ALARApproach and Landing Accident

Data Overview (1980–1997)

Applicable to: PilotsPrior Knowledge: Have a valid licenseRegion: EveryoneCountry: AnyLanguage: English

ALAR Develop: EAQ RO Feb. 18, 2015 2

This presentation, which was included in the original FSF ALAR Tool Kit released in 2000, was reviewed in 2009, and its contents remain valid. The statistical data in this presentation are from the original ALAR study. The ALAR study was updated in 2009, and the associated statistical data are available in the presentation titled “Approach and Landing Accident Data Overview (1995–2007).”

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Data Analyses • Study 1: High-level analyses of 287 fatal accidents

(1980–1996)

• Study 2: In-depth study of 76 accidents and serious incidents (1984–1997)

• Study 3: Line observations of 3,300 flights

• High correlation with other studies

All recommendations are supported by data.

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Conclusions

• Standard operating procedures• Missed approaches• Unstabilized approaches• Communication• Environment• Radio altimeter• Safety data monitoring• Information sharing

Approach-and-Landing Fatal Accident Rates by Region

0

0.5

1

1.5

2

2.5

3

0 0.13 0.160.43

0.88

1.64 1.65

2.43

Region

Acci

dent

s per

mill

ion

depa

rtur

es

Western-built Jets,* 1980–1996

* With maximum takeoff weights above 12,500 pounds/5,700 kilograms. JAA = Joint Aviation Authorities

Australasia NorthAmerica

Europe(JAA)

World Europe(non-JAA)

South/CentralAmerica

AfricaAsia

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ALAR Develop: EAQ RO Feb. 18, 2015 6

Case Study Sample of 76 Accidents and Serious Incidents

• Period: 1984–1997

• Major, Regional, Air Taxi, Corporate Ops

• Passenger, Freight and Positioning Flights

• Fixed-wing Jet and Turboprop Aircraft

• Worldwide

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Most Common Types of Approach-and-Landing Accidents

• CFIT

• Loss of control

• Landing overrun

• Runway excursion

• Unstabilized approach

These comprised 76 percent of the sample.

Causal Factors in Approach-and-Landing Accidents and Serious Incidents

Series10

102030405060708090

100

Occ

urre

nces

(per

cent

)

Interactionwith

Automation

Disorientation/Visual

Illusion

Lack of Training/Experience/Qualification

High/Fast onApproach

(continued)ALAR Develop: EAQ RO Feb. 18, 2015 8

Series10

102030405060708090

100

ProceduralViolations

“Press-on-itis”

Occ

urre

nces

(per

cent

)

Low/Slow on Approach

ATC: IncorrectAdvice/Service/

Instruction

ATC = Air traffic control

Causal Factors in Approach-and-Landing Accidents and Serious Incidents (continued, #2)

(continued)ALAR Develop: EAQ RO Feb. 18, 2015 9

Series10

102030405060708090

100

Lack of Position

Awareness

Inadequate CRM

ProceduralErrors

Inadequate Judgment/Airmanship

Occ

urre

nces

(per

cent

)

Flight Handling

CRM = Crew resource management

Causal Factors in Approach-and-Landing Accidents and Serious Incidents (continued, #3)

ALAR Develop: EAQ RO Feb. 18, 2015 10

Series10

102030405060708090

100

Inadequate RegulatoryOversight

Lack of Safety

Equipment

InadequateRegulation

Occ

urre

nces

(per

cent

)

Runway Condition

InadequateGround

Aids

Circumstantial Factors in Approach-and-Landing Accidents and Serious Incidents

(continued)ALAR Develop: EAQ RO Feb. 18, 2015 11

CRM = Crew resource management

Circumstantial Factors in Approach-and-Landing Accidents and Serious Incidents (continued, #2)

Inadequate training

Management failure

Inadequate procedures

Inadequate CRM

Poor visibility0

10

20

30

40

50

60

70

80

90

100

Occ

urre

cnce

s (pe

rcen

t)

ALAR Develop: EAQ RO Feb. 18, 2015 12

Go-around Initiated When WarrantedO

ccur

renc

es (p

erce

nt)

Yes No0

10

20

30

40

50

60

70

80

90

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Pilot Flying in Approach-and-Landing Accidents and Serious Incidents

CAPT FO Single Pilot Unknown0

10

20

30

40

50

60

Chart Title

Occ

urre

nces

(per

cent

)

CAPT = CaptainFO = First officer

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Summary of FSF ALAR Task Force Findings

• Air Traffic Control– Training/procedures/communication during

abnormal conditions

– Demanding/inappropriate clearances

• Airport– Inadequate ground aids

– Rescue procedure/communication deficiencies

(continued)

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Summary of FSF ALAR Task Force Findings (continued, #2)

• Inadequate situational awareness– Aircraft position, terrain, energy, automation

• Procedural errors and violations

• Inadequate tactical decision making – Judgment/airmanship– “Press-on-itis”/unstabilized approaches/no go-around

• Poor monitoring/cross-check

• Aircraft handling difficulties(continued)

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Summary of FSF ALAR Task Force Findings (continued, #3)

• Flight operations management

– Inadequate safety culture

– Inadequate planning and procedures

– Inadequate standard operating procedures (SOPs)

– Inadequate crew training

– Nonfitment of safety equipment

• Environment– Poor visibility, adverse weather,

runway contamination, visual illusions(continued)

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Summary of FSF ALAR Task Force Findings (continued, #4)

• Regulatory authorities– Inadequate regulation

– Audit/surveillance oversights

• Accident/incident investigation – Noncompliance with Annex 13*

– Poorest safety data in highest ALA rate regions

– Absence of flight data recorder (FDR) and cockpit voice recorder (CVR)

* International Civil Aviation Organization Annex 13, Aircraft Accident Investigation

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Interesting Facts• The approach-and-landing accident (ALA) rate for freight,

ferry and positioning flights is eight times higher than the ALA rate for passenger flights.

• The accident risk is five times greater for commercial aircraft flying a nonprecision approach than for those flying a precision approach.

• The approach and landing (from the outer marker to landing) typically comprise 4 percent of the flight time, yet account for 45 percent of the hull losses.