Emerging Hazards in Commercial Aviation—Report 1: Initial Assessment of Safety Data and Analysis Processes (2022) / Chapter Skim
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Pages 85-96
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The committee reviewed the list of 126 Commercial Aviation Safety Team (CAST) Safety Enhancements (SEs)
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86 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 System alerts. In 2013, numerous CAST SEs addressed LOC accidents and 2014 brought focus to runway excursions.
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APPENDIX A 87 described below we use the date of the implementation plan unless specific target dates for implementation are provided within them. Figure A-2 shows that, overall, of the 126 SEs, nine (7%)
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88 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 reports. Although CAST is a North American, largely U.S., enterprise, the International Civil Aviation Organization has issued similar guidance on many of the CAST SEs.
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APPENDIX A 89 will be undertaken by the Aircraft Accident Investigation Board (AAIB)
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90 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 bank angle. The first officer (FO)
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APPENDIX A 91 The go around followed a poorly flown instrument approach. There were no malfunctions with the aircraft (although one investigator disagreed with this, there was no physical evidence)
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92 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 The Crew's CRM was limited during approach, further weakened at go around. The accident resulted from: • The lack of a common action plan during the approach and a final approach continued below the Minimum Descent Altitude, without ground reference acquired • The inappropriate application of flight control inputs during a go around and on the activation of Terrain Avoidance and Warning System (TAWS)
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APPENDIX A 93 as soon as he attempted to intervene on the controls enabled the FO to continue to force the airplane into a steepening dive. UPS 1354, A300F 8-14-13, CFIT on a non-precision approach.
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94 EMERGING HAZARDS IN COMMERCIAL AVIATION -- REPORT 1 the low-speed cue was visible would have likely reduced opportunities for her timely recognition of the impending event; the failure of both pilots to detect this situation was the result of a significant breakdown in their monitoring responsibilities and workload management. The flight crewmembers' performance during the flight, including the captain's deviations from standard operating procedures and the FO's failure to challenge these deviations, was not consistent with the crew resource management (CRM)
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From page 95... ...
APPENDIX A 95 to cope with maneuvering changes commonly experienced at major airports and would allow them to be more proficient in establishing stabilized approaches under demanding conditions; in this accident, the pilot flying may have better used pitch trim, recognized that the airspeed was decaying, and taken the appropriate corrective action of adding power.
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