Transcript VOR use - GHAFI

CFIT Ooops! Whoop!
AC No: 61-134
Schlumberger Private
1.
2.
3.
4.
5.
6.
JL.Pous Property, do not duplicate
without authorization. Slide 1
Definitions
Some Data on CFIT
The Administrator’s view
VFR & IFR
How to avoid CFIT
Perspective in Alaska
June 2010
Definitions
ICAO International Civil Aviation Organization
Controlled flight into terrain (CFIT) accidents and incidents, are those in
which an aircraft, under the control of the crew, is flown into terrain (or
water) with no prior awareness on the part of the crew of the impending
disaster (Wiener, 1977).
JL.Pous Property, do not duplicate
without authorization. Slide 2
June 2010
Schlumberger Private
FAA
CFIT is defined as an event in which a mechanically normally
functioning airplane is inadvertently flown into the ground, water, or an
obstacle.
FAA AC 61-134
Controlled Flight into Terrain (CFIT). CFIT occurs when an airworthy
aircraft is flown, under the control of a qualified pilot, into terrain (water
or obstacles) with inadequate awareness on the part of the pilot of the
impending collision.
Definitions
ICAO International Civil Aviation Organization
Controlled flight into terrain (CFIT) accidents and incidents, are those in
which an aircraft, under the control of the crew, is flown into terrain (or
water) with no prior awareness on the part of the crew of the impending
disaster (Wiener, 1977).
JL.Pous Property, do not duplicate
without authorization. Slide 3
June 2010
Schlumberger Private
FAA
CFIT is defined as an event in which a mechanically normally
functioning airplane is inadvertently flown into the ground, water, or an
obstacle.
FAA AC 61-134
Controlled Flight into Terrain (CFIT). CFIT occurs when an airworthy
aircraft is flown, under the control of a qualified pilot, into terrain (water
or obstacles) with inadequate awareness on the part of the pilot of the
impending collision.
Definitions as per AC61-134e


Situational Awareness. As used in this AC, means the pilot is aware of what
is happening around the pilot's aircraft at all times in both the vertical and
horizontal planes. This includes the ability to project the near term status and
position of the aircraft in relation to other aircraft, terrain, and other potential
hazards.
Education Vs Training:
 Education and training are term loosely used among operational personnel.
 They are, however, quite distinct and certainly not interchangeable (ICJO,
1989). While familiar with training, operational personnel is seldom
exposed to education, since it is assumed that it forms part of the basic
individual baggage that everyone carries before being hired.
JL.Pous Property, do not duplicate
without authorization. Slide 4
June 2010
Schlumberger Private

Loss of Control refers to emergency situations from which a pilot may have
been able to recover but did not, such as problems with situation awareness,
recovery from windshear, mishandling of an approach, and recovery from a
stall.
Definitions as per AC61-134e


Situational Awareness. As used in this AC, means the pilot is aware of what
is happening around the pilot's aircraft at all times in both the vertical and
horizontal plane. This includes the ability to project the near term status and
position of the aircraft in relation to other aircraft, terrain, and other potential
hazards.
Education Vs Training:
 Education and training are term loosely used among operational personnel.
 They are, however, quite distinct and certainly not interchangeable (ICJO,
1989). While familiar with training, operational personnel is seldom
exposed to education, since it is assumed that it forms part of the basic
individual baggage that everyone carries before being hired.
JL.Pous Property, do not duplicate
without authorization. Slide 5
June 2010
Schlumberger Private

Loss of Control refers to emergency situations from which a pilot may have
been able to recover but did not, such as problems with situation awareness,
recovery from windshear, mishandling of an approach, and recovery from a
stall. (remember the second part of this talk is SPIN awareness)
Some Statistics
Annual Rate (CFIT per million TO)
The worldwide accident rate (which includes CFIT), for the
commercial jet fleet, decreased significantly in the 1960s and 1970s.
This rate stabilized at that time and remains fairly stable today .
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 6
June 2010
Some data
Annual Rate (CFIT per million TO)
The worldwide accident rate (which includes CFIT), for the
commercial jet fleet, decreased significantly in the 1960s and 1970s.
This rate stabilized at that time and remains fairly stable today .
Schlumberger Private
Us Jet Fleet
Non-Us Jet Fleet
CFIT Accidents Worldwide
68 69 70
71 72 73 74
JL.Pous Property, do not duplicate
without authorization. Slide 7
75 76
77 78
79
80 81 82 83
84 85 86 87 88
89 90
91
92
93
94
95
GPWS Implementation
June 2010
Worldwide Airline Accidents Classified by Type
1991Through 1995
1,000 Fatalities, from which
336 are due to CFIT
Schlumberger Private
The important thing to understand about these accidents is that they happened with
normally functioning airplanes. These are, accidents, that operators could have prevented.
JL.Pous Property, do not duplicate
without authorization. Slide 8
June 2010
Worldwide Airline Accidents Classified by Type
1991Through 1995
1,000 Fatalities, from which
336 are due to CFIT
Schlumberger Private
The important thing to understand about these accidents is that they happened with
normally functioning airplanes. These are, accidents, that operators could have prevented.
JL.Pous Property, do not duplicate
without authorization. Slide 9
June 2010
As an appetizer….
On how the administrator may think…
Schlumberger Private
….. nearly philosophical
JL.Pous Property, do not duplicate
without authorization. Slide 10
June 2010
Aviation authorities' recognized CFIT

JL.Pous Property, do not duplicate
without authorization. Slide 11
June 2010
Schlumberger Private
First in 1975:
Concern over CFIT occurrences was first reflected in regulations after
a B-727 struck a mountain during a non-precision approach to Dulles,
Virginia:
 A premature descent was attributed to ambiguous pilot-controller
communications and unclear information in the approach chart
(NTSB-AAR-75-16).
 Therefore two solutions were proposed:
 In Aircraft >>> Ground Proximity Warning System (GPWS)
requirement for large, turbine-powered airplanes engaged in
international operations,
 And its ground counterpart, the Minimum Safe Altitude
Warning (MSAW) as a feature of the automated radar terminal
system (ARTS-3),
Aviation authorities' recognized CFIT

(*) This was accompanied by the inevitable exhortations about cockpit
discipline and professional behavior, elusive terms which escape sound
definition and only generate foggy solutions with rather dubious results
JL.Pous Property, do not duplicate
without authorization. Slide 12
June 2010
Schlumberger Private
Then During the 1980’s, enthusiasm for Human Factors led industry
efforts to reduce CFIT occurrences through enhanced flight crew
performance:
 The trigger was a DC-8 crash during approach to Portland, Oregon,
after running out of fuel. This CFIT was attributed to breakdowns in
flight crew coordination & discipline.
 Therefore two solutions (*) were proposed:
• Crew resource management (CRM)
• Line-Oriented Flight Training (LOFT) stressing the need for:
– Improved intra-cockpit communication,
– Exchange of relevant operational information and of course
– Situational awareness..
We need a CFIT Training Package?

Schlumberger Private

The success of the Takeoff Training aid package (1992) and the Windshear
Training package (1997) in reducing Take off windshear-induced accidents – has
lured the industry in adopting similar approaches to other observed safety
deficiencies…
Not surprisingly, many advocate for a training package to reduce CFIT
occurrences. It is asserted, however, that neither technical nor Human
Factors training are the solution to reduce CFIT statistics.

Any CFIT training package would be redundant with existing training curricula
hence a waste of resources, Didn’t we leaned (all of us)?


Take off, Departure procedures, Navigation, altimeter setting, Standards
approaches procedures…. And so forth…
So What to tackle?

The thinking “on something else” already started after the crash of a DC10 in an
active volcano in Antarctica….
JL.Pous Property, do not duplicate
without authorization. Slide 13
June 2010
Aviation authorities' recognized CFIT

The study of the Crash of a DC10 in an active volcano in Antarctica - due to
incorrect coordinates in its computer-generated flight plan - showed shortcomings of
systemic nature.
Circumstances to be put forward:

Aviation since the 90 has become an incredibly complex system



leading to the safest mean of transportation of the world,
Any interference on such system can lead to catastrophic consequences.
We just showed that approach to reduce human error was mainly:
Technology
driven i.e we modify eqpt to minimize Human Error,
Stopped at the Micro Level rather than the Macro Level of systems

Therefore some to think that we did not eliminate the error but merely
displaced it because of the “de facto” piece meal approach.
JL.Pous Property, do not duplicate
without authorization. Slide 14
June 2010
Schlumberger Private

Aviation authorities' recognized CFIT

Hence the new approach was to:


And implemented via:


Systemic analysis of interactions between Human and Machines in a complex
environment,
Consider Education versus training.
JL.Pous Property, do not duplicate
without authorization. Slide 15
(*) leading to the safest mean of transportation of the world,
June 2010
Schlumberger Private

Answer to CFIT occurrences lies in looking at them from a systems
perspective and act upon the Latent failures which have slipped into the
system,
The latest combined with operational personnel active-failures and, further
compounded by adverse environmental conditions, may combine to produce
an accident.
Do we hear frequently, Pilot Error?
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 16
June 2010
Example of Latent Failures

Poor strategic planning of operations,


Lack of strategic planning, or with incompatible goals,
Inconsistent with declared safety goals….. among others.
No clear channels of communication between mgt & operations,
JL.Pous Property, do not duplicate
without authorization. Slide 17
June 2010
Schlumberger Private


Failure to properly train personnel to achieve them,
Example of Latent Failures


Poor strategic planning of operations,
to properly
personnel
to achieve
ItisFailure
impossible
to acttrain
upon
a problem
unless them,
awareness about
Lack
of strategic planning, or with incompatible goals,
it is gained:

operational personnel:




“What
measured
gets done”,
a widely lamented
butgets
seldom
acted upon,
Deficient SOP (Standard Operational Procedures) a direct
Hence management
and ops people need education on
consequence
of the aforementioned,
how to recognize latency.
Corporate objectives which are difficult or impossible to achieve
with existing resources and corporate goals,
Failure to communicate corporate goals,
JL.Pous Property, do not duplicate
without authorization. Slide 18
June 2010
Schlumberger Private
Inconsistent with declared safety goals….. among others.
Or using
famous
snapshot:of communication between mgt and
Absence
of aclear
channels

Fokker F-28 Mk 1000 Accident
On 15 November 1975, a Fokker F-28 Mk l 000 with 6 crew members and
65 passengers crashed while attempting to land following a circling nonprecision night approach in IMC at Concordia, Argentina.
JL.Pous Property, do not duplicate
without authorization. Slide 19
June 2010
Schlumberger Private
An honest analysis was directed inside the cockpit and the pilot was fined
by the civil aviation authority and demoted by the airline. He was to be reinstated as another analysis showed an abundance of latent failures:
Fokker F-28 Mk 1000 Accident
On 15 November 1975, a Fokker F-28 Mk l 000 with 6 crew members and
65 passengers crashed while attempting to land following a circling nonprecision night approach in IMC at Concordia, Argentina.


This started with in-house training with no flight simulator manned with tng
staff with doubtful qualifications and stability,
The Company operational procedures were rushed and not concise,
JL.Pous Property, do not duplicate
without authorization. Slide 20
June 2010
Schlumberger Private
An honest analysis was directed inside the cockpit and the pilot was fined
by the civil aviation authority and demoted by the airline. He was to be reinstated as another analysis showed an abundance of latent failures:

Lack of strategic planning with lack of resources to achieve goals:
Fokker F-28 Mk 1000 Accident
On 15 November 1975, a Fokker F-28 Mk l 000 with 6 crew members and
65 passengers crashed while attempting to land following a circling nonprecision night approach in IMC at Concordia, Argentina.



This started with in-house training with no flight simulator manned with tng
staff with doubtful qualifications and stability,
The Company operational procedures were rushed and not concise,
Faulty tactical planning like:


Mismatch in crew matching (the captain had no turbine time and the FO
fresh from school just hired by the Airline)
Company dispatch overestimated the capability of the aircraft in considering
weather limitations….
JL.Pous Property, do not duplicate
without authorization. Slide 21
June 2010
Schlumberger Private
An honest analysis was directed inside the cockpit and the pilot was fined
by the civil aviation authority and demoted by the airline. He was to be reinstated as another analysis showed an abundance of latent failures:

Lack of strategic planning with lack of resources to achieve goals:
Conclusion
Typical Latent failures like we just saw, generate working environments
which foster human error.
Even more important, such environments oftentimes make
violations inevitable if tasks are to be achieved.

Unless environments are corrected, they force crews to ignore
warnings, thereby generating violations to fulfill the task.

Eventually environment or task conditions which generate errors
and violations lead to system-induced accidents.
Accident databases are replete with CFIT
occurrences which support this contention.
JL.Pous Property, do not duplicate
without authorization. Slide 22
June 2010
Schlumberger Private

Conclusion
Typical Latent failures like we just saw, generate working environments
which foster human error.
Even more important, such environments oftentimes make
violations inevitable
if tasks
be achieved.
Allow
meareatoquestion,

Unless revised, they force crews to ignore warnings, thereby
How can
youtouse
- what
weto just
sawprocedures.
generating
violations
operational
orders
fulfill such
(studied) - in your profession as
 Eventually environment or task conditions which generate errors
Certified
Flight Instructor?
and violations
lead to system-induced
accidents.
Accident databases are replete with CFIT
occurrences which support this contention.
JL.Pous Property, do not duplicate
without authorization. Slide 23
June 2010
Schlumberger Private

HOW DO CFI PREVENT CFIT?

When this is not accomplished and the potential for
impact with the ground, water, or obstacles is imminent,
the proper escape maneuver must be used to improve
the chance of surviving.
JL.Pous Property, do not duplicate
without authorization. Slide 24
June 2010
Schlumberger Private

The most important goal for any flight crew is to maintain
vertical and horizontal situational awareness in relation to
the ground, water, and obstacles. Of course in VFR and
IFR.
It is real…. Nall report 2008
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 25
June 2010
VFR-ONLY PILOTS OPERATING IN
MARGINAL VFR/IMC CONDITIONS.

Therefore the root cause can be:
 The importance of complete weather information, to correlate the
pilot's skills and training, aircraft capabilities, and operating environment
with an accurate forecast cannot be emphasized enough.
JL.Pous Property, do not duplicate
without authorization. Slide 26
June 2010
Schlumberger Private

Scud Running:
 National Transportation Safety Board (NTSB) & FAA data, cite one of the
leading causes of GA accidents is to continue VFR flight into IMC.
 The result is often a CFIT accident when the pilot tries to continue flying or
maneuvering beneath a lowering ceiling and hits an obstacle or terrain or
impacts water.
 Some pilots, including some with instrument ratings, continue to fly
VFR in conditions less than that specified for VFR.
 The accident may or may not be a result of a loss of control before the
aircraft impacts the obstacle or surface.
VFR pilots in reduced visual conditions may develop
spatial disorientation & lose control,
Failure to understand the weather conditions that resulted in reduced conditions, and
failure to turn around to avoid deteriorating conditions when first able. Will result in
CFIT as:
People

Skills:

Loss of situational awareness:


Getting lost or being off the preplanned flight path:
 Increased risk of hitting one of many new low altitude towers (for cell –phones). This risk is
especially great along major highways (VFR pilots trying to follow a highway when lost ).
Time:



Inability of the pilot to operate the aircraft at its minimum controllable airspeed.
 Loss of aircraft control.
Reduced reaction time to see and avoid rising terrain or obstacles.
Environment
Reduced pilot reaction time in the event of A/C problem because of a low or lowering altitude.
Processes:



Breakdown in good aeronautical decision making.
Failure to comply with appropriate regulations.
Failure to comply with minimum safe altitudes.
JL.Pous Property, do not duplicate
without authorization. Slide 27
Equipment
Processes !
June 2010
Schlumberger Private

IFR PILOTS OPERATING IN IMC CONDITIONS.

Risks:

People & Processes:


Equipment:


IFR operations can be dangerous for those not prepared to operate or not
current and proficient in the IMC and IFR environments.
IFR operations can be dangerous with minimum, operational current
equipment to operate in IMC and IFR environments.
Results:

Many of these accidents result in fatalities.
JL.Pous Property, do not duplicate
without authorization. Slide 28
June 2010
Schlumberger Private

IMC operations pose special risks, whether it is :
 Failure to follow safe takeoff and departure techniques,
 Failure to follow recommended en route procedures ― which includes
loss of situational awareness
 Failure to maneuver safely to a landing,

People (AC No: 61-134):
Knowing when not to fly.

In a crewed aircraft, both pilots have adequately briefed the flight and
operation of the aircraft, including shared responsibilities.

Importance of maintaining situational awareness, both horizontal and
vertical, throughout the flight to avoid flying into hazardous terrain or known
obstacles.

Complete knowledge on how to operate all equipment onboard the aircraft.

Use Auto Pilot to reduce load is widely encouraged…(2.1.2 FAA Material)
JL.Pous Property, do not duplicate
without authorization. Slide 29
June 2010
Schlumberger Private


Equipment:


Environment:

Having complete weather data for the flight, including knowing where visual
meteorological conditions exist or a safe alternative is since many GA
aircraft flown IFR have limited range or speed to fly out of un-forecasted
weather conditions.
Processes:






Knowledge of minimum safe or sector altitudes and of the highest terrain in
the area.
Properly using an installed autopilot, if so equipped, to reduce pilot
workload.
Proper use of checklists
The increased CFIT risk of non-precision approaches.
The increased CFIT risk of high descent rates near the ground.
The importance of flying a stabilized approach.
JL.Pous Property, do not duplicate
without authorization. Slide 30
June 2010
Schlumberger Private

Importance of the aircraft being properly equipped for the intended flight.
TOP 10 RECOMMENDED INTERVENTION STRATEGIES.
(1)
Education (AC No: 61-134 ):
(1)
(2)
(3)
People:
4.
(3)
Equipment:
(1)
(2)
(3)
(4)
Improve pilot training (i.e., weather briefing, equipment, decision-making, wire and
tower avoidance, and human factors
Promote dev/use of a low cost terrain clearance and/or a look ahead device.
Standardize and expand use of markings for towers and wires.
Use high visibility paint & other visibility enhancing features on obstructions.
Processes / Organization:
(8)
(9)
(10)
Improve the quality and substance of weather briefs.
Enhance the flight review and/or instrument competency check.
Eliminate the pressure to complete the flight where continuing may compromise
safety.
JL.Pous Property, do not duplicate
without authorization. Slide 31
June 2010
Schlumberger Private
(2)
Increase pilot awareness on accident causes,
Improve safety culture within the aviation community,
Develop and distribute mountain-flying technique advisory material.
Stall / Spin Awareness
1.
2.
3.
JL.Pous Property, do not duplicate
without authorization. Slide 32
Some Data on Stall/Spin
Basics on Stall
What to do
June 2010
Schlumberger Private
AC 61-67C
Some statistics Nall report 2008
Schlumberger Private
56%
JL.Pous Property, do not duplicate
without authorization. Slide 33
June 2010
Some statistics Nall report 2008
Schlumberger Private
56%
JL.Pous Property, do not duplicate
without authorization. Slide 34
June 2010
Basic on Stalls (1/4)

What say the administrator:




The fact:

A STALL CAN OCCUR AT ANY AIRSPEED, IN ANY ATTITUDE AT ANY POWER SETTING.

Any given airplane will stall at the SAME Angle Of Attack, regardless of Weight,
Load Factor, Airspeed, and Density Altitude.. This assumes that the wing is NOT
Altered by damage or ice..
Weight:



The Critical Angle of Attack (AOA) does not depend of the weight, but additional lift can be
obtained by higher airspeed, therefore the aircraft will stall at higher Airspeed but at the same
AOA.
Generally 20% increase in aircraft weight (Light GA A/C) will result in 10% increase in stall
speed.
In absence of AOA indicator, the airspeed is a crutch to stay away from a stall..
JL.Pous Property, do not duplicate
without authorization. Slide 35
The stall of the elevator is not exposed here
June 2010
Schlumberger Private

The FAA concentrates on STALL RECOGNITION & PREVENTION,
Only CFI have to have a SPIN endorsement (is this advanced training?),
We can teach Imminent stall in any aircraft but should teach fully achieved stall in an Aircraft
which have known and safe spin characteristics.
Basic on Stalls (2/4)


A STALL CAN OCCUR AT ANY AIRSPEED, IN ANY ATTITUDE AT ANY POWER SETTING.

Any given airplane will stall at the SAME Angle Of Attack, regardless of Weight, Load
Factor, Airspeed, and Density Altitude. This assumes that the wing is NOT altered by
damage or ice.
Weight:


We just did it.
Load Factor:


The Critical Angle of Attack (AOA) does not depend of the Load Factor, but the centripetal
Force is ADDED to the normal weight of the A/C. Therefore the aircraft will stall but at the
same AOA. but at a MUCH higher Airspeed.
The Stall Speed increases as the square root as the load factor:





At 60º bank the wings are producing twice as much lift than in S&L Flight, referred as 2G,
For instance VSO = 60 Kts become 85 Kts
At 75º bank the wings are producing 3.86 as much lift than in S&L Flight, referred as 3.86G,
At 80º bank the wings faces 5.76G and at 81º bank the wings faces 6,25G
We all know the famous graph …
JL.Pous Property, do not duplicate
without authorization. Slide 36
June 2010
Schlumberger Private

The fact:
Basic on Stalls (3/4)


A STALL CAN OCCUR AT ANY AIRSPEED, IN ANY ATTITUDE AT ANY POWER SETTING.

Any given airplane will stall at the SAME Angle Of Attack, regardless of Weight, Load
Factor, Airspeed, and Density Altitude. This assumes that the wing is NOT Altered by
damage or ice.
Airspeeds:


We just covered the airspeed, according to weight and Load Factor….
Density Altitude (Altitude and Temperature):


Schlumberger Private

The fact:
Altitude as LITTLE or no effect on the stall speed,
Wing damage or Ice:


Like wing damage, ICE can result in loss of lift and increased weight…
Wing damage: yes I saw some… bird strike mainly.
JL.Pous Property, do not duplicate
without authorization. Slide 37
June 2010
Basic on Stalls (4/4)

The fact is that we fly with different payloads:

The fact is that we fly a multitude of aircrafts with different wings.. .




We cannot describe them all
But the common factor is:
 The wings are designed to produce a gradual and symmetrical loss of lift,
 This loss progresses from the root till the ailerons, leaving the ailerons virtually untouched at
the Critical AOA.
 The “root” stall produces a turbulent flow which affects the elevator, hence the “Buffet” that
we feel .. This is much before the Critical AOA…
But watch:
 Piper Cub, Stinson, Luscomb, and Areonca, the wing tip stalls at the same time as the root.
Another fact … but equally important:


The stall speed is affected by turbulent conditions
Any updraft current will modify the direction of the airflow relative to the wing hence creating a
pseudo AOA, invisible to the pilot…
JL.Pous Property, do not duplicate
without authorization. Slide 38
June 2010
Schlumberger Private

Yes the COG has an effect on the Stall Recovery:
 A forward CG implies a higher stall speed at the Critical AOA, greater forces to stall, to recover,
 An AFT (After) CG implies lighter forces to stall, but high load can be induces in recovery
 An AFT CG can lead to flat spin…. GENERALLY IMPOSSIBLE TO RECOVER.
Where and which types of stall (6)?
1. P/Off
Slow Flight
1600 RPM
1/3 Flap
1 .P/Off
TURN
Schlumberger Private
Slow Flight
1600 RPM
2/3 Flap
1. P/Off
6. X.Control
Stall
2. P.On
Approach
1600 RPM
3/3 Flap
4. Elevator
Trim
Full Power
3. Secondary
Stall
5. Accelerated
Stall
1. P/off
JL.Pous Property, do not duplicate
without authorization. Slide 39
June 2010
Anatomy of a Spin…. (by Budd Davisson March 2006) 1/3

In Budd’s eyes, it is not that people do not know to recover from a SPIN


To SPIN two factors are needed:

A/C MUST BE stalled
A/C must have excess yaw.
But:

In today’s aircraft the student must go VERY SLOW (High AOA) with a LOT of yaw.

Slow >>>>> nose too high, versus horizon?:



Even the most poorly trained pilot will detect it.
So it must happen in a nearly normal looking condition…….
Ball totally off center:


Again a lot of rudder will be needed and the pilot will detect it.
So what is happening????
JL.Pous Property, do not duplicate
without authorization. Slide 40
June 2010
Schlumberger Private


The problem is that they do not know what they were doing wrong to cause a spin…
Anatomy of a Spin…. (by Budd Davisson March 2006) 2/3

Well, it starts with AILERON and finishes with rudder

Showing the adverse yaw:

Back to our case: The Pilot is slow & late to turn onto final, and he/she overshoots:



As he/she banks the aircraft too get back on a center line,
 The pilot exceed his zone of comfort …. Too much bank…
 So the pilot applies outside of the turn aileron…. Driving the ball off center and
slowing down the turn..
 Now the pilot feeds more rudder in direction of turn, driving the ball even more off
center….
 We are IN THE PERFECT CASE OF Crossed Control
The turn drives the stall speed UP, and the X-control lower again the Lift
We are good to go FOR SOMETHING BAD..
JL.Pous Property, do not duplicate
without authorization. Slide 41
June 2010
Schlumberger Private

Slow down the A/C to approach speed or below, no rudder and apply aileron:
 The ball moves in the direction of the ailerons,
 The slower the airspeed, the worse is the adverse yaw.
Anatomy of a Spin…. (by Budd Davisson March 2006) 3/3


We are good to go FOR SOMETHING BAD..
This is when the pilot becomes distracted, let say a traffic call:



Schlumberger Private

The pilot lets the nose comes up…but not even closer that extreme attitude
So the pilot won’t see it:
With the flap down the stall is more abrupt, and starts to roll over the top.
 At this time the instinct calls for opposite aileron of the roll,
 This stall “even better” the inside wing..
 The spin occurs.
There is not enough time to do a full turn …

So what is the point to teach recovery from a fully developed spin?
HENCE TEACH SPIN PREVENTION IS MORE ADAPTED TO REALITY
The best would be recovery from a SPIN DEPARTURE….
But what type of airplane can you use for Spin Departure?
JL.Pous Property, do not duplicate
without authorization. Slide 42
June 2010
So it went bad and you have enough altitude:
Remember:
A
R
E
JL.Pous Property, do not duplicate
without authorization. Slide 43
Schlumberger Private
P
Power Idle
Aileron Neutral
Rudder Full Opposite
Elevator, brisk mvt down (for AOA)
June 2010
The end
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 44
June 2010
Ace Check:

The quickest way to recover an airplane from a stall situation is to:

Teaching full stalls:
a. Can be safely instructed in any airplane make and model
b. Should be instructed only in airplanes which have known and safe spin characteristics
c. Is no different than teaching imminent stalls

An airplane make and model will stall at the same indicated airspeed regardless of
the airplane altitude :
a. True
b. False
JL.Pous Property, do not duplicate
without authorization. Slide 45
June 2010
Schlumberger Private
a. Pull back (nose up) on the elevator control
b. Reduce engine power
c. Reduce the load on the wing by pushing forward (down) on the elevator control
Back Up Slides

OTHER DEFINITIONS
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 46
June 2010
Other definitions

Organization:
The broader analysis of organizations is commonly referred to as or organizational studies / behavior
or organization analysis.

Management:


in all business areas and organizational activities are the acts of getting people together to
accomplish desired goals and objectives.
Management comprises planning, organizing, staffing, leading or directing, and controlling an
organization (a group of one or more people or entities) or effort for the purpose of accomplishing
a goal.
JL.Pous Property, do not duplicate
without authorization. Slide 47
June 2010
Schlumberger Private
Is a social arrangement which pursues collective goals, controls its own performance, and has a
boundary separating it from its environment. We can cite:
 Organization – process-related: how an entity is being organized to complete a task.
 Organization – functional: organization as a function of how entities like businesses or state
.authorities are used (organization as a permanent structure).
 Organization – institutional an entity is an organization (organization as an actual purposeful
structure within a social context).
Other definitions

Systems:
Is a set of interacting or interdependent entities forming an integrated whole (*).

Most systems share common characteristics, and have:
 Structure defined by parts and their composition;
 Behavior which involves inputs, processing and outputs of material, levels of energy,
 Interconnectivity, where the various parts of a system have functional as well as structural
relationships between each other.
 by themselves functions or groups of functions .

The scientific research field which is engaged in the study of the general properties of systems
include:
 Systems theory,
 Dynamical systems and
 Complex systems

These researches investigate the abstract properties of the matter and organization, searching
concepts and principles which are independent of the specific domain, substance, type, or
temporal scales of existence.
(*)The concept of an 'integrated whole' can also be stated in terms of a system embodying a set of relationships
which are differentiated from relationships of the set to other elements, and from relationships between an element
of the set and elements not a part of the relational regime.
JL.Pous Property, do not duplicate
without authorization. Slide 48
June 2010
Schlumberger Private

Back Up Slides

HOW TO AVOID CFIT WHILE ON IMC / IFR
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 49
June 2010

People:






JL.Pous Property, do not duplicate
without authorization. Slide 50
June 2010
Schlumberger Private

Knowing when not to fly.
Importance of the pilot in command (PIC) being qualified, current, and
proficient for the intended flight.
In a crewed aircraft, both pilots have adequately briefed the flight and
operation of the aircraft, including shared responsibilities.
Importance of maintaining situational awareness, both horizontal and
vertical, throughout the flight to avoid flying into hazardous terrain or known
obstacles.
Complete knowledge on how to operate all equipment onboard the aircraft.
This includes the limitations and operations of new types of navigation
equipment.
In a crewed aircraft, the crew is aware of and follows FAA and industry
recommended crew resource management principles. If a single-piloted
flight, the pilot knows to use all available resources including air traffic
control to help ensure a safe flight as well as any onboard resource such
as a passenger or onboard charts or manuals.
PIC is aware of the risks involved when transitioning from visual to
instrument or from instrument to visual procedures on takeoff or landing.



Equipment:


Importance of the aircraft being properly equipped for the intended flight.
Environment:

Having complete weather data for the flight, including knowing where visual
meteorological conditions exist or a safe alternative is since many GA
aircraft flown IFR have limited range or speed to fly out of un-forecasted
weather conditions.
JL.Pous Property, do not duplicate
without authorization. Slide 51
June 2010
Schlumberger Private

PIC uses all available safety equipment installed in the aircraft and on the
ground.
PIC is aware of the risks involved in setting the aircraft's altimeter including
inherent limitations of barometric altimeters.
Knowing the air traffic control system well enough to be proficient in it.

Processes:







JL.Pous Property, do not duplicate
without authorization. Slide 52
June 2010
Schlumberger Private

Having the proper charts and approach plates for the intended flight. VFR
charts, although not required, should be onboard because they can provide
important obstacle and terrain data for an IFR flight.
Knowing the planned procedure well enough to know if air traffic is issuing
an unsafe clearance or if the pilot flying, when a crewed aircraft, is not
following the published procedure.
Knowledge of minimum safe or sector altitudes and of the highest terrain in
the area.
Properly using an installed autopilot, if so equipped, to reduce pilot
workload.
Proper use of checklists as outlined in the aircraft manual or if not listed,
before reaching 1,000 feet above ground level (AGL) to minimize any
distractions when operating close to the ground.
The increased CFIT risk of nonprecision approaches.
The increased CFIT risk of high descent rates near the ground.
The importance of good communications between the pilot and air traffic
control concerning any flight instruction or clearance. The old rule of asking
for clarification whenever in doubt about any instruction or clearance
applies.



JL.Pous Property, do not duplicate
without authorization. Slide 53
June 2010
Schlumberger Private

The dangers of complacency for the single-pilot, as well as multi-piloted
crews, when making routine flights.
The dangers of misunderstanding air traffic control instructions or
accepting an incorrect clearance.
The dangers of not knowing the safe altitudes for your en route as well as
your terminal area.
The importance of flying a stabilized approach.
 Although originally designed for turbojet aircraft, a stabilized approach
is also recommended for propeller-driven aircraft.
 The idea is to reduce pilot workload and aircraft configuration changes
during the critical final approach segment of an approach.
 A common definition of a stabilized approach is maintaining a stable
speed, descent rate, vertical flight path, and configuration throughout
the final segment of the approach.
 The goal is to have the aircraft in the proper landing configuration, at
the proper approach speed, and on the proper flight path before
descending below the minimum stabilized approach height. above the
airport or touch down zone elevation during IMC.
2.1.2 Use of Autopilots (FAA Material)

The use of autopilots is encouraged during all
approaches and missed approaches, in
instrument meteorological conditions (IMC),
when suitable equipment is installed.
JL.Pous Property, do not duplicate
without authorization. Slide 54
June 2010
Schlumberger Private

Flight crews do not take full advantage of
automatic systems to manage the progress of a
flight and reduce workload.
Back Up Slides

PILOT PERSPECTIVE ALASKA CFIT
Schlumberger Private
JL.Pous Property, do not duplicate
without authorization. Slide 55
June 2010
CONTROLLED FLIGHT INTO TERRAIN IN ALASKA:
A STUDY OF PILOT PERSPECTIVES (Aug.2000)

In 1995, the National Transportation Safety Board (NTSB) issued the
safety study, Aviation Safety in Alaska, which highlighted two accident
types of major consequence:


The report states that accidents related to VFR into IMC are less
frequent but account for a larger percentage of the fatal accidents,
making them the leading safety problem for Alaskan commuter airlines
and air taxis (NTSB, 1995).



Of 126 fatality accidents 89 (71%) involved CFIT.
All occurred in Alaska between January 1, 1990, & December 31, 1998,
And now:

69 of the 89 (77.5%) fatal CFIT occurred when crew pursue VFR into IMC
JL.Pous Property, do not duplicate
without authorization. Slide 56
June 2010
Schlumberger Private

accidents during takeoff and landing,
and accidents related to flying under visual flight rules (VFR) into instrument
meteorological conditions (IMC).
Human Factors Analysis and Classification System
(HFACS, Weigmann & Shappell, 1998),

The first HFACS level is the Unsafe Act itself, for example:
The pilot failed to scan the instruments at a critical time during the flight (Skill-Based Error) or
 The pilot entered IMC unexpectedly (Decision Error) and lost control of the aircraft.
 Before those events took place, however, certain preconditions for the unsafe acts had to occur.

A second level calls for “Preconditions for Unsafe Acts”:

They are events that could have led to the unsafe act itself, for example:
 Fatigue (Substandard Condition of the Operator), could have led to the pilot’s poor scanning.
The third level in the taxonomy is Unsafe Supervision:

In above example it would have been the inadequate supervision for pilot rest requirements
 This entails the adverse physiological & mental consequences that could arise from a lack of sleep


The fourth and final HFACS level involves Organizational Influences:
Still
following above example, a reduction in the budget (Resource Management), could have
eliminated the training regarding pilot rest requirements, then create an
Organizational
JL.Pous Property, do not duplicate
without authorization. Slide 57
Climate permitting to work beyond the recommended normal work schedule.
June 2010
Schlumberger Private

CONTROLLED FLIGHT INTO TERRAIN IN ALASKA:
A STUDY OF PILOT PERSPECTIVES (Aug-2000)



and

Eliminate pressure to complete a flight.
JL.Pous Property, do not duplicate
without authorization. Slide 58
June 2010
Schlumberger Private

Increase pilot awareness of CFIT safety-related issues,
Improve company safety culture,
Improve pilot training in the environment in which they
commonly fly,
Improve weather briefings,