NTSB GAAP Symposium
September 21, 2000

Day 1, of 2
day 2

A G E N D A

AGENDA ITEM:

Call to Order
Dennis Jones, Chief
Regional Operations and General Aviation
Division
National Transportation Safety Board

Welcome and Opening Remarks
Jim Hall, Chairman
National Transportation Safety Board

Remarks
Honorable Frank R. Lautenberg
Ranking Democratic Member
Subcommittee on Transportation
Senate Committee on Appropriations

Stall/Spin Accident
Jeff Kennedy, Southeast Regional Office
National Transportation Safety Board

Visual Flight Into IMC Accident
Wayne Pollack, Southwest Regional Office
National Transportation Safety Board

Helicopter Accident 154
Clinton O. Johnson, Northwest Field Office
National Transportation Safety Board

Maintenance-Related Accident 213
Nicole Charnon, South Central Regional Office
National Transportation Safety Board

P R O C E E D I N G S

(8:39 a.m.)

Call to Order

MR. JONES: Good morning and welcome. My name is Dennis Jones. I'm the Chief of our Regional Operations and General Aviation Division for the Office of Aviation Safety.

I want to welcome you to our General Aviation Accident Prevention Symposium.

Today, we will feature four panels, two this morning and two this afternoon, with breaks as indicated in the agenda in your handbooks.

The subject matter of the four panels today involve the discussion of safety issues involving stall/spins, visual flight into instrument meteorological conditions, helicopter safety, and aircraft maintenance.

There will be no formal activities associated with the lunch break. There are many eating establishments available upstairs in the L'Enfant Plaza Promenade upstairs.

This evening, there will be a reception and dinner banquet in the L'Enfant Plaza Hotel, and our guest speaker will be the Honorable Congressman James Oberstar, who is on the Transportation and Infrastructure Committee.

Congressman Jim Oberstar serves as an ex-officio member of the Subcommittee on Aviation, Coast Guard and Marine Transportation, Public Building and Economic Development, Railroad Surface Transportation and Water Resources and Environment. Oberstar has worked tirelessly to improve safety and efficiency for the traveling public.

Also speaking with be Roger Shaw of the FAA Civil Aeromedical Institute, who will talk about spacial disorientation.

Located in the room to the rear and to your right as you enter the conference room is the FAA General Aviation Spacial Disorientation Trainer, which is being provided to us during the course of this symposium by the Aeronautical Education Division of the FAA, Civil Aeromedical Institute, in Oklahoma City, Oklahoma.

The device is the first of its kind in the world and is being used in general aviation training courses offered at the Civil Aeromedical Institute in support of the National Accident Prevention Program throughout the United States.

The device is used in the civil aviation Pilot Certification Program to expand the spacial disorientation in meteorological flight conditions as well as the importance of relying on cockpit instrumentation for safe flight in these conditions.

I hope that during the next two days, you will have a chance to visit the demonstrator.

You may also find in your books information about the accidents that are the center of our panels and the associated panel discussion.

There will also be a list of attendees that will be available later this afternoon.

We're looking forward to presenting you the opportunity to discuss the many safety issues. The symposium is being videotaped, and it will be posted next week on the NTSB web site at www.ntsb.gov, under the heading of "News Events".

It is my pleasure to introduce Chairman Jim Hall. Chairman Hall has been head of this agency for the past six years. He has led the agency through some unprecedented times in our history, including major aviation accidents, such as ValuJet in the Everglades of Florida, TWA Flight 800 near Long Island, New York, Korean Air Flight 801 in Guam, American Airlines Flight 261 in Little Rock, Arkansas, and Egypt Air Flight 990 near Nantucket Island, Massachusetts, and more recently, Alaska Air off the coast of California.

Chairman Hall has also been at the helm of the agency for highly-publicized general aviation accidents involving Jessica Duboff, John Denver, John F. Kennedy, Jr., and more recently the golfer Payne Stewart.

Today, we are here because of his on-going efforts in addressing the safety concerns of general aviation. Chairman Hall has been diligent and tenacious in his efforts to obtain the necessary resources for the agency so that the investigation of the nearly 2,000 and mostly general aviation accidents each year can be investigated appropriately and in a thorough and tedious manner so that issues that warrant corrective actions can be addressed.

He has been the impetus behind the legislative action to ensure that surviving family members of transportation accidents receive appropriate care.

He has also been at the forefront for issues involving highway safety, jet skis, railroad grade crossings, and pipeline safety. As Chairman Hall identifies safety issues that can be improved, he has provided a forum for public debate, such as this symposium.

This is the sixth symposium that the Chairman has held, the others involving human fatigue, the effect of corporate culture, and how to effect safety within an organization, a symposium on family affairs to help standardize the direction that the industry will proceed, a symposium on transportation event records, such as cockpit and flight data recorders, and more recently, a symposium titled "Transportation Safety".

Chairman Hall is from the great state of Tennessee, and, so, in my professional development to navigate successfully the internal politics of the agency, I have versed myself on Tennessee history.

One of the first historical facts I learned of the state was that the word "Tennessee" is derived from the UT Indian word "Tenace", which means meeting place.

So, it is quite appropriate and also my honor that today in our open NTSB Board Room and Conference Center or perhaps I should say our "Tenace", which is another one of his many accomplishments as the Chairman, that I ask you that you all join me in welcoming Chairman Jim Hall.

(Applause)

Welcome and Opening Remarks

CHAIRMAN HALL: Thank you. Well, let's see if this is working, right? Very good.

Well, good morning, everyone. It's a pleasure to be here. Dennis had the extended introduction for the Chairman, which was to be used if the Senator had not yet arrived. So, we had the extended introduction, but first let me welcome Senator Lautenberg, and we look forward to your comments shortly, sir.

I'd like to welcome everyone to our first-ever General Aviation Accident Prevention Symposium. I'm very proud of the program that has been put together under the leadership of Dennis Jones, and I'd like to acknowledge and thank Julie Beal at this time and others on our staff who have assisted in trying to ensure that the facilities and support for this symposium are in place for today and tomorrow.

In addition, I would like to welcome all of you all on behalf of the National Transportation Safety Board and joining me in this morning is Member John Goglia, who's at the back of the room, who is with us.

I certainly also welcome you on behalf of Member John Hammerschmidt, Member George Black, and our newest member, Carrol Carmody. John is here. I see John, and is Carrol here? I know George is out, but -- so, John -- the two Johns are with us this morning.

I certainly hope that you will have an opportunity this evening to attend the banquet because we have arranged, in addition to Senator Lautenberg, as Dennis mentioned, Congressman Oberstar, who is well known for his leadership in aviation activities and is a very informative and entertaining speaker, and I hope you will be able to join us for that presentation this evening.

I called for this symposium to bring together members of the general aviation community to discuss operational, airworthiness and maintenance issues that affect the safety of general aviation flight.

The NTSB regional investigators will present information on accidents, followed by panel discussions on the issues associated with the specific accident. The accident reports presented today involve stall/spin, spacial disorientation, visual flight into instrument meteorological conditions, and adequate maintenance, crowd resource management, and a mid-air collision.

It is most fitting, I think, that this gathering is hosted by this agency. For decades, the Bureau of Safety within the Civil Aeronautics Board investigated civil aviation accidents. With the advent of the United States Department of Transportation in 1967, the Bureau of Safety was removed from the CAB into the newly-formed nucleus of the NTSB.

The 187 employees of the Bureau were supplemented by investigators from the other modes of transportation to fill the new multimodal role of this new investigative agency.

The Board was pretty well stretched from Day 1 in 1967. The original NTSB had only one metallurgist and shortly thereafter got a second. There was one individual in the Cockpit Voice Recorder Lab and two individuals in the Flight Data Recorder Lab.

The flight data recorders of that era, as many of you all remember, were recorders that recorded only five pieces of data with the stylus and had to be read up by an individual using a magnifying glass and the naked eye.

With electron-scanning microscopes and solid-state recorders containing data from literally hundreds of parameters, you can see how dramatically the work of the National Transportation Safety Board and that involved in accident investigation has changed over the years.

General aviation has changed over the years, too. After a decade or so of dormancy, the industry is on the rebound. I think people from other parts of the world would be astounded to learn the extent of aviation in our country.

There are more than 640,000 pilots flying in all aspects of aviation, from air carrier to general aviation. This number is expected to grow to over 700,000 in 2003. We have over 206,000 actively-flying GA aircraft, and by 2003, that number is expected to grow to over 215,000. General aviation pilots are flying about 30 million hours each year and is expected to increase to over 33 million hours by 2003.

The industry is large and getting larger. The General Aviation Manufacturers Association has amassed some very impressive statistics to prove that. In 1999, industry billings reached 7.9 million, up 35 percent in one year. It was just three years earlier that GAMA announced with great fanfare for the first time in the industry's history, it had an annual billing of just over 3 billion.

The industry reached a double-digit increase of general aviation aircraft shipped. In 1999, GAMA companies shipped 2,525 total units, 14 percent more than in 1998. Turbine engine shipments also grew in 1999. Total turbine shipments were up 13 percent to 778. Although turboprops dropped 3 percent, to 264 units in 1999, turboprop shipments increased by 24 percent, to 514 units.

The general aviation industry is a significant contributor to our nation's balance of payments. Exports increased 5 percent, from 535 units in 1998 to 562 units in 1999. The dollar value of those exports reached 2.5 billion, up 53 percent from the previous year.

Overall, exports accounted for 32 percent of total industry billings last year. Exports have been going up consistently for a number of years now. That is particularly interesting when you consider the environment in which this growth has been occurring.

To quote GAMA's newsletter, "In the past few years, Mexico has gone through a very painful devaluation of the peso. Asia caught the flu. Brazil experienced a financial crisis, and significant military actions have occurred in and around the Balkans. Still, despite all the instability in the world economy, GAMA continues to see a growing demand for America's general aviation aircraft."

Clearly, there is growing worldwide acceptance of general aviation as both an important business tool and a necessary element of economic development. There is a huge amount of untapped potential for this nation in the international arena.

Among the many challenges affecting the general aviation industry is a source of new pilots for the air carrier industry. In the past, the major supplier of pilots was the military. This pile is dwindling, and now they look to general aviation pilots as a major source of new pilots.

General aviation pilots acquire their certificates by contracting with a certified flight instructor or by attending a pilot training school. These pilots have many factors to consider as they move into the more complicated world past the private certificate.

One such area is, of course, the instrument rating, which gives a pilot the flexibility to fly the aircraft in instrument conditions. The challenge of flying more sophisticated aircraft is accomplished by achieving the multiengine rating and, finally, the air transport rating.

As you probably know, the general aviation community, the Federal Aviation Administration, as well as the NTSB, have joined together in an important safety initiative called "Safe Skies". I am pleased that our agency is participating in this initiative and look forward to the positive effects of the end product of that work.

That, of course, brings me back to the NTSB's primary role in general aviation, to facilitate the improvement of transportation safety. The Board is responsible for the investigation, the determination of facts, conditions and circumstances as well as the probable cause of accidents involving civil aircraft and certain public aircraft.

As you know, the Board makes transportation safety recommendations to federal, state and local agencies and private organizations for the purpose of reducing the likelihood of recurrences of transportation accidents.

We currently have 45 regional investigators located in nine different offices who conduct over 2,000 investigations each year. Additionally, we have two investigators now who are totally dedicated to the approximate 100 foreign accidents that are occurring each year.

By the way, the number of foreign accidents we worked on last year tripled in number.

The investigators who primarily investigate aircraft accidents in the United States have an average workload of 45 cases. Depending on the accident, a simple ground loop to loss of control in the flight of a turbojet aircraft, the number of hours of investigative work by a single investigator can vary from as few as 24 to more than 200 hours per case.

In many of the more complex accidents, additional help in the form of air traffic control specialists, engineering or weather specialists, or other specialists, may be required, thus increasing the time expended in the investigative work.

More importantly, during the course of the investigation is the need to identify safety issues and the subsequent proposals sent by the investigative team to the Board, suggesting recommendations that would prevent the likelihood of recurrence of the aircraft accident.

Ours is an awesome task and a very responsible one. It is the core of the mission and the core of the reason that Congress created the National Transportation Safety Board.

For example, many Part 91 flights are closely related to commercial operations in their common use of aircraft components and air space. Let me just give you one example. You'll hear many others through the symposium.

A regional investigation of a Part 91 Cessna Citation accident in Billings, Montana, generated a safety proposal that resulted in a special investigative report with 19 recommendations related to Boeing 757 aircraft, weight, turbulence and air traffic control procedures.

Many of our regional investigators are here today, both in the audience and making presentations. I am very proud of each and every one of these individuals. They are outstanding public servants, and I would ask them to stand so we can recognize them at this time.

(Applause)

CHAIRMAN HALL: Remain standing just a second. For our guests in the audience, these are not only investigators, but for these two days, they are also ambassadors of this agency. So, if you have any questions or need any assistance, in addition to those of us with the staff, please ask any of these individuals who are standing.

Thank you all very much.

These individuals are talented, dedicated people who have chosen a career field that I believe is emblematic of the very best in public service. They travel to the scenes of accidents that vary from deserts and triple-digit temperatures to the far north with temperatures as low as minus 40 degrees. They face wild animals.

One of our investigators recently learned in Alaska, when he was challenged by no fewer than five bears, one bear is not enough for an NTSB investigator. The bears departed the site only after being shot at and threatened by a helicopter.

I am mindful that funding that Senator Lautenberg and others have provided us will allow us to increase the number of regional investigators, allowing them more time to address the associated safety issues because they are working in a field that is growing and growing with new aircraft and new pilots each and every day.

I would like to recognize at this time now the men and women of the Federal Aviation Administration, particularly those who assist us in our mission, which, of course, is a mandate to be a party in our investigations.

FAA inspectors, by law, have nine areas of responsibility to examine on each and every accident, and I would like to thank Jane Garvey, the Administrator of the FAA, for her continued support of our investigations through the FAA's Flight Standard District Office investigators and inspectors.

In closing, let me say that the NTSB is not only one of the premiere accident investigations in the world, it is also what I call the national archives of what not to do.

We have investigated well over 100,000 aviation accidents in our 33-year history. Final reports on approximately 40,000 of them are available to everyone in the world on our web site, www.ntsb.gov. It is our mission and our responsibility to share this information with the general aviation community, so we can continue to improve the accident rate trend.

Just in the past decade of the 1990s, the rate of accidents for general aviation aircraft per 100,000 hours dropped 9 percent. The final accident rate dropped 19 percent.

Let me say to you, these are not just statistics. These are human lives saved. Productive individuals who go safely home to their families and their communities.

Just over a year ago, our nation experienced the pain that just one of these crashes caused two families to endure. This is being repeated by other families every week, and that is why it takes all of us, all of us, not only at the Board but throughout the general aviation community, from the manufacturers and the pilot community to the people who write the many magazines and periodicals that cover the aviation community, to the FAA investigators, it takes all of us to get this safety message out to the hundreds of thousands of general aviation pilots.

As a means of getting this safety message out of this symposium, we are making a broadcast, and you can note these cameras, and this meeting will be available live -- well, not live but delayed on our web site, and tapes of it are being made so it can be shown at fly-ins, such as Oshkosh, Sun and Fun, and if there are other uses that those in the audience might want to make of the proceedings of this symposium, please let us know because the whole purpose of this is to get the safety message out to the general aviation community.

We have two full days ahead of us, and we have a very special treat to kick off those very important two days. I am honored to introduce a United States Senator who has worked tirelessly to improve safety in all modes of transportation, the Honorable Frank Lautenberg from New Jersey.

I first met the Senator shortly after I became a member of the Board as a result of the unfortunate tragedy of a pipeline accident in Edison, New Jersey, and I have noted throughout my tenure at the NTSB the strong support and interest that Senator Lautenberg has brought to the area that brings us together today.

Senator Lautenberg and I have several things in common. We're both Democrats. We're both military veterans, and we will both soon be leaving our current positions.

The Senator is retiring after 18 very active years. I will be leaving the Board after seven years of some level of activity as well. Senator Lautenberg is currently the Ranking Member of the Transportation Subcommittee of the Senate Appropriations Committee.

Before the 1994 elections, he was chairman of that subcommittee. His years of service in the United States Senate have been distinguished by his concern for the well-being of the America's traveling public as well obviously as his constituents in the great state of New Jersey.

During his tenure, he authored laws that established 21 as the national drinking age, and you just don't know how many lives of our young people that law has saved. I can personally attest to that.

That legislation reduced the human toll that drinking and driving that has been exacted on our teenage population. In fact, this law saved approximately 19,000 lives according to statistics since 1984.

Senator Lautenberg is now working to establish .08 as a national drunk-driving standard, another measure that I personally support.

Senator Lautenberg wrote the Aviation Security Improvement Act of 1990, which was passed in the wake of the downing of PanAm Flight 103, and he authored key elements of the Federal Aviation Administration Act of 1996, which tightened airport and airline safety and security rules. He was also the driving force in banning smoking among U.S. airliners.

Please join me in welcoming and bringing to this podium a great friend of the aviation community and of this agency, Senator Frank Lautenberg.

(Applause)

Remarks

SENATOR LAUTENBERG: Thank you very much, Chairman Jim Hall, and to all of you in the audience, I am pleased to be here with you today because there are a couple of myths that I would like to air with you.

First of all, how do you feel about having a fellow talk to you about safety when he comes like this? It sounds like not a very good kick-off to me, but this was coming out of the grocery store. That's what I tell people anyway.

First, I want to say to Jim Hall and the NTSB team, we are very proud of you, the work that you do, the investigators, all parts of the NTSB organization, because there's a feeling of confidence.

When you see someone from the NTSB show up at an accident, that we are there not to stand and mourn or grieve but to learn but to make a difference in the future, to see if these kinds of things can be prevented, and they do the job very, very well.

This is an agency that in my view is in favor with all parts of the Congress and both parties as well. So, I'm pleased to be here to share this day.

There are a couple of things that I'd like to put on the table right away. Are there people outside the agency here? Do we have people from the general aviation community? Pilots, airplane owners, etc.? Yes? Oh, good. Okay. Because I'd like to direct some remarks your way.

I used to think that -- and by the way, Jim Hall mentioned that with the terrible tragedy that took place with PanAm 103, that we did learn things, and I was on the Aviation Study Committee. It included then Congressman Hammerschmidt, then Senator D'Amato, Congressman Oberstar, myself, a few other people, and we learned an awful lot.

We traced the journey that 103 took from starting in Frankfurt, Germany, and went to Lockerbie, Scotland, to talk to the people there, and it was very helpful, and it encouraged us to stimulate and encourage the research on explosion prevention, security devices, a lot of that done in New Jersey at the Bill Hughes Aviation Research Center, in Pomona, New Jersey.

I am a part-owner of a KingAire 90, and I have an affection and an affinity for general aviation. I love to fly. I'm not a pilot. I'm a warrior, but I sit in the second seat, and I help us stay on the look-out, and by the way, we have in that airplane TCAS equipment, and I mention that because you learn when you fly in the New York-New Jersey area how crowded the skies are and how often the device responds to you, traffic, traffic, traffic, and, so, you know what to look for, and you know that you have to be on the alert, and, boy, I'll tell you something, I've flown in lots of things, little and large, and it is so comforting to have that kind of device, but if you don't have it, it's expensive, then it makes the task just a little more difficult.

When I first saw a sign that said -- a bumper sticker called "PAL", I always thought that was the Police Athletic League. Turns out that in New Jersey, there's an organization called Pilots Against Lautenberg, and I said -- forgive me. I said, "What the hell could that be?" I encourage aviation. I want to see that equipment is developed that helps prevent incidents. I want to see general aviation part of the system.

I am very much in favor of general aviation as the Chairman, Chairman Jim Hall, said in his remarks, but I did want to examine the usefulness of two airports, one Atlantic City, and I've flown in there, and there's a couple radio towers there that are on a field this small, and we've had accidents there, and frankly we've opened a major new facility, not opened a major -- expanded a facility that existed there, Atlantic City International Airport.

We took the ownership of that airport out of local hands to try and make it more representative of the community and the area, to make it more efficient, make it warm and friendly for pilots, general aviation. There are some military there and a significant amount of commercial aviation, and it functions well, and, yes, it's 15 minutes further away from Atlantic City than Baker Field, which is almost in the lap of the hotels, and, so, that's my view, safety, and there's a little baseball park there.

I threw out the first pitch when the league started there, just about reached home plate, people thought I was bowling, but I had a reason for expressing my views.

Linden Airport's another. Linden Airport's in the glide path of Newark. Now, Newark is a fairly busy airport, in case it wasn't realized. There are a few single engines there, and I'm not demeaning single engine aircraft, but it's a very small population, sits in the highly-industrialized area, and it is a property of great value to the community, and thusly I incurred the rage or the ire of the pilot community, and I think that it's a bum rap, I've got to tell you.

With a record that you can examine, that says yes, Lautenberg was there to support all the advances that we could. If you ask Jane Garvey, Frank Lautenberg, and I don't want to boast, but that's not like a politician, but I managed to scrape a couple hundred million dollars out of the budget when they were going to deprive FAA of its required funding.

So, I made sure that they got it, and I'm here because I hope that we can continue the wonderful development of general aviation.

I know that smart airplanes are getting ever-more expensive, that people who years ago were able to jump into a single, a small single and fly, enjoy flying, are often prohibited by price. Look at the price in the used aircraft market today. It's gone crazy.

If you want to buy one of the larger private jets, general aviation kind of equipment, you might have to wait two or three years to get an airplane. People are selling place-holders and making lots of money because that's the condition of our economy and our world today. Thank goodness, good leadership in this economy in this country has put us where we are in this economy.

I'm also the Ranking Member of the Budget Committee, and I can tell you firsthand that President Clinton deserves a lot of credit for having gotten this economy to the point that it has, and as a consequence, we see an interest, a greater interest in aviation.

So, I'm here to just talk to you about a few things that I hope will be of interest. First, let me tell you a story because Jim Hall reminded us about the hazards that the investigators sometimes go through, finding wild animals, incurring high risk as they get into dangerous places.

Well, there was a time in California when a fellow appeared in court, and the charge was that he had eaten a California condor, and the judge was irate. He said, "The whole world is working to save the condor." He said, "There are six of them alive that we know about, and you ate the condor." He said, "I'm going to throw the book at you. You're going to jail, brother, and you're going to stay there a long time", and the person who was charged stood up and said, "Your Honor, please, give me a minute. I've got to relay the conditions."

He said, "I was flying my airplane, single engine, in the Sierra Madres. I landed, and I crashed, and I was pinned in the wreckage, and I was there for three days, and I was beginning to starve, and I reached out when a condor landed nearby, and I grabbed it by the leg, and I plead guilty. I was starving to death, and I ate the condor."

The judge said, "Gee, those are rather unusual circumstances." He said, "I'll have to rethink my decision." He said, "I'm going to let you go, but we're going to publicize this so that it's an example for people across the world." The defendant said, "Thank you, Your Honor", and he started walking out, and the judge said, "By the way, what did the condor taste like?" He said, "It tasted like a spotted owl."

Anyway, I assume that your investigators aren't doing that kind of thing.

Let me take a minute to recall an incident that recently happened in New Jersey, just this past August. It was a bright sunny morning, Piper Navajo took off from Lakehurst Naval Air Engineering Station, Central Jersey, stopped at Trenton-Mercers Airport to pick up passengers and then headed toward Maryland, carrying seven civilian Navy employees and two crew members.

About the same time, a Piper Seminole carrying a flight instructor and a student took off from Northeast Philadelphia Airport. 8:00 in the morning, approximately, the two planes collided in mid-air, clear as a bell out there. They were about 10 miles south of Trenton, 11 people on the two airplanes died, and the debris came down in an area called Burlington Township.

One airplane crashed through a roof and set fire to the house, the other plane landed in a field nearby. Amazingly, no one on the ground was hurt. The tragedy that alarmed those on the ground, I'm sure, sent shock waves throughout the general community, brought a reaction.

The questions that were raised. Why did this happen? How could they not know? Couldn't they see? All of the things that all of you interested in aviation have heard, and I'll tell you what happens, is the reaction of the community at large is to say shut down these airports, stop private flying general aviation. It's an overreaction, but one can understand when you look at what's happened.

These crashes highlight the reason that you're gathered here today, to analyze why they happen, figure out how to prevent them. In New Jersey, we've had several accidents, and it's frightened people substantially. They think it was the general aviation pattern, that there are things that happen, and we didn't -- that wasn't the only tragedy that we had in New Jersey.

We had several serious crashes in the last year involving small craft. In May of last year, a Cessna 206 lost power when it struck a tree, caught fire, trying to make a forced landing at Piscataway, New Jersey.

November, a Beech 35 collided into a restaurant in Newark, came out of Linden Airport. A Beech 58 crashed into a house in Hasbrouck Heights, and NTSB was there, and I was there as well.

It does disturb the general population. Today, there's all kinds of actions trying to shut down the hours that Teterboro operates, but with a more ominous message in the back, and Teterboro Airport, I don't know whether anybody here has the statistics, but it's one of the busiest airports in the country, including all the commercial airports, and is strictly a general aviation airport. I use it a lot. It's an excellent airport, but folks don't understand why it is that we can't control it, and we know the safety record of general aviation is pretty darn good.

We heard it from Jim Hall. 1990-1999, general aviation pilots flew more than 228 million hours, and it's a testimony to the diligence of people like yourselves that general aviation accident rate has decreased over the past few years.

Last year, there were 7.05 accidents per 100,000 general aviation flight hours compared to 10.9 accidents in 1982, a significant improvement, means the skies are safer, but as we saw in the New Jersey crash, we have room for improvement, and your efforts will help greatly.

If we can learn something from every crash, perhaps we can help ensure safer travel, and it's sad, and I realize as you do, motor vehicles are involved in about 10 times as many accidents per mile as do general aviation aircraft, but people on the ground have little or no tolerance for small plane crashes. There are not enough of them that are involved in the activity, particularly when they read in the paper about how a plane ended up on a road or fell through a house.

Those who live near small airports shouldn't have to worry while they're going about their normal business that a plane is going to drop out of the sky. Five million general aviation flight hours were flown in New Jersey in the past nine years, and many who live near small airports worry about accidents. I hear from them frequently.

I can tell you that people are concerned. I recommend a few things. First, I urge, as you always do, work to improve pilot training. With every crash that occurs, we can learn a little bit more about what can go wrong. For instance, analysis has shown that many accidents occur when pilots are engaged in tasks that take up little time but are critical and often complex.

We also know that a substantial number of fatal accidents occur while pilots are maneuvering single engine planes, and knowing that kind of information ought to be able to help us better prepare pilots for the cockpit, to help them avoid trouble.

Second, I urge that you use existing and future technology to improve safety. The more information you have about such things as to what other pilots are doing in weather, the safer we're all going to be.

Finally, I hope that the FAA will look closely at what it can do to help make flying safer. I know that the officials there, the organization there, are so focused on commercial aviation, they have to be, that it's thought that they may overlook the needs of general aviation, but regulators can help, and I don't believe that they should or do play an adversarial role.

So, the message, I guess, is we should all work together to make flying safer. I think one of the important things that has to happen is that it has to be understood how safe the general aviation is, what a strong influence and part of the general community it is, that it isn't primarily a hazard or a menace, it's primarily an asset that has helped this country build the economy and the structure that we have, and, so, I think it's very important that we all join in in getting the message out there.

I don't expect the PAL signs to be ripped off the bumpers in New Jersey, that's part of the job, but I think that if the message is clear that -- and we can examine whether or not an airport has a value in its operation, that we ought to make that known.

But if there is a replacement airport nearby, if it doesn't serve the task that we originally thought it might, that we ought to take a look at these things and not be afraid to either criticize or recommend something different be done with those airports.

So, my friends, fellow airplane owners, and I can't say fellow pilots because I haven't taken -- someone said to me, "Well, why don't you take a" -- what do they call it? A course, the one-day course. It's a pinch-hitter course. Said, this pilot friend of mine, said, "What happens if we're flying along, and I suddenly go, I said I go", and thank you very much for the opportunity. I've got to run, Jim.

(Applause)

CHAIRMAN HALL: Thanks very much.

SENATOR LAUTENBERG: I've got to run, Jim. Thanks very much.

CHAIRMAN HALL: I for one represent pilots for Senator Lautenberg.

MR. JONES: We'll be taking a short break and return for our first panel. Thank you.

(Whereupon, a recess was taken.)

MR. JONES: Okay. Our first panel will be about stall/spins. The program will consist of presentations about selected accident investigations by air safety investigators from NTSB Regional offices.

The seven investigators you will see over the next two days represent collectively over 40 years of accident investigation experience. They represent each of our six regional offices. These are the people who are on call 24-hours a day to respond to mostly general aviation accidents throughout the nation.

It seems that accidents generally do not usually occur during business hours, Monday through Friday, but during weekends, which means they spend much time away from their families as well.

I know many of you have read our accident reports over the years, but I would hope that during the symposium, that you get to know some of our investigators who are behind these reports.

Their presentations will be followed by a panel discussion with a panel comprised of industry, government and organizational authorities. Each panel will be headed by a moderator. We have assembled a panel of professional aviators who are widely respected from the accident investigation, training, academic, maintenance, regulatory, manufacturing and safety communities, who we feel will provide interesting insight and comments on the various subject matters.

The panels have been asked to discuss their thoughts about the accident and how the accident could have been prevented. After the panel discussion, there will be question and answer periods for the panelists. The NTSB investigators will not be included during the question and answer period because they're here simply to provide a scenario and a seque into the discussion about the subject matter.

We have provided index cards or, I should say, there is in your manual, a note page that you can use for your questions that you can pass to our staff people. We have Beverly Drake and Craig Flynn, who will be picking up questionnaires that we will use for our question and answer period.

With that, we'll start, and I'd like to introduce you to Jeff Kennedy, who will be our first presenter. I've known Jeff for quite a few years. In fact, we go back well over about 20 years, isn't it, and because I'm very young and probably the Safety Board broke a couple of child labor laws in order to hire me some years ago, but we've known each other ever since back at Embry Riddle, well back into the early `70s.

Jeff has been employed by the National Transportation Safety Board as a senior air safety investigator and is assigned to the Southeast Regional Office in Miami, Florida.

During 17 years with the NTSB, he has investigated over 900 aircraft accidents and incidents. He was the investigator-in-charge for accidents or incidents involving a McDonnell-Douglas DC-9 in flight spoiler activation on short final approach at Nashville, Tennessee, a Boeing 747 and McDonnell-Douglas MD-11 ground collision at Miami, Florida, and an Airbus A300 in-flight engine fire at San Juan, Puerto Rico.

Prior to being employed by the NTSB in 1983, Jeff worked as an aviation insurance adjustor and an airline pilot. Jeff holds Master degrees in Aeronautical Science and Business Administration from Embry Riddle Aeronautical University.

Mr. Kennedy is a graduate of the NTSB and University of Southern California, Aircraft Accident Investigation Schools, the Air Force Jet Engine Accident Investigation School, and the NTSB Fire and Explosion School.

Mr. Kennedy holds FAA airline transport pilot, flight engineer, air frame and power plant mechanic, aircraft dispatcher, and ground instructor ratings. Mr. Kennedy has 3,500 flight hours.

Please join me in welcoming Jeff Kennedy.

(Applause)

Stall/Spin Accident

MR. KENNEDY: Can everybody hear me okay? I can hear that you can hear me now.

Good morning. Again, I'd like to welcome you to the National Transportation Safety Board, General Aviation Accident Prevention Symposium.

This morning, I will be presenting a case on an accident involving a stall/spin. The accident occurred at Homestead, Florida, on May 25th, 1997. The airplane involved was a Cessna 205, November 8214 Zulu. The accident resulted in the fatal injuries of six persons and one person received no injuries.

The accident occurred at 1:51 in the afternoon, and the weather at the time was scattered clouds at 25,000 feet, visibility of seven miles, temperature of 84 degrees, and the winds from 120 degrees at 10 knots with gusting to 15 knots.

Homestead, Florida, where the accident occurred, is located south of Miami on the southern tip of Florida. Most of you'll probably remember Homestead as being the center of destruction caused by Hurricane Andrew in August of 1992.

The airport that the aircraft operated from was the Homestead General Airport, and it is located to the northeast of the town of Homestead. To the southeast of the airport, there has been a designated jump zone where the parachutists are dropped.

The stall/spin accident we're talking about involves a flight that was for the purpose of dropping parachutists, and the crash site where the aircraft crashed was approximately two miles southeast of the center of the airport.

The airplane involved is a Cessna 205. This is a picture of a similar type aircraft. The airplane was -- had installed a special jump door for parachutists to exit the aircraft, and it also had a step for the parachutists to stand on prior to jumping mounted on to the right main landing gear.

This investigation involves a pilot who failed to maintain air speed while approaching to drop -- approaching a drop zone to drop one of several parachutists which resulted in the aircraft stalling, entering a spin and crashing.

The next slide will be a video tape that was taken by a bystander at the Homestead General Airport, happened to have his video camera running, and when his attention was brought to the airplane spinning down, he did manage to capture the airplane spinning on video as well as the aftermath of the solo parachutist who jumped from the aircraft prior to impact, and the smoke from the crash site itself.

We do not have any sound with this particular clip. We did not include the sound with this.

There's the airplane in the spin. This is the solo parachutist that had jumped, and the smoke is caused by the aircraft itself. One thing about the sound that was recorded by the video recorder from the witness, we did hear engine noise on the video tape, and to the naked ear, it sounded as if the engine was running at a higher power than idle.

We did bring that video tape up to the laboratory, the Cockpit Voice Recorder Laboratory, here in Washington, and the sound technicians did analyze the sound, and the spectrum that they came up with indicated that the engine and the propeller were turning at 1,350 rpm which would probably be representative of the engine at idle in that configuration.

The flight departed from the Homestead General Airport at 1:45 p.m. On board were the pilot and six parachutists. One parachutist was to jump from approximately 3,500 feet. Two parachutists were to jump tandem with instructors from a higher altitude, and the final parachutist was a cameraman that was to jump behind the two tandem parachutists and video tape their jump.

As the flight slowed at 4,200 feet as seen on radar, with the solo parachutist on the right wing step preparing to jump, the airplane entered into a spin to the left. After several rotations, the solo parachutist jumped from the aircraft and came to the ground on her chute. The solo parachutist observed the airplane as she descended in her chute continue in the spin and crash into a field, which resulted in the fatal injuries to the pilot and five parachutists that remained on the aircraft.

The solo parachutist's statement to the NTSB is that the normal jump speed was 80 miles per hour, that they usually slowed the aircraft to 80 miles per hour, and that she would exit the airplane on to the step and then jump from there.

She stated that this day, as she exited the airplane and stepped out on to the jump platform, the wind resistance was not as strong as it had been on her previous jumps. As she moved on to the step, the one instructor, who was also the owner of the jump company and also a pilot, moved into the right front position of the aircraft's cabin.

The two tandem jumpers were located in the middle area of the airplane, and the other instructor was located in the aft area of the airplane along with the photographer.

As she was out on the wing waiting for the instructor to give her the signal to jump, she stated the left wing of the aircraft dropped, the aircraft started turning to the left, the nose of the airplane then dropped, and the aircraft began spinning to the left.

As she was looking into the cabin at the instructor for the jump signal, she saw that he was turned from her and was looking at the airplane instruments on the left panel of the aircraft.

There was only one control wheel in the airplane, and that was in the left panel position. The right control wheel had been removed to accommodate jumpers.

After an unknown number of revolutions, she finally jumped from the aircraft. As she descended in her chute, she observed the aircraft continue in a spin until ground impact. She stated to us that upon ground impact, the aircraft pivoted on the left wing and nose and impacted flat on the ground coming to rest.

This was a source of confusion for us during the investigation as when you see the photos, the impact looked similar to that of an airplane that possibly was in a flat spin, but we know from the video that it descended behind the building.

The airplane was still in a nose-down spin, and that as she descended in her chute, she did verify to us that the airplane continued in a nose-down spin until the left wing and nose contacted the ground at which time the airplane did go flat.

Radar data, which was captured by the FAA Miami Approach Control, showed the following information. At 1:50:28 Eastern Daylight Time, the aircraft was at 4,200 feet on a heading of 110 degrees at a ground speed of 77 knots.

At 1:50:37, the airplane was still at 4,200 feet heading 117 degrees at a ground speed of 75 knots, and then at 1:50:42, the airplane was still at 4,200 feet heading 122 degrees with a ground speed of 73 knots. At 1:50:46, the airplane has descended to 4,000 feet heading 122 degrees, and the ground speed is 71 knots.

The next radar data that was recorded from the aircraft occurs 24 seconds later, and the airplane at that time is now at 900 feet. There was an associated heading and ground speed with that radar hit. However, at that point, the aircraft is in a spin and proceeding towards the ground.

This is a view of the airplane looking towards the north. The airplane did impact or come to rest, rather, on a 180-degree heading, and again as I spoke, notice the flat appearance. The airplane is basically upright, but it just has the appearance of being -- impacting the ground in a flat attitude.

This is a view of the wreckage towards the southeast. It shows the right wing and the right side of the airplane in the right tail area. A view to the south, again showing the wreckage, again notice the flat appearance of the wreckage. A view to the southwest showing the tail area, the vertical fin, the rudder, the left elevator and horizontal stabilizer, and a view to the southwest again showing the left wing of the aircraft.

The pilot of the aircraft attended an aeronautical university where he obtained flight training and graduated in 1994 with an FAA commercial pilot certificate with airplane single engine land, airplane multiengine land, and instrument airplane ratings.

The pilot certificate -- his pilot certificate was last issued on June 14th, 1994. The pilot's log book showed that he did not log any flight hours from August 15th, 1994, until March 26th, 1997. During this period, and at the time of the accident, the pilot was employed as an aircraft dispatcher for a commuter airline in Miami, Florida.

On March 29th, 1997, the pilot completed a biennial flight review, and on March 31st, 1997, the pilot flew with the owner of the sky-dive company, who was also the fellow that was in the right front area of the airplane at the time of the accident.

They flew in a Cessna 172, and the purpose of the flight was to instruct the new pilot on parachute operations. They did not use the Cessna 205 for the training for parachute operations because the airplane only had one seat. The rest of the seats had been removed to accommodate parachutists.

The pilot began flying the Cessna 205 for parachute operations on April 2nd, 1997.

At the time of the accident, the pilot had accumulated about 82 flight hours in the Cessna 205 during parachute operations. At the time of the accident, the pilot had accumulated about 290 total flight hours.

The pilot log book records and records from the university where he attended showed no entries for in-flight spin training in airplanes. The log book records as well as the university records did show entries for ground instruction in spins and spin awareness, and that is required by the regulations for the recreational and private pilot certificate.

The pilot's roommate stated to NTSB after the accident that the pilot had talked about performing spins at one time in an airplane, but none of -- this was not -- we could not find any entry of this in his pilot log book, reflecting that he had had in-flight training or had performed spins in an airplane.

Current FAA regulations require that applicants for recreational and private pilot certificates in airplanes have received ground instruction in "stall awareness, spin entry, spins and spin recovery techniques".

Current FAA regulations do not require that applicants for recreational, private, commercial and airline transport pilot certificates in airplanes have received in-flight instruction in spin entries, spins and spin recovery techniques.

Current FAA regulations require that applicants for flight instructor certificates have received flight and ground instruction in stalls and spins.

The findings. The pilot held an FAA commercial pilot certificate. The pilot had no alcohol, drugs, carbon monoxide or evidence of medical incapacitation. No evidence of aircraft structure, flight control systems, power plant or propeller failure was found after the accident.

The weight and balance was found to be within limits, and we discussed that briefly just before the presentation in reviewing the report with the center of gravity was found to be approximately in the mid-area of the limits, and, so, basically, he was in the center of the limits.

The information of how we developed the weight and balance conditions was based on the location of the victims after the accident as well as the information that was supplied to us by the solo parachutist that jumped and her positioning of the folks in the airplane.

The other finding. The airplane did enter a spin and did not recover. The standard light airplane spin recovery techniques are effective in the Cessna 205. This was information that we obtained from Cessna Aircraft and the flight test documents for when the airplane was flight-tested back in the early 1960s.

The FAA has no spin flight training requirements for recreational, private, commercial or airline transport pilot applicants.

The National Transportation Safety Board determined that the probable cause of this accident was the pilot-in-command's failure to maintain air speed as he slowed for a parachutist to jump from the aircraft, and his failure to apply spin recovery emergency procedures prior to ground impact.

The NTSB also determined that contributing to the accident was the pilot-in-command's lack of training in spin recovery emergency procedures in an aircraft and the FAA's failure to require that a pilot demonstrate spin entry and spin recovery techniques in an aircraft.

This concludes my presentation. I now turn the floor over to Mr. Gene Littlefield, the moderator for this panel.

(Applause)

MR. LITTLEFIELD: Good morning. The NTSB's dissection of this situation, and it promotes a lot of questions, and our own experience in Illinois, we run an aerobatic school there. This is what we do. We're in our 30th year teaching aerobatics.

Spins and spin recovery techniques are a given, and as a matter of fact, the spin in some cases is a rather benign maneuver that can be handled very well.

Interestingly, this airplane, which Cessna says will recover in its -- in, I believe, the -- within the given parameters that the -- is set for airplane spin recovery, but still placarded against spins, interesting.

I'll try to be brief with what I have to say about this. The aircraft performance. Everyone stated in some form or another that the engine was under power even after the nose pointed downward. Jeff mentioned that in checking this, it appears now that that was simply a sound, and that he had retarded the throttle.

I put in my notes that the expected closure of the throttle didn't happen, and that may be incorrect.

The speed was questioned by both a witness at take-off. I believe it was the airport manager who said he just barely cleared the fence. Something else to think about in this, and a jumper survivor who said that the speed was not what she expected when she stepped out.

So, in the case of an engine under full power, as this was, and most of the controls were found in that position at impact, also the cowl flaps were closed, which may be impact-related, but since we're talking about an airplane that wasn't performing right on that particular flight, it's possible the cowl flaps were closed for the entire climb. If so, may have accounted for some of the performance problems.

The pitch down of the airplane by the -- who was -- by -- as witnessed by the jumper survivor, she also said that the owner-instructor, who, by the way, was the instructor for the parachutists and this pilot, and owner of the company, he moved up into the position that she occupied doing several things.

He was going to help this pilot as the airplane pitched down. He began to help the pilot or did what he could in the situation that he didn't see coming, but he also blocked the only exit in the airplane.

There's a very small exit in the back of a 205. I don't think that you could exit that with jump gear on, and I'm not sure how many of the jumpers were prepared to go at that point. Two of these were tandem jumps. They had to be tied together, and whether they were tied together at that point or whether they would join up prior to their exit from the aircraft, again a point to make.

The stub that was -- that you heard him talk about, the controls were only in the left position for the pilot. There was a stub still in the panel, just another interesting side note. Whether it had anything to do with this or not, one of the maintenance assistants said that the stub would operate only the aileron and not the elevator.

From a mechanical standpoint, I'm not sure how that happened, but that's what he said.

The minimal or no spin recognition training for this pilot and minimal time set up a lot of the scene. His experience was minimal at best. There wasn't a confirmation really of the completion of a biennial flight review.

If you've read this text, one pilot or instructor, rather, started the biennial. The chore was turned over to another instructor, and from what I could read really didn't complete it, and I'm not sure about the sign-off. I didn't find that in the text. So, it's possible that he did not have a completed biennial flight review.

The maintenance records were not available and still are not. Airworthiness wasn't confirmed by either a repair station or an inspection authorization.

Another maintenance assistant stated that the maintenance was poor. The flaps had been disabled because they were deploying in an uneven state. So, they were either purposely locked in position or just the pilot was told not to use them.

It is my understanding that that determines the airplane then to be in an unairworthy condition. The flaps do have to operate for that airplane to be airworthy.

The wreckage photos, you saw those. The photos were taken from angles, rather flat angles, and not from the above position that I -- it kind of stirred my curiosity there.

The normal wing forward separation that's found in a nose-down impact wasn't there. The wings are -- did not move forward. If they did, it wasn't much and hardly visible in the photograph. However, everyone said it was, and the video confirms that, that the airplane was in a nose-down condition, and at this point, we believe power off.

The occupants. I mentioned the small baggage door in the rear of the aircraft, and also I'm not sure whether everyone, other than the video jumper, was ready to jump. Possibly the pilot ready to jump if he was wearing a parachute as he should have been, and the owner-instructor would have been ready to jump. The other four, maybe not, but in any case, the only exit was blocked by the man who was the owner-jumper-instructor who was trying to help the pilot.

This plane was not airworthy because if, for no other reason, because of disabling the flaps to not even in an MEL could you do that, I'm sure, and then, of course, the main exit being blocked and, of course, that was -- that certainly wasn't planned. The instructor-owner was trying to help the situation, not hinder it.

Our industry -- just an interesting side note. I have our 30 years and 30 consecutive years of teaching aerobatics. We get into the spins. Many times great anxiety about spins, and it's more and more prevalent because students, instructors, very seasoned pilots, we have pilots that come to us who fly for airlines and are ex-military.

We make light of it. We tell them, you know, please don't apologize for that. We can teach you to fly anyhow, and that we have a very experienced -- from very inexperienced to great experiences, and you would be amazed at the amount of anxiety that comes from just we're going to spin the airplane.

We've pulled away, and I say here that the industry for various reasons has continuously pulled back from training with regards to the spin and stall or deep stall recognition and correction in flight.

We've got instructors who have only come close to the incipient stage of either of those, and they're told don't let the aircraft spin. Many of the new airplanes, some now, the more recent entries into the general aviation training market, are t-tailed. They can't do soft field take-offs or short field take-offs and are placarded against spins.

See the placard. It says can't spin that airplane. Well, the mindset comes up not far after that that it won't spin. Well, it will, and you need

-- and in most cases standard spin recovery will right the airplane, but we don't take that that far. It certainly isn't on the placard. If we had to explain the total spin situation, we'd be writing all the way down the side walls to the floor of the aircraft.

Pilots with extensive experience in stall and spin recovery are phasing out for various reasons, attrition, certainly age, some gray hair. So, we have instructors who in some cases have never experienced a stall/spin situation teaching other instructors, thus creating problems rather than solutions.

Most general aviation aircraft, and I make this point because it again comes back to what we do, there are two things an airplane won't do by itself. It will never render itself inverted. Just isn't going to get there. The other thing that it won't do, it will not spin by itself. Those are pilot-imposed maneuvers, and in our pulling away from training in that regard, it needs to be looked at.

We need to rethink why we did that to begin with, and whether we can at this point back up far enough to get this training back into our industry.

It's kind of frightening. I put at the bottom here, and I will sum it up with this, it's kind of frightening to think that a pilot simply through ground fear would descend all the way to impact with full up elevator and never allow the airplane to fly due to poor or no training in regards to spins or stalls. I think that's -- it kind of goes without saying, but it really needs to be said, and it's going to be said rather often here this morning.

That is the end of my summation. I want to introduce the first member of our panel, Mr. T.R. Proven, and he began his Federal Aviation Administration career in 1975 as a general aviation operations inspector. He's been active in general aviation subject since that time.

Mr. Proven has done tours with the FAA, Air Carriers, Flight Standards and International District Offices. He completed an FAA Headquarters tour in 1993, has been an air safety investigator with the Office of Accident Investigation since 1998.

Mr. Proven is a former naval aviator who retired from the Naval Reserve after 26 years. During his career, he flew a variety of attack fighter and transport aircraft, was also an FAA-designated airline check captain on the BA-111, BA-737, B-737, I beg your pardon, and the DC-8.

Mr. Proven is a certified flight instructor for airplane and holds an advanced instrument ground instructor certificate.

I'd like to introduce him at this point.

MR. PROVEN: This one works? Okay. I must tell you that having read the other presentations this morning for the first time, that my presentation became much shorter. There's no reason to cover the material that will be covered in just a few minutes.

But I did want to make one point, and that is that when I read this accident report, much like Gene here has said, the airworthiness issue jumped right out at me, and, unfortunately, this is a recurring issue with sky-diving accidents. The airworthiness of the aircraft is suspect or known to be deficient.

Jim Silliman knows about Michigan, and the FAA Office of Accident Investigation has recommended to the Flight Standards District Office -- excuse me -- to the Flight Standards District folks, division, that surveillance of the maintenance of sky-diving aircraft be increased to ensure that at least they meet Part 91 standards and will begin to deal with the issues of should they be at a higher level some other time, but at least reach Part 91 standards in terms of their maintenance.

But I must say, after reading the material, that it looks like everybody else has done a fine job, and I'll just bow out and let them take over.

Gene?

MR. LITTLEFIELD: Thank you. Let me get my stuff together again.

Our next panel member is Bob Schuster, and let me introduce you, Bob. He's currently an Assistant Professor in the Division of Flight Training at Florida Institute of Technology, a great place, Director of Operations for FIT Aviation, Incorporated, and his responsibilities include in-house accident/incident investigations for the university, FBO, as well as teaching a course that deals with crew coordination, crew resource management utilizing the university's Turbine Flight Training Device.

Prior to his tenure at FIT, Mr. Schuster was the Flight Training Coordinator for Broward Community College in Pembrook Pines, Florida, responsibilities included developing and teaching single and multiengine turbine transition in the school's Flight Training Devices and the oversight of the school's 410 CFR 141 Flight Training Program.

Mr. Schuster has over 25 years of flying experience, has been instructing since 1986. His certificates and ratings include ATP, airplane motor engine land, commercial, single engine land, certified flight instructor, airplane single and multiengine, and instrument flight and ground instructor.

He has a Master of Aeronautical Science degree from Embry Riddle Aeronautical University and holds an MA and BA in Education from Florida Bible College.

Presently, Mr. Schuster is a member of the Aircraft Owners and Pilots Association, the Experimental Aircraft Association, the National Aeronautic Association, also serves as a Federal Aviation Administration safety program counselor, has been a speaker at FAA safety seminars and is a participant in the FAA Wings of Safety Program, Level 12. Wow.

Bob Schuster.

MR. SCHUSTER: Thank you. Let me see if I can get the -- do I have to flip the on button here?

It's a pleasure to speak with you all today. I didn't realize I would be standing in the shadows of such great individuals as I am with the panel and out here.

As I present my presentation, one thing I would ask you all to do, I'm amongst some of the greats in aviation, but as we look at the facts and a lot of what I'm going to present are a rehash of what Jeff brought out, please take away all your personal experience because there's so many things that as we look at this accident, you're going to say, "gee, I would have never done that or I would have gone out and got a couple of hours in the 205 just to see how the aircraft flew before I got into the business of being a jump pilot".

Push all that aside and look at it just from the aspect of the Federal Aviation Regulations and the requirements that are there.

As we look at the facts from the investigation, there are certain things that come to light. There were no mechanical problems with the aircraft. In fact, Jeff pointed out there were no failures of the air frame, of the power plant, of the flight controls, of the propeller.

The aircraft was within limits with regard to CG, was right in the center, and the flight was conducted under 14 CFR -- VMC under 14 CFR 91. There were no violations as far as no violations of the Federal Aviation Regulations.

Okay. Everything stacks up. Everything's great. The pilot was a recent graduate of a highly-respected aeronautical university, held a commercial pilot certificate with airplane single, multiengine land and instrument airplane ratings. His training received from this university was conducted under 14 CFR 141 which, as you all know, is the highly-structured and regulated method of instruction.

In short, he had some of the best training available, and those of you that are graduates and alums from that particular aeronautical university would probably agree.

The pilot held a first-class medical certificate. During the report, the tox screens showed that there was no alcohol, no drugs, no carbon monoxide, or no incapacitation on the pilot. He was physically capable of conducting the duties of the pilot-in-command that day.

He had just completed a flight review, and I did check, it is in his log book. Yes, sir. And as prescribed by 14 CFR 61.56, and the log book, even though it was scarce, indicated that he did receive jump training and operations in the procedures.

The individual was, in all respects, current and qualified to act as pilot-in-command of that flight. However, based on these facts, there was no reason for that accident to occur.

Again, putting away all your personal experience, if we just stack the facts up, there's no reason that it should have happened.

In a recent Sport Aviation newsbrief dealing with stall/spin avoidance, it was reported that 10 percent of general aviation accidents, 20 percent of fatal GA accidents, were attributed to the loss of aircraft control due to inadvertent stall/spin, and it's interesting.

This news blurb that was in August Sport Aviation was talking about a $50,000 amount of money given by the FAA to the IAC, the EAA, the U.S. Air Force, and NAFFI, to produce a stall/spin avoidance video. So, the FAA realizes there's a problem there.

If we look at the pilot certification and training required, and Jeff went through most of these, I'll just quickly go through these again, we'll see that there are two areas that deal with certification and training.

As most of you know, it's 14 CFR 61 which deals with pilots and flight instructors, and 141 deals with pilot schools. Under Part 61, two areas where the subject material stall/spin are addressed are Subpart (d) for recreational pilots and Subpart (e) for private pilots. Both areas require applicants for certification receive ground training in stall awareness, spin entry, spins and spin recovery techniques. There are no flight requirements.

Again as Jeff pointed out under the commercial pilot certificate, there are no requirements in flight or ground instruction dealing with the stall/spin.

Under 141, which again is that more stringent flight training, Appendixes A and B have the same requirements as 61, ground lessons only. Appendix D parallels 61 in that there is no flight or ground requirements for stall or spin.

In dealing with recurrency, under 14 61 -- excuse me -- 14 CFR 61.56, states that "no pilot may act as pilot-in-command of an aircraft unless he or she has completed a flight review, a pilot proficiency check or completed one or more phases of the wing program within the preceding 24 months".

Again, that points out that there's -- requires that a person complete one hour of ground and one hour of flight instruction. Ground instruction covers parts that are applicable under Part 91, and flight instruction review of those maneuvers and procedures that, at the discretion of the person giving the review, are necessary for the pilot to demonstrate the safe exercise of the privileges of the pilot certificate.

There is no requirement. It's up to the CFI basically is what this is saying. If you think about this, you can take an individual that holds an airline transport pilot certificate, and whether they will fly 135 or 121 or any of the other carriers, where they have to maintain current checks, even if they do that, depending on the airline industry or the airline they're operating for, the only time that they ever dealt with stall/spin was a ground lesson back when they had their private pilot training. That's it.

They can go through every phase of their aviation and that's the total sum of the training that they received. In fact, a flight instructor is only required to do one ride basically for stall/spin, and he can -- and it's required that he demonstrate that as part of his check ride.

However, the examiner, if my memory serves me right, has the opportunity to waive that requirement as long as the applicant can show in his log book or in some sort of training syllabi that he has received spin training. So, basically, you're talking about a flight instructor with a one flight spin ride, and that's all he has had. It's rather scary to say the least.

Recommendations that I feel are important are these. If they amend 61.141 to deal with recreational and private pilot certificates to include a flight requirement that are basically titled "Recovery from Departure of Uncoordinated Flight".

I'm not advocating spin training for the private pilot at this point. I'm saying let's put the private pilot or the recreational pilot in a situation possibly nose-high/deep-stall uncoordinated where the aircraft is about to break or just as it breaks and teach them how to recover, the proper technique to recover from that type of scenario.

I suggest that because I feel that that would help reduce the problems that there are with stall spins and would also, looking at the aircraft as Gene pointed out, a lot of the aircraft today, the Cantana, I know the American General Tiger that's coming back out, the PA-28 series that Piper -- the new Piper Aircraft Company has out, are not allowed to be spun.

So, do we just push all these aircraft aside and say I'm sorry, we have to buy all new aircraft, general aviation, so we can go out and do spin training? No. But I believe that we could do something along the lines of recovery from departure of uncoordinated flight in these type of aircraft. Don't get it into a spin, but show -- get to an area short of that, where they can see what happens.

I'd like to see Part 61.141 that deal with the commercial pilot certificate to include spin training. If we look at individuals that hold a commercial pilot certificate, so often we think, especially with the hiring boom that's going on right now, okay, they're going to the airlines. They're going to be flying turbine equipment. They're going to be flying heavy iron, whatever.

But if we look at what happens with the commercial certificate, you have people out there doing banner-towing. Now that requires a sign-off or an authorization from the local FSDO before they can go out and tow banners, but you have areas, such as sight-seeing, pipeline patrol, aerial photography, law enforcement, traffic patrol, I've done my share of that, looking at accidents, and sky-diving. These do not require any sort of sign-off, and as we've seen in the sky-diving accident, it a lot of times requires the pilot to fly low and/or slow and to divide his attention, his or her attention, between flying the aircraft and other items that are going on.

I strongly believe that commercial pilot applicants should receive spin training, both in ground and in flight training.

Additionally or finally, I believe that recurrency training as set up under 61.56 should include some sort of training of recovery from departure of uncoordinated flight. What we have is good, but again by the strict letter of the law, it's left up to the flight instructor's judgment who is giving this flight review as to what needs to be covered under 61.56, and there's not enough meat there.

As we all know, safety is paramount, and I think that it should be the foremost precept by which the standards for training are established. I feel the addition of these changes to the Federal Aviation Regulations will help to ensure that the number of stall/spin accidents will decrease and in turn improve general aviation safety.

Thank you.

(Applause)

MR. LITTLEFIELD: Okay. Here we go.

MR. STOWELL: Can you hear me? Hello.

MR. LITTLEFIELD: Back again. Our next panelist, Rich Stowell, leading authority on flight training, Rich has given over 4,000 hours of spin, emergency maneuver, aerobatic instructions since 1997.

He's experienced in clearance, performing more than 17,000 instructional spins with students, the equivalent of over 800 vertical miles traveled while spinning. He has developed the emergency maneuver training program, EMT, a registered trademark.

Mr. Stowell has hosted several critically-acclaimed videos, including recently acting as script-writer for the FAA/NOAA Video, "Avoiding the Inadvertent Spin", which made its debut during the Experimental Aircraft Association Air Venture 2000 in Oshkosh this year.

Mr. Stowell has written numerous articles for Flight Training, Plane and Pilot, Sport Aerobatic Magazines, and has authored two informative textbooks, PAR-registered in the emergency spin recovery procedure and emergency minimum training.

He has a spin/stall awareness book due out in the years 2000-2001. Rich also maintains the Aviation Awning Center, an interactive internet web site, specializing in all attitude training resources and active aviation safety counselors since 1992.

Mr. Stowell presents safety seminars across the United States and Canada. He also has traveled to Indonesia and Japan to conduct spin and aerobatic training clinics and flight demonstrations for military and civilian pilots in those countries.

For his contributions to aviation safety, Rich received the FAA's Western Pacific Regional Flight Instructor of the Year Award in 1993, the International Aerobatics Club President's Award in 1994 and in 2000, and the FAA Flight Standards District Office, Aviation Safety Council Award in 1996. He also earned six wings through the FAA Alliance Program and the Basic Sportsman and Intermediate Aerobatic Achievement Awards through IAC.

He has a Bachelor's Degree in Mechanical Engineering from Rensalear Polytechnic Institute, Troy, New York.

Rich?

MR. STOWELL: Thank you, Gene. Good morning. Stall/spin accident rates in general aviation have remained essentially constant since the 1960s, continuing to account for roughly 10 percent of all accidents but 25 percent of fatal accidents.

Some studies have suggested that the stall/spin accident rates are largely attributable not to improvements in pilot training but rather to airplane designs introduced in large numbers throughout the 1960s. Flight lines today in fact still bear a striking resemblance to those of 30 years ago.

The stall/spin accident under review involved a 1963 Cessna 205 being used as a parachute jump plane. The mission profile of the accident flight may seem inapplicable to activities normally involving light airplanes. Examination of this case, however, reveals just how closely it fits a typical stall/spin accident model.

Failure to maintain an air speed, for example, is cited as causal in nearly 90 percent of stall/spin accidents. A line-by-line comparison with a typical stall/spin accident is equally revealing.

Under the category of who is more likely to encounter a stall/spin versus a genuine engine failure, statistically we would predict it would be a pilot with less than 500 hours total time or less than 100 hours in type. In this accident, the pilot had 200 hours total time and 82 hours in type.

The weather conditions we would predict as being daytime VMC, the same conditions as the accident in Homestead.

We would also predict that the flight would be in all likelihood a pleasure flight. In this case, it was a dual purpose flight. It was certainly business for the commercial operator and the pilot but certainly pleasure for the sky divers on board.

We would also predict that the airplane would probably be in slow flight at the time of the stall/spin departure as was the case in the Homestead accident.

Also, there'd be a 50/50 chance that the stall/spin would occur within one mile of an airport. In this case, the accident occurred exactly one mile from Homestead Airport.

Contributing factors would be pilot distraction as well as knowledge and skill deficiencies, all of which were present in the accident in Homestead.

The role of the airplane. A story published by the Society of Automotive Engineers in 1976 ranked 31 airplane designs by combining their stall/spin accident rates. The five single engine designs emerging with the best stall/spin accident records are all Cessnas. The 210 and 206, close relatives of the Cessna 205, were ranked fourth and fifth, respectively.

For certification, the Cessna 205 demonstrated recovery from a one-turn spin and not more than one additional turn. According to FAA Advisory Circular 23-1, issued in 1964, this one-turn margin of safety was intended to provide adequate controllability when recovery from a stall is delayed. Beyond the first turn in a spin, however, recovery cannot be guaranteed.

The Cessna 205 pilot-operating handbook states, "Should an inadvertent spin occur, standard light plane recovery techniques should be used." Such a superficial treatment of spins is typical in older handbooks, and what are the so-called standard light plane recovery techniques?

Advisory Circular 23-1 explains that all spin recoveries should be made using the NASA Spin Recovery Technique. Ailerons neutral, full opposite rudder, followed by forward elevator.

During the 1960s at least, the NASA procedure was understood to be the de facto standard for spin recovery.

AC-23-1 also states, "Evidence of an uncontrollable spin would be present if recovery cannot be effected within one additional turn by using normal NASA control recovery movement."

Yet Cessna 205 spin test documents show a non-standard use of ailerons against to confine recovery to less than one turn. Notwithstanding the lack of detailed spin recovery information available to the pilot, a conflict exists between the NASA standard spin recovery actions alluded to in the POH and the wholly non-standard use of aileron against used to satisfy the one-turn spin test requirements.

The role of the instructors. The FAA implemented sweeping changes to soft spin awareness training in 1991. The pilot-in-command received his private and commercial flight instruction between 1992 and 1994.

In 1993, the Transportation Research Record published a study that assessed the stall/spin knowledge of general aviation flight instructors. 513 instructors participated. 95 percent of them failed to receive training in either spin dynamics or the likely conditions preceding an inadvertent spin. 94 percent understood neither aircraft spin certification requirements nor the operating limitations imposed as a result.

The most foreboding aspect of this study, however, involved the hands-on spin experience of flight instructors. 98 percent noted that their formal spin training consisted of no ground instruction and a mere two spins. Nonetheless, instructor applicants readily received log book endorsements certifying that they were competent to teach spins.

The changes made to Part 61 attempted to improve stall/spin awareness across all levels of flight training, yet more than a year after implementation of the new standards, 97 percent of CFIs surveyed were still unaware of the regulatory changes. In fact, 35 of the instructors surveyed had been certified after the changes went into effect, yet not one of them was aware of the changes. Most instructors knew nothing about Advisory Circular 61-67(b), Stall and Spin Awareness Training, either.

The role of the pilot-in-command. Pilots spend 6 percent of their flight time in the critical phases associated with the traffic pattern, take-off, initial climb, approach and landing. These phases, however, account for a disproportionate 57 percent of aviation accidents.

It's clear that every pilot should be spending considerably more time practicing the skills necessary to operate safely during the most critical phases of flight.

The stall/spin accident under review was initiated during a sky-diving jump run. Though not a critical phase in the traditional sense, the conditions nonetheless emulate those associated with traffic pattern operations.

Log book entries show stalls specifically listed in the Remarks Section done on flights totaling approximately 15 hours. The pilot logged stall practice in the accident airplane on one flight. Total time of this training flight, 30 minutes.

Based on log book entries, I estimate the actual time spent practicing stalls, stall recoveries and likely stall/spin scenarios to be on the order of three hours, around 1 percent of the pilot's total flight time.

The role of FAA. As mentioned earlier, the FAA mandated stall/spin awareness training in 1991. The campaign to educate pilots about stall/spin awareness, however, has largely been ineffective.

According to an informal survey taken during safety seminars across the U.S. in 1998, only 10 percent of pilots who had earned private, commercial or flight instructor certificates after 1991 had also received a copy of the AC-61-67(b) as part of their stall/spin awareness training package.

Pilots who rely on the FAA's new airplane flying handbook will find just two and a half pages dedicated to this complex topic, and little guidance is provided regarding the spin training required of flight instructor applicants.

Consequently, pilots continue to be under-trained with respect to stall/spin dynamics and stall/spin accident scenarios.

Conclusion. The net effect of fallible pilots flying imperfect airplanes at invisible angles of attack is significant. Close to 33 percent of stall accidents are fatal. 66 percent of spin accidents are fatal. One out of four aviation accidents and fatalities tied to a stall spin.

Accident prevention must be proactive if it's to be effective. As an industry, our challenge is to do a better job educating pilots about stall/spins. At a minimum, let's get 61-67(b) into the hands of students and flight instructors. Let's ensure that flight instructor applicants are intimately familiar with 61-67(b) as well as the FAA's new video, which I have a copy here, "Avoiding the Inadvertent Spin", recently released as part of the FAA's Safer Skies Agenda.

Let's more strongly encourage pilots to practice slow flight and stalls on a regular basis. Let's demand more than two spins as sufficient for a flight instructor applicant, and although I do not believe it would be feasible to require spin training of all pilots, let's challenge pilots to rise above the minimum acceptable training standards and to seek out spin training from qualified instructors as part of their continuing education.

Thank you.

(Applause)

MR. LITTLEFIELD: Thank you, Rich. The transfer of electronics to Lowell.

Our next panelist, Lowell Foster, currently works as a flight test engineer in the FAA Small Airplane Directorate Standards Office.

His responsibilities include Part 24 flight tests, preliminary category, and balloons with involvement in cockpit system issues, accident data reviews, and FAA safety program.

Prior to his employment with the FAA, Mr. Foster worked as a flight test engineer at Boeing Aircraft. He worked in the TLS/TCP Programs and managed development of the Aerobatic Template Entry into the Air Force EFS Trainer Program.

Mr. Foster also worked on several amended test programs and served for a short time as an engineering analyst in the Marketing Department.

In addition, Lowell was an Air Force flight test engineer at Edwards Air Force Base, worked on the Avionics and Weapons Integration Flight Test Programs and on the F-16 XO down-wing prototype, the F-16-A/B model, was also in Flight Status for both the T-38 and the F-16.

Lowell has a Bachelor's Degree in Mechanical Aeroengineering from Oklahoma State University, holds both instrument pilot and glider ratings.

Lowell Foster. Lowell.

MR. FOSTER: Thank you. Good morning. I don't hear this, but it's on, isn't it? Okay. Thank you.

I'm going to bring a different perspective on this accident and on this issue. I come from the equipment side, aircraft research deals with the airplane, not the pilots. We leave that to Flight Standards.

What I want to talk about leans more towards how do we prevent these accidents, and I've done a number of studies to get there as well as we've worked on actual programs.

I show the slide off with the Lance Air and Cirrus because both of them incorporate spin-resistant technology, something we're pushing fairly hard in our office and working with the Europeans to adopt, and what you have in my presentation is a lot of statistics that I hope to go through and explain to you, so you can take them back with you with a fairly good understanding.

The first three, I just want to cover quickly. I took a look at, I believe, the top 10, summed them up into the top five accidents. I used the AOPA's 1991 study of airplane accidents. This is the only comprehensive study of GA accidents that I know of.

They looked at about 16,200 accidents, and what I did is instead of taking this from a pilot perspective, which is what you tend to see in something like a Yaw Report, I tried to look at this from an engineering aircraft perspective.

I took the top 95 and then whittled those down into the areas you see, and inadvertent stall for fixed-gear aircraft is Number 2, and that, the way I did it and the detail in that reported allowed me to actually pull out reckless flying.

This is what I would consider inadvertent, where the pilot was doing everything they considered correctly. They weren't horsing around. They weren't doing acrobatics. They actually were doing what they thought was right, and that's what you see in inadvertent.

It's still Number 2. Fixed-gear aircraft to me are training aircraft, more local flight, more rental aircraft.

Next one, retractable gears. You'll notice it's a little different. It's Number 4. These aircraft to me are used more for cross-country and IFR flying and that's fairly understandable.

When we get to multiengine, it goes back to Number 2. It's interesting, but if you give that some thought and think about multiengines, they're used for training again. So, we're back into the training realm, and also a lot of our light twins don't fly low on one engine. I think that's reflected here, also.

When I came to the FAA from Mooney, I was a believer that this issue needed to be addressed with pilot training, and that was up until I read 1,771 accident reports, looked at the narratives and looked at the statistics.

If you take a look, 93 percent of these accidents are below pattern altitude. That's where the departure from controlled flight started. There wasn't an altitude there to recover the airplane, even if they had the ability.

Interestingly enough, if you took a look at all of these and approved for spins is 3.3 percent, well, that's 3.3 percent of the accidents where they were above pattern altitude. Those were in airplanes approved for spins, but actually in the 93 percent, 47 percent or roughly half of all these airplanes are in airplanes approved for spins, and they should have recovered but they didn't.

For the airplanes above pattern altitude, half were approved for spins, roughly the other half were either at night or in weather, to where they didn't have a horizon and probably wouldn't have been able to recover anyway. Only about a half a percent in this study were in an environment where they should have been able to recover, and we can't really tell why they didn't.

The next slide basically is a text version of that. If you take a look, though, what stood out to me is over the 20-year period, only about nine aircraft in this were actually in an environment where if the pilot did everything right, they had a chance to recover.

If we take a look at the U.K. and since we're working with the JAA, I got on the Internet and had to do this, it looks about the same. This is a major chunk of their accident rate, and if you read German, you'll see that the German accidents are the same. The largest chunk are loss of control.

Richard did a great job of going over our requirements, and the 205 had to meet a one-turn spin requirement. That's all. It met it at gross weight and FCG. If you go beyond one turn, you become a test pilot, and that's true of all our normal category aircraft, hence that's why they have the placard not approved for spins.

That one turn is essentially not a spin, it's a post-stall gyration, and what we're looking for is the ability of the aircraft to be flown out of that given a standard recovery.

Our current requirements, and I'm going to be a little critical of our requirements, require that we be able to stall the airplane and maintain a 15-degree wing rock essentially.

Well, that's a good requirement if you're talking about the average pilot, and the average pilot in a lot of these accidents are under 500 hours, but when company test pilots fly these, and when FAA test pilots fly, it's extremely hard for them to represent the average pilot. Their ability to get these planes to pass versus, say, my ability with 600 hours is very different, and I think that's part of what we see in the field.

This is just a real quick study I want to share with you from the `70s. It may be the same one that you talked about, Richard. If you take a look at this, the upper right, this is basically a ratio. Stall mush accidents versus fatal stall mush accidents, which are more critical, and your X axis is the total accident rate for that aircraft.

I don't think it will surprise any of us to see that the Swifts are up in the upper right, and the Cessnas are down in the lower left, and I won't go into why, but it really does tell us there's a lot to learn from this if we go look at the aircraft. There are a lot of other factors, too, on how the aircraft's used, how it's typically loaded.

I would say a 210 and a 206 may be similar. They're a little bit different on here, and that may be how they're used. The 210 probably is flown with two people in the front more often than a 206. So, it's more forward-loaded, harder to get there.

This is essentially a summary of the study. I'd just like to point out that in all these planes, in an uncoordinated stall, the first result was yaw, and in these, that yaw couldn't be countered with aileron and remember that as we get into the next slides.

The recommendations are pretty much straightforward. This study precedes NASA's work with spin resistance, and they were actually doing this at a time when they were trying to promote flight pass spoilers, and that's why you see what you see here.

The conclusions I came from and what shifted me from thinking this is a pilot-training issue to an aircraft stall-handling issue -- let me back up. A pilot-training for spin recovery issue versus preventing the aircraft from stalling and spinning in the first place was that when you're talking about all these occurring at or below pattern altitude, even a skilled pilot probably couldn't recover this airplane before it hit the ground.

Most of the spins we see in flight tests take anywhere from 600 to 1,200 feet to recover, and that's to go through the turn, to stop the rotation and then the pull-out, and you'll blow well through pattern altitude when that all happens.

The other part of that is that if you add a skilled pilot that could recover, they probably wouldn't be there in the first place. This is happening to people who aren't going to be able to deal with a spin.

Finally, the critical issue is we need to address preventing the entry in the first place instead of trying to address learning how to recover from it.

This is where we're heading from an airplane standpoint, and what we're trying to promote in the FAA, and there are leading edge cuffs. This is straight from NASA's research and what both Lance Air and Cirrus employ.

In the `80s, NASA did very thorough, fairly large programs using all four of the aircraft you see. The red are the leading edge cuffs. They're fairly settled in what they look and how they affect cruise performance and what they do to the airplane, but when you get back into a stall, their effect's tremendous as far as changing the characteristics of the aircraft.

88 to 98 percent of those four aircraft -- okay. I just said that wrong, and I apologize. Of those four aircraft, 88 to 96 percent of the spin entries attempted resulted in a spin, and they should have, because all those aircraft were certified to do a one-turn spin.

With the cuffs, only 5 percent of those aircraft were able to be put into a spin, and to get there, it took aggravated control use, and it took loading the aircraft out the aft CG.

The basic concepts, and this is where -- remember the results of the `77 report where we talked about roll control. The basic concept here, I'd like you to take home, is that issues of roll dampening and maintaining roll control and having roll power to overcome the yaw rate.

Now, actually in layman's terms, what we're talking about is what the air coupe did, but we need to be able to do this for future aircraft without the limitations the air coupe suffered under, and we're finding we can do that now if we incorporate NASA's technology.

Now, an important point is spin resistance is not spin proof. These airplanes spin, but you've got to want to spin it. You've got to purposely put the airplane there. The airplane gives you lots of time and lots of warning to say I don't like being here. Something's wrong, and you need to do something different. You have lots of time to figure out what's wrong.

One of the things we've bantered back and forth between our test pilot and some of the folks in the office and our applicants is, you know, while we're pushing for this spin-resistant concept, and this applies to this 205 accident, also, when a wing drops because you've let the aircraft slow down, pilots may not intuitively push the correct rudder.

We don't need rudder a whole lot any more for those of us who are trained in nose-wheel aircraft. If you're a tail-wheel pilot, you've got rudder skills that allow you to keep the nose straight, and they're more intuitive, but for nose-wheel-trained pilots, you may or may not push the rudder the right way, but the ailerons are different.

Pilots will intuitively turn the aircraft the correct way if the wing drops. It's intuitive, and we have a high confidence level that pilots will do that. That's why this issue of roll control exceeding yaw rate is very important.

This is just a picture of the difference that these cuffs make in a wind tunnel picture, and I'll finish up just by saying that we have a mandate in the agency and throughout the government and industry to reduce accidents.

Stall/spin accidents are a big chunk of that, and we don't want to go back in old airplanes, even though something as simple as vortex generators could take an airplane like the 205 and allow you to fly it at aft stick with just a lot of bucking and shaking but no break.

We're not talking about anything that radical, but we're talking about saying it's time to move from here on and look at addressing the issue of departure instead of recovery, and to do that, we have to essentially maintain aileron control in excess of the rudder.

That concludes what I have. Thank you.

(Applause)

MR. LITTLEFIELD: Thank you, Lowell. Yes, and we've got a lot of horsepower here, and we can help with any questions that you have. I believe there were cards, and if you have questions for the panel, we would be glad to take them at this point. Any at all? Don't tell me we've covered every issue. Here we go. A card. Thank you.

The statement says that Canada requires actual spin training for private pilots. What is the rate of spin accidents in Canada versus the U.S.?

I believe, Rich, you had something on that.

MR. STOWELL: Yes. Does this work? Good. All right.

Actually, believe it or not, there has been some debate in Canada, and I'm not exactly sure if that is still true at this point. If it is true, it's just for the private pilot level, but accident statistics up there really are not a whole lot different from what they are down here with our stall/spin awareness or stall avoidance training methodology, which leads to the other interesting question.

What is spin training, and just going up and doing a couple of one-turn spins is not all there is to spin training, any more than flying one or two instrument approaches is all there is to instrument training.

A true spin-training program would encompass probably several flights, and it must also be integrated with the typical accident scenarios that pilots are likely to get into.

If you just do the maneuver as a spin completely devoid of how it relates to its getting base to final turn, in the end, it has no value. So, we need to have a proper definition of what spin training is toward the goal of reducing the departure in the first place because as Lowell pointed out, in the traffic pattern, it's too late to know how to do spin recovery. We have to know how to prevent it in the first place.

MR. LITTLEFIELD: All right. Hopefully, that answered that question.

The next statement or -- yes, it is a statement. The FAA Aviation Safety Programs and the United States Parachute Association just released a new video, "Flying for Sky-Dive Operations".

Additionally, FAA, IOC and EFI will issue the new stall/spin video to FAA FSDOs in October of this year, 2000. Contact the FSDOs for information, and also "Avoiding the Inadvertent Spin", which is what Rich had mentioned.

This card. Was an analysis conducted on the pilot's sleep the previous 72 hours?

All right. The answer is yes. Pardon me for choking there.

The question was, what was the elevator trim setting, and I'm not sure that that -- it was in the right position or appeared to be at the indexing.

By having a requirement to demonstrate proficiency in a skid for automobile driver training, as a consequence, it is not done. That's an interesting comment.

You know, we have those handy footrests at the bottom of the airplane, and some of this is -- does -- as it comes back to the pilot, that to be able to use your feet, you know.

It's kind of funny, but it was commented at our airport often, you know, that the airplane has room when they put the battery in it, and then the ruin the pilot when they put the tail on the end.

How can the pilot electronically help in a stall warning with -- I'm not sure about the -- there's been a number of -- there's been some steps taken in that direction. The heavier single engine Pipers use two phases of stall warning. One for clean warning and another stall warning that is in a slightly different position on the wing for flap-configured stall warning.

So, there is a lot of work in that regard. Whether that will happen or not, I'm not sure.

The real tip vortex generators, such as the Cirrus and Lance Air, make theirs susceptible to ice and other effects.

Lowell?

MR. FOSTER: We're actually not there yet. There haven't been any icing tests done on the Lance Air and Cirrus.

Since it's still basically an air foil, though, I don't -- I wouldn't expect to see a big difference, unlike you might see with vortex generators, which are fairly good ice collectors.

MR. LITTLEFIELD: Historically, can someone address the reluctance to mandate spin training, and why did this come about in the first place, and I assume what you mean is how did it come about where we did move away from spin/stall recognition training.

MR. PROVEN: I'm not speaking for the FAA. Is this on? Is it? Okay. But I would just simply say that the facts that were presented by Lowell here this morning and my facts which I did not present but mirror his thoughts, consistently we see that the spin training has a very small impact on the stall recovery. It's done too close to the ground. Stall avoidance is the answer and not spin training, and obviously the Administration is always looking whether they should change, but based on the information we saw today, there's not an awful lot of value added.

Each life is valuable, and that should be saved, and I encourage exactly what Rich was saying about encouraging unusual attitudes that you get into stalls, don't make it just the standard slow recovery into this one-turn spin, but explore the envelope a lot more.

Nonetheless, there's very little return to be received.

MR. LITTLEFIELD: Bob, do you have anything you want to add?

MR. SCHUSTER: I'd also like to add, Gene, that -- boy, mine sounds really loud. That the problem we have now is that logistically, it would be very difficult to go back to actual hands-on spin training, mostly because the flight -- core flight instructors, as I noted, in the 1993 study themselves are not equipped or prepared to conduct spin training.

Also, the availability of spins-approved airplanes, and then we have air space and insurance issues and things like that, but certainly that doesn't deny anybody from -- or us as an industry from encouraging pilots that it's not required, but we would strongly recommend that you now go out and seek out spin training from an aerobatics school that specializes in this type of training.

MR. LITTLEFIELD: Yes, and I certainly agree. Yes, Lowell?

MR. FOSTER: I'd just like to share with you something that came from Matt McClellan in a Flying editorial, and I'm going to trust that Matt's statistics are right, but he went back and found that the only time there's been an actual significant decrease in the number of spin accidents were after -- was just post-1940s, after they deleted that from the pilot-training requirement, and the problem was that the training was creating more accidents than the lack of training, and, so, even though in a perfect world, the right answer is to train somebody to fly the entire envelope of the aircraft and then ask them to stay proficient, apparently that's not what we're able to do, and the statistics follow that.

MR. LITTLEFIELD: Certainly interesting. Well, I believe our comments were covered. We hope that we have covered the things that you'd like to hear.

Thank you so much to our panel, and thank you for your attention, and Dennis.

(Applause)

MR. JONES: Thank you. We're going to take a 10-minute break to prepare for the next panel. We're a little behind schedule. So, please come back quickly from your 10-minute break, and we'll make the adjustment for the schedule, so we can end appropriately at the end of the day.

(Whereupon, a recess was taken.)

(Introduction of Visual Flight into IMC Accident Panel, Wayne Pollack, Southwest Regional Office, National Transportation Safety Board)

Visual Flight into IMC Accident

MR. POLLACK: Operating under Part 91, the accident occurred at 6:59 Local Time. However, significant events related to this crash were set in motion hours earlier.

This slide shows an overview of the route of flight. The pilot departed from the Santa Rosa Airport and headed southbound over a course nearly paralleling U.S. Highway 101 toward her destination in Oakland, California. The departure airport is shown in the upper left corner of the slide, the intended destination at the bottom of the slide.

The accident occurred when the pilot was nearly halfway to her destination. This pilot was flying a twin-engine airplane over a very familiar route of flight. The pilot initiated the cruise descent at night under marginal weather conditions and impacted the rising terrain.

The factors I'm going to be speaking about during this presentation include the pilot's qualifications, the weather conditions during the night time flight, the airworthiness of the airplane, the terrain, and other factors that may have influenced or motivated the pilot.

This pilot held an airline transport certificate, flight instructor certificate for single and multiengine airplanes and instruments. The pilot did not have any limitations or waivers on her first-class medical certificate. She was physically able to handle all of the airplane's flight controls.

During the autopsy, no evidence was found of any preimpact cardiovascular or physical anomalies. The pilot was 33 years old. No drugs or alcohol were found during the toxicological examination. The pilot's total flight time was about 4,300 hours, and during the 90-day period which preceded this accident, she had flown for 63 hours.

She was very familiar with the route of flight, having flown between Santa Rosa and Oakland approximately two to three times per week during the previous two years.

Regarding her currency, within the last six months, she'd passed an FAA 135 check ride in the same model of airplane, and, finally, during the Safety Board's review of her training records, no deficiencies or aircraft-handling weaknesses were found.

The airplane was certified for flight into IFR conditions, and it was appropriately equipped. No evidence of unairworthy conditions was found during the maintenance records check, and no evidence was found of inoperative radios. The airplane was equipped with dual altimeters, VORs, ADF, DME, HSI, RNAV, etc. It has TIO-540 engines, each rated at 350 horsepower, and the propellers had de-icing capabilities.

That's my cue. During the investigation, no evidence was found to indicate that the pilot had received a weather briefing. An extensive area of low stratus clouds, rain and fog existed over the Central California area. Marginal weather conditions were quite prevalent.

The accident occurred again at 6:59 Local Time. Santa Rosa, the departure airport, reported at 6:50 visibility five miles, light rain and mist, ceiling broken at a thousand feet, overcast at 3,000, and temperature dew point spread was only two degrees. The altimeter there was 29.78.

Napa Airport, which is about 15 miles east of the crash site, reported at 6:45 in the evening, six miles visibility with light rain, 1,300 foot overcast, and the altimeter was 29.75.

The destination airport, Oakland, at 6:47 in the evening had scattered clouds at 800, ceiling of 2,000, temperature dew point was 11 and 6, and the pressure there was the lowest at 29.73.

An air event had been issued for IFR conditions and the mountain obscurations along the route of flight.

Another pilot in the company for whom the accident pilot worked was also flying from Santa Rosa to Oakland at about the same time. This pilot reported to the Safety Board that he flew a very similar route but was a few miles east of the pilot's route and a few minutes ahead of her in time, and according to this company pilot, he had to descend to between 1,200 and 1,500 feet in VFR -- to remain in VFR conditions on his flight.

As I indicated, the accident occurred at night under an overcast sky. The glow of city lights was possibly observed in the distance a few miles ahead of the accident aircraft. Moon was in the first quarter with 58 percent illumination above the clouds.

U.S. Highway 101 is oriented along a north to south course and approximately parallels the direct route between Santa Rosa, the departure airport, and the San Francisco Bay near Oakland.

The departure airport's elevation is a 125 feet, and en route, had the pilot followed the highway, she would have passed three other airports. Their elevations are 2, 5 and 87 feet, and Oakland, the destination airport, had an elevation of 6 feet.

Significantly, however, at one location about two miles west of the pilot's route on Highway 101 or by Highway 101, the terrain rose to 1,600 feet.

The total distance between Santa Rosa and Oakland is 55 miles, and the distance between Santa Rosa and the crash site was just 25 miles. The direct route of flight between Santa Rosa and Oakland, a straight line route, was a 133 degrees magnetic.

According to the recorded radar data that we have on the airplane, during the airplane's last 36 seconds of flight, its track was about a 139 degrees. During the last three radar hits, the aircraft was flying along a course of about a 141 degrees.

Wreckage distribution measurements taken by the Safety Board's investigator, who was on scene, indicated the principal axis of the wreckage distribution occurred along a 144-degree course. Essentially, then, the pilot was flying a pretty straight course all the way to impact.

This slide was derived from radar data, and it shows the airplane's altitude during the flight, virtually from take-off to impact, over the 11-minute long flight.

You'll note that during the en route portion shown now, the aircraft cruised at about 2,000 feet, plus or minus about a hundred feet. Finally, during the last 36 seconds of recorded flight, the pilot gradually descended to about 1,500 feet, which is the approximate impact altitude.

Here's a presentation of the last one-half minute of recorded flight using the same radar data, and note the location of U.S. Highway 101 a couple of miles east of the airplane. The route was five miles west of the route typically flown, and it crossed over higher elevation terrain.

This next slide shows an aerial view that's been oriented along the pilot's perspective of about a 140 degrees. The airplane's relative position was plotted using the same recorded radar data, and here you can see Highway 101 and the lower elevation terrain off to the airplane's left wing.

Finally, this slide shows the airplane's position during its last 12 seconds of recorded flight, the last couple of hits, and perhaps this is what the pilot should have seen.

The on-scene examination of the wreckage, the terrain, and a review of the recorded radar data, show the collision occurred about a hundred feet below the mountaintop in a near wings-level attitude while in a cruise descent.

The width of the initial swath through the trees was consistent with the nearly 41-foot long wing span of the aircraft.

Post-impact fire consumed major portions of the wreckage.

As identified in the NTSB report, there were several factors that really affected the pilot judgment. She was flying from Oakland to make a speech for her college final class examination. Her professor had advised her that he would not hold over class beyond its normal dismissal time to accommodate her possible late arrival.

The pilot was found to be technically competent. However, dealing with these external events may have created internal pressures which manifest certain emotions and affected her judgment.

There were numerous good operating procedures which were not followed by this pilot. For example, she did not correctly set either of the aircraft's altimeters. She didn't receive a weather briefing. She didn't file a flight plan when the weather became inclement, and, finally, rather than flying a slightly longer route over the highway, she elected to proceed over a somewhat shorter and more direct route which required over-flying the mountainous terrain.

Significant findings of this accident investigation are as follows. The pilot was qualified, current, and experienced. The airplane was adequately equipped and maintained. It was airworthy. Marginal weather conditions existed. Night-time flight over the rising terrain required precise navigation, and the pilot was off-course.

Finally, the pilot's performance was impaired or compromised because of self-induced psychological pressures.

In closing, the NTSB stated that the probable cause of this accident was the pilot's failure to maintain adequate terrain clearance after initiating a descent over mountainous terrain at night under marginal VFR conditions. The pilot's self-induced pressure to arrive at class with enough time remaining to take the final examination was a factor in the accident.

That concludes my presentation. I'd like to turn it over to the moderator. Rudy.

(Applause)

MR. KAPUSTIN: Good morning. As the moderator, that means I don't know a hell of a lot, but I know a lot of people that do. That's how our consultant works, also. That's no joke. That's the way it is, and it's kind of intimidating to be surrounded by all this horsepower. But Dennis told me don't dilly-dally, don't gab, just do it quick, we're behind schedule. Sorry, Dennis.

I'll just do a quick overview in the general topic of VFR and the IMC, and my skills at PowerPoint are limited.

Just showing the 10-year period, `83 to `92, there seems to be kind of a gradual decrease. I broke it up into two separate charts, and, of course, the 1999 are not complete. All the data is not in yet for NTSB or AOPA.

Compared to the flight hours for the same time period, from `83 to `92, there was a lot more flight hours back in `83, and then there was some drop and again an increase, and I don't know what the reason is, probably fuel costs and litigation cutting back on flight operations probably and for awhile airplane production.

That's 1983 to `92. You see the flight hours as they dropped, and then you see them again increase back in `98 and `99.

Okay. What are the reasons for visual flight in IMC? Inadvertent/inadequate preflight preparation, unexpected or not-forecast IMC encounter, and, of course, the old failure to do a 180. Then, of course, homitis, which possibly was the case here, not to get home but to get to a place that seemed to be important to the lady, and the ego. I'll show him, I can make it.

What's the possible reasons for a decreased in VFR in IMC accidents? There was a decrease of 1,593,000 general aviation flight hours between 1983 and 1999. That's the overall increase. There we go. Improved training programs, improved communications to GA pilots, trade publications, flight training, AOPA/FAA and, of course, last but not least, NTSB's in-depth investigations and recommendations in some of these cases. The improved technology for weather data acquisition and forecasting. There was one other one. I'll show that in the next one.

Improved state-of-the-art systems. I'll get this straight. Improved state-of-the-art systems for real-time weather data availability to pilots, simple and easy access to up-to-date weather data sources, such as weather.com DUATS, weather.com DUATS, etc. There's a new one that I just saw, and I forget what the name of it is. Anybody, help me. It's something that Honeywell put together with AVCOM. That's supposed to go on line. I didn't have it when I made up these slides. Anybody know? It's some new program for weather, real-time weather.

MR. FIDUCCIA: Flight Information Services Data Link.

MR. KAPUSTIN: What's the acronym for it?

MR. FIDUCCIA: It's Flight Information Services Data Link.

MR. KAPUSTIN: Flight Information Data -- Services Data Link. Right? Okay. I just saw that in the trade publications the other day.

Okay. How do we prevent visual flight into IMC accidents? Continued educational efforts to convey to pilots the dangers of attempting VFR and marginal VFR or IMC conditions. I always have marginal VFR problems with that.

Questions of the wisdom of continued use of special VFR. That's always given me a problem. It's either VFR or it's IFR. If it's not VFR, and you're not instrument-qualified to fly an IFR flight plan, don't go.

How not to -- oops. This thing is too sensitive for me. How not to try to prevent visual flight in IMC conditions? More regulations probably won't do it. If pilots complied with the existing regulations, it probably wouldn't ha