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51-423: Accidents where the aircraft is out of control at the time of impact, because of mechanical failure or pilot error , are classified instead as uncontrolled flight into terrain, or UFIT. Incidents resulting from the deliberate action of the person at the controls, such as a forced landing , an act of terrorism , or suicide by pilot , are also excluded from the definition of CFIT. According to Boeing in 1997, CFIT

102-542: A contracting State, on arrival in the territory of another contracting State and retained on board on leaving the territory of that State shall be exempt from customs duty, inspection fees or similar national or local duties and charges. This exemption shall not apply to any quantities or articles unloaded, except in accordance with the customs regulations of the State, which may require that they shall be kept under customs supervision. Article 29 : Before an international flight,

153-413: A desired altitude). CTM training focuses on teaching crew members how to handle concurrent tasks which compete for their attention. This includes the following processes: The need for CTM training is a result of the capacity of human attentional facilities and the limitations of working memory. Crew members may devote more mental or physical resources to a particular task which demands priority or requires

204-696: A known cause. Chicago Convention on International Civil Aviation The Convention on International Civil Aviation , also known as the Chicago Convention , established the International Civil Aviation Organization (ICAO), a specialized agency of the United Nations charged with coordinating international air travel. The Convention establishes rules of airspace , aircraft registration and safety , security, and sustainability , and details

255-690: A major cause of air accidents. In 2004, it was identified as the primary reason for 78.6% of disastrous general aviation (GA) accidents, and as the major cause of 75.5% of GA accidents in the United States . There are multiple factors that can cause pilot error; mistakes in the decision-making process can be due to habitual tendencies, biases, as well as a breakdown in the processing of the information coming in. For aircraft pilots, in extreme circumstances these errors are highly likely to result in fatalities. Pilots work in complex environments and are routinely exposed to high amounts of situational stress in

306-413: A number of other qualitative assessments which pilots may perform before or during a flight to ensure the safety of the aircraft and passengers. These checklists, along with a number of other redundancies integrated into most modern aircraft operation systems, ensure the pilot remains vigilant, and in turn, aims to reduce the risk of pilot error. One of the most famous examples of an aircraft disaster that

357-479: A sparsely populated area away from the airport while they dealt with the problem (with, as a result, very few lights visible on the ground to act as an external reference), the distracted flight crew did not notice the plane losing height and the aircraft eventually struck the ground in the Everglades , killing 101 of the 176 passengers and crew. The subsequent National Transportation Safety Board (NTSB) report on

408-437: A strong presence in all types of aviation as a means of managing error and reducing the possibility of risk. Checklists are highly regulated and consist of protocols and procedures for the majority of the actions required during a flight. The objectives of checklists include "memory recall, standardization and regulation of processes or methodologies." The use of checklists in aviation has become an industry standard practice, and

459-935: Is defined as any action or inaction leading to deviation from team or organizational intentions. Error stems from physiological and psychological human limitations such as illness, medication, stress, alcohol/drug abuse, fatigue, emotion, etc. Error is inevitable in humans and is primarily related to operational and behavioral mishaps. Errors can vary from incorrect altimeter setting and deviations from flight course, to more severe errors such as exceeding maximum structural speeds or forgetting to put down landing or takeoff flaps. Reasons for negative reporting of accidents include staff being too busy, confusing data entry forms, lack of training and less education, lack of feedback to staff on reported data and punitive organizational cultures. Wiegmann and Shappell invented three cognitive models to analyze approximately 4,000 pilot factors associated with more than 2,000 U.S. Navy aviation mishaps. Although

510-407: Is difficult to measure the success of CRM programs, studies have been conclusive that there is a correlation between CRM programs and better risk management. Cockpit task management (CTM) is the "management level activity pilots perform as they initiate, monitor, prioritize, and terminate cockpit tasks." A 'task' is defined as a process performed to achieve a goal (i.e. fly to a waypoint, descend to

561-481: Is the "effective use of all available resources by individuals and crews to safely and effectively accomplish a mission or task, as well as identifying and managing the conditions that lead to error." CRM training has been integrated and mandatory for most pilot training programs, and has been the accepted standard for developing human factors skills for air crews and airlines. Although there is no universal CRM program, airlines usually customize their training to best suit

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612-713: The United Nations Economic and Social Council (ECOSOC). The convention has since been revised eight times (in 1959, 1963, 1969, 1975, 1980, 1997, 2000 and 2006). As of March 2019, the Chicago Convention had 193 state parties, which includes all member states of the United Nations except Liechtenstein . The Cook Islands is a party to the Convention although it is not a member of the UN. The convention has been extended to cover Liechtenstein by

663-417: The line operations safety audit (LOSA), implementation of crew resource management (CRM), cockpit task management (CTM), and the integrated use of checklists in both commercial and general aviation . Some other resources built into most modern aircraft that help minimize risk and manage threat and error are airborne collision and avoidance systems (ACAS) and ground proximity warning systems (GPWS). With

714-450: The "coordinative and cognitive ability to handle both routine and unforeseen surprises and anomalies." The desired outcome of TEM training is the development of 'resilience'. Resilience, in this context, is the ability to recognize and act adaptively to disruptions which may be encountered during flight operations. TEM training occurs in various forms, with varying levels of success. Some of these training methods include data collection using

765-609: The Java Sea due to several fatal mistakes made by the captain in the poor weather conditions. In this case, the captain chose to exceed the maximum climb rate for a commercial aircraft, which caused a critical stall from which he was unable to recover. TEM involves the effective detection and response to internal or external factors that have the potential to degrade the safety of an aircraft's operations. Methods of teaching TEM stress replicability, or reliability of performance across recurring situations. TEM aims to prepare crews with

816-456: The SI": the foot (for vertical distance = altitude ), the knot (for speed ), and the nautical mile (for long distance). Article 24 of the Chicago Convention stipulates that when flying from one contracting state to another, the kerosene that is already on board aircraft may not be taxed by the state where the aircraft lands, nor by a state through whose airspace the aircraft has flown. This

867-518: The chain of events which may have led to the particular incident or crash. Apart from checklists issued by regulatory bodies such as the FAA or ICAO , or checklists made by aircraft manufacturers, pilots also have personal qualitative checklists aimed to ensure their fitness and ability to fly the aircraft. An example is the IM SAFE checklist (illness, medication, stress, alcohol, fatigue/food, emotion) and

918-499: The cockpit during critical phases of the flight, such as when operating at below 10,000 feet (3,000 m). Pilot error In aviation , pilot error generally refers to an action or decision made by a pilot that is a substantial contributing factor leading to an aviation accident. It also includes a pilot's failure to make a correct decision or take proper action. Errors are intentional actions that fail to achieve their intended outcomes. The Chicago Convention defines

969-471: The completion of checklists from memory is considered a violation of protocol and pilot error. Studies have shown that increased errors in judgement and cognitive function of the brain, along with changes in memory function are a few of the effects of stress and fatigue. Both of these are inevitable human factors encountered in the commercial aviation industry. The use of checklists in emergency situations also contributes to troubleshooting and reverse examining

1020-423: The consolidation of onboard computer systems and the implementation of proper pilot training, airlines and crew members look to mitigate the inherent risks associated with human factors. LOSA is a structured observational program designed to collect data for the development and improvement of countermeasures to operational errors. Through the audit process, trained observers are able to collect information regarding

1071-425: The course of a flight. Accounting for the way human factors influence the actions of pilots is now considered standard practice by accident investigators when examining the chain of events that led to an accident. Modern accident investigators avoid the words "pilot error", as the scope of their work is to determine the cause of an accident, rather than to apportion blame. Furthermore, any attempt to incriminate

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1122-468: The course of every flight, crews are intrinsically subjected to a variety of external threats and commit a range of errors that have the potential to negatively impact the safety of the aircraft. The term "threat" is defined as any event "external to flight crew 's influence which can increase the operational complexity of a flight." Threats may further be broken down into environmental threats and airline threats. Environmental threats are ultimately out of

1173-416: The crew, may mislead them into improperly guiding the aircraft despite other information received from properly functioning equipment. CFIT is a constant hazard during aerial application and aerial firefighting operations, which involve routine low-altitude flight along varying routes over terrain that may be unfamiliar to the pilots. Before the installation of the first electronic terrain warning systems,

1224-445: The flight crew suitably licensed by the state in which the aircraft is registered. Article 32 : The pilot and crew of every aircraft engaged in international aviation must have certificates of competency and licensees issued or validated by the state in which the aircraft is registered. Article 33 : (Recognition of Certificates and Licences) Certificates of airworthiness, certificates of competency and licensees issued or validated by

1275-503: The following: LOSA was developed to assist crew resource management practices in reducing human error in complex flight operations. LOSA produces beneficial data that reveals how many errors or threats are encountered per flight, the number of errors which could have resulted in a serious threat to safety, and correctness of crew action or inaction. This data has proven to be useful in the development of CRM techniques and identification of what issues need to be addressed in training. CRM

1326-526: The hands of crew members and the airline, as they hold no influence on "adverse weather conditions , air traffic control shortcomings, bird strikes, and high terrain." Conversely, airline threats are not manageable by the flight crew, but may be controlled by the airline's management. These threats include "aircraft malfunctions, cabin interruptions, operational pressure, ground/ramp errors/events, cabin events and interruptions, ground maintenance errors, and inadequacies of manuals and charts." The term "error"

1377-667: The immediate safety of the aircraft. CTM has been integrated to pilot training and goes hand in hand with CRM. Some aircraft operating systems have made progress in aiding CTM by combining instrument gauges into one screen. An example of this is a digital attitude indicator, which simultaneously shows the pilot the heading, airspeed, descent or ascent rate and a plethora of other pertinent information. Implementations such as these allow crews to gather multiple sources of information quickly and accurately, which frees up mental capacity to be focused on other, more prominent tasks. The use of checklists before, during and after flights has established

1428-498: The implementation of CRM circa 1979, following the need for increased research on resource management by NASA , the aviation industry has seen tremendous evolution of the application of CRM training procedures. The applications of CRM has been developed in a series of generations: Today, CRM is implemented through pilot and crew training sessions, simulations, and through interactions with senior ranked personnel and flight instructors such as briefing and debriefing flights. Although it

1479-535: The incident blamed the flight crew for failing to monitor the aircraft's instruments properly. Details of the incident are now frequently used as a case study in training exercises by aircrews and air traffic controllers. During 2004 in the United States , pilot error was listed as the primary cause of 78.6% of fatal general aviation accidents, and as the primary cause of 75.5% of general aviation accidents overall. For scheduled air transport , pilot error typically accounts for just over half of worldwide accidents with

1530-447: The needs of the organization. The principles of each program are usually closely aligned. According to the U.S. Navy, there are seven critical CRM skills: These seven skills comprise the critical foundation for effective aircrew coordination. With the development and use of these core skills, flight crews "highlight the importance of identifying human factors and team dynamics to reduce human errors that lead to aviation mishaps." Since

1581-457: The normal procedures, protocol, and decision making processes flight crews undertake when faced with threats and errors during normal operation. This data driven analysis of threat and error management is useful for examining pilot behavior in relation to situational analysis. It provides a basis for further implementation of safety procedures or training to help mitigate errors and risks. Observers on flights which are being audited typically observe

Controlled flight into terrain - Misplaced Pages Continue

1632-474: The only defenses against CFIT were conventional see-and-avoid aviation practices, pilot simulator training, crew resource management (CRM) and radar surveillance by air traffic services . While refinements applied to those practices helped reduced the incidence of CFIT accidents, they did not eliminate them. To further assist in preventing CFIT accidents, manufacturers developed terrain awareness and warning systems (TAWS). The first generation of those systems

1683-689: The permission of the state or states whose territory is entered. Any license holder who does not satisfy international standard relating to that license or certificate shall have attached to or endorsed on that license information regarding the particulars in which he does not satisfy those standards. The convention is supported by nineteen annexes containing standards and recommended practices ( SARPs ). The annexes are amended regularly by ICAO and are as follows: Annex 5, Units of Measurement to be Used in Air and Ground Operations , named in its Table 3-3 three "non- SI alternative units permitted for temporary use with

1734-428: The pilot in command must ensure that the aircraft is airworthy, duly registered and that the relevant certificates are on board the aircraft. The required documents are: Article 30 : The aircraft of a state flying in or over the territory of another state shall only carry radios licensed and used in accordance with the regulations of the state in which the aircraft is registered. The radios may only be used by members of

1785-412: The pilots does not consider that they are part of a broader system, which in turn may be accountable for their fatigue, work pressure, or lack of training. The International Civil Aviation Organization (ICAO), and its member states, therefore adopted James Reason's model of causation in 1993 in an effort to better understand the role of human factors in aviation accidents. Pilot error is nevertheless

1836-500: The ratification of Switzerland . Some important articles are: Article 1 : Every state has complete and exclusive sovereignty over airspace above its territory. Article 3 bis : Every other state must refrain from resorting to the use of weapons against civil aircraft in flight. Article 5 : The aircraft of states, other than scheduled international air services , have the right to make flights across state's territories and to make stops without obtaining prior permission. However,

1887-468: The rights of the signatories in relation to air travel . The convention also contains provisions pertaining to taxation. The document was signed on December 7, 1944, in Chicago by 52 signatory states. It received the requisite 26th ratification on March 5, 1947, and went into effect on April 4, 1947, the same date that ICAO came into being. In October of the same year, ICAO became a specialized agency of

1938-415: The state in which the aircraft is registered, shall be recognized as valid by other states. The requirements for the issuing of those certificates or airworthiness, certificates of competency or licensees must be equal to or above the minimum standards established by the convention. Article 40 : No aircraft or personnel with endorsed licenses or certificate will engage in international navigation except with

1989-421: The state may require the aircraft to make a landing. Article 6 : (Scheduled air services) No scheduled international air service may be operated over or into the territory of a contracting State, except with the special permission or other authorization of that State. Article 10 : (Landing at customs airports): The state can require that landing to be at a designated customs airport and similarly departure from

2040-444: The system has proved very effective in preventing further CFIT accidents. Smaller aircraft often use a GPS database of terrain to provide terrain warning. The GPS database contains a database of nearby terrain and will present terrain that is near the aircraft in red or yellow depending on its distance from the aircraft. The sterile flight deck rule was implemented to limit pilot distraction by banning any non-essential activities in

2091-609: The term "accident" as "an occurrence associated with the operation of an aircraft [...] in which [...] a person is fatally or seriously injured [...] except when the injuries are [...] inflicted by other persons." Hence the definition of "pilot error" does not include deliberate crashing (and such crashes are not classified as accidents). The causes of pilot error include psychological and physiological human limitations. Various forms of threat and error management have been implemented into pilot training programs to teach crew members how to deal with impending situations that arise throughout

Controlled flight into terrain - Misplaced Pages Continue

2142-492: The terrain below and immediately ahead of them. Fatigue can cause even highly experienced professionals to make significant errors, which culminate in a CFIT accident. CFIT accidents frequently involve a collision with terrain such as hills or mountains or tall artificial obstacles such as radio towers during conditions of reduced visibility while approaching or departing from an airport. A contributing factor can be subtle navigation equipment malfunctions which, if not detected by

2193-512: The territory can be required to be from a designated customs airport. Article 12 : Each state shall keep its own rules of the air as uniform as possible with those established under the convention, the duty to ensure compliance with these rules rests with the contracting state. Article 13 : (Entry and Clearance Regulations) A state's laws and regulations regarding the admission and departure of passengers, crew or cargo from aircraft shall be complied with on arrival, upon departure and whilst within

2244-479: The territory of that state. Article 16 : The authorities of each state shall have the right to search the aircraft of other states on landing or departure, without unreasonable delay. Article 24 : Aircraft on a flight to, from, or across the territory of another contracting State shall be admitted temporarily free of duty, subject to the customs regulations of the State. Fuel, lubricating oils, spare parts, regular equipment and aircraft stores on board an aircraft of

2295-400: The three cognitive models have slight differences in the types of errors, all three lead to the same conclusion: errors in judgment. The three steps are decision-making, goal-setting, and strategy-selection errors, all of which were highly related to primary accidents. For example, on 28 December 2014, AirAsia Flight 8501 , which was carrying seven crew members and 155 passengers, crashed into

2346-615: The workplace, inducing pilot error which may result in a threat to flight safety. While aircraft accidents are infrequent, they are highly visible and often involve significant numbers of fatalities. For this reason, research on causal factors and methodologies of mitigating risk associated with pilot error is exhaustive. Pilot error results from physiological and psychological limitations inherent in humans. "Causes of error include fatigue , workload, and fear as well as cognitive overload , poor interpersonal communications , imperfect information processing , and flawed decision making." Throughout

2397-515: Was a leading cause of airplane accidents involving the loss of life, causing over 9,000 deaths since the beginning of the commercial jet aircraft . CFIT was identified as a cause of 25% of USAF Class A mishaps between 1993 and 2002. According to data collected by the International Air Transport Association (IATA) between 2008 and 2017, CFITs accounted for six percent of all commercial aircraft accidents, and

2448-417: Was attributed to pilot error was the night-time crash of Eastern Air Lines Flight 401 near Miami, Florida on 29 December 1972. The captain, first officer, and flight engineer had become fixated on a faulty landing gear light and had failed to realize that one of the crew had accidentally bumped the flight controls, altering the autopilot settings from level flight to a slow descent. Told by ATC to hold over

2499-508: Was categorized as "the second-highest fatal accident category after Loss of Control Inflight (LOC-I) ". While there are many reasons why an aircraft might crash into terrain, including poor weather and navigational equipment failure, pilot error is the most common factor found in CFIT accidents. Behind such events there is often a loss of situational awareness by the pilot, who becomes unaware of their actual position and altitude in relation to

2550-519: Was intended to prevent double taxation. However, there is no tax regulation in the Chicago Convention to refuelling the aircraft before departure. The Chicago Convention does not preclude a kerosene tax on domestic flights and on refueling before international flights. Although the ICAO has produced various policy documents suggesting that no taxes of any kind should be placed on aviation fuel, none of these are legally binding, and they are not found in

2601-410: Was known as a ground proximity warning system (GPWS), which used a radar altimeter to assist in calculating terrain closure rates. That system was further improved with the addition of a GPS terrain database and is now known as an enhanced ground proximity warning system (EGPWS) . When combined with mandatory pilot simulator training which emphasizes proper responses to any caution or warning event,

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