Page:KAL801Finalreport.pdf/118

 The FSF, using statistics from the United Kingdom's CAA global database, found that 287, or 46 percent, of the 621 fatal CFIT accidents worldwide between 1980 and 1986 occurred during the approach and landing phase of flight. A study commissioned by the CAA for the FSF examined these 287 fatal approach and landing accidents. According to the study, these 287 accidents resulted in 7,185 fatalities to passengers and crewmembers, which averaged 25 fatalities per accident, or 63 percent of the total aircraft occupants.

The study indicated that 75 percent of the accidents occurred when a precision approach aid was neither available nor used and that nighttime accidents occurred at three times the rate of those that occurred during daylight conditions. The lack of ground aids was cited in at least 25 percent of the accidents. The study concluded that the "most frequent circumstantial factors were non-installation of currently available safety equipment (generally GPWS systems) and the failure to emphasize the use of crew resource management."

The study determined that, in 279 of the accidents, the 5 most frequently identified primary causal factors--omission of action/inappropriate action, lack of positional awareness in the air, flight handling, "press-on-itis," and poor professional judgment/airmanship--accounted for 71 percent of the accidents. According to the FSF, omission of action/inappropriate action generally referred to the crew continuing the descent below the DH or MDA without visual reference or when visual cues were lost. Lack of positional awareness in the air generally involved a lack of appreciation of the aircraft's proximity to high ground, frequently when the aircraft was not equipped with a GPWS and when precision approach aids were not available. Press-on-itis referred to a flight crew's "determination to get to a destination or persistence in a situation when that action is unwise." The study also determined that all five primary causal factors involved crewmembers.

The study reported that the number of accidents and the number of fatalities showed an overall increasing trend and that, if the trend were to continue, "...by 2010 there will be 23 fatal ALAs [approach and landing accidents] with a total of 495 fatalities annually involving Western-built aircraft (commercial jets, business jets and turboprop airplanes)...." On the basis of the results of this study, the FSF Approach and Landing