS).

1 1 2

523 MANUFACTURERS/REGULATORS –DESIGN – Aircraft design allowed criticalflight controls to be moved inadvertently andinappropriately.

1 1


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524 SIMULATOR/AIRCRAFTMANUFACTURERS – Lack of realisticsimulation of aircraft handling characteristicslikely to be encountered during normaloperations. (see 458)

1 1

526 MANUFACTURERS/REGULATORS –DESIGN – Lack of reliable process forperforming system fault analysis duringoriginal design or subsequent modification.

1 1

527 MANUFACTURERS/REGULATORS –DESIGN – Design does not comply withcertification standards.

1 1

528 MANUFACTURERS – DESIGN – Failure toprovide warning of flight critical systemunsafe status .(see 14)

1 1

529 FLIGHTCREW – Lack of communications.Failure to adequately differentiate itemsrequiring action from items that areinformative.

1 1

531 REGULATORS – Failure to evaluate and/orestablish requirements for standardization offlight deck information/controls to preventnegative transfer effects on flight criticalsystems.

1 1

532 AIRLINES/OPERATORS – TRAINING –Improper, incomplete, and/or inadequatetraining.

1 1

534 FLIGHTCREW – Failure to refuse clearancethat is in conflict with desired aircraft energystate and/or standard operating procedures.

1 1

535 MANUFACTURERS – DESIGN – Multi-function computer internal logic precludedflight control usage at a critical time.

1 1

536 REGULATORS – Insufficient analysis ofprevious incidents and lack of availableincident information to the operators due tolack of oversight on the part of theregulator(s). (see 32, 469, 505)

1 1 2

537 REGULATORS – Known critical flight safetyinformation not available to the flightcrew dueto the failure of the regulators to ensure thatthe information was disseminated.

1 1


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538 REGULATORS – Timely flight safetyinformation was not shared between thevalidating authority and certificating authoritydue to a lack of compliance with the terms ofthe bi-lateral airworthiness agreement.

1 1

539 REGULATORS – Insufficient icingcertification requirements to ensure safeflight throughout the atmospheric icing andexpected operational environment.

1 1

540 AIR TRAFFIC SYSTEM – Ineffective use oftraffic management programs by Air TrafficControl System Command Center / TrafficManagement Unit due to lack ofcomprehensive working knowledge of thetraffic management program.

1 1

541 FLIGHTCREW – Distracting cockpit activitiesdue to lack of cockpit discipline resulted ininattention to aircraft and environment.

1 1

542 MANUFACTURERS/REGULATORS – Somenormally encountered operationalconfigurations, in icing, not addressed duringairworthiness certification.

1 1

543 FLIGHTCREW – Flightcrew failure torecognize the seriousness of iceaccumulation and it's affect on aircraftperformance and controllability.

1 1 2

544 MANUFACTURERS – DESIGN – Autoflightdesign masks the onset of slowly developingadverse flight control conditions and does notprovide adequate cues to aid flightcrewsituational awareness.

1 1 2

546 MANUFACTURERS – DESIGN – Iceprotection system design was not appropriatefor conditions encountered.

1 1

547 MANUFACTURERS – DESIGN – Autopilotlimit logic caused the system to disconnectwhile the autoflight system was still applyingproper control inputs.

1 1 1 3

548 REGULATORS – Current practical teststandards overemphasize minimum altitudeloss during approach to stall recovery thatmay lead to a negative training transfer for astalled wing recovery.

1 1

549 AIRLINES/OPERATORS – Failure toconsider human factors in checklist design. 1 1


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550 REGULATORS – Regulations inadequate toensure proper flight crew proficiency for thetype of operations being conducted.

1 1

551 REGULATORS – Lack of regulatoryrequirements for post stall recognition andrecovery training.

1 1 2

552 AIRLINES/OPERATORS – TRAINING –Failure to provide post stall recognition andrecovery training.

1 1

553 FLIGHTCREW – TRAINING – Failure toproperly interpret cues/indications of mainwing stall versus tail plane stall due toinadequate training and experience.

1 1

554 REGULATORS/MANUFACTURERS –DESIGN – Aircraft design and certificationfailure analyses do not adequately addressthe potential for flightcrew error or inaction.

1 1

555 REGULATORS – Icing roughness onprotected surfaces during normal operation inicing is not defined for certification.

1 1

556 AVIATION COMMUNITY – Misunderstandingand misinformation about the existence of icebridging is prevalent within the aviationcommunity.

1 1

557 AVIATION COMMUNITY – Characteristicsand effects of ice accretion on aircraftperformance not fully understood.

1 1

558 AIRLINES/OPERATORS/REGULATORS –Failure of or inadequate airline/operatorprocess to determine the criticality ofoperational information and to identify theproper distribution method to address theinformation.

1 1

559 AIRLINES/OPERATORS – MAINTENANCE– Failure of or inadequate procedures for themaintenance and replacement of airframecomponents.

1 1 2

560 REGULATORS – Requirements for ATIS tohave all unpublished NOTAM informationplaces an excessive burden on the voicebroadcast.

1 1

561 AIR TRAFFIC SYSTEM – Air traffic systempractices that may compromise safety orincrease flight crew workload (see 46)

1 1 2


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562 AVIATION COMMUNITY – Lack ofinformation available regarding the effects ofdelayed pneumatic boot operation in icingconditions.

1 1

563 AIRLINES/OPERATORS – TRAINING –Approach to stall training inadequatelyaddresses pre-stall audible and tactile cues.

1 1

564 AIRCRAFT EQUIPMENT – FDR not fullyfunctional during the accident (for futureaccident prevention)

1 1

566 AIRLINES/OPERATORS – TRAINING –Failure to provide adequate training fordistinguishing between main wing stallversus tail plane stall.

1 1

567 AIR TRAFFIC SYSTEM - Failure to followvertical separation procedures (SOP) (refSPS 8, 30)

1 1

568 MANUFACTURERS/REGULATORS – Stallwarning systems are not designed andcertified to account for a sufficiently widerange of entry conditions.

1 1

569 MANUFACTURERS/AIRLINES/OPERATORS –Economic and operational pressures conflictwith safety considerations

1 1

570 AIRLINES/OPERATORS/REGULATORS –Lack of objective no-fault reporting andsharing of pertinent standardized informationon pilot performance, qualification, and safetyhistory.

1 1

571 AIRLINES/OPERATORS – Selection processfor initial hire and upgrades allowed the hiringand upgrade of unqualified pilots

1 1

572 AIRLINES/OPERATORS – Failure tomaintain all relevant/required trainingrecords.

1 1

573 AIRLINES/OPERATORS – Lack of safetyculture that encourages threat-free reportingof safety information (including repeatederrors and poor performance) within theairline.

1 1

574 AIRLINES/OPERATORS/REGULATORS –Failure to require structured return to dutyrequirements after sick leave. (i.e. medicalclearance).

1 1


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575 AIRLINES/OPERATORS – Training notconsistent with the airline operations manual. 1 1

576 FLIGHTCREW – Failure of first officer to takecontrol of the aircraft when it is clear that thecaptain is not performing adequately.

1 1

577 AIRCRAFT EQUIPMENT - Autopilot designdoes not warn of inappropriate aircraftresponse to autopilot input (i.e. roll inputversus a/p command, etc) or approachingautopilot control limits.

1 1

578 AIRLINES/OPERATORS – Failure of orinadequate procedures for the maintenanceand replacement of engine controls.

1 1

579 AIR TRAFFIC SYSTEM – Lack of awarenesson the part of the controllers of existingweather conditions at altitude resulted in aninadvertent hold in hazardous weatherconditions.

1 1

580 FLIGHTCREW – Failure to perform dutiesdue to emotional state, i.e., tension, anxiety,etc.

1 1

581 REGULATORS – Failure to provideadequate oversight of operator training todistinguish between various stall onsettriggers (see 566)

1 1

582 REGULATORS – Lack of sufficientlyobjective handling qualities criteria incertification requirements (See 456)

1 1

583 AIRLINES/OPERATORS – TRAININGTraining environment and practices not fullyaligned with line operations.

1 1

585 AIRLINES/OPERATORS – Use of flight idlefollowing propulsion system malfunction on aturboprop airplane can result in increaseddrag and possible loss of control (if theengine is not shut down and the propeller isnot feathered)

1 1

586 AIRLINE OPERATORS/MANUFACTURERS– Correct procedural information on the useof pneumatic boots was not disseminated tothe operators.

1 1

587 REGULATORS - Inadequate aircraftcertification criteria. Gusts not considered incrosswind limitations.

1 1


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588 FLIGHTCREW - Over reliance on automationduring critical phase of flight due toautomation dependency

1 1

589 AIRLINE OPERATIONS / REGULATORS –Lack of common industry standards andguidelines in aircraft angle of attack / lowairspeed indicator system design, equipageand training

1 1

590 REGULATOR - Regulators failed toadequately identify training requirements thatinclude engine out training in the initialtakeoff climb phase.

1 1

591 FLIGHT CREW – Pilot’s excessive attentionto factors that were inconsequential to thecompletion of a safe flight let them to executea more difficult, non-standardprocedure/piloting technique than waswarranted by conditions.

1 1

592 MANUFACTURER – DESIGN – Automatedsystems designs are based on a limited setof assumptions which do not cover all routineoperations.

1 1

593 MANUFACTURER – Failed to providesufficient documentation and/or trainingregarding a design feature or operationalcharacteristic.

1 1

594 AIRLINE/OPERATOR – Failure of companyto realize the unintended consequences ofnew flight operations policies.

1 1

595 MANUFACTURERS – DESIGN – Lack of apowered control system alloweduncommanded control deflections and highrecovery forces.

1 1

708 AIR TRAFFIC SYSTEM – Control Judgment(Anticipated Separation). Failure to correctlyanticipate separation.

1 1

709 AIR TRAFFIC SYSTEM – Control Judgment.(Prioritization). Failure to correctly prioritizecontrol actions.

1 1


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716 AIR TRAFFIC SYSTEM –Communications/Practices/ProceduresIncreased Flight Crew Workload During aCritical Phase. ATC practices/procedurescaused a disruption in crew activities andcontributed to an increased flight crewworkload during a critical phase of flight.

1 1 2

APPENDIX K: ICING

241

Appendix K: Icing

The JSAT data set was modified, in response to direction from CAST, to includespecific loss-of-control accidents where aircraft icing was a factor. CAST did notintend that this JSAT complete a definitive study of icing, but to identify icing-relatedcontributions to loss of control and recommend interventions. CAST requested thatthe product of this JSAT related to icing also be passed to the follow-on WeatherJSAT which will conduct a more exhaustive study of icing issues. The LOC JSAT,therefore, separated icing-related interventions to provide a special focus on thissubset of the accidents examined. Icing was a contributing factor in the events thatled up to 3 of the 24 accidents reviewed. The 3 that the LOC JSAT analyzed were:

• ACA 6291, J4100, Columbus, Ohio;• Simmons Airlines 4184, ATR-72, Roselawn, Indiana; and• COMAIR 3272, EMB120, Monroe, Michigan.

Some common features of the accidents were:• Twin-engine, turboprop airplanes;• Pneumatic deicing boot ice protection systems on wings and tail;• Commuter/regional routes below 20,000 feet; and• Airplanes certificated to fly in icing conditions per FAR Part 25, Appendix C

icing criteria.

Nineteen of the Loss of Control interventions were developed exclusively to addressaircraft icing problems. The interventions address four broad areas of activity:

• Icing Certification and Regulation (Certification)• Ice Detection/Protection System Design and Operation (Icing Protection

System)• Icing Effects Training (Training)• Icing Weather Tool Development (Weather)

Twelve of the 19 interventions were rated in accordance with the JSAT ProcessHandbook, as described in Section IV. Five of the 19 icing-related interventionsrequire some type of research and were ranked according to the process describedin the Research-Related Interventions section. Another unrated interventionrecommends that FDRs record the detection of ice and the status (on/off) of iceprotection systems. Below is a list of all 19 icing-related interventions.

APPENDIX K: ICING

242

1. Icing Interventions

IS# Intervention Strategy OE

457

457 To ensure full protection throughout the icing envelope,regulators/manufacturers should expand icing certificationcriteria to include ice accretions due to residual, intercycle,delayed activation and system malfunction to ensure that icingprotection equipment and/or procedures provide full operationalenvelope coverage.

4.6

516

516 To ensure full protection throughout the operationalenvelope, regulators/manufacturers should expand icingcertification criteria to include performance and handlingqualities testing which consider ice accretions due to residualicing, intercycle icing, delayed system activation and/or systemmalfunction. (See 457, 459)

4.6

154154 Airlines/operators should improve/increase training toincrease awareness of icing effects on airplane type includingdynamic simulator training.

3.1

500

500 To ensure that flight crews initiate correct in-flight icingprocedures, the regulators should require installation of icedetection system that provides annunciation that alerts the crewto respond appropriately to the icing hazard.

2.8

511

511 To reduce the number of hazardous icing encounters and tokeep air traffic apprised of current weather conditions,regulators should recommend that flight crews report all icingconditions to air traffic control and be required to report theoccurrence of moderate to severe icing conditions. (ref. FAR91.183)

2.8

498

498 To ensure safe operating speeds in icing conditions,regulators shall require that minimum safe operating speeds inicing conditions be published in the aircraft flight manual(section 1) for all aircraft operating configurations.

2.7

460

460 To ensure a better understanding by air crews ofappropriate procedures for use of ice protection systems,operators, manufacturers and regulators should expedite themodification of training programs and distribution of media, toinclude ice bridging and deicing boot operation.

2.4

497

497 To minimize exposure to flight operations in icingconditions, air traffic service providers should initially andperiodically train controllers on the hazards/impacts of icing onaircraft performance when holding or vectoring aircraft to thefinal approach course in areas of known or reported icingconditions.

2.1

504

504 To provide more tactile cues to flight crews on turbopropaircraft in icing conditions, airlines/operators should developSOP’s calling for flight crews to disengage autopilot duringmaneuvering, when workload permits.

1.5

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IS# Intervention Strategy OE

508

508 To ensure that flight crews have and use all necessaryweather information, airlines/operators shall train flight crewsand airline dispatchers on the importance of reviewing weatherinformation for potential in-flight icing.

1.5

446446 To decrease the probability of ice buildup, manufacturersshould design and install a system that automatically sheds icefrom flight-critical surfaces

1.3

466

466 To further improve the quality of weather informationprovided to the flight crews, regulators should implementrecommendations from the weather product working group ofthe 1999 FAA In-flight Icing Operations Conference.

0.0

2. Icing Research & Development Recommendations

IS# Intervention Strategy Priority #

499

499 To make flight crews aware of the possibility of airframe iceaccretion, research should be conducted to develop reliable means ofaircraft surface ice detection, as well as ground and aircraft basedmeans of detection of meteorological icing conditions.

1

459

459 For a full understanding of aircraft performance and handlingqualities in icing conditions, research should be conducted to definethe effects of all ice accretions, with particular emphasis on the rolleffect due to ice contaminated wings (intercycle or residual).

2

509

509 To reduce the risk of encountering hazardous weather conditions(e.g. super-cooled large droplets (sld), thunderstorms, etc.) researchmust be conducted to develop methods for accurate prediction andidentification of these conditions.

3

461461 To reduce the adverse effects of ice accretion roughness,regulators and NASA should conduct research leading to improvedice protection technologies.

4

510510 To better understand the effects of super-cooled large droplets(sld) icing research should be conducted on ice protection systemdesign and operation in this weather phenomena.

4

458*458 To enhance the safety of all aircraft, regulators should ensurethat appropriate revised icing certification criteria apply to FAR Part23, 27 and 29 certificated aircraft in addition to FAR Part 25 aircraft.

NR

462

462 To enhance the ability to analyze, identify and take correctiveactions for preventing accidents, manufacturers should include, andregulators should require, the recording of ice detection / protectionsystem state on the flight data recorder. (FAR 121 requires recordingof ice detection) (See 576.)

NR

*Note: Intervention (458) addressed general aviation certification. Consequently, the JSATdid not rate that recommendation but forwarded it to the General Aviation Joint SteeringCommittee.

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Though the interventions discussed in this section are specific to icing, a number ofstandard interventions cited elsewhere in this report also can relate to icing under certaincircumstances. For example, the highest ranked intervention is to develop and implementflight envelope protection. However, flight envelope protection needs to consider the effectsof icing because the presence or absence of icing will significantly modify the availableenvelope and the performance of sensors that influence the boundary of envelopeprotection. Similarly, higher fidelity simulators for upset recovery training should alsoconsider an iced aircraft model since icing would affect recovery characteristics. Therefore,although icing-related problems and interventions may be a subset of the total accident dataset, there is value in recognizing the icing aspect in developing other interventions to gainthe maximum leverage from the “standard” interventions.

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