ALAR Overview

1. ALAR
Approach and Landing Accident
Data Overview (1980–1997)
Applicable to: Pilots
Prior Knowledge: Have a valid license
Region: Everyone
Country: Any
Language: English
ALAR Develop: EAQ RO Feb. 18, 2015 1

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).”
ALAR Develop: EAQ RO Feb. 18, 2015 2

3. 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.
ALAR Develop: EAQ RO Feb. 18, 2015 3

4. Conclusions
• Standard operating procedures
• Missed approaches
• Unstabilized approaches
• Communication
• Environment
• Radio altimeter
• Safety data monitoring
• Information sharing
ALAR Develop: EAQ RO Feb. 18, 2015 4

5. Approach-and-Landing
Fatal Accident Rates by Region
0 0.13 0.16
0.43
0.88
1.64 1.65
2.43
0
0.5
1
1.5
2
2.5
3
Accidentspermilliondepartures
Region
Western-built Jets,* 1980–1996
* With maximum takeoff weights above 12,500 pounds/5,700 kilograms. JAA = Joint Aviation Authorities
Australasia North
America
Europe
(JAA)
World Europe
(non-JAA)
South/Central
America
AfricaAsia
ALAR Develop: EAQ RO Feb. 18, 2015 5

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
ALAR Develop: EAQ RO Feb. 18, 2015 6

7. 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.
ALAR Develop: EAQ RO Feb. 18, 2015 7

8. Causal Factors in Approach-and-Landing
Accidents and Serious Incidents
0
10
20
30
40
50
60
70
80
90
100
Occurrences(percent)
Interaction
with
Automation
Disorientation/
Visual
Illusion
Lack of Training/
Experience/
Qualification
High/Fast on
Approach
(continued)
ALAR Develop: EAQ RO Feb. 18, 2015 8

9. 0
10
20
30
40
50
60
70
80
90
100
Procedural
Violations
“Press-on-itis”
Occurrences(percent)
Low/Slow on
Approach
ATC: Incorrect
Advice/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

10. 0
10
20
30
40
50
60
70
80
90
100
Lack of
Position
Awareness
Inadequate
CRM
Procedural
Errors
Inadequate
Judgment/
Airmanship
Occurrences(percent)
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

11. 0
10
20
30
40
50
60
70
80
90
100
Inadequate
Regulatory
Oversight
Lack of
Safety
Equipment
Inadequate
Regulation
Occurrences(percent)
Runway
Condition
Inadequate
Ground
Aids
Circumstantial Factors in
Approach-and-Landing Accidents and
Serious Incidents
(continued)ALAR Develop: EAQ RO Feb. 18, 2015 11

12. CRM = Crew resource management
Circumstantial Factors in
Approach-and-Landing Accidents and
Serious Incidents (continued, #2)
0
10
20
30
40
50
60
70
80
90
100
Inadequate
training
Management
failure
Inadequate
procedures
Inadequate
CRM
Poor visibility
Occurrecnces(percent)
ALAR Develop: EAQ RO Feb. 18, 2015 12

13. Go-around Initiated When Warranted
Occurrences(percent)
0
10
20
30
40
50
60
70
80
90
Yes No
ALAR Develop: EAQ RO Feb. 18, 2015 13

14. Pilot Flying in
Approach-and-Landing Accidents
and Serious Incidents
0
10
20
30
40
50
60
CAPT FO Single Pilot Unknown
Occurrences(percent)
CAPT = Captain
FO = First officer
ALAR Develop: EAQ RO Feb. 18, 2015 14

15. 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)
ALAR Develop: EAQ RO Feb. 18, 2015 15

16. 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)
ALAR Develop: EAQ RO Feb. 18, 2015 16

17. 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)
ALAR Develop: EAQ RO Feb. 18, 2015 17

18. 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 InvestigationALAR Develop: EAQ RO Feb. 18, 2015 18

19. 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.
ALAR Develop: EAQ RO Feb. 18, 2015 19