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«1st Edition NOTICE DISCLAIMER. The information contained in this publication is subject to constant review in the light of changing government ...»

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Controlled Flight Into Terrain

Accident Analysis Report


1st Edition


DISCLAIMER. The information contained in this

publication is subject to constant review in the

light of changing government requirements and

regulations. No subscriber or other reader should

act on the basis of any such information without

referring to applicable laws and regulations and/ or without taking appropriate professional advice.

Although every effort has been made to ensure accuracy, the International Air Transport Association shall not be held responsible for any loss or damage caused by errors, omissions, misprints or misinterpretation of the contents hereof.

Furthermore, the International Air Transport Association expressly disclaims any and all liability to any person or entity, whether a purchaser of this publication or not, in respect of anything done or omitted, and the consequences of anything done or omitted, by any such person or entity in reliance on the contents of this publication.

© International Air Transport Association. All Rights Reserved. No part of this publication may be reproduced, recast, reformatted or transmitted in any form by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval

–  –  –

Controlled Flight Into Terrain Accident Analysis Report ISBN 978-92-9252-777-8 © 2015 International Air Transport Association. All rights reserved.

Montreal—Geneva Table of Contents Section 1—Introduction

Section 2—Data Source

Section 3—Exclusions

Section 4—Scope

Section 5—Global Accident Data

Section 6—Controlled Flight Into Terrain (CFIT) Definition

Section 7—Controlled Flight Into Terrain (CFIT) Accident Data

7.1 Controlled Flight Into Terrain (CFIT) by Aircraft Propulsion

7.2 Controlled Flight Into Terrain (CFIT) Severity

IOSA Registered Carriers Versus Non-IOSA Registered Accident Rate

7.3 7.4 Impact of Operational Service Types

7.5 Controlled Flight Into Terrain (CFIT) Accidents by Flight Phase

7.6 Controlled Flight Into Terrain (CFIT) Regional Analysis

7.7 Controlled Flight Into Terrain (CFIT) Accidents by Regional Aviation Safety Group (RASG) Regions

7.8 Controlled Flight Into Terrain Contributing Factors

7.9 Mitigation of CFIT Accidents

7.10 Accident Scenarios of Interest

Section 8—Conclusion

Section 9—Appendix A – IATA Accident Criteria and Definition

9.1 Type of Operation Criteria

9.2 Definitions

9.2.1 Hull Loss

9.2.2 Substantial Damage

9.2.3 Phase of Flight:

Section 10—Appendix B – IATA Regions

Section 11—Appendix C – RASG Regions

Section 12—Appendix D – Challenges with Applying Taxonomies

–  –  –

List of Figures Figure 1: Global Accident Categories Breakdown

Figure 2: Number of Fatal Accidents per Accident Category

Figure 3: Frequency of Fatal Accidents per Year

Figure 4: Percentage of Total and Fatal Accidents by Accident Category

Figure 5: High Risk Accident Category

Figure 6: Number of CFIT Accidents per Year

Figure 7: CFIT Accident Rates per Million Sectors

Figure 8: Distribution of Jet and Turboprop Aircraft CFIT Accident Count

Figure 9: Distribution of Jet and Turboprop Aircraft CFIT Accident Rates

Figure 10: Hull Loss and Fatal CFIT Accidents

Figure 11: CFIT Fatal Accidents by Aircraft Propulsion per Year

Figure 12: IOSA Versus Non-IOSA CFIT Fatal Accident Rates

Figure 13: Percentage of CFIT Fatal Accidents in Each Flight Phase by Type of Service

Figure 14: Fatal Versus Non-Fatal CFIT Accidents by Phases of Flight

Figure 15: Distribution of Jet Versus Turboprop Fatal CFIT Accidents by Phases of Flight............... 16 Figure 16: CFIT Accidents by Region of Operator

Figure 17: CFIT Accident Rates by IATA Region of Operator

Figure 18: CFIT Fatal Accident Rates by Region of Operator

Figure 19: Distribution of CFIT Fatal Accidents by Service Type and Region of Operator.................. 18 Figure 20: CFIT Accidents by RASG Region of Operator

Figure 21: CFIT Accident Rates by RASG Region of Operator

Figure 22: Distribution of Fatal and Non-Fatal CFIT Accidents by RASG Region of Operator

Figure 23: RASG Regional Fatal CFIT Accidents by Aircraft Propulsion

Figure 24: CFIT Fatal Accident Rates by RASG Region of Operator and Aircraft Propulsion

Figure 25: World Most Frequent CFIT Contributing Factors

Figure 26: Latent Conditions Contributing to CFIT Accidents

Figure 27: Environmental and Airline Threats Contributing to CFIT Accidents

Figure 28: Flight Crew Errors Contributing to CFIT Accidents

Figure 29: Undesired Aircraft States Contributing to CFIT Accidents

ii List of Tables Table 1: Top Three Fatal Accident Categories

Table 2: CFIT Fatal Accident Rates and Fatalities per Aircraft Propulsion

Table 3: CFIT Fatal Accident Count and Survivability by Aircraft Propulsion

Table 4: IOSA Versus Non-IOSA Registered Accident Rates

Table 5: CFIT Fatal Accident Rates for Operators of Turboprop and Jet Aircraft on the IOSA Registry Versus Non-IOSA Registry

Table 6: CFIT Fatal Accidents by Types of Service

Table 7: CFIT Accidents by Scheduled Versus Non-Scheduled

Table 8: Distribution of Flight Phase by Service Type for Fatal CFIT Accidents

iii Section 1—Introduction The International Air Transport Association (IATA) is dedicated to implementing a data driven approach to the evaluation of aviation safety risks and the development of potential solutions. This Controlled Flight Into Terrain (CFIT) analysis evaluates the risk factors from recent CFIT accidents and presents information designed to aid industry in the implementation of mitigation strategies. Accidents from 2010 through to 2014 were reviewed for this analysis. The data set includes aircraft over 5,700 kg maximum take-off weight that were engaged in commercial operations according to the IATA definition, included in this report. See appendix A for the IATA accident definition used for data in this report.

CFIT refers to accidents in which there was In-flight collision with terrain, water, or obstacle without indication of loss of control. The critical distinction in these types of accidents is the fact that the aircraft is flyable and under the control of the flight crew. There are numerous causal and/or contributing factors of such events.

Typically, aircraft malfunction is not the main cause of CFIT accident; rather the accident’s probable and immediate causes are often attributed to flight crew or human error, such as non-compliance with established procedures (SOPs), inadequate flight path management, lack of vertical and/or horizontal position awareness in relation to terrain, unstabilized approaches, and failure to initiate a go-around when a go-around was necessary. The absence of precision approaches has also been noted as a factor in CFIT accidents. This report presents the contributing factors categorized into latent conditions in the system, external threats to the flight crew, errors in the handling of those threats and undesired aircraft states resulting from deficiencies in managing these threats or errors. The contributing factors are based on the information available at the time of classification.

Although few in number, CFIT accidents are almost always catastrophic; 91 percent of the accidents involve fatalities to passengers or crew. CFIT, which is the second largest fatal accident category after Loss of Control Inflight (LOC-I), has contributed to 707 of 2,541 fatalities, in the period evaluated. Given this severity, CFIT accidents have been assessed by the IATA Safety Department and the industry to be the second highest risk to aviation safety, and deemed to be an area for increased attention.

This report summarizes the 34 CFIT accidents that occurred during the five (5) years of the period, which resulted in 31 fatal accidents and 707 fatalities.

2010-2014 Controlled Flight Into Terrain Accident Analysis Report Section 2—Data Source This report is focused on the commercial air transport industry; it uses data from Global Aviation Data Management (GADM) accident database over the period of 2010-2014.

Section 3—Exclusions

This report specifically excludes accidents involving the following types of operations:

 Private (general) aviation  Business or military aviation  Flights as part of illegal activities  Humanitarian relief flights  Crop spraying or other agricultural flights  Security-related events (e.g. hijackings)  Experimental or other test flights Section 4—Scope This report is intended to provide a detailed understanding of Controlled Flight Into Terrain (CFIT) accident statistics. It provides accident breakdown by aircraft propulsion, by scheduled/unscheduled services, cargo/passenger operations, and rates of occurrence involving jet and turboprop aircraft, as well as IOSA vs.

non-IOSA and regional accident rates.

Such as post maintenance functional check flights

Section 5—Global Accident Data This report was generated from worldwide reports of accidents resulting in hull loss or substantial damage to all jet and turboprop aircraft, greater than 5,700 kg, from January 2010 to December 2014 inclusive.

There were a total of 415 accidents during this period. Of these accidents, 34 were classified as CFIT and form the primary focus for this report. Figure 1 illustrates the global breakdown of accidents across all categories. It should be noted that 409 (99 percent) of the accidents could be assigned an accident category or End State ; the remaining six (6) accidents lacked sufficient information for classification.

Figure 1: Global Accident Categories Breakdown

Of the total 415 accidents between 2010 and 2014, 88 accidents were fatal resulting in 2,541 total fatalities.

The breakdown of fatal accidents by occurrence category is shown in Figure 2. Note that 86 of the fatal accidents were assigned an End State.

CFIT was the second most frequent category of fatal accident representing 31 fatal accidents or 36 percent of total fatal accidents with sufficient information for classification. These CFIT accidents resulted in 707 fatalities among passengers and crew.

An End State is reportable event. An End State is unrecoverable, also known as the Accident Category.

2010-2014 Controlled Flight Into Terrain Accident Analysis Report

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The relative percentage of fatal accidents remained fairly constant from 2010 through 2014, at three to six percent (3 to 6%) of the total number of commercial aircraft accidents. Although the number of commercial aviation fatal accidents fluctuated year to year, the number of fatal accidents that occurred annually between 2010 and 2014 declined overall from 23 to 12. Figure 3 presents the frequency of fatal accidents per year.

Figure 3: Frequency of Fatal Accidents per Year

CFIT accidents are almost always catastrophic; 91 percent of CFIT accidents between 2010 and 2014 involved fatalities to passengers and/or crew. Over this period, 8.3 percent of all accidents were categorized as CFIT, whereas this category contributed to 28 percent of the total fatalities (707 out of 2,541). Given this disproportionate ratio of fatalities, CFIT accidents represent the second highest risk to life in commercial aviation safety. Figure 4 illustrates the percentage of total accidents and fatal accidents broken down per accident category.

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Figure 5 presents the concept of high-risk accident categories and was designed to go beyond the traditional method of frequency as the metric for prioritization of mitigation efforts and to establish a priority metric for accident outcome related to survivability.

Each accident category is plotted by the average number of occurrences per year and the percentage of fatalities relative to the total number of people on board. The bubble size increases as the absolute number of fatalities for the category increases; empty bubbles indicate no fatalities for that accident category. From this analysis Loss of Control In-Flight (LOC-I), Controlled Flight Into Terrain (CFIT) and Runway Excursions were identified as the top three high risk categories to be addressed by IATA.

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2010-2014 Controlled Flight Into Terrain Accident Analysis Report Table 1 shows that LOC-I was the primary cause of commercial aviation fatalities between 2010 and 2014, followed by Controlled Flight Into Terrain (CFIT). The improving trends in other accident categories have resulted in LOC-I becoming the leading cause of fatal accidents in air transportation worldwide but it is only recently that LOC-I accidents have overtaken CFIT as the leading fatal accident category. The fact that LOC-I is receiving substantial industry attention despite a relatively low number of accidents is due to the disturbing number of fatalities they have produced. The remainder of this report focuses specifically on CFIT.

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See Appendix D for additional information on taxonomy-issues Section 6—Controlled Flight Into Terrain (CFIT) Definition The definition of Controlled Flight Into Terrain as stated in the IATA Safety Report is an accident in which there is In-flight collision with terrain, water, or obstacle without indication of loss of control.

2010-2014 Controlled Flight Into Terrain Accident Analysis Report Section 7—Controlled Flight Into Terrain (CFIT) Accident Data In the five (5) years covered in this report there were 34 CFIT accidents reported, with an average of

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