On a near moonless night in November 2007, two Civil Air Patrol pilots boarded their Cessna T182T Turbo Skylane and departed North Las Vegas Airport headed southwest to Rosamond, Calif. About 13 minutes into the otherwise routine flight, the aircraft impacted a near vertical rock face on the southeast side of Mount Potosi, about 1,000 feet below its summit. Despite the pilots’ vast experience (over 53,000 hours of flight time between them), a nearly new turbocharged aircraft, and a Garmin G1000 capable of displaying terrain proximity information, the crew didn’t maintain adequate terrain clearance during climb out. The NTSB cited rising terrain, darkness, the pilot’s loss of situational awareness, and ATC failure to issue a terrain-related safety alert as contributing factors.
This chilling account of controlled flight into terrain, or CFIT (see-fit), is all too familiar. While technological advances over the years have curtailed the rate of CFIT to some extent, it remains a persistent problem, especially within the general aviation (GA) community. As the example illustrates, there’s usually a lot to unpack with CFIT accident scenarios. Many have multiple contributing factors, but CFIT accidents typically share one common thread: lack of situational awareness. In this article you’ll learn more about what CFIT is and why it happens, along with some new strategies aimed at mitigating this long-standing and often fatal problem.
Let’s start by understanding what CFIT is and what it isn’t. According to FAA Advisory Circular (AC) 61–134, General Aviation CFIT Awareness, CFIT occurs when an airworthy aircraft under the control of a qualified pilot is flown into terrain (water or obstacles) due to the pilot’s inadequate awareness of the impending collision. Note the qualifiers — airworthy aircraft, qualified pilot, with pilot’s lack of awareness. A mechanical failure in flight or pilot’s loss of control would not be categorized as a CFIT.
According to 2003 AC 61–134, CFIT accidents accounted for about 17-percent of all GA accident fatalities at that time. That rate has decreased in recent years, but not by enough. The FAA and the General Aviation Joint Steering Committee (GAJSC), a joint government/industry safety effort, have consistently ranked CFIT as a top three GA accident causal factor for the last two decades. A recent GAJSC analysis (2011–2019) shows a total of 171 CFIT accidents (as recorded at that time), placing CFIT number three on the list of accident causal factors (loss of control and powerplant system component failures rank ahead of CFIT).
A Team Approach
So what causes a capable pilot in a structurally sound airplane to have an unexpected and unwanted cumulo-granitus encounter? That’s the question the GAJSC set out to answer by chartering the CFIT Working Group (WG) in 2017. This team consisted of about two dozen government and industry aviation experts, including representatives from the Aircraft Owners and Pilots Association (AOPA), Experimental Aircraft Association (EAA), FAA, Honeywell, Jeppesen, National Business Aircraft Association (NBAA), Piper Aircraft, Society of Aviation and Flight Educators (SAFE), and Textron Aviation.
Over the course of two and a half years, with meetings every six to eight weeks, the team meticulously pored over details from 67 CFIT accidents (from 2008–2018) using a well-tested data analysis process. Their goal: to better understand CFIT causes and to develop suitable strategies to prevent them.
“It was an exceptional experience, one that was very personal and incredibly humbling,” says Kieran O’Farrell, acting manager of the FAA’s Specialty Aircraft Examiner Branch and government co-chair of the CFIT WG. With 24 years of Alaska floatplane flying under her belt, Kieran knows a thing or two about CFIT. “I lost 17 friends in aircraft accidents,” she says, “and 15 were due to CFIT.” After WG meetings, Kieran often found herself pondering the sobering accounts of accident scenarios. “I saw myself in a number of these accidents,” she says, “doing things no different than these people did.” That personal connection further fueled her resolve to find answers.
The WG also benefited from on-site meetings with diverse organizations that added key insight to the team’s findings. They visited AOPA headquarters to gather member feedback and engaged with employees at both Honeywell and Jeppesen. The WG also met at the campuses of Embry-Riddle Aeronautical University in Florida and the University of Alaska, seeking opportunities to discuss CFIT firsthand with aeronautical students. Another meeting at NetJets’ corporate headquarters in Columbus, Ohio, provided critical insight into the complex and demanding world of part 135 operations.
The humbling part of CFIT is that it can happen to anyone, anytime, and in any kind of terrain.
This up-close and personal approach was especially helpful with one of the biggest challenges — getting inside the accident pilot’s head. Identifying the kinds of stress or distractions a pilot experienced in the lead-up to a CFIT flight is extremely difficult and sometimes impossible. “There’s always a part of the picture that’s hard to see,” says Kieran. “No pilot wakes up and says today’s the day I’m going to die in an airplane. There’s always something else, whether they dialed in the wrong approach, or just thought they were somewhere else. Wishful thinking never levitates an airplane over that mountain.”
The team worked hard at piecing all available information on each accident together to better understand the range of reasons behind each tragic outcome. In one fatal scenario, a pilot rushing to attend a funeral was likely dealing with a level of grief and “get-there-itis” that contributed to a lack of sound decision-making.
After scores of meetings and detailed discussions, the CFIT WG sorted and ranked a series of intervention strategies based on feasibility and effectiveness. From that list the team compiled a final set of recommended Safety Enhancement (SE) topics that could have the greatest impact on addressing and mitigating root causes of CFIT accidents. The SEs addressed CFIT mitigation strategies from different perspectives, including training and education, policy, and technology. There is also a large human factors component that addresses external pressure to continue a flight. These more insidious factors can have a huge impact on your decisions (or indecisions) during flight. (If you’re interested in reviewing the SEs, along with a description of the WG’s methodology and conclusions, you can read a report expected to appear this fall on GAJSC.org.)
“SE” for Yourself
This issue of FAA Safety Briefing is largely focused on the subjects of those SEs, so please read on to learn what’s being done to combat CFIT. You’ll find information on some powerful and precise technological solutions making their way into the GA fleet, best practices for CFIT avoidance at night and in IMC, and remedies for treating the deadly affliction of “get-there-itis.”
“Our ultimate goal is to provide pilots with the right tools, education, and technology to be situationally aware of where they are both physically and mentally in the airplane,” says Kieran. “That might mean reaching out to pilots and tasking industry in different ways than we have in the past.” The SEs are a mechanism to do just that by stressing key educational points and driving innovation towards safer and more affordable solutions.
Thinking Outside the Box
On a broader scale, Kieran also hopes WG efforts promote a culture shift to improving a pilot’s critical thinking skills. One example she often touted during WG meetings was the unintentional IMC escape plan. She notes that the 180-degree turn is too narrowly focused and relies more on muscle memory than a brain-based calculation. To prove the point, Kieran phoned a flight instructor she knew during one meeting who connected her with a pilot in training to ask about IMC escape plans. Despite his effort to explain how he would avoid such a situation in the first place, the 180-degree turn response confirmed Kieran’s suspicion.
“It’s not necessarily the wrong answer, but is it the same answer if you’re in Florida or Alaska, or if you’re in icing?” she asks. “Maybe it’s better to climb up out of it. It’s situationally dependent.” For Kieran and the team, this kind of scenario reinforces the need to better develop a pilot’s critical thinking skills and situational awareness. That’s easier said than done, but they are optimistic about the initiative to overhaul the WINGS Pilot Proficiency Program to help with the culture shift.
The CFIT WG also stressed the need for technology advances to bolster real-time situational awareness of weather and terrain. Products like electronic flight bags (EFBs) or a digital co-pilot could warn pilots of rising terrain in three miles, or of an approach not aligned with the runway. Augmented reality goggles could reveal terrain cloaked in clouds or darkness. Some of these and other promising and potentially game-changing technologies are already being developed for GA.
The FAA and its GAJSC partners are committed to finding ways to support and develop a range of CFIT mitigation strategies. “The humbling part of CFIT is that it can happen to anyone, anytime, and in any kind of terrain,” says Kieran. The accident described at the beginning of this article reinforces the point, despite there being no shortage of pilot experience or helpful technology. Kieran adds that “the way to avoid it is to properly make use of all available tools and keep your ‘SA’ at all times.” The hard part is conveying this advice in a way that registers. The CFIT WG Safety Enhancements are an important step towards not only better understanding, but also helping to advance a data-driven game plan that tackles CFIT prevention in new and more meaningful ways. The future of CFIT-less skies is bright.
Tom Hoffmann is the managing editor of FAA Safety Briefing. He is a commercial pilot and holds an A&P certificate.