Term Paper: CFIT

[Diesel]

Guys-

I'm writing a term paper on CFIT accidents where technology has both saved and caused the accident. Basically i'm looking at the roll of how automation in the cockpit has played a roll in CFIT.

I've got some pretty good accidents but if anyone has any other ideas on some accidents that I can look up it would be appreciated.

uuuuugh college

 

[mar]

Are you familiar with the Capstone system?

I don't have an opinion on it either way.

You could start with a search on this website.

Naturally I assume you already investigated the AA Cali crash.

 

[FN FAL]

uuuuugh college

I can't think of any CFIT accidents where automation played a factor, but I can relate to the fun of doing papers. I just did a real ass grinder on the history of the Irish Republican Army. I can tell you all about Theobald Wolfe Tone and how the first Governor of Montana was an IRA Exile that served in the Union Army during the U.S. civil war and lead the IRA cause in U.S. based IRA fundraising and armed raids into Canada, if that will help. :nuts:

Good luck and I hope you get a good grade on your paper!

 

[imacdog]

Wasn't there an airbus accident or near-accident where the crew accidentally punched in a descent of 3000fpm instead of 3.0 degrees?

 

[KeroseneSnorter]

I cannot for the life of me remember the airline, but see if you can find info on a 747 CFIT that involved repeated warnings from the Ground Prox system.

Early GPWS systems were prone to false warnings, when the real thing was happening the crew ignored the warning.

Maybe someone else here can remember the date and airline.

 

[Diesel]

Yeah i'm using cali. That's a great example of how the reliance of automation has caused a CFIT accident.

 

[Kream926]

not automation but what about the eastern crash where all 3 guys were fixating on the burned out light on the grear indicator

 

[CE402]

Wasn't there an airbus accident or near-accident where the crew accidentally punched in a descent of 3000fpm instead of 3.0 degrees?

This was an Air Inter (French Domestic Airline) A-320 in the early 1990s I believe blying between Lyon and Strasbourg France. Not sure if it was a definitive cause or not but apparently the same selector knob can choose either FPA (Flight Path Angle) or VS (Vertical Speed) and the displays look quite similar (they both read on the same little screen)...so that in an attempt to select a 3.3 degree FPA you could select a 3300 FPM descent (which would be abbreviated 33 on the screen) if you weren't looking real closely at it.

Also, don't forget the granddaddy of technology causing a CFIT accident -- American Airlines 757 near Cali Colombia.

 

[jumppilot]

Guys-

I'm writing a term paper on CFIT accidents where technology has both saved and caused the accident. Basically i'm looking at the roll of how automation in the cockpit has played a roll in CFIT.

I've got some pretty good accidents but if anyone has any other ideas on some accidents that I can look up it would be appreciated.

uuuuugh college

A 747 was involved in a CFIT accident, where the controler told the crew to "descend 2-400 feet", pronounced, "two-four-zero-zero feet." The crew thought the controller meant "to 400 feet."

The GPWS was barking all the way to the ground.

 

[FN FAL]

Yeah i'm using cali. That's a great example of how the reliance of automation has caused a CFIT accident.

Give em a break, they're pilots. :laugh:

Edited: When I wrote that, I thought you were giving the poster a brow beating about staying on topic...don't know where I got that from, but that's what I was thinking. I wasn't making fun of the American crew.

Moving on, automation didn't cause that CFIT crash.

 

[Stifler's Mom]

http://www.findarticles.com/p/articles/mi_m0UBT/is_16_16/ai_84985136

 

[mar]

Can't remember the date

I cannot for the life of me remember the airline, but see if you can find info on a 747 CFIT that involved repeated warnings from the Ground Prox system.

Early GPWS systems were prone to false warnings, when the real thing was happening the crew ignored the warning.

Maybe someone else here can remember the date and airline.

Flying Tigers at Kuala Lumpur.

 

[FN FAL]

Flying Tigers at Kuala Lumpur.

If that's the one where the flight crew got the two NDB's mixed up, automation didn't cause that one either.

 

[PJO]

I'll sugest you go to ASRS web site and FAA website. In the ASRS web you will find good feedback from the pilots in some of the report. Ihope you find this info helpfull to you.
http://asrs.arc.nasa.gov/report_sets_nf.htm
Good luck

 

[KeroseneSnorter]

If that's the one where the flight crew got the two NDB's mixed up, automation didn't cause that one either.

Not automation, but relevant to his technology portion of the question.

Once someone gets used to a constant stimulus they tend to ignore it. Example would be car alarms, who even bothers to look up when they hear one anymore? The early GPWS systems had similar flaws. It cried wolf so much that when it really meant it, nobody bothered to look up.

 

[FN FAL]

I'll sugest you go to ASRS web site and FAA website. In the ASRS web you will find good feedback from the pilots in some of the report. Ihope you find this info helpfull to you.
http://asrs.arc.nasa.gov/report_sets_nf.htm
Good luck

The NTSB website would be a good place to look as well, but I'm betting the reason that Diesel is having a hard time finding information for his paper, is that there is a dearth of information regarding automation causing CFIT accidents.

 

[FN FAL]

Wasn't there an airbus accident or near-accident where the crew accidentally punched in a descent of 3000fpm instead of 3.0 degrees?

Yea, that would be automation causing a CFIT accident. Not that pilots are supposed identify, verify and do instrument scans or anything remotely close to that...because that would be considered flight crew negligence. Unless someone could prove that the training department was negligent in training the flight crew. Maybe the company that built the plane was negligent in telling the company about the mode control panel and all the funny looking buttons on it.

 

[KeroseneSnorter]

Yea, that would be automation causing a CFIT accident. Not that pilots are supposed identify, verify and do instrument scans or anything remotely close to that...because that would be considered flight crew negligence. Unless someone could prove that the training department was negligent in training the flight crew. Maybe the company that built the plane was negligent in telling the company about the mode control panel and all the funny looking buttons on it.

I would think that his paper is going to deal with the Human factors and how we interact with automation. Or in some cases do not interact with automation. I know my brain used to be able to hold an assigned altitude longer than the 5 seconds it takes to dial it up in the alt. selector window, but now after so many years with an altitude alert and pre select window, when I fly light aircraft I find myself having to ask for the altitude again.

Little things like that can have a profound effect on a flight. Is it a human error? Yes. Was it automation induced? Well that might be a good paper!

 

[imacdog]

Yea, that would be automation causing a CFIT accident. Not that pilots are supposed identify, verify and do instrument scans or anything remotely close to that...because that would be considered flight crew negligence. Unless someone could prove that the training department was negligent in training the flight crew. Maybe the company that built the plane was negligent in telling the company about the mode control panel and all the funny looking buttons on it.

I'm not saying that automation caused the accident, but it was certainly an accident in which automation played a role.

 

[Kingairrick]

desiel;
PM me your address, I took that class too, and I have what you need.
In the mean time:
Airbus A320- Fec 14th 1990, Indian Airlines, 92 Fatals, NTSB cited automation as a contributing factor.
Airbus itself blames automation in the famous vidoe of the 320 at the airshow hitting the tees.

 

[Diesel]

I appreciate all the responses but my paper has to deal with automation and how it has caused CFIT accidents and prevented it. So the cali incident is an excellent choice. for example they were comletley relying on the FMS. Both were heads down typing and typing away. I EGPWS had been available at the time they would have been able to perform an evasive action sooner and maybe cleared the mountain.

I'm thinking i might have to narrow my thesis to just how the reliance on automation has caused CFIT incidents. I might do a blurb about how there are technology out there that is preventing this but the reliance on the "box" is no longer having us do any sort of backup.

I'm writing this partly because my boss got killed in a cfit accident into the mountains. If we had TAWS at the time this would never have happened.

Kingairik pm is on the way.

 

[JediNein]

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20030605X00790&key=1

The above CFIT accident occurred in a plane equipped with dual Garmin GNS 430 GPS units. This means dual GPS, dual VOR, dual Comms, and at least one set of charts aboard. Multiple means of position orientation were available, yet the CFII did not use them.

Another accident, another CFII blindly following ATC Radar Vectors, the Glendale 6? departure off Van Nuys: http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001213X35001&key=1

Enjoy the term paper!

 

[mar]

Hang on a sec.

So the cali incident is an excellent choice. for example they were comletley relying on the FMS. Both were heads down typing and typing away. I EGPWS had been available at the time they would have been able to perform an evasive action sooner and maybe cleared the mountain.

Don't be quite so dismissive towards the crew. Like most accidents this one had several factors layered on top of each other.

It's not so simple as to say their "heads were down typing" and EGPWS could've saved them.

You're focusing on the computer right? Then you need to realize that there were two different beacons with the *same* identifier in the database.

They "typed" in the identifier and the plane took them to the wrong one.

They knew something was wrong but didn't figure it out in time.

Throw in a loss of situational awareness, poor ATC communication and speedbrakes that were not retracted during the climb and suddenly you have an accident.

 

[Diesel]

Okay lets ignore for the fact that the crew would never have been able to land from the point where they were cleared for the straight in.

There are many identifiers that have the same key. That's not uncommon. It was the reliance on the crew that the box must be right because it came up with the identifier and not cross checking it before hitting the excute button.

The reliance on automation to help them figure out where they were going was a serious player in the accident.

Let's say if the crew had a map display on the MFD do you think they would have hit the mountain? Would that type of technology have prevented this type of accident?

I look forward to your responses. Too bad I can list flightinfo.com as a source of reference.

 

[Diesel]

Jedi- Cool thanks for the info.

 

[FN FAL]

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20030605X00790&key=1

The above CFIT accident occurred in a plane equipped with dual Garmin GNS 430 GPS units. This means dual GPS, dual VOR, dual Comms, and at least one set of charts aboard. Multiple means of position orientation were available, yet the CFII did not use them.

Another accident, another CFII blindly following ATC Radar Vectors, the Glendale 6? departure off Van Nuys: http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001213X35001&key=1

Enjoy the term paper!

What about the Nascar racing team crash?

 

[mar]

Better question for a 757 pilot.

There are many identifiers that have the same key. That's not uncommon. It was the reliance on the crew that the box must be right because it came up with the identifier and not cross checking it before hitting the excute button.

Let's say if the crew had a map display on the MFD do you think they would have hit the mountain? Would that type of technology have prevented this type of accident?

I certainly don't have any official reference beyond my own experience but I'd certainly question the protocol of instituting two navaids within the same FIR with identical identifiers.

For the most part I'm just speaking as a pilot who's made many nighttime approaches in crappy weather to crappy airports in Alaska.

In other words, I don't know what I'm talking about.

But yeah, I agree, all things being equal if some sort of graphical display of the terrain had been available their (the crew) "red flags" would've been raised a lot sooner...

...but the elimination of just *one* of the factors in that accident would've prevented it: Better info in the FMS; Better ATC system; Better situational awareness; Better GPWS escape maneuver (speedbrake retraction).

In my last post I was just trying to point out that the AA crew got suckered...or maybe let themselves get suckered into a bad situation but they weren't asleep at the wheel so to speak.

Good luck.

 

[KigAir]

http://www.findarticles.com/p/articles/mi_m0UBT/is_16_16/ai_84985136

Capt. Wu, 32 years old and with just one year as captain in the B767, elected instead to fly a circling approach, in rain and mist.