“Do Not Fly into Terrain” Placard: How Not To CFIT

“Do Not Fly into Terrain” Placard: How Not To CFIT

  • August
  • 19
  • 2019
  • Advanced Aircrew Academy

There are directions on jigsaw puzzles that state "Some assembly required"; on blowtorches "Not to be used for drying hair"; on chain saws "Do not attempt to stop chain with your hands"; and headscratchers on bags of chips that announce "You could be a winner! No purchase necessary. Details inside." What may seem obvious to you might not be obvious to others.

Do Not Fly Into Terrain

If your aircraft had a placard in the cockpit stating "Do Not Fly into Terrain", you would roll your eyes because that's obvious. If you are operating under Part 91 or 135, the FAA has no specific training requirement on how not to perform CFIT. There was an International Standard for Business Aircraft Operations (IS-BAO) training requirement for CFIT under the category of “other training required to ensure a safe operation”, but the CFIT training notation was removed in 2015 replaced by Approach and Landing Accident Reduction (which was then removed in the 2018 standard).

If the FAA and IS-BAO don’t specifically require CFIT training, then we must have solved the issue of CFIT, right?

Unfortunately, CFIT remains the #2 leading cause of fatal accidents worldwide. Controlled Flight into Terrain (CFIT) was added to the NBAA's Top Safety Focus Areas in 2019. In the NTSB's 2019-2020 Most Wanted List, as part of the Improve the Safety of Part 135 Aircraft Flight Operations, the NTSB states "part 135 operators…should mandate controlled flight-into-terrain-avoidance training that addresses current terrain-avoidance warning system technologies." The NTSB calls CFIT "the problem that never went away." We have seen about 50% of the Part 135 operators we provide training for have a specialty curriculum added to their training manual for CFIT.

The problem with CFIT, besides the obvious, is that it's never just one error. If we look at the causal factors, you'll see "Loss of Situational Awareness" often as the summary, but that's not the cause. The pilot didn't lose situational awareness, rather:

  • They had a firm belief and awareness of their situation, it was just wrong.
  • They didn’t allow their situational awareness to open to the other possibilities.
  • They were too firm in their belief.
  • The sequence of specific actions based on the wrong interpretation of the given information puts you and your perfectly flying aircraft into terrain.

Some Facts

Non-precision approaches have a five-times greater risk of CFIT than precision approaches. Self-fulfilling prophecy in the name. Many Business Aviation destinations are to airports under radar contact, but there are always those weird trips, often at the last minute, that take you into Podunk nowhere and then you’re cleared for the FULL approach. When is the last time you performed a procedure turn, not in the simulator?

The industry has been working on Continuous Descent Final Approach (CDFA) techniques. The name of the idea explains itself. The FAA has published Advisory Circular 120-108 on the topic. When operating in the European Union, use of CDFA is required. The approach and landing phase (within five miles of touchdown) constitutes only 4% of the flight time, but where 48% of the hull losses occur. Simply having an approach where you are leveling off for just a moment, adjusting power, and then descending again, for just a moment, again and again is a teeter totter that can throw us all off.

Some of the other contributing factors include:

  • incorrect altimeter settings (extreme cold)
  • ATC (oops, they forgot to clear you for the approach and you flew thru the localizer - the 45-degree banking turn felt like the right decision at the moment to get back on course…)
  • fatigue
  • complacency


It should come as no surprise, but the rate of CFIT accidents declined after the introduction of Ground Proximity Warning Systems (GPWS)/Enhanced GPWS (EGPWS) and Terrain Awareness Warning Systems (TAWS). It can also help with erroneous visual cues that lead you into black holes, but many pilots don’t understand all the modes of EGPWS and because it alerts so often, is ignored when it really matters.

Most pilots will turn on the GPWS/TAWS Terrain display on the EFIS when operating in mountainous terrain, but how many pilots use it for obstacle awareness? Wheeler Downtown Airport at Kansas City and Peachtree-DeKalb in Atlanta (KPDK) both have very tall towers or buildings close to the airport. Using technology available in the aircraft can help you maintain SA in relationship to obstacles. Modern avionics offers us the ability to create a VNAV path to almost every runway we are approaching; however, a quick check of distance versus altitude is a skill that you should not let deteriorate.

To add to the challenges, each company has different rules regarding your actions if your Enhanced Ground Proximity Warning System (EGPWS) starts issuing Cautions and Alerts. There may be different policies regarding your response during day, night, VMC, or IMC. Your company manuals may dictate always complying with an alert, or the manual may state if you can "see and avoid," then you can disregard an EGPWS alert.

It may also be dependent upon the type of options that are installed in your aircraft. You must understand how the EGPWS works in your aircraft. Follow your company guidance and AFM procedures!


In contrast to technology, do you remember the old-fashioned Visual Descent Point? VDPs are only published for straight-in instrument approaches to specific runways and, if your approach has one, you shouldn’t descent below MDA before reaching the VDP. Pilots are asked about it every year during training, but during the busy minutes of an approach, the meaning of that symbol can be illusive.

Sometimes the TERPS chart maker figures it out for you, and it's just a guideline, but just divide MDA by 3. They're hoping you're on a 3-degree glideslope so if your MDA is 367', your VDP is 1.2 nm from the end of the runway. If you fly past your VDP point and haven't seen the runway, you probably aren't in a position to land, even if you're not at your missed approach point. It's not a legal requirement, but it's a good indication you won't be flying a standard profile, your descent rate will be higher…ergo, you're not flying a stabilized approach.

If the descent rate while approaching the airport is abnormal, pay attention! Something about the situation is not right. You know what descent rate the VSI normally shows while landing. If the descent rate is outside of normal parameters, mental warning flags should start popping up.


Here's the thing about CRM; if your CRM is perfect, you will never fly your airplane into terrain by accident. The person sitting next to you in the cockpit, even if their breath is horrible, is the best indicator, but only if you are BOTH active participants in CRM. We've all flown with those captains that snarl at you because it's "their airplane", or copilots that think they know so much they can't be bothered with SOPs, but each little bad behavior causes the weakest link to break.


Captains (or Flying Pilot/FP), pay attention when your Copilot (or Pilot Monitoring) says, "something's not right…" Conduct a thorough briefing that includes the dangers of the airport ahead and have a bailout plan even before the missed approach point. Be willing to change if ATC or the other crewmember has a better idea.


Copilots (or Pilot Monitoring), you have the most important job of all. Be willing to firmly state that something is not right, or you don't agree with the flying pilot's actions. Be willing and ready to speak up or call for a go-around.


Each CFIT accident has ultimately been held to be the pilot's responsibility, because it is. As all pilots know, it's not just one weak link in the error chain that leads to an accident, that's why Advanced Aircrew Academy has a CFIT eLearning module that provides perspective, details, and best practice procedures to strengthen the potential weak link. The NBAA Safety Committee and NTSB recommend training to mitigate the hazard of CFIT.

Whether you're flying Part 91 and/or 135, we can build Initial and Recurrent curriculums for the specific type of missions you’re flying for a price your accounting department will love. For more information, email, call 843-557-1266, visit or find us on any major social media site.