.  Lack of or restricted radar coverage;
.  Lack of precision approach and/or lack of VASI/PAPI; and,
.  Limited and/or low-intensity approach and runway lighting.

.  Navigation charts:
.  Lack of published departure and/or approach procedures;
.  Lack of published information on minimum radar vectoring altitudes; and,
.  Absence on colored terrain contours on approach charts.

.  Training :
.  Absence of area and/or airport familiarization training; and,
.  Inadequate knowledge of applicable obstacle clearance and/or sector minimum vectoring altitude.

.  Standard operating procedures:
.  Inadequate briefings;
.  Monitoring errors (i.e., inability to monitor the aircraft trajectory and instruments while performing FMS entries or while being interrupted or distracted);
.  Inadequate monitoring of flight progress (i.e., being behind the aircraft);
.  Incorrect use of or interaction with automation;
.  Omission of a normal checklist or part of a normal checklist (usually because of interruption or distraction); and/or,
.  Deliberate or inadvertent non-adherence to procedures.

Terrain Awareness – When and How ?
Page 8

.  Pilot/Controller Communications:
.  Omission of position report at first radio contact in an area without radar coverage (i.e., reducing the controller’s situational awareness);
.  Breakdown in pilot / controller or intra-crew communications (e.g., readback/hearback errors, failure to resolve doubts or ambiguities, use of non-standard phraseology); and/or,
.  Accepting an amended clearance without prior evaluation.

.  Human Factors and CRM:
.  Incorrect CRM practices (absence of crosscheck and back-up for AP mode selections and AP/FMS data entries, late recognition of monitoring errors);
.  Inadequate decision-making;
.  Failure to resolve a doubt or confusion;
.  Fatigue;
.  Complacency;
.  Spatial disorientation; and/or,
.  Visual illusions.

Summary of key points
The following key points and recommendations should be used in the development of company prevention strategies and actions enhancing terrain awareness.
Approach Charts
Providing flight crews with departure and approach charts featuring terrain with color shaded contours.
Altimeter setting
Promoting strict adherence to adequate SOPs to reduce altimeter-setting errors and for optimum use of baro-altimeter bug and radio-altimeter DH.
To reduce altimeter-setting errors, flight crew should:
.  
Be aware of altimeter setting changes due to prevailing weather conditions (e.g., extreme cold or warm fronts, steep frontal surfaces, semi-permanent or seasonal low pressure areas);

.  
Be aware of the altimeter setting unit in use at the destination airport;

.  
Be aware of the anticipated altimeter setting, using two independent sources for cross-check (e.g., METAR and ATIS messages);

.  
Ensure effective cross-check and back-up;

.  
Adhere to SOPs for:

.  reset of altimeters in climb and descent (per FCOM or per company’ SOPs);
.  use of standby altimeter to cross-check main altimeters;
.  altitude callouts;
.  RA callouts; and,
.  setting of baro-altimeter bug and RA DH.

.  Cross-check that the cleared / assigned altitude is above the sector minimum safe altitude (unless crew is aware of applicable minimum vectoring altitude for the sector).
Flight progress monitoring
Flight monitoring for terrain awareness includes:
.  
Monitoring FMS guidance and FMS navigation accuracy;
　
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