NTSB GAAP Symposium
September 22, 2000

Day 2, of 2
day 1

A G E N D A

AGENDA ITEM:

Spacial Disorientation Device Demonstration
Roger Shaw
Civil Aeromedical Institute

In-Flight Loss of Control Accident
David Muzio, Northeast Regional Office
National Transportation Safety Board

Corporate Aircraft Accident
Steve Demko, Northeast Regional Office
National Transportation Safety Board

Mid-Air Collision Accident
Pam Sullivan, North Central Regional Office
National Transportation Safety Board

Closing Remarks

P R O C E E D I N G S

(8:04 a.m.)

MR. JONES: Good morning, everyone. Welcome to Day 2 of our symposium.

The first thing I'd like to do is thank you very much for attending the banquet. I think that was quite a festivity, and the food was very good, and I don't know how you got so motivated to come, but we really appreciate your time there last night.

We're going to spend about 10 minutes this morning. We've deviated from the schedule just a little bit. Roger Shaw, who is the Spacial Disorientation Demonstrator, will give us a 10-minute presentation on the Spacial Disorientation Trainer, and followed by that, we'll be doing the panel that will be the first one on our agenda for today.

We plan to conclude this session around 1:00, hopefully earlier, today, so you can meet your traveling needs back home.

I've talked to Roger about the Spacial Disorientation Device, and he tells me that approximately about 45 people have gone through the trainer and are having a good time. I wish I had the opportunity to go through it. I've been busy up front here, but I understand it's a great opportunity, and if you have a chance during the next few hours, please partake in that. I think you'll get a lot out of that.

Having said that, I'd like to introduce you to Roger, and he's got a kind of interesting bio here, which I'll try to read.

Roger Shaw is currently the team leader at the Airman Education Program at the Aeromedical Education Division of the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma.

The Airman Education Program supports the National Aviation Safety Prevention Program and teaches aviation physiology, human factors and survival courses.

Mr. Shaw earned a Master's of Science Degree in Education from Portland State University and a Master's in Aeronautical Science from Embry Riddle Aeronautical University.

He's a retired U.S. Air Force pilot with over 3,000 hours in the C-7 Caribou, B-52 bombers, and rescue helicopters. Mr. Shaw has been married to the same woman for 31 years. They have had seven children, 25 cars and 12 dogs. Where is Roger at? Is Roger around here? Okay. There you are. 25 cars and 12 dogs?

MR. SHAW: That's over the period of time.

MR. JONES: Okay. Well, please join me in welcoming Roger Shaw.

(Applause)

Spacial Disorientation Device Demonstration

MR. SHAW: Yeah. Good morning. You weren't supposed to read that last paragraph. I usually only read that when I talk about stress and fatigue because I'm a real good winner on that. On aeronautical decision-making, they say, well, how did you end up with seven kids? I don't want to talk to you about that this morning.

I want to tell you about education and some of the things that went on last night. I'm glad we didn't-my wife is an English major, and she's always asking me, say, "Well, how do you talk and teach physiology to pilots because your English is so bad, your sentence structures are terrible?" I say, "Well, I always talk to pilots. They understand, don't have a problem."

Well, that forum last night was not the average pilot. So, she was smirking when I was leaving Norm and going "Now what are you going to do?" So, I'm going to show a lot of pictures and keep it simple on the KISS method, keep it simple, stupid.

So, I'm going to talk to you this morning about some education. You don't fly these things, do you? Is that showing up on there? Where's my man? I was supposed to hit that right button only, right? As a pilot, if this thing doesn't work, you call maintenance, because I don't take off with it, I'll tell you.

What we're going to talk about this morning is a little spacial disorientation, and I've got 10 minutes to tell you why I think education-last night, they touched on pilot education, and I think we got some issues coming, and I want to try to get across to you spacial disorientation and give you some definitions, but we started out and the reason we talked about it and the reason you're all here is because we don't want to take this aircraft and turn it into this aircraft, okay, and that's why we're really here, to learn to get away from that, and this pilot took off in Oklahoma City in `92 in 00 weather, as you see up there.

He was a non-instrument-rated pilot in the left seat, and look at the instrument-rated pilot in the right that's supposed to be monitoring this flight. Where's he at? He's down with his head down looking at the LORAN set, and if you go in that gyro, you understand if we mess up two of those three semi-circuit canals, you've got an issue when it comes to IFR flying.

So, we're concerned about that. We started off in this type of aircraft. We mentioned it last night. The congressman did. We're stepping up. The hardware's getting better. The software's getting better. The environment's not changing. Is the human being changing any? Well, if we educate them, maybe they are, but we're not so sure.

What if we step them up into a flight like this? We're talking a pretty high-performance aircraft. So, we're saying how are we going to train this guy in physiology, not the technical flying part. Does he understand the physiology that's happening to the body when he steps himself from a glider up to a high-performance aircraft, getting around 25,000 feet, and that's our concern because under high periods of stress, you don't rise to occasion, even though we like to think of that in America, but you get to the level of your proficiency.

So, how proficient are you in that aircraft to fly instruments, and how proficient are you in understanding what's happening to the body, and we've got some issues there in the education area that I think we need to look at.

I started flying this aircraft in 1970. I got 40 hours. By the time I got to those airplanes right there, I had 40 hours of aviation physiology. 24 of them were exactly dealing with the body and the aviation physiology, and the subjects we talked about were the orientation perception problems that we deal with when we talk disorientation.

The vision, inner ear. See the pant. We've got some feeling of what auditory systems give you as far as help in that business in the cockpit.

We understood the eye. We understood the problems with it as far as visual illusions. We didn't understand the tension processing of the limits that you can deal with when you look at that instrument panel, and you're dealing with what kind of information you can process to overcome the senses when you get into an IFR condition.

We got scared enough to understand there was a problem, but we really didn't understand the tension processing, and I got involved in that at the last couple of years in the Air Force with F-16/F-15 folks down south because they have so much to process on the computer, and there's a lot of new pilots that are stepping in from low-performance aircraft into a high-performance aircraft that don't understand the processing of all that information is limited, and they don't know how to prioritize it, and you really get into a single-seat CRM at that point, but we're not going to deal with that.

We understood the middle ear. We understood the semi-circuit canals, yaw, pitch and roll, relationship to that aircraft, and how we flew it when we didn't have visual cues to fly the aircraft.

Did we understand the middle ear? I can tell you when we came out of there, we didn't understand it. We knew the problems that happened to it, but we didn't even with 24 hours of physiology have a grip on what's really happening in the middle ear. We just knew, hey, if you do this, you got a problem.

So, education's got to go-with 24 hours, if you're not getting it, we've got some issues because we've got pilots flying that don't understand the limits of that middle ear. They really don't understand landing illusions. Okay. We've got some issues, whether it's over water, depth perception and those issues in there, black hole. There's a whole bunch of issues in there, and, boy, talk about night flying.

In the military, we really have some issues with night flying because you're really stepping up the speed. Well, you do the same thing in general aviation. As you step up in the machine side of the world, the environment doesn't change, but the physiology of the body stays the same, and we have a problem with that because the general aviation pilot doesn't understand that.

It's really nice to go flying at night because it's really pretty, and it looks good, but we need to educate better what the problems are at night, and we've got some issues with that because night VFR is really-if you go our west in Oklahoma on a nice starry night, and you've got some light cities out there, where's the horizon? We don't know where it's at, and if you don't know how to look at that instrument and fly that, then you've got some problems in there.

If we educate the pilots with this area and that's what our job is in the aviation physiology business, we run a class in Oklahoma City. We give you six hours of physiology in a chamber flight at 25,000 feet.

How many people a year do we reach? 2,000. How many pilots are there? 680, going up over 700,000. We got pilots. We go out to Oshkosh. We go to Sun and Fun. Somebody comes up and starts talking to us about hypoxia. They start talking to us about these different subjects, and you know that they don't really have a grip, but they want to learn. So, we've got some issues on how to get that out there.

I'm not going to touch on the survival stuff and the human factor issues, but we have put together 13 tapes, and this is the reason I stand here, because I wanted to tell you about them, and, so, we can get some interaction.

If you need this kind of stuff, and you leave this building without talking to me or getting some interaction as far as educational capability and physiology, you're missing out on a good deal.

These tapes are 15 minutes long max. We have one of them out there on the tv. It's Spacial D, Part 2. Those tapes are set up to give you the shoe leather stuff on whatever subject's listed up there. So, if you have a CFI out there that says, listen, I want you to know what hypoxia is, he can take that hypoxia tape that's 12 minutes long, plug it in on a rainy day, and that student then can look at that hypoxia tape, get a grip on what hypoxia is, and then follow up with some didactic material.

We're trying to put it out for the safety program managers. We're trying to get these tapes out in the flight standards district offices, but we're trying to get it on the Internet. We've just developed them, and one of the problems is getting it out there, but they're out there for educational purposes, and I want you to-if you have any need with this, you talk to me, and you send me a letter, and I'm going to get you some tapes because we've got to get from here out, and this is where this is going to help pilots get better.

Then when we can start talking about risk assessment because up there in long-term memory, we got some issues with CFIs don't have enough hours, and up in long-term memory, if there's nothing up there stored in there on what's happening to the middle ear, what's happening to the visual cues, what's happening to the processing of information in that cockpit, then you can't make someone make a judgment and say, well, we need to look at aeronautical decision-making. We can't look at that to say the guy really-the person really knew what was going on educational-wise and academically, and what's happening to the body.

If we know that's happening, then we get back down to aeronautical decision-making and some of the ego problems we have with pilots.

When I started teaching-I won't get into that about egos because that might touch somebody's toe. The difference between long-term memory up here and short-term memory is I'm flying with a guy up there in Oklahoma, and we're about five miles from a thunderstorm, and this gentleman's just going bonkers. He wants to move out, and I'm going, "Well, there's no problem here. I don't have a problem with that. I've flown this close to thunderhead on this side of it, no problem."

But up there, long-term memory, what's this guy got a picture of? Store deck down there. About a year ago, he was about this distance from that storm, and what happened to him? He got some of that Oklahoma rain that got hard. He got hailed on, got his prop all bent up. So, up in long-term memory up there, he's got a picture up there from what he scratching on short-term memory, and he's got a lot of stress on that risk assessment, where we're at in that picture. I don't have that stress.

So, there's where you run into some issues, and what we're trying to do in education is get up there in long-term memory the academic subjects so they understand academically, get the CFIs qualified up there so they understand or have the didactic material to at least teach that, so that the pilot has something in long-term memory to measure the physiology of the body. Then he can make a good decision because he understands the environment and the times and conditions that you're after.

The second paragraph. What we'd like every pilot to do is understand the times and conditions that are conducive to giving you spacial disorientation, and if they have the capability then to do that, then you have a judgment error.

We like to get back to the human factor with 80 percent. We'd like to get back to just dealing with the gentleman or the person made a judgment error, but they had the academic back-up at least to back up that judgment error, and that's really important, and that's what we're doing in education, trying to get that out.

This is what I'm going to end on because I don't want to take away from the rest of the panel here today. If we lose a pilot, we got a problem because we haven't cross-talked either, you know, from pilot-to-pilot or if you're a contemporary, you need to tell somebody about that, and that's what this meeting is all about, try to share the assets so that we can get out there, and in the business of aviation physiology, that's what we would like to do.

We have some global survival stuff we're developing in human factors, but let's get back to physiology because we have airplanes that are going higher and faster, and you can put a pressurized aircraft 20,000, we got people in those aircraft, they do not understand what decompression sickness is.

We've had some letters with people that have DCS. They don't even know what it means because they're all of a sudden shooting themselves up unpressurized 20,000 feet, and, bam, they get DCS, and they don't know what the heck it is.

So, we have a job to do, and that's what this group is all about, educating the pilots. We heard about it last night. We have a lot of pilots that are going to have to funnel in. They used to come from the military. They get 24 hours of physiology. They're coming now from schools and different places. We have to make sure that they've got the understanding and academic background to make a good decision when they start that aircraft on.

Anything else? That's 10 minutes? Where you at, Dennis? Any questions?

(No response)

MR. SHAW: Please come see us, ride the gyro. No one's ever been sick in it. We can fix it so you won't get sick, and we have educational material, and if you have any need for any of this stuff we have, we'd like to spread the word out on how to get it out to you, and we'd be glad to help you out. I'm done.

(Applause)

MR. JONES: Thank you, Roger. We're going to start our next panel now, but I did want to share a few things with you about the accident investigation business.

Quite often, people think that everything we do is traumatic, and trust me, we do see a lot of terrible things in our work, but there are a lot of humorous things that we see during the course of our investigations, and before we start our next panel, I wanted to share one that I experienced a few years ago.

This happened on Long Island, and I think Phil was with us here from Long Island. He can confirm this accident. I'm not making this up. We had a small airplane that took off at night from a grass field, and as it was going down the runway, something appeared in front of the airplane. The pilot thought it may have been a deer. So, he pulled back on the control and tried to out-climb whatever it was.

Unfortunately, he wasn't able to out-climb it, and the main gear hit whatever it was, and he felt the thump, but it didn't damage the airplane. He was able to continue and climb up in the air, but he circled the airport-I see you're smiling, Phil. He circled the airport to look down to see what it was that he had hit, but he couldn't tell because it was too dark.

Well, he continued on to his destination airport, which was only a few miles away. Upon landing there, there was a phone call waiting for him where he was to be advised of what he had hit. Well, he had learned that he had hit a person. There was a person on the runway. He hit the person, and the person had critical injuries.

Well, the question is, what was this person doing on the runway at night? Well, it turned out that this person was mooning the airplane, and guess what the tire hit?

Well, at that time, on our accident report forms, there was a portion of it for night accidents. We had to determine, to note whether it was a full moon or night. So, I said in this particular situation, we're going to have to ask him.

Well, what a relevant seque to our next panel. Our next panel is titled simply "In-Flight Loss of Control", and the presenter will be David Muzio.

David Muzio works in our Parsippany, New Jersey, office, and we recruited him from California, and we didn't know how easy that was going to be, because some people have a problem with going from the West Coast, particularly to New Jersey, but he's acclimated quite well. In fact, he even says New Josey now very, very well.

So, please join me in welcoming David Muzio.

(Applause)

In-Flight Loss of Control Accident

MR. MUZIO: Thank you very much, Dennis. As Dennis said, my name is David Muzio, and I'm from the Northeast Regional Office.

Today, I'll be presenting an in-flight loss of control that involved a Beechcraft S-35 in Newark, New Jersey, on November 26^th, 1999.

As a result of this accident, the pilot and two passengers received fatal injuries. In addition, two individuals on the ground received serious injuries and 25 received minor injuries.

Later on in my presentation, I'll go over the actual damage to some buildings and vehicles at the site.

To give you a quick overview of the accident or the history of flight, the pilot departed on an instrument flight plan in instrument conditions. He contacted Departure Control and then reported a gyro problem.

The airplane continued to fly for approximately two minutes after the pilot reported the problem, and then heading altitude and air speed continued to change, and the pilot was not able to comply with any ATC instructions.

Now we're going to listen to a copy of the ATC communications tape, and I want to add this is not an exact duplication of the tape. A gentleman in our CVR Lab was nice enough to edit out some of the conversations or some of the transmissions that did not relate to the accident airplane, and he also added in some delays where there was a rapid exchange of communication.

So, if you could go ahead and start that.

(Audio recording)

MR. MUZIO: Can you stop it up there because that's definitely not coming through very well? Go ahead and start it again, would you, please?

(Audio recording)

MR. MUZIO: That was the last transmission recorded from the accident airplane.

The chart that's up on the screen right now is from a vehicle performance study done by Dr. Bolde here at the Safety Board.

As you can see, the chart portrays after 1,100 feet, after the aircraft reached 1,100 feet, that the heading continued to vary all the way to the last radar contact or until radar contact was lost.

This chart also created by Dr. Bolde shows that in the final moments of flight, the airplane's rate of descent exceeded 10,000 feet per minute.

At the time of the accident, Newark International Airport, which is approximately about two miles to the southeast of the accident site, reported two and a half miles of visibility and a ceiling of 1,300 feet.

If you look at the area just to the right of where the fire department is deploying water, there's some bricks missing from the top of the roof. That's where the right wing initially or made initial impact. After that, the debris path transitioned from the right side of a residential street over to the left side, crossed a street, went through a parking lot for a fast-food restaurant, crossed another street and came to a stop. The overall distance was approximately 760 feet.

To give you an overview of the damage, approximately 18 buildings received varying degrees of damage. The damage ranged from broken windows to structural. Three of the buildings were actually condemned and then demolished.

The City of Newark estimated the property damage to be $1,150,000. In addition, approximately eight automobiles were damaged with four of them being destroyed.

This was the first vehicle hit. As you can see, it really shows how much energy the airplane had developed during the descent.

There's an interesting story behind this photograph. The driver of this car had just made a right turn and saw the airplane impact the building. He got out of his car and was able to run fast enough to avoid the debris that was proceeding towards him at a high rate of speed.

This picture was taken about 400 feet from the accident site. It's looking south. It's the same car that the driver was able to escape from.

Now, the picture on the right here depicts the main wreckage area, which was comprised about 30 percent of the overall mass of the airplane and was less than two and a half feet high. We looked at the fracture surfaces for both wings and the tail section. We didn't identify any preimpact failures. Actually, all the fractures were consistent with overload.

Flight control continuity was verified for approximately 90 percent of the airplane, and during our examination of the flight control system, we identified no preimpact failures or malfunctions.

Both propeller blades had separated from the propeller hub, and both displayed scratching and leading edge gouging. Both blades were broken into two sections, and the fractured surfaces were consistent with overload.

On the engine, all six cylinders displayed evidence of impact damage, and approximately 80 percent of the crank case had been compromised. In addition, our on-scene examination of the engine revealed no pre-impact failures or malfunctions.

Both the standby and the primary vacuum pumps had separated from their respective engine mounts, and an external and internal examination of both these units was performed on scene, and no preimpact failures were identified. Continuity of the vacuum system plumbing could not be verified because of impact damage to the aircraft.

The pilot held an airline transport pilot certificate with an airplane single engine land rating. In addition, he held a commercial pilot certificate with ratings for airplane multiengine land, single engine sea, and glider.

The pilot had approximately 5,800 hours of total flight experience with a 120 hours of that being in the last six months. In addition, he had 1,308 hours of actual instrument experience.

Now, we recovered three gyros and three gyro housings, meaning three rotors. I've got four of them displayed up here on the slide. In the upper left-hand corner is the HSI gyro housing, and on that, our Materials Lab identified static marks, consistent with no rotation.

In the upper right-hand corner is the HSI rotor itself. No rotational scarring was identified on that. In the lower left-hand corner is the attitude indicator gyro housing, and the lab was able to identify rotational scarring with that component.

In the lower right-hand corner is the turn coordinator. Now, the turn coordinator housing was not recovered, but we did recover the rotor, and no rotational scarring was found on that item either.

Toxological test was performed on the pilot revealed 3.239 micrograms per milliliter of Butalbital in the pilot's muscle tissue. Butalbital, along with aspirin and caffeine, are combined to make Fiorinal, which is used for the relief of symptoms of complex tension headaches.

A special study conducted by the FAA Toxicology and Accident Research Laboratory in Oklahoma City, Oklahoma, compared muscle and blood levels of Butalbital in post-mortem specimens. The laboratory reported that blood levels were higher than muscle levels in every individual tested, on the average 1.52 times higher.

According to the pilot's pharmacy records, the pilot was dispensed over 6,000 tablets of Fiorinal or the generic equivalent from 1992 to October 1999, with 800 of that being in the last year.

According to the Physician's Desk Reference, the most frequent adverse reaction to Fiorinal is drowsiness and dizziness.

The pilot received a non-FAA medical examination on February 16^th, 1976. During the examination, it was noted that he suffered from migraine headaches, and that he was using Fiorinal to control the pain.

Over the next several years, the pilot continued to be examined for migraine headaches, and his Fiorinal usage continued to increase.

On all the pilot's FAA medical applications, he stated that he was not taking any prescription or non-prescription medication and had never suffered from severe or frequent headaches.

According to the October 1999 FAA Guide for Aviation Medical Examiners, a history or presence of migraine headaches, migraine-equivalent, cluster headaches, chronic tension headaches, or conversion headaches would preclude the issuance of a medical certificate.

Go over a few findings here. It was a Part 91 personal IFR flight. IMC prevailed for the flight. The pilot reported a gyro problem. There was a high rate of descent prior to impact. Flight control continuity was verified for approximately 90 percent of the airplane. Static marks on the HSI gyro housing were found.

The pilot had 1,308 hours of IMC flight experience. The pilot tested positive for Bitalbital. Side effects of Bitalbital was drowsiness and dizziness.

The National Transportation Safety Board determined that the probable cause of this accident was the pilot's failure to maintain aircraft control. Factors in the accident were failure of the horizontal situation indicator for undetermined reasons, and the pilot's use of inappropriate medication.

That will conclude this portion of the presentation. I'm going to hand it over to the moderator now.

(Applause)

MR. COLLINS: Okay. That was an excellent presentation of the type accident that really should never happen but that does.

The loss of control by an instrument pilot in instrument meteorological conditions is something we're trained to avoid, but when you look at the accidents themselves, about one-half of all the IFR and IMC accidents are loss of control. So, that makes it a big factor.

Usually when we look at loss of control accidents, we can identify a distraction that led to the loss of control. In this case, it was the failure of one or more instruments, it seems.

The majority of the distractions, though, when we look at the accident reports, the biggest one in 1995 was ice. Ice was the distraction in eight out of 29 loss of control accidents that year, and these weren't the typical ice accidents, you know, where you envision an aircraft festooned with ice, you know, descending slowly into a mountainside.

Actually, the ice-most of the airplanes that were lost in the ice accidents were airplanes that probably had de-icing equipment, and what happened was the ice was the distraction that led the pilot to lose control of the airplane while he was maneuvering.

There were four twins in that year that were lost because of engine problems. The engine failure itself, I mean, a twin-engine airplane flying along at cruise, if the pilot knows what he's doing, he should be able to lose an engine and, you know, fly to an airport and land.

But that's still a big distraction, and when you're flying an airplane in clouds, maybe bumpy clouds, and you're dealing with an engine failure, and you have to maintain control of the airplane, it apparently just doesn't work very well. So, that's a big distraction.

Two singles were lost that year. Both of those were systems failures, which systems failures is similar to instrument failures in providing a major distraction, and systems failures-we were talking about it this morning.

In most light airplane training, the way you simulate a systems failure is to put covers over some of the instruments, which doesn't really simulate a systems failure because you're actually making it easier for the person, not harder, when you cover the offending instruments, and then he sees exactly what he's got left to fly with, and he sees exactly what is correct, and, so, he can transition to that.

In the actual failure, the pilot is looking and trying to decide which one is correct, and a lot of us have put standby instruments in our airplanes, but we still have to develop the ability to discern which instrument's right and which one's wrong, and in the case where you've only got, for example, a turn coordinator and an artificial horizon, you don't have any best two out of three.

Three airplanes were lost that year in thunderstorms, which I think any pilot would agree that that is a really major distraction and for various other reasons.

Most of the airplanes that are lost in loss of control accidents are retractables, as was the airplane at Newark, and when I was looking at this, I came upon something I thought was unusual because, you know, we've often said in airplanes that people are what they fly, and pilot personality has a lot to do with it.

Well, in this year, fully half of the airplanes lost in loss of control accidents had vanity N numbers on them, ending in two letters, which in most cases, at least in the case of my airplane, it's my initials. What that has to do with it, I don't really know.

One thing I've learned in looking and studying accident histories is the simpler the airplane is, the better the accident rate it has. The Cessna 172, for example, has got a much, much better accident record than do any of the retractables and so does the Cessna 182.

Among the retractables, the Mooney has got the lowest fatal accident rate that I've calculated, and the reason for that is because it's got very strong spiral stability. It's one of the strongest spiral-stable airplanes that we've got.

Another reason that the fixed-gear singles do better is again we get back to distractions. There are less distractions.

When I think about accidents like this, I think about two in particular that outline the problem. Both pilots were friends of Flying Magazine. One of them was last year, the obvious one, it was John Kennedy, whose magazine "George" is published by the same company that publishes Flying, and our flying editor, Mac McClellan, was-advised Kennedy when he bought his Skylane and then when he bought his Saratoga.

You know, that was a case-it was a relatively low-time private pilot, flying at night, a hazy night. The weather wasn't all that bad, and he lost control of the airplane for undetermined reasons.

There was a lot of speculation right after the accident, almost endless speculation, about what happened, and when the excellent report finally came out on the subject, a lot of people backpedaled. I mean, you know, this pilot had had a lot of training. He was on his way to his instrument rating, and one person even came up with what I thought was an interesting observation.

They said that they thought he had had too much dual instruction, that nobody could have ever really learned anything having that much dual instruction, and I thought about that, and then I thought, well, I guess what that means is that no first officer on an airline should ever become captain because he hadn't flown the airplane solo enough, and-but, I mean, I think you look at that.

He had trained at the premiere training school, and he had really just done all the things that we tell people they ought to do to be able to fly more safely.

The other one that we think about was another friend of ours. He was flying a Cessna 340 at night again, and he was IFR at 21,000 feet, and he reported he had a problem, subsequently lost control of the airplane, and I know Dave mentioned that the Bonanza was descending at 10,000 feet a minute, which a lot of pilots, when you talk to them about this, they don't believe an airplane can come down that fast.

Well, in the case of the 340, from what I was able to glean from the accident report, it actually lost 16,000 feet in less than one minute. So, when control of an airplane is lost, I mean, once it's lost, it's gone. The key is to staying in control.

In both those cases, you know, a pilot was killed along with his wife, in the case of Kennedy his sister-in-law, and, you know, they're just the kind of accidents you look at, and you think, you know, how do we prevent these, and that's a tough question.

But I'm very much like John King. He said yesterday, you know, that we fail as an industry and as government to educate people on the risks in aviation. I mean, you know, the whole emphasis is on, you know, can you stay within 50 feet or, you know, five knots or whatever, and there's no emphasis on risks and risk management, and as an example, I would like to-of how poorly we do on this, I would like to use night flying for an example because those two accidents I just mentioned happened at night.

It's impossible to come up with an exact number on accidents, you know, accident rates because we don't know how many hours people fly. We don't know how many hours they fly at night or-I mean, all of the hour numbers are approximate.

But anyway you slice it, if you look at flying at night in either marginal VFR conditions or in IFR conditions on IFR flight plan, the fatal accident rate seems to be at least three times worse at night than it is in the day time, and then we look at what we do about that.

From a regulation standpoint, all you have to do to be able to fly IFR at night or marginal VFR is to have made three take-offs and landings at night in the past 90 days, which doesn't really address the problem.

There's no night IFR training required, and a lot of people get an instrument rating without ever flying at night. For marginal VFR, you know, I mean, a pilot, when he gets his private license, we finally did require some night flying, but it can all be on a clear night with a full moon.

Then when we look at this, and we look at the bad accident rate, and we consider that a pilot can get an instrument rating with as little as 75 hours of flying time in an airplane, and that he can, with that instrument rating, he's perfectly legal to go on a dark and stormy night to Washington National Airport with passengers, and that doesn't make a lot of sense, and I think as we go on this morning, we're going to have some interesting presentations, and the first one is going to be quite interesting.

It's Dr. Dennis Canfield, who's the Manager of the Toxicology and Accident Research Laboratory of the FAA's Civil Aeromedical Institute. He's going to talk to us a little bit about that part of the subject.

Dr. Canfield.

DR. CANFIELD: Well, I guess everyone knows my place here because I'm the one who signs all the reports that go out to the different agencies. So, everyone probably knows my name, and for now, you're going to get an image that you can recognize when you talk to me on the phone.

It's my job here today to talk about the drugs that were found in this pilot's body at the time of his death, at the time of the crash, and I do want to emphasize the fact that the drug being used was something that would be extremely dangerous for a pilot to be engaged in, and that's the barbituric acids which are sedating in nature.

They also are intoxicating, and they have effects very similar to alcohol. So, we have to be aware of that, but the other thing which is very important here is the fact that the disease itself is incapacitating.

Migraine headaches can be extremely incapacitating and could make it impossible for the pilot to operate his aircraft. As a matter of fact, I got some statistics off the Internet. 23 to 25 million Americans suffer from migraine headaches. This results in 64 million work days lost in the United States due to this one disease.

Obviously the disease is incapacitating. These people have lost work and were unable to perform their duties. So, we had a multiple problem here. We had a problem with the drug itself, which is incapacitating, and then we also have the problem of the disease, which is incapacitating.

The other problem I see in this case is that we have-we know for a fact that he started some time before 1976 taking this drug, and he was still taking it in 1999. Not only was he taking it, but his use of the drug had increased. This is clear signs of tolerance and addiction. So, we now have a pilot who is addicted and has created a tolerance to it.

The one thing that is a problem, and I'm not sure what the answers are, and I'm not sure I can help you in this situation, is the pilots are on an honor system. The honor system being that when they come to their AME, they're required to report to the FAA their medical conditions and the drugs that they're taking.

If they fail to do that, then there's no way that Medical Certification can take any actions to prevent them from flying their plane.

We conducted some research several years ago, I guess about five or six years ago, where we looked at pilots who were taking drugs used for the medical conditions which could cause incapacitation of the pilot, and what we were really looking for was how many of them reported this illness to their AME, and I was doing this for the reason that I kept getting calls from NTSB, and they would say to me, "Dr. Canfield, your lab made a mistake", and I'd say-well, you know, obviously that gets my attention. I'm a little bit concerned when somebody says my lab has made a mistake.

So, I'd say, "Well, what's the problem?", and he'd say, "Well, you found a drug in this pilot, but there's no record by his AME that he was ever taking the drug or that he ever suffered from any medical condition." I'd say, "Well, you need to check with his personal physician because you might find that he did take the drug in fact."

In every case, they always went back, checked the medical history and found that the person was in fact taking the drug. Not only were they taking the drug, more than likely, either the drug or the medical condition was a factor in that accident. So, obviously we need to be looking very carefully at these issues.

But in the study we did, there were 48 pilots who were suffering from some neurological disease, psychiatric disease, or cardiovascular disease, that may have incapacitated the pilot, and sadly, I have to say that only three of them had reported their medical conditions to the FAA. The other pilots did not report it.

Now, I will say that in many of the cases, if the pilots had reported it, because they're suffering from seizures, I don't know about you, but I don't want to step in a plane with somebody suffering from seizures, but these pilots felt like they could still fly planes with seizures. They didn't report it obviously because they felt they would be disqualified and more than likely they would have.

I have to say, though, many of the cardio-vascular problems that were present in these pilots would have probably received certification if they had applied. So, these are some of the issues we face here.

One of the other things I want to point out here, and this is what I call the big lie, the big lie is-and I've heard pilots tell me this. "I've used alcohol and flown planes, had no problems. I've used a drug, flown the plane, had no problems."

I can tell you from the research that's been done in regards to pilots, as long as the pilot is flying a routine flight, where everything is by, you know-he doesn't even know he's doing it. He automatically flies the plane. Everything goes smoothly. You're right. You can do that.

The minute that an emergency occurs in that aircraft, where you no longer are flying it by instinct any more, now you have to rely on your mental ability to react to that aircraft's problem, you are in serious problems-you have a serious problem, and all research has shown that your ability to react to those have been seriously impaired.

As a matter of fact, in the case of alcohol, there was a study done which showed that of the pilots that were put into a flight simulator with very low amounts of alcohol and subjected to some problem with the aircraft that more than likely would have caused a crash, only 11 percent of them corrected it. The other 89 percent would have crashed the airplane.

If they were just put in the plane, and they were just to fly it from one place to another, with no problems, gyros are fine, flaps are not having a problem, there's no problem with the aircraft, they could fly it, and there would be no problems.

So, the point I'm trying to make is don't believe the big lie, and that is, that you can fly that airplane with drugs or even a medical condition that you think you're fine with, because you've been able to do it for so many years.

The truth of the matter is, is if you get into an emergency situation, I doubt you're going to survive it. I'm going to see you in a box some day, and I don't want to see any of you in a box. That's the way I see people that are pilots. I see you in a box, and that's not what I want to see any more. I want to see the end of that.

What I really want to do now is, you know, -- is this an isolated incident? Is this the only case of drugs or medical conditions that we have to face, that the NTSB has to deal with on a daily basis? The rest of this talk has to deal with that particular issue.

Let me see here. I'm not going to spend any time on this. This is just the fact of what we have to do in our job. Our job is to make sure you guys are physically able to fly that airplane when you get in it. Medically, you're ready to go.

Also, the NTSB has a great interest in the fact that they want to know if you're using drugs or if you have some problem that may have caused this accident, and they actually had a safety recommendation which now has been closed satisfactorily.

Now, what we've done is we've done two studies in our laboratory. One of them started in 1989 to 1993, and then in 1994 to 1998, where we looked at the number of pilots that had drugs in them, and what proportion of the pilots had drugs in them. Basically, this will-this slide tells us a little bit about what we found.

Now, when it says C1, what we're talking about there is Controlled Dangerous Substances, Schedule 1. Now, in your handout, you actually have the paper that was published on this subject, and it has a little legend below it, this one doesn't, to tell you what each one of those categories address, and you can see from 1989 to 1993, we had about a 4-percent positive rate for controlled dangerous substances, marijuana, cocaine, which is-I consider to be fairly high.

Then we look at the prescription-the next class would be the Controlled Dangerous Substances, Schedules 3 through 5. Those are things like tranquilizers, antidepressants, drugs like that, and here we had a very low incident rate, and we'll talk about that a little bit later, and then prescription drugs, we're talking about cardiovascular medications, neurological medications, again very low rate during that five-year period.

Over-the-counter drugs, about 17 percent of the pilots were found with some kind of-and to me, if you want the truth, I consider the over-the-counter drugs to be a bigger danger to you than the controlled dangerous substances because I don't believe, especially in this group of people, that many of you are in fact using those kind of substances, but I wouldn't be surprised if you were using some common over-the-counter antihistamine which could be extremely dangerous.

A good example of that would be diphenhydramine. Diphenhydramine is a drug which you can buy, Benadryl, over the counter, and it has effects which are actually more severe than alcohol. So, if you were to take that drug and fly your airplane, you might-you can fly it. I'm not saying you can't, in the sense of you can't, FAA-wise. We say you shouldn't fly your plane when using Benadryl, but you could probably safely get from one place to the other, assuming you don't get into a situation like this pilot did, and then the other thing you have to remember about these drugs is the problem gets more severe when you're multi-tasking.

So, here we have air traffic hollering at this guy, you know, change your heading, change your altitude, and he's got a problem he's trying to deal with, and he's got a divided attention problem. These drugs, you can't do that. You can't divide your attention. You have to focus on one thing, if you're going to survive.

So, the best thing maybe is to just turn it off or at least tell the man, which I thought was surprising, just declare an emergency and tell air traffic, you know, clear the traffic, I can't control this aircraft, and I'm going to have to be in control and switch it off and move on. I'm not sure that's FAA-approved, but I'm not speaking for the FAA there, please.

I'm just saying that you really-when you

-- especially if you've got a drug on board-if you don't have a drug on board, you shouldn't have any problem. You should be able to deal with multi-tasking without any problem, but if you've got a drug, you cannot do it. It's impossible.

Now let's look at the next five years here, and you'll see that we've had a slight increase in abused drugs from a 4 percent to a 5 percent. We've had a jump from 1.5 percent to 3 percent for the Schedules 3 through 5, which are the antidepressant drugs.

The thing here is I don't think there's really an increase there. I think that that's caused by the fact that we are constantly improving our ability to detect these drugs, and I think that the increase actually is the fact that we've just improved our ability to see them.

The same thing's true of prescription drugs. We're now up from 6 percent to 14 percent. We have significantly improved our ability to detect cardio-vascular drugs. My boss came to me in 1995 and said, "I know that there's more cardiovascular drugs out there than you guys are seeing", he says, "I want you to find a way of doing that." Of course, I sent him a bill for a $150,000 and said, okay, I'll do it, and he gave me the money, and, so, I bought the equipment, and now we can see cardiovascular drugs, and, so, that's where the increase occurred in there.

Over-the-counter drugs were up to 18 percent. Alcohols are staying about the same. The only thing you have to be aware of in regards to looking at those alcohol numbers is that that's .04 percent or higher, which is a violation of FAA regulations. That's why we include them, but many of those are post-mortem alcohol.

We don't separate them out. That's just 7 percent of the people that had a .04 percent or higher. So, the actual rate is, I would say, much lower than that. I would say the actual rate is probably around 4 percent probably, about half that number is from ingestion of alcohol and not post-mortem alcohol.

I hope you're going to keep me on track now and not let me go over my 10 minutes. You got a hook on me? Okay. Good. Thank you. Because I'm noted for doing that.

Let's see. Oh, this is breaking it out by the type of operation, whether they were flying Part 91, and the interesting thing here is if you look at Part 121, you'll see that there were six accidents, and none of the accidents involved the use of any kind of drugs at all, any drugs or alcohol was found.

The problem we have is there's just so few accidents, six accidents, I wouldn't want to put any statistical significance to this particular number. You can see that the most accidents that we have are in the Part 91 pilots.

Now, this breaks it down by whether or not the pilot has a Class 1 medical and an air transport pilot certificate, and in this case, if you look at that, these are abused drugs. There are the ones that-not all of them, but these are the ones that you would be tested for if you were under the random drug testing program, and I'm sure that many of the people in this room are subjected to random drug testing, and what you'll see is there was only one Class 1 air transport pilot that had morphine in him. He didn't have codeine morphine. He had morphine in him, and that morphine came from emergency medical treatment.

So, the reality of the situation is, is that none of the Class 1 air transport pilots had any abused drugs in them, abused drugs.

This just goes over the same thing. Now, in the study that we published in 1995, we did find about 2.8 percent of the Class 1 air transport pilots did have drugs that would be a violation of the random drug testing program.

Now, the question has to be, okay, in that first five-year period, we were just starting up the random drug testing program, and in the second period, it was pretty well established and operational.

Did the random drug testing program have any impact on changing this from a 2.8 percent positive rate to zero? I don't know the answer to that question. So, you don't have to ask me that.

I will say, though, that it does show that these people are doing the right things. They're not using those drugs. I would also say, though, that we did find some Class 1 air transport pilots who were using diphenhydramine. They were flying Part 91 now. They weren't flying in the Part 91 -- I mean Part 121 when they had the accident, but they did have diphenhydramine on board, and the Part 91 flights that they were taking, usually recreational flights.

I did-I just want to point out it's not-I don't think-it's in the paper, but there were a 131 Class 1 air transport pilots. So, this is a pretty representative sample. So, I think the numbers are real here. I think that we just have a good pilot population that are not using abused drugs, and, of course, our random drug testing program shows that, too, because if you look on the Internet, you'll see that the-that it's less than 1 percent of the pilots-I shouldn't say pilots because here, we're talking about anyone in a security-related position.

So, they're doing a good job, and I'm glad to hear-to see that. We've already talked about antihistamines and the problems associated with that. Most frequently found drug in fatal aviation accidents, and in many cases, it is either a factor or in my opinion the cause of the accident.

That's it. That's my talk. I really thank you for letting me come here and present my material, and hopefully I can help you some day in the future.

Thank you.

(Applause)

MR. COLLINS: Martha and John King have been leaders in aviation education for almost 30 years, and this morning, we have Martha King with us.

MS. KING: Thank you very much, Dick, and I think that Dennis's comments are very appropriate regarding the issue of medication.

One of the things that we have to talk about and think about is why didn't this pilot properly evaluate the risk of flying (a) with that medical condition, and (b) with the situation of taking the medication for it, and what happened is that the combination of that made him apparently vulnerable to an equipment failure, the failure of the HSI and perhaps of some other equipment.

This pilot appeared from the report to be cautious in some areas, in that he had intended an early morning departure which got delayed until almost noon, called Flight Service three or four times for weather updates. So, he was exercising some caution regarding the weather conditions, but he was not exercising appropriate caution regarding his medical condition, and one of the questions we have to answer is why not, and what are we as an industry failing to do in these situations to make people aware of it?

Airlines have lots of help in risk management with dispatchers and crew and capable aircraft and advanced systems, and although it's not listed on here, we can't really forget the function of the cockpit voice recorder perhaps in risk management.

General aviation pilots fly intrinsically much more risky situations, but they do it without the risk management help that airline pilots get from so many sources, and yet in our general aviation pilot training, and this has been mentioned before, we continue to focus on teaching physical skill and physical precision with the airplane with very little emphasis on the risk management which is really the primary job that a pilot should be focused on on the flight.

So, we need to give pilots a framework for analyzing that risk, controlling that risk, being able to evaluate it and work with it.

We need as an industry to think about our training programs and make sure that every training program includes both risk evaluation and risk management to the use of very realistic scenarios and easy-to-use tools, mnemonics, things that are going to help people when it becomes essentially a life and death kind of situation.

One of the new programs that is out, thanks to the FAA's Aviation Safety Program that we worked on with them, along with Ohio State University, is their personal minimums checklist with a mnemonic PAVE, and the four risk factors of a flight being the pilot, the aircraft, the environment and external pressures.

Clearly in this case, the primary risk factor was the pilot in terms of flying with both a disqualifying medical condition, the headaches, and also flying with unapproved medication.

In many cases, an additional risk factor, as you mentioned, Dick, is the night flying, although it wasn't a night flight in this particular case. The accident statistics that John and I use when we talk about-when we give safety talks is that about 10 percent of general aviation flying takes place at night, but about 50 percent of general aviation accidents occur at night. So, clearly night flying adds a very significant environmental issue to that.

How do we get people, how do we get pilots to properly evaluate how much risk they're taking, particularly in the issue of the medications, as you said, Dennis. They apparently just don't recognize how significant an impact it's going to have as far as their performance is concerned.

One of the things that does happen in general aviation is that in many of the training programs that we put pilots through, we don't train them adequately to use some of the major resources that we in general aviation do have, such as, for instance, the auto-pilot and the GPS.

A lot of flight instructors out there seem to have the attitude that to use these is a sissy thing to do or they have the attitude, well, it could fail, which clearly it could. So, don't use it, don't rely on it, don't worry about learning it.

Clearly, without question, any pilot who is instrument-rated must, has to be able to fly instruments without depending on the auto-pilot and without depending on a GPS.

On the other hand, if those resources are available to them in the airplane, in a life-threatening emergency, there are cases where those could save their life, and, so, we are really failing pilots if we don't give them the training, the resources, the background and the mindset to make use of these when those resources are available, and they have a significant problem in the aircraft.

For instance, on the auto-pilot, many auto-pilots will work in the wing-leveler mode without the heading indicator being operative. The pilot needs to know whether that's the case in their particular aircraft, and the 172, ours, it works using the turn coordinator. So, if you have a vacuum failure, lose the attitude indicator and the heading indicator, the auto-pilot will still work in the wing-leveler mode.

If you use it in conjunction with the GPS, the GPS can be giving you your heading indication. You could safely turn to and follow a desired track, even with vacuum system or HSI failure.

The GPS in the heading-in the track mode, it's great as a back-up heading indicator. When we train pilots to use GPS for approaches and en route, are we training them to think of this in an emergency situation as a potential back-up?

Many pilots, even when GPS is available in their airplane, and it's going to be more and more a resource of the future, aren't trained to do it and especially not for this.

One of the things that we did in the new Cessna program, which was somewhat controversial, is that we said when you're doing a partial panel situation and need a partial panel approach, one of the things to think about is if you're familiar with your GPS, and you have one in the aircraft, do a GPS approach as your partial panel approach if you have to do one to get down.

Because of the track information that the GPS gives you, it makes flying without a heading indicator and even without the attitude indicator, much, much easier than if you were trying to do a conventional VOR approach.

On most check rides, you are not allowed to use the auto-pilot. In my opinion, you should be required to demonstrate the use of the auto-pilot on a check ride. Again, you must be able to fly without it, but it can be a life-saver if you have an unusual situation, equipment failure, you have problems going on.

We don't have that attitude of not using the auto-pilot by the time we get up to turbine aircraft training and turbine aircraft flying. If you go to Flight Safety, Simuflight, any of the training operations for turbine aircraft, you are required to use the auto-pilot and demonstrate its use, and you get graded down as far as your cockpit resource management if you don't use it.

Why aren't we doing that as far as general aviation is concerned?

In many ways, our training can be thought of as being stuck in the `50s. In some ways, we focus on busy work in the cockpit, but not strategies for workload reduction. We cover up the heading indicator and attitude indicator, make people fly using only the magnetic compass turn coordinator and clock, but we don't teach them that the auto-pilot and the GPS are also viable resources when they've got this kind of an emergency equipment failure situation.

We need to make sure that pilots are trained in the GPS and the other great new avionics and equipment that are coming out for general aviation. We need to make sure that pilots have the mindset to use it, and we need to change the training focus in general aviation away from simply teaching physical skill and precision to a much heavier focus-I know we've started on it, but we're really not there yet-a much heavier focus on teaching risk management, and one way to do that is to make sure that we've taught pilots to use all their resources and think of all their resources when they do have a problem.

Thank you very much.

(Applause)

MR. COLLINS: Next, we'll hear from Dave Menconi, who's National Chief Flight Instructor for American Flyers.

MR. MENCONI: Thank you. As I talked to a number of people that attended the symposium, and they found out I was going to be talking a little bit about spacial disorientation, even with the vast experience everybody seemed to have, everybody had an episode or an event that they could relate to where they got in a situation where they had an overwhelming feel that they were losing control of the aircraft, even though all instruments were available.

They went back to the law of primacy and said, well, I better get on my flight instruments and concentrate on controlling this airplane. Concentrating on the attitude indicator for direct pitch and bank control is obviously the way we can get through these situations.

They're gyroscopic instruments. You have to have faith in those gyroscopic instruments, and in this accident, I think you can see that there was some real concern by the pilot whether these gyroscopic instruments were in fact accurate.

That's a terrible scenario to have to deal with because that's what's going to get you through something like this.

I'd like to just take a couple of minutes and talk about some of the training techniques that are used in general aviation today and some recommendations.

The information that pilots learn about spacial orientation begin at their most primary and basic level. The information that's included in the aeromedical fact for pilots talk about the inner ear, talk about delusions of flight that will result in spacial disorientation.

The experience that pilots get has been improving since the FAA has required that we are required now at the most basic level, at the private pilot level, to even include three hours of instrument flight in an airplane.

The problem is having a realistic experience in this area of spacial disorientation. I went through a lot of training myself and had over 5,000 hours of instruction given, but I didn't experience my first spacial disorientation till I had about 3,000 hours of experience. I thought I did, but I really didn't.

I didn't realize how overwhelming that could be. My situation was I was coming out of a climb, coming out on top of some towering cumulus clouds, and as I leveled off on the top of the clouds, I felt a little negative g, and I had a very strong sensation that I was in a free fall.

Again, the gyroscopic instruments were able to get me through that, direct indications of pitch and bank.

Let me put you through what most instructors see at the first indication of a pilot who is going into instrument conditions and trying to transition from visual flight to instrument flight.

They go in instrument conditions, and the first thing they do is recognize that I was told if I ever get in this situation, to get the heck out and get back where I was. So, the attempt to make a level turn is initiated.

Once the turn's initiated, the inner ear starts messing with you a little bit because if you don't transition and use your instrument for bank control, and you're using your body to determine if you are in a bank condition and turning flight, eventually that inner ear is going to lie to you and tell you you're not turning anymore.

The result is that the pilot will continue to increase the bank, increasing load factor, a resultant dive ensues, and if he's really good, he'll recognize the unusual attitude, recover from the unusual attitude, and by the time this is all finished, he's probably back on his heading that he originally was on when he entered the clouds.

This is why the old aviation-the old instructor's joke is when you enter clouds, let's get out of here with a 360-degree turn. It just doesn't work.

It requires an instructor to familiarize a student by having some realistic maneuvers. Much like we do with VMC demonstrations and single engine performance demonstrations and multiengine operations, it would be a great, I think, idea and recommendation to develop some maneuvers that we can put in the instrument flying handbook and in the airplane flying handbook, and the instrument flying handbook, I understand, is being rewritten as we speak, to help our students and our pilots get familiar with spacial disorientation.

Some common maneuvers that instructors use to introduce this and familiarize students with this is basically to have the student close their eyes. If they just close their eyes and try to fly the airplane and maintain orientation by what their body's telling them, 99 percent of the time, they're going to end up in a diving spiral, or the instructor could fly the airplane in a level turn, and after about 90 degrees of turn with the student's eyes closed, ask him are you still turning. They're normally going to say no, they won't feel like they're turning, only to find out that they are.

We experience a lot of things in our every-day life that confirms that the sensing system within the body just is not going to give us correct indication about our position.

I'll give a couple examples. I'm sure we all felt that we were in a turn in a commercial airliner when we were in the clouds only to find out that we weren't. One of the most common questions I get as an instructor when we-when people hear about fatalities or accidents associated with loss of control of an aircraft is how can a pilot let an airplane crash into the ground with all the instruments available showing that they're in a steep descent and not take any corrective action?

They don't realize how strong this spacial disorientation effect can be on a pilot. So, developing maneuvers to help students get familiar with this, we think, is a very good idea in order to help in this area of spacial disorientation, and to also increase the ability to recognize and anticipate what to do when this kind of situation occurs.

One of the things I noticed right off the bat when I looked at this accident was the failure of the pilot to declare an emergency and take full advantage of all the resource management skills that were available through ATC and others.

It was mentioned earlier that we want to make sure that we train our pilots to take advantage of all of those means.

When a gyro problem occurs, and aircraft control is being-is in jeopardy, the first thing the pilot should recognize is the significance of the urgency of the situation and report it to air traffic control as an emergency partial panel.

As an instrument pilot, you're required to demonstrate a task that deals with failure of a gyro, and one of the requirements in that, besides aircraft control, is to execute an approach.

In reality, though, is that going to be the first option that a pilot would normally take? Prudent pilot, first of all, Number 1 priority is to control the airplane. All other things are secondary, including clearances from ATC. That's why the emergency report is really necessary. At that point, you'll get their attention.

After that, what's the pilot want to do? Well, if I'm having problems controlling the airplane by instruments, I guess I don't want to be in instrument conditions anymore. What was the nearest visual conditions that a pilot could get to? Could air traffic control help them in this situation?

Resource management. There are other options available. Ground-controlled approaches versus regular approaches. A standard instrument approach. There's such a thing as a no-gyro ASR approach, where a ground-controlled approach controller will help navigate and step you down in altitude in order to minimize the workload of the pilot, in order to have the pilot spend most-all of his time and his concentration on aircraft control.

These are things we emphasize in training. These are practical things. These are things that maybe should even be included in the practical test standard as steps to be followed when you have a gyro failure. That's another recommendation.

There was already some discussion talking about how we simulate this situation. The spacial disorientation simulator out in the lobby is an excellent step in this area because, like we said earlier, most instructors are taught to practice this area of gyro-failing and spacial disorientation by going through some unusual attitudes and cover-up instruments.

The whole idea of covering up instruments is not reality. It would be a good idea if we needed part of the minimum requirement list to have instrument coverage just in case this happens, but the biggest distraction in a partial panel situation is that you have that attitude indicator that you have been spending hundreds and hundreds of hours controlling this airplane in that give direct indication of pitch and bank not available or you don't believe what it's telling you because of other factors, and you have to go to other instruments, pressure instruments, indirect indications of pitch and bank, which can be used to control the airplane but not as accurately as with the attitude gyro or the other instruments that you normally use.

If you ever have an opportunity to-and I've had many opportunities to evaluate pilots, both in the airplane using standard techniques for evaluating their ability to handle failures of gyros and also in trainers, even on non-motion trainer, like the FRASC Flight Training Devices, where you have the ability in a very realistic-without any motion, of course, but at least an unannounced vacuum failure, an attitude gyro failure, and see the reaction of low time pilots and high time pilots, and it's always amazing to see that they lose control of that trainer very easily because they're not anticipating that, and they haven't practiced that partial panel emergency scan in a long time.

The flight review required every 24 months, we talked about yesterday, as far as beefing that thing up a little bit, having some direction. We've done that with the instrument proficiency check. There are certain conditions where an instrument pilot-it would be mandatory for them to go to an instructor and complete an instrument proficiency check.

In the past, it used to be up to the person conducting the instrument proficiency check on what areas are going to be covered, but now we have our practical test standard for the instrument, includes mandatory areas that have to be covered for an instrument pilot.

The flight review can be done in the same manner. This area would be a good one to include.

Being able to react to failures in instrument conditions, most instructors will recognize, especially people with limited actual instrument experience, that concept of swimming in glue.

The difference between having a gyro failure and having some type of unusual attitude develop from it and not is really a matter of reaction and anticipation.

If a pilot has minimal actual instrument experience, you're probably going to see when a situation like this arises not a whole lot of action happening. We call that the old swimming in glue concept, right.

There is instrument requirements necessary for every rating now, but there is no requirement for actual instrument conditions. We may not be able to write that in the regulation, but like American Flyers, we've always promoted having all our students get some actual instrument experience time only because we find with people with some actual experience time are much quicker to react to things in those kind of conditions.

Another area is quality of instruction. Most flight schools will not hire instructors with just an airplane instructor rating. They're required to do instrument instruction, but they're not necessarily have to be an instructor for instruments.

Practically speaking, I don't know any school that will hire an airplane instructor without them at least saying that they're going to get training or enroll in training for the instrument instructor.

Before an instructor can qualify, there's a prerequisite that they hold a commercial certificate with a commercial instrument rating. The commercial and instrument rating means that they have acquired the knowledge and skill in order to operate in the left seat of the airplane or whatever pilot-in-command in instrument conditions.

To become an instructor, if you look in the regulations and the practical test standards, it's not so much the skill of flying the airplane or doing instrument approaches. It's the ability to disseminate information to a student, to be able to do it in a logical and orderly manner, to be able to evaluate students and understand the standards. That's really the concept of becoming an instructor.

So, we would recommend to put more emphasis on the instrument portion of all these ratings, that all instructors meet the same qualifications as an instrument instructor, and we can do really away with the instrument instructor rating, just have an airplane instructor, and the airplane instructor would be then qualified to teach airplane students, whether they be primary students or instrument students.

The bar's going to be raised for the instructor. The bar's going to be raised to be able to demonstrate their ability to do instruction and be an instructor not only for airplane issues, to be able to do stall shantels and Lazy 8s, but also to apply those same skills to the instrument which is going to incorporate partial panel and unusual attitudes and the like.

We think that would be a great way of meeting some of the demands of the instrument requirements that these ratings are addressing.

Judgment and decision-making. No matter what we do in the flight training industry to better train our pilots, other factors cannot be anticipated but must be taken into consideration before operating any airplane. Even additional instrument flight training or upgrading of instructor qualifications, it's always going to be the judgment of the pilot and the decision-making that's going to be the final determination on whether these kind of accidents stop.

Factors, such as health/medication currency recency, weather and other items, have to be considered before deciding on operating an airplane. Pilots must also be trained to evaluate and use of good judgment in exercising their privileges and maintaining their currency.

Most pilots have what we call personal minimums. Personal minimums are really based on how current are we, because we all could be walking around with instrument ratings in our pocket and have a lot of experience, but if we haven't exercised those in a long time and haven't made attempts to stay current for all conditions, we raise those minimums accordingly.

But no matter what we do, we have to remember that for private pilots and commercial pilots, even though we are emphasizing instruments more, they have to realize they're not instrument pilots and have to limit their operations accordingly.

Thank you very much.

(Applause)

MR. COLLINS: Phil Poynor is a principal in and General Manager of Nassau Flyers, a large independent flight school on Long Island.

Phil.

MR. POYNOR: Thank you, Dick.

In instruction, I try to simplify things, and in looking at this accident, I asked myself, what is safety, and I've come up with a triangular approach to safety or the safety triangle. It's predicated, first, on equipment and equipment redundancy.

The second thing is training. What does the pilot bring to the safety equation? This is the precision, the skill, the manipulation that Martha was talking about, and that seems to be where most of the focus of the training industry is based.

The third side of the safety triangle, as I see it, is judgment or perhaps viewed more largely, we've heard several speakers at this conference talk about risk management, and I think perhaps it would be time to begin to replace the concept of judgment with that of risk management.

I think the two are very highly related, and we can analyze this accident, I think, looking at it in terms of this safety triangle.

Equipment and redundancy. What we're talking about with that is good equipment, backed up-where critical system failure is backed up with another critical system, so that a single loss of a system doesn't result in loss of aircraft or aircraft control.

Training is the physical manipulations, and the judgment is how do we bring our training and our equipment to look at completing a specific mission and analyzing whether if or if it's possible to complete that at an acceptable level of risk.

Using that model, this accident is very difficult to analyze, and the reason is, I think we've had breakdowns in all three legs of the safety triangle. We've had significant breakdowns that then don't lead to easy answers or easy suggestions.

For example, if we look at it from an equipment failure point of view, we definitely had an HSI failure in this accident, but there's a suggestion also that the turn coordinator had failed. That's the system that's designed to back up in the event that you do lose gyro instruments that are operating automatically.

If you think about that failure, and I've thought a lot about it since reading and going into this accident, thinking how are we taught when we're trained? What would we do if we had a turn coordinator HSI failure?

Well, what we're taught to do is look at our three basic-our instruments that are providing bank information and to try to determine which one has failed and which one is working and then discard the one that's failed and continue the flight.

On light aircraft, we have four basic sources of bank information. We have an ADI, the turn coordinator, an HSI or heading indicator, and a mag compass, and for those of us that are pilots, I think we understand that maneuvering flight in most cases, the mag compass is next to useless due to the depth error and turning error and acceleration error and other problems with it, which really leave us three instruments to rely on for our bank information.

We have the ADI, the turn coordinator, and in this case an HSI. When looking at it, if those two instruments had failed, the turn coordinator and the HSI, they'd be in agreement, and I think a well-trained pilot would probably then conclude from that, that the conflicting instrument is the attitude indicator and would exclude that from the scan and proceed to control the airplane by the reference to the two instruments, which, unfortunately in this accident, are the ones that may well have failed.

This leads to a sort of ironic conclusion of how well trained was the pilot? I would suggest perhaps the better trained he was, the more trouble he may have gotten into in this particular accident.

Well, if you look at how well trained he was, and this is one of the issues that we had heard mentioned earlier, David mentioned about the possibility of increased proficiency checks and proficiency training, the fact is he had taken an ATP check ride in February of `99.

The examiner who flew with him at that time had formally notified the NTSB in a letter that he was a very competent pilot and tried diligently to maintain proficiency in both VFR and IFR flying.

In fact, in preparing for this presentation, I called a number of respected leaders in the flight training community and was astounded at the number of people who had either known the pilot or even flown with him. A number of people had. It's-to me, it was remarkable feeling to get when I called colleagues of mine and find out how many people actually knew him.

More than one of these pilots called him Mr. Needle Ball and Air Speed. That was his nickname, which is a clear reference to the fact that in both training personally and training other pilots, he had spent a lot of time doing partial panel work. He even instructed for a major organization conducting dozens of ground schools. So, clearly training was a major focus of this pilot.

The conclusion might be that the very training in this case may have made him so well trained that he wasn't able to deal with the emergency that came to light.

That brings us to judgment, and I would start judgment as a technical pilot would in looking at this accident and say, okay, well, if we have a well-trained pilot, a well-equipped airplane, the weather conditions that we would be encountering that morning after the weather had cleared from the early morning fogs really weren't very challenging. There were two and a half mile visibility. That's just a half a mile short of VFR conditions. 600-foot scattered with 1,300-foot broken. That would qualify as VFR.

In other words, it was really a fairly light IFR. In fact, I would suggest the kind of weather that a lot of new beginning fairly-inexperienced IFR pilots would look for to go fly, to get some experience flying in.

So, I think when we begin with the judgment equation, once the weather got to that condition, I don't think we could fault either the judgment or the risk assessment.

On the other hand, once we introduced the drugs into the picture, then we have an entirely different focus on this accident.

Apparently some people respond to those class of drugs by exhibiting drowsiness and dizziness. Others demonstrate an adaptive complex which means that their bodies adapt to it over time, and it has little direct effect.

However, this drug would have precluded the issuance of a medical certificate and certainly would have been contraindicated to flight, and, so, in this case, the judgment side of the triangle broke down as well.

So, with the breakdowns in all three legs of the safety triangle, it's difficult for me to see where sweeping recommendations could come from this specific accident.

However, I would think there are a couple of things that we can do. First off, as a number of speakers have said, we must become more assertive in teaching risk management, especially in the general aviation and especially in the private and personal flying segment of general aviation. We prize our freedom of use of the aircraft, and yet that freedom is what gets us in trouble. I'm not proposing additional regulations limiting the personal freedom, but we have to improve the training and that may be a regulatory consideration.

Another point is, I think it's unlikely that as many people as flew with him, both students and respected leaders of the flight training industry, it seems to me somewhat inconceivable that there weren't some pilots that were aware of the fact he was taking these drugs, and I'll conclude by asking rhetorically but very seriously, are our brother's keepers in this matter?

Does the pilot community owe it to each other and even to ourselves to get involved when we repeatedly see friends, peers, colleagues taking undue risks, committing FAR violations, being macho in the airplane, doing the kinds of things that all of us as pilots have seen other people do, and yet outside things like the safety program within the FSDOs and the safety counseling program, there's really no formal structure for other pilots to get involved, and I would question whether that's something we should be doing as an industry as well.

Thank you.

(Applause)

MR. COLLINS: Thank you, Phil. And now, Dennis, we'll have some questions.

MR. JONES: This will be the period for questions.

MR. COLLINS: All right. Could someone please comment on the controller's response to the situation, and could he have made a difference?

Martha?

MS. KING: It seems to me not, you know, having had controller training and being in any way an authority on that, that the controller's response was not as aware as it could have been. He did send the USAir flight around because-but his attitude seemed to be more of one of impatience and this pilot is lost, rather than one of this pilot really has a problem.

From that standpoint, I have a perception that the controller either was not as aware or not as empathetic as he could be.

On the other hand, you do have the issue that has been brought up by several other people that the pilot did not declare an emergency and did not really make it clear to the controller how much of a problem he was or was not having with the gyro and certainly left the implication that he had his problem straightened out.

So, I think the controller could have been more helpful, but I don't think the pilot gave him much help in making that determination.

MR. COLLINS: Thank you, Martha. Anybody else want to address that?

MR. MENCONI: One of the things in training is to be able to instill a pilot-in-command attitude in a student or in any pilot. With the experience level this pilot had, it's kind of unreasonable-you wouldn't expect him to have a real problem in this area.

But when you're used to taking commands from air traffic control for hundreds of hours, and a situation like this is experienced, the pilot has to immediately recognize who's pilot-in-command at that point and start directing actions, and this is something we try to instill in our pilots in training, but I'll tell you right now, it's a difficult skill to acquire, and it's something you don't see a lot of, and at the point this situation addressed itself, you would have hoped the pilot-in-command would have taken a much more aggressive posture in directing ATC's direct actions instead of ATC directing his.

MR. COLLINS: All right.

MS. KING: Can I add just one more thing to that, Dick? The complication that we have to throw in here also is an awareness that this was the New York Metropolitan Area, and that's going to put a lot of pressure on the pilot to try and conform to ATC because this person, this pilot in particular, with his experience level would be very aware of the stress that he was going to put on the ATC system in the New York Metro Area if he wasn't able to follow the controller's instructions.

MR. COLLINS: That's correct, and he was used to major areas because he was based in the Washington area.

Dr. Canfield, which category does caffeine fall in, and do you consider coffee as a contributor to accidents? 10 out of 10 pilots in my flight line use coffee to repair their fatigue problems.

DR. CANFIELD: I'm not concerned with the use of caffeine. It's a stimulant, may actually improve your ability to fly a little bit, but if you're fatigued, the fatigue could certainly cause an accident, but I wouldn't be worried about the drug itself, no.

MR. COLLINS: Recency of IFR experience, and was the pilot a doctor? The answer to the last question, I think, is correct. What was the recency of experience?

PARTICIPANT: He had a 120 hours in the last six months.

MR. COLLINS: He had a 120 hours in the last six months. So, he was apparently fairly current.

Dr. Canfield, I think this one's for you. Is there a benefit of requiring a blood test as part of a medical?

DR. CANFIELD: The cost involved with that and the other problems associated with that, first of all, I don't think we could afford something like that or the pilots could afford something like that, and I still would like to prefer using some type of an honor system or some other mechanism, other than through blood testing, if possible.

MR. COLLINS: All right. The next question. I have seen a general decline in the skill or capability of recently-certificated private pilots. The overall quality of flight instruction has also decreased. These same people will be moving into the airlines with marginal skills. Any comments for improvements?

Phil?

MR. POYNOR: This is an area that causes me probably more concern in terms of the short, intermediate and long-range future of this industry.

The last two or three years, I've been on the association circuit, trying to make this point, and until probably this last May at the NATA meeting in Tampa, haven't really received much attention to it, but now it's becoming critical because as the airlines, particularly the commuters, reduce their hiring standards, and in our flight school, we're losing people typically now at about 800 hours total time, a hundred hours multiengine time, going to the commuters, my prediction is that within another few months, we're going to be seeing most of the people in the airline career track, which has been our traditional source of instructors, bypassing the instructor route entirely because the commuter airlines are going to be hiring them directly out of the commercial certificate.

Even at that, I like to analogize that we have babies training babies, and the feedback loop of several cycles of babies training babies training babies, we've simply lost the experiential component to instruction, and I think that's a problem that the industry is going to really have to address, and, unfortunately, I think it's probably going to end up in the regulatory basket as well.

I think as we lose the experience and the instructor cadre and don't make up for it in any meaningful way, we're going to have really significant shortage of instructional capability.

MR. MENCONI: I'd like to add, we've seen this cycle before. It's been many, many years since we've seen inexperienced pilots getting into the airlines or less experienced pilots. Let's put it that way.

The airlines and the commuters are used to getting highly-experienced people, and the extent of their training basically has been a systems familiarization and a type rating.

One area that they have to take a proactive stand in is recognizing if they are going to be lowering their standards, then their training has to improve to make sure that they're qualified to meet the duty.

MR. COLLINS: All right. David, this one is for you, too. You note that the pilot should have declared an emergency. It seems many pilots are afraid to make an emergency declaration for fear of FAA retribution, including critical review of all aspects of the pilot's life and the aircraft maintenance history. Comments, please.

MR. MENCONI: I agree.

MR. COLLINS: That was pretty simple, wasn't it?

MR. POYNOR: One of the things is that I'm also an aviation lawyer, and in the practice of aviation law, and that's the only law I practice, is basically representing airmen in enforcement actions, is that's one area that we really need to get the word out, that the FAA is not nearly as harsh as perceived in the pilot community as to what happens after the declaration of an emergency.

Unless there's something really-either causes a major separation issue that then goes into the enforcement side from that or unless there's an indication that there's been some really major egregious violation of other regulations that got them into the emergency, there's almost never repercussion from that, and I think the pilot community doesn't understand that, and they're terrified of that interface with the FAA, and it really inhibits from the declaration of the emergency.

MR. COLLINS: Okay. Thank you. That's all the questions we've got, and I guess-you want to say anything, Dennis?

MR. JONES: No.

MR. COLLINS: Okay. We'll take a short break, I guess.

(Applause)

MR. JONES: Thank you, Dick, for such a fine job.

We will take a 10-minute break, be back in 10 minutes, and we'll start our next panel.

(Whereupon, a recess was taken.)

MR. JONES: Okay. Our next panel we have identified or titled just simply Corporate Aircraft Accident. The regional investigator who will be giving the presentation is Steve Demko of our Northeast Regional Office in Parsippany, New Jersey, and the moderator will be Jack Olcott of the National Business Aviation Association.

Steve.

Corporation Aircraft Accident MR. DEMKO: Thank you, Dennis. On July 1^st, 1999, about 22:24 Eastern Daylight Time, a Learjet 60, November 219 FX, was substantially damaged while landing at the Barnstable Municipal Airport in Hyannis, Massachusetts.

The certificated airline transport captain, first officer, and two passengers were not injured. Night visual meteorological conditions prevailed, and an instrument flight rule flight plan was filed for the flight that originated at the Dulles International Airport.

The passenger flight was conducted under 14 CFR Part 91. The airplane had been previously positioned to the Bradley International Airport in Windsor Locks, Connecticut, for a maintenance inspection. While in maintenance, the landing gear actuator extend pressure hoses were replaced and inspected.

On July 1^st, the airplane was released from maintenance, and the flight crew was instructed to fly the airplane from Windsor Locks to the Dulles Airport and pick up two passengers.

The airplane landed and departed Dulles uneventfully, performing one landing gear cycle, and proceeded to the Hyannis Airport.

While being vectored for the Runway 2-4 ILS approach with the flaps selected to 20 degrees, the captain called for the extension of the landing gear. The landing gear extended, and three lights were confirmed.

As the captain called for the landing checklist, the left and right hydraulic pressure lights illuminated, and he announced that they were losing hydraulic pressure.

The first officer remarked that they could go to a longer runway and queried the captain where the alternate airport was. The first officer also stated that if they missed the approach, the flaps could not be retracted.

The captain then added that the landing gear could not be retracted, and that they had plenty of fuel. This was followed 12 seconds later with the captain stating, "Let's continue."

The flight crew reported to Cape Approach Control that they had had a hydraulic problem and continued the approach. In preparation for landing, the captain pulled the emergency brake lever out of its detent. The airplane continued to the airport and landed about five minutes after the first illumination of the hydraulic lights.

The pilot's estimate that the airplane touched down within the first 300 feet of the runway. When the captain applied normal braking, the brakes did not respond. The captain then reached for and tried to apply emergency braking, but the emergency brake lever would not move. The captain then requested that the first officer apply the emergency braking.

As the first officer used both hands to free the lever, the captain advanced the throttles and announced he was going around. This was followed by the first officer announcing he was applying the emergency brake.

The airplane then proceeded off the departure end of the wet runway, struck a localizer antenna and came to rest in a fence. On an additional note here, I'm also conducting an accident at this same airport on the same runway.

It happened about nine months after this accident, and it was a corporate-owned Falcon 900 that also proceeded through the fence, across Route 28, which is a major road in Cape Cod, and came to rest in a parking lot where it released 2,200 gallons of jet fuel into their water supply.

A passenger then attempted to exit from the forward boarding door but could not open it. The first officer appeared from the cockpit and said to exit from the back of the airplane. A second passenger opened the rear emergency exit and egressed, followed by the first officer, the first passenger and the captain.

Examination of wreckage revealed a stream of hydraulic fluid from the underside of the airplane that ran from the left wheel well to the tail section. The fluid trail was most noticeable on the lower surface of the delta fins. The hydraulic reservoir was drained, and the fluid measured approximately 49 ounces.

Of the 49 ounces drained from the reservoir, 38 ounces was available for use by the electric hydraulic pump. When the hydraulic reservoir was serviced and the hydraulic pump was turned on, the left main landing gear actuator extend hose began to leak hydraulic fluid at the actuator hose fitting.

The fitting was tightened one-third turn, and the leak stopped. Hydraulic pressure built up until the pressure gauge indicated 1,100 psi, and the pump shut off. Both the pilot's and co-pilot's brake pedals were actuated and had a normal feel and held pressure.

The hydraulic system was then checked for leaks, and none were observed.

Using the torque wrench, the torque on both the actuator and air frame hydraulic fitting connections of the left main landing gear actuator extend hose were tightened to a value specified by the manufacturer. The actuator hose fitting needed a total of two-thirds of a turn to be tightened, and the air frame hose fitting was tightened a total of one-third turn.

The right main landing gear actuator extend hose was also checked and found to be under-torqued. No leakage of hydraulic fluid was observed from the right actuator extend hose.

The cockpit instrument panel was inspected after the accident, and the hydraulic pump switch was found in the on position. When the captain was questioned why the pump was on, he replied that he had selected it to the on position after the accident.

The airplane flight manual stated that in the event of a hydraulic pressure loss, landing distance with no flaps, no spoilers, no thrust reversers and no antiskid would be greatly increased. The actual landing distance for any skid on would then have to be multiplied by a factor of three.

The calculated landing distance uncorrected was 3,690 feet. When the factor of three was applied, this required an 11,070-foot long runway. No abnormal or emergency quick reference checklists were found in the cockpit.

An airplane flight manual, which contained an abnormal checklist and procedures section, was found in the side packet next to the captain.

Additionally, there was no mention of abnormal or emergency procedures by the captain or first officer in the CVR transcript.

After the accident, the first passenger stated that he and the other passengers had not been briefed on any safety items as they boarded the airplane.

Examinations of files revealed that the captain had been issued an employee warning notice in August of 1998 for failure to follow instructions and rudeness to employees or customers. The notice also stated that numerous first officers reported that the pilot was rude and discourteous when he addressed them, and that he was not promoting good CRM.

The National Transportation Safety Board determined that the probable causes of this accident was the flight crew's inadequate coordination and their failure to utilize checklists. Also causal was the captain's improper decision to continue the approach to a runway with insufficient length. A factor in the accident was the improper maintenance.

That concludes my presentation. Thank you.

(Applause)

MR. OLCOTT: Thank you very much, Steve.

This particular accident is very enlightening. Corporate aviation has a safety record that is on a par with and at times better than that amassed by the largest scheduled airline. Why then did something like this occur?

What it says to us is that the excellent safety record of corporate aviation can never be taken for granted. It is highly dependent on pilots, and the dedication, the focus on discipline, standard operating procedures and training, that is part and parcel of the corporate aviation culture we find in our community.

We have three excellent panelists, very experienced, who will address this issue. The first is Richard Aarons, Dick Aarons. You all know as the former editor-in-chief of Business and Commercial Aviation, and the acting editor-in-chief while a new editor's being appointed.

Dick is a recognized expert in aviation safety. He participates on the National Business Aviation Association's Safety Committee and has been on several Flight Safety Foundation programs.

We're very privileged to have Dick Aarons speak to us about this accident, an experienced pilot, an excellent journalist. Dick Aarons.

(Applause)

MR. AARONS: Thank you. Good morning. Do I have this thing working? Can everybody hear?

In a minute, you're going to hear from the real experts on this airplane and this situation. I wanted, though, to take a moment with Jack's permission to address the investigators, the field investigators who are here this morning, because I understand at this point, about half of us in the room are-half of you in the room are indeed field investigators.

Last night, Jim Hall observed that you rarely get thanked for the accidents that don't happen. Well, I spend most of my working day mining your work product to pass the gems, the safety gems that you uncover on to our readers at BCA as do the other safety editors in our trade industry, and let me tell you, we're in a good position to hear back from the readers, and we do hear back.

I get letters and calls every year, and I know Jack did when he was editor of BCA and author of the "Cause and Circumstance" column. When a reader would say, "You know, I read about that accident. I read what those investigators said, and that changed the way we do things in our my flight department" or "I recognized myself in a situation that was developing that those investigators were talking about, and I was able to head it off, so thank you".

Now, we are remiss as safety writers not to pass that information on to you, the investigators, but I do want to let you know that you should hear about the accidents you prevent. You do prevent them, and we hear about them.

Last night, also referencing last night's wonderful dinner, afterwards, I stopped by the sundry shop, and there's a long line of guys there and ladies there with these badges on it, and I stood in line, and in front of me was a lady who looked a bit bedraggled. She had-she was clutching some M&Ms in one hand, and she had an overnight bag on wheels in the other, and she had obviously just arrived from an experience on the nation's airlines and was looking forward to having a second drink and getting to bed.

She looked at the badge and said, "Oh, you guys are with NTSB. What'cha doing?" I said, "Well, we're here talking about general aviation safety accident prevention", and I thought perhaps she was one of you, and I said, "Are you with the NTSB?" She said, "No. I'm a psychologist, and I'm here with the American Psychological Association", which is meeting today, I guess, in the hotel.

She thought for a minute, and she said, "But, you know, I guess in a way, we're in the same business", and I said, "What's that?" She said, "Changing people's behavior", and I thought about it for a minute. She was right, and then she looked at me intently, and she said, "And you know that is very, very difficult to do", and she's right.

When you think about the frustrations of your jobs as investigators or communicators or as chief pilots, operations people, you must become very frustrated when you look at the pile of 60 accidents in your in-basket and realize that basically all of those 60 accidents represent three or four or five causal factors that you see again and again and again and again, and as we've seen in the last two days, the lessons from each of these accidents, no matter how individual they are to the set of circumstance, come down for the most part to flight crews and maintenance people and the way we behave, the way we behave in our normal day-to-day activities and the way we behave under pressure.

I want to talk to you very briefly about that. This business of changing behavior. It occurs to me that rarely, and I should be able to say never, but with some of the investigations, I know, that happened in Parsippany, it would seem that the appropriate word is "rarely" do people set out to have an accident.

Usually people set out to have a normal day, to get an airplane from Point A to B, but something intervenes, something intervenes, and part of what goes on, and I think it's reflected in this accident, and what you'll hear about from the experts in terms of the communications in this cockpit, our systems and our airplanes at the high end of general aviation, the turbine airplanes, are remarkably safe airplanes. For the most part, our people are well trained, and for the most part, our bulging creaky old ATC system does its job and keeps it separated.

When we sit in the cockpit, we don't expect to have problems, and we do have problems, we tend to be optimists today, and we tend to underestimate the consequences.

When you look at this accident closely, these guys set out to have a routine day, and as their day progressed, they got close to the destination, warning lights flickered, and they entered into a discussion of the problem, and that discussion, interestingly enough, never rose above the level of simply that, a discussion, while their original goal to get the airplane on the ground continued to be their primary focus, and in fact, right down to a hundred feet off the ground, they are still discussing it in a rather casual manner.

"I wonder what's going to happen when we apply the brakes. What's going to happen, captain, when you push on the pedals, and the brakes aren't there?"

As we've seen from Steve's report, checklists weren't used. The appropriate CRM was not used. That company's briefings were not applied. Its procedures were not applied.

So, it brings me to the question why. Why? Why do well-trained people find themselves in a situation where this situation was allowed to progress to an overrun accident, to an incident, and in fact, it's only because what they hit was relatively soft and relatively cheap that it wasn't a major accident and a major incident.

I'd suggest to you that the key word to describe it is simply complacency. We are used to things working. Something has to jar us when we're in the cockpit out of our normal operating mode into an alert risk-evaluating mode when the lights start clanging, and I'm sure the experts will look at that.

I'm just going to show you briefly a preview of one approach to breaking the circle of complacency. As you know, Flight Safety Foundation and NBAA and several other organizations, ATA, have worked very hard, diligently, over the last couple of years to develop and analyze CFIT programs and training and accident approach and landing risk reduction programs.

NBAA is involved in one right now that, for the first time, brings together the training organizations for a joint syllabus that all of the training organizations, that is Flight Safety, Simuflight, PanAm, Bombardier, will use, unless a customer comes with their own, that says that on approach, when something abnormal happens, when the approach destabilizes, you must immediately go to a set of SOPs.

It's the SOPs, the existence of the Standard Operating Procedures, that will break the complacency loops and will indicate to the crew that they must abandon the approach and go out somewhere and think about their alternatives.

Having said that, I will turn the panel back to Jack with your thanks again, not only for listening this morning but for the wonderful work you do in the field in bringing this stuff to the attention of us, the operator.

(Applause)

MR. OLCOTT: Thank you very much, Dick. You make two excellent points, and that is, that the good work of the NTSB and their investigators really does make a difference. It does prevent the accident that you never have to investigate, and, secondly, you talk about complacency.

Complacency is the silent killer of the professional aviator. We all have to guard against complacency, particularly in a community that has for the most part such an outstanding safety record.

An individual who has practiced excellent aviation for almost 50 years and has nearly 50,000 hours of flying time is Clay Lacy.

Clay began his aviation career at the age of 12, flew with United Airlines for most of his professional career, but he was able to also take Air Force training and was an Air Force jet pilot in the middle `50s, truly an individual who exemplifies the best of our community.

Clay Lacy.

(Applause)

MR. LACY: Thank you, Jack. Is this on? Okay. Well, most accidents are attributed to pilot error. Usually there are other contributing factors that are out of the norm, as we just were talking about, that we expect everything to work right.

In this particular accident, there was certainly more than one factor, although I think the primary reason for the accident by far was pilot error or lack of cockpit resource management, failure to follow SOPs.

There is a second situation here, and that is, that maintenance failed to tighten the hydraulic lines that led to the loss of hydraulic fluid.

A third thing in my opinion, they have less than a desirable system design on the hydraulics-out procedure. Inasmuch as with the aft engine-driven hydraulic pumps, you cannot activate the spoilers or the thrust reversers, when all earlier model Learjets, you could operate them on the aux hydraulic pump.

The crew could possibly have prevented this accident with-at Dulles, when they were on the ground at Dulles. I don't know what kind of a post-flight inspection they did on landing, if any, but on an airplane like a Learjet or most of these corporate jets, if you just take a look under the fuselage and under the engines every time you land, you'll see if you're leaking any fluid.

Possibly they would have seen the hydraulic leak that as on the slides there and investigated it and found that they were losing hydraulic fluid at that point.

Then, when both hydraulic lights flickered, they were approaching the final approach fix, bogey intersection, and they realized they had a problem. At that time, they had the opportunity to go into hold or request a hold over bogey, and which they certainly should have done, and they should have completed the hydraulic failure checklist or they should have reviewed the systems affected or that are out.

They would have-if they'd have read the checklist, they'd have realized that when you have this situation, that you're supposed to factor your landing distance by three times, which was in excess of 9,600 feet, and the captain should have reviewed with the co-pilot the things that he wanted him to monitor and call-outs on hydraulic pressure, if there was any change in it, or air speeds.

The voice recorder did not indicate that they were even making air speed call-outs during the approach, other than one call-out when they thought they hit wind shear, and they called out 160, but it doesn't indicate that the second-in-command was calling out any air speed call-outs as he approached the runway.

Then, of course, the really baffling thing is that they did not turn on the standby-electric standby hydraulic pump, and this is something that you turn on almost every time you get in the airplane to set the parking brakes, and if they'd have had that pump on, it would have had normal brakes from the beginning, which I'm sure would have prevented the accident.

As was pointed out, more than the 38 ounces of fluid left for the brakes and the flaps, with the electric hydraulic pump, was in the reservoir, but I think that I always say what if this happens? I think that on every landing, prior to landing, you should run through your mind if it's a short runway or if it's a wet runway, braking action nil, or you have some type of emergency or abnormal, not emergency particularly but something abnormal, that you should mentally review what your-where everything's at, mentally review the hydraulic, the aux hydraulic pump, the emergency brakes.

I know that I fly a lot of different airplanes, and I always mentally review two or three things that I think are real important. How do you get the gear down in an emergency? And then where the emergency brakes are, and anything that's real important to landing the airplane, you should always review these things in your mind on every flight.

When both lights flickered, they knew they had a total hydraulic system failure, engine-driven hydraulic system failure coming up, and they were low on fluid.

The-with a known problem, the pilot still elected to continue the approach when they were in a perfect position, as I said, to hold over the final approach fix. For some reason, the pilot had in his mind that he had a mindset that he was going to land the airplane. Whether he was in a hurry, whether he was panicked, I don't think he was. He didn't sound like it on the voice recorder, or he was complacent.

For some reason, he decided to go ahead and land, and the review of the voice recorders shows a less-than-proficient cockpit management. The call-outs and things were somewhat less than professional.

As far as experience, the pilot-in-command had very good qualifications, total time of around 7,800 hours, I think, with 1,600 hours in type. His training records were very good. All of his reports were average to above average, all phases, including what cockpit resource management training that he had received.

The second-in-command also had above average training reports with comments that he should be able to check out early as captain, pilot-in-command, but in actual operation for some reason, the pilot-in-command had been reported by co-pilots of having poor cockpit procedures as far as not using good CRM and not giving good training to the second-in-command.

It appears that he may be a pilot that was a very good pilot, but he really didn't want to take the time to do training with the second-in-command or to do good review, that he was kind of a one-man show in a way. I may be wrong on that, but that's what it appears to me.

I think the single most important factor was his hurry to get on the ground and not reviewing the checklist, not taking time to analyze the big picture, what the effect of the hydraulic malfunction was, and not reviewing it with himself and his second-in-command, and the fact they didn't go through this, both pilots forgot and failed to use the electric hydraulic pump for brakes.

As I said before, on every landing, you should go through a mental review of what's happening, and what if he had turned on the aux hydraulic pump? He would have stopped the airplane because even though the spoilers didn't work, and the reversers he didn't have, I'm sure he would have stopped the airplane because on the time line there, when you figure it out, the first time they really applied the brakes, they only had 1,300 feet of runway left, of wet runway, that they-if they touched down at this 300-foot point, they had already used up 972 feet by the time the pilot made the comment that he had no brakes.

They had used up 1,620 feet by the time they discussed no reverse, and by the time they pulled out the emergency handle and got it out of the detent where they could use it, they had used up 2,940 feet.

When he talks about going around and started go-around, they had used up 3,700 feet, and when the co-pilot made the comment "there it is", that he's got the handle out where he can use it, they had used up 3,920 feet. When he started to apply the brakes, and he started to make the comment "hard brake or hard, hard, put on the brakes harder", they had used up 4,120, and then when he started-the second-in-command started saying "I have the handle all the way on", they had 1,000 feet left.

Talking about the maintenance. The aircraft had been in maintenance for two weeks, which is quite a long time on this type of airplane, for the amount of work that it showed they had done, but the mechanics failed to tighten the hydraulic lines, and apparently, I don't know what the inspection procedures were, but it's hard to see if you need one-third of a turn or two-thirds of a turn on a hydraulic line.

Once again on the preflight and the postflight, possibly, the flight crew would have seen the hydraulic fluid. In talking about the aircraft design, I mentioned this, I'll touch on it, but the very first Lear 23 came out in 1964 with the electric hydraulic pump, provided pressure to spoilers, flaps and the gear, and when the first thrust reversers came out for that airplane, for the 20 series airplane, the reverse system has an accumulator to provide reverse deployment with hydraulic system failure.

It kind of surprises me that Lear Bombardier didn't keep those systems when they -- 30 years later, when they have a heavier aircraft with higher landing speeds.

It's always more than one thing that causes an accident, and in this case, it was-for starters, they had a rather short runway, 5,400 feet. It turned out it was a wet runway. They then had a hydraulic failure, possible higher speed on touchdown due to the wind shear, all could have been saved by the pilot if he had followed procedures and not hurried.

If he had reviewed emergency procedures and really taken time to get the big picture, this accident wouldn't have happened, and I think that's basically my comments here.

Okay. Thank you.

(Applause)

MR. OLCOTT: Thank you very much, Clay. Obviously you bring a lot of insight to that accident. You emphasized the need to see the big picture. Obviously over your 50 years, you developed a culture, an attitude to never take safety for granted.

Your key points of how about a postflight inspection, very important. How about expecting a problem, not being complacent and expecting everything to work out, planning ahead, and then when there is a problem, relying on standard operating procedures. Great insight.

Our next speaker is Bob Agostino, who is Director of Flight Operations for Learjet, Bombardier Aerospace Business aircraft.

Bob has a degree from Renselear Institute of Technology, more than 15,000 hours of flying, and is responsible for 17 demonstration pilots and many of the aircraft that Bombardier produces.

We're fortunate to have Bob, a true specialist in Learjets and somebody very familiar with the Lear 60.

Bob Agostino.

MR. AGOSTINO: Thanks, Jack. Is this working?

(Applause)

MR. AGOSTINO: Is this working? Okay, okay. We're officially in our mid-morning slump. So, we'll try to get through this about as quick as we can.

MR. OLCOTT: Can you hear Bob?

MR. AGOSTINO: Okay. I believe it appropriate at this point in time to take one minute to thank Chairman Hall for the opportunity to be here, and as a personal note, and in the most sincere of terms, I would like to thank all the dedicated men and women of the NTSB.

Without your effort and without your sacrifice, the United States would not enjoy the safest aviation system in the world today. You are truly part of an outstanding American institution. That institution has never been compromised in terms of its integrity or its commitment, and believe me when I tell you, you do make a difference.

We always talk about human factors, and we're going to talk a little bit about that right now, and I honestly can tell you none of us have compared notes, but the accident, I believe, is self-evident.

Good human factors you experience each and every time we get in the back of a commercial or private aircraft. We are not at the controls, and we entrust our lives to the crew up front. Chances are, if they got us to where we wanted to be, they exercised good CRM, they exercised good judgment, and they executed it frequently.

A lot of good examples. Sioux City, hopeless situation, amazing example of how people communicate, listen, interface and produce extraordinary events. We can even go further to the Apollo 13