ALAR

ALAR
Approach and Landing Accident Reduction
Flight Operations and Training

CFIT and ALAR Task Forces
Steering Committee
and
Working Groups
CFIT ALAR
Flight Safety Foundation
ALAR Task Force Organization
Steering Committee
Data Acquisition
Operations and and Analysis
Training Working Working Group
Group
FSF CFIT/ALAR
Action Group
(CAAG)
Air Traffic Control Aircraft Equipment
Training and Procedures/ Working Group
Airport Facilities
Working Group
ALAR OBJECTIVES
• To reduce the approach-and-landing accident (ALA)

rate by 50% within 5 years of issuing final
recommendations in 1999
• To identify equipment, operational, regulatory and

training measures that will improve safety for aircraft
from commencement of approach through circling,
landing or missed approach
Statistics for
Approach-and-landing Accidents
(ALAs)
• 56% of Western-built large commercial jet accidents

are ALAs.
• Approximately 50% of fatalities are the result of
Western-built large commercial jet ALAs.
• By 2010, the task force estimates 23 Western-built
large commercial jet fatal accidents will occur annually.
• Controlled-flight-into-terrain (CFIT) accidents are not
showing a downward trend.
ALAR Data-driven Strategy
• High-level analyses of 287 accidents
• In-depth study of 76 incidents and accidents
• Line observations on 3,300 U.S. flights
• All conclusions supported by data

Inadequate Situational
Awareness in ALAs
• Inadequate situational awareness was a factor
in 51% of ALAs.
• Currently available safety equipment was not
installed in 29% of the aircraft in ALAs.
Food for Thought:
The captain was the pilot flying in

74% of ALAs involving dual-pilot
operations.
From the Outer Marker
To the Landing
4% of flying time results in 45% of

hull-loss accidents involving
Western-built large commercial jets.
Most Common Types of
Approach-and-landing Accidents
• CFIT
• Loss of control
• Landing overrun
• Runway excursion
• Unstabilized approach
Missed Approach
• Failure to recognize the need for a missed

approach and to execute a missed approach is a
major cause of ALAs.
• Companies should declare and support no-fault
go-around policies.
Factors in Unstabilized
Approaches and
Missed Approaches
• 42% involved “press-on-itis.”

• 36% were low and/or slow on approach.
• 30% were high and/or fast on approach.
• Only 17% of crews initiated go-arounds.
Unstabilized Approaches
• Unstabilized approaches contribute to ALAs.
• Operators should define the parameters of a stabilized approach in their

flight operations manuals.
• Operator policy should state that a go-around is required if the

approach becomes unstabilized below the minimum stabilization
height.
• The implementation of certified constant-angle, stabilized-approach

procedures for nonprecision approaches should be expedited globally.
Minimum Stabilization Height
The approach should be stabilized by 1,000

feet in IMC, 500 feet in VMC.
IMC = Instrument meteorological conditions

VMC = Visual meteorological conditions
Recommended Elements of a
Stabilized Approach
1. The aircraft is on the correct flight path;
2. Only small changes in heading/pitch are required to maintain

the correct flight path;
3. The aircraft speed is not more than VREF + 20 knots indicated

airspeed and not less than VREF;
4. The aircraft is in the correct landing configuration;
(continued)
Stabilized Approach (continued, #2)
5. Sink rate is no greater than 1,000 feet per minute; if an
approach requires a sink rate greater than 1,000 feet per
minute, a special briefing should be conducted;
6. Power setting is appropriate for the aircraft configuration

and is not below the minimum power for approach as
defined by the aircraft operating manual;
7. All briefings and checklists have been conducted;
(continued)
Stabilized Approach (continued, #3)
8. Specific types of approaches are stabilized if they also fulfill
the following: instrument landing system (ILS) approaches
must be flown within one dot of the glideslope and
localizer; a Category II or Category III ILS approach must be
flown within the expanded localizer band; during a circling
approach, wings should be level on final when the aircraft
reaches 300 feet above airport elevation; and,
9. Unique approach procedures or abnormal conditions

requiring a deviation from the above elements of a
stabilized approach require a special briefing.
CRM, SOPs and Training
Factors Involved in ALAs
• 74% - Inadequate crew decision making
• 72% - Inadvertent nonadherence to procedures
• 63% - Failure in CRM (cross-check/coordination)
• 46% - Failures in company management
• 40% - Deliberate nonadherence to procedures
• 37% - Inadequate training
CRM = Crew resource management
SOPs = Standard operating procedures
Standard Operating Procedures
• Establishing and adhering to adequate SOPs and flight crew
decision-making processes improves approach-and-landing
safety.
• States should mandate, and operators should develop and
implement, SOPs for approach and landing operations.
• Operators should implement routine and critical evaluation of
SOPs to determine the need for change.
• Operators should provide education and training that enhance
flight crew decision making and risk management.
Communication Factors
• 33% of the ALAs and serious incidents

involved incorrect or inadequate ATC
instruction/advice/service.
Pilot-Controller Communication
Improving communication and mutual

understanding between controllers and pilots
of each other’s operational environment will
improve approach-and-landing safety.
Terminal Area Infrastructure
• 21% of ALAs involved lack of ground aids.
• 12% of ALAs involved lack of ATC equipment (terminal
approach radar, minimum safe altitude warning).
• The risk of ALAs during no precision approaches is five times
greater than the risk of ALAs during precision approaches.
• The risk of ALAs in the absence of terminal approach radar is
three times greater than the risk of ALAs with terminal
approach radar available.
Terminal Area
Infrastructure (continued, #2)
• Precision approach capability and approach radar reduce the
risk of ALAs.
• Encourage crews to use more precise approach guidance at
all times such as ILS, GNSS, PAPI and VASI.
• Develop precision approach capability to all runways by
application of technology (e.g., GNSS and LAAS).
• Implement MSAW or equivalent on all approach radars for
ATC terrain warning.
GNSS = Global navigation satellite system PAPI = Precision approach path indicator
VASI = Visual approach slope indicator LAAS = Low altitude alert system
MSAW = Minimum safe altitude warning system
ENVIRONMENT
• 59% of ALAs involved poor visibility.
• 21% of ALAs involved disorientation/visual illusion.

• 18% of ALAs involved runway condition:
- 73% of ALAs involved overruns on contaminated runways.

• 37% of ALAs involved precipitation/winds.
(continued)
ENVIRONMENT (continued, #2)
• The risk of ALAs is higher in operations conducted in low light
and poor visibility, on wet or otherwise contaminated
runways, and with the presence of visual or physiological
illusions.
• Flight crews should be trained in operations involving these
conditions before they are assigned line duties.
• Flight crews should make operational use of a risk-assessment
tool to identify approach and landing hazards. Appropriate
procedures should be implemented to reduce the risks.
Safety Data
Monitoring Programs
• Through the collection and analysis of in-flight parameters,
FOQA programs identify performance trends that can be used
to improve approach-and-landing safety.
• FOQA should be implemented worldwide in concert with
information-sharing partnerships such as GAIN, BASIS and
ASAP.
• Provision should be made on aircraft for equipment to support
data collection and analysis.
FOQA = Flight operational quality assurance
GAIN = Global Aviation Information Network
BASIS = British Airways Safety Information Service
ASAP = U.S. Federal Aviation Administration Aviation Safety Action Program
Aviation Safety Information
• Global sharing of aviation information decreases the risk of
ALAs.
• FOQA data must be de-identified.
• Public awareness of the importance of information sharing
must be increased.
• Airlines and regions that share information have the lowest
accident rates.
• Crews that are aware of an accident and its causes are less
likely to repeat that type of accident.
FOQA = Flight operational quality assurance (program)
• Flight Safety Digest: “ALAR Briefing Notes”
ALAR Tool Kit
• Flight Safety Digest: “Killers in Aviation: FSF Task Force Presents Facts About Approach-and-
landing and Controlled-flight-into-terrain Accidents”
• FSF ALAR Task Force Conclusions and Recommendations
• FSF ALAR Task Force Members
• Selected FSF Publications
• Approach-and-landing Risk Awareness Tool
• Approach-and-landing Risk Reduction Guide
• Standard Operating Procedures Template
• ALAR Information Posters
• CFIT Checklist
• CFIT Alert
• Flight Operations and Training
• Equipment for Aircraft and Air Traffic Control
• Air Traffic Control Communication
• Pilot Guide to Preventing CFIT
• Approach-and-landing Accident Data Overview
• An Approach and Landing Accident: It Could Happen to You
• CFIT Awareness and Prevention
• Links to Aviation Statistics on the Internet

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Approach and Landing Accident Reduction

Flight Operations and Training

• To reduce the approach-and-landing accident (ALA)

• To identify equipment, operational, regulatory and

• 56% of Western-built large commercial jet accidents

• In-depth study of 76 incidents and accidents

• Line observations on 3,300 U.S. flights

• All conclusions supported by data

The captain was the pilot flying in

4% of flying time results in 45% of

• Failure to recognize the need for a missed

• 42% involved “press-on-itis.”

• Operators should define the parameters of a stabilized approach in their

• Operator policy should state that a go-around is required if the

• The implementation of certified constant-angle, stabilized-approach

The approach should be stabilized by 1,000

IMC = Instrument meteorological conditions

2. Only small changes in heading/pitch are required to maintain

3. The aircraft speed is not more than VREF + 20 knots indicated

4. The aircraft is in the correct landing configuration;

6. Power setting is appropriate for the aircraft configuration

7. All briefings and checklists have been conducted;

9. Unique approach procedures or abnormal conditions

• 33% of the ALAs and serious incidents

Improving communication and mutual

• 21% of ALAs involved disorientation/visual illusion.

- 73% of ALAs involved overruns on contaminated runways.

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