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 happen anyhow. Some politician said some time ago that they can't legislate morality, and I guess you can't legislate common sense, and most of these accidents of this type boil down to using the head.

With that, I'll turn it over to my distinguished panel. Our first panelist is Grant Brophy, and I'm going to have to read this. This is pretty impressive.

Grant Brophy received a Bachelor's of Aviation Systems Management from Massey University, located in Thomaston, North New Zealand. He also holds a Master's of Aeronautical Science degree in Aviation Aerospace Safety Systems from Embry Riddle.

Mr. Brophy joined Embry Riddle Aeronautical University, Aviation Safety Office, in September 1997. He also provides independent safety consulting services to the aviation industry. Ah, getting into my business. I didn't know that.

Prior to this, Mr. Brophy was an aviation safety consultant and assistant flight safety advisor for New Zealand's Flag Carrier New Zealand Limited. His involvement in aviation safety began in 1980, when he was appointed General Manager of Technical Operations for Advanced Business Methods, Aviation Telecom Division.

During 20 years of involvement in the aviation industry, Mr. Brophy has participated in air safety investigations involving general aviation through heavy air transport category aircraft.

His areas of expertise include aircraft emergency response crew member and training, domestic and international flight operations. He holds a flight crew license with operational experience in Boeing 767-300ER, Boeing 747-200, Boeing 747-400 types.

Mr. Brophy is an active member of the International Society of Air Safety Investigators. He's also a member of the American Institute of Aeronautics and Astronautics, Aircraft Operations Technical Committee. He's a Federal Aviation FAA-appointed aviation safety counselor.

His recent publications include "Study on General Aviation, Mid-Air Collisions", CRM, Crew Resource Management Training Handbook, entitled "It's Not All Dials and Numbers", and Wake Turbulence Avoidance-Related Material for Civil Aviation Authority of New Zealand.

Grant Brophy.

(Applause)

MR. BROPHY: Good morning, everybody, and before you ask, no, I'm not an Australian, although I've got hay fever. So, I probably sound a little bit like it this morning. I'm from New Zealand but of late from the United States. I just can't lose the accent.

I just wanted to start things off this morning with an opening thought, and it's one that I'm sure you've all seen or heard of or read in some sort of publication.

"Aviation to an ever greater extent than the sea is terribly unforgiving of any carelessness, incapacity or neglect", and having been involved in an accident myself, a serious accident, I can speak to how true that really is.

When we look at this Visual Flight into IMC Accident, rather than look at the weather in my case, I wanted to look at some other factors, and we've already touched on it, but leading into that, the probable cause, the pilot's failure to maintain adequate terrain clearance after initiating a descent over mountainous terrain at night under marginal VFR conditions, and just as Rudy said, I have trouble with the words "marginal" and "spacial" as well. It's either one thing or the other.

A contributing factor that they alluded to in this investigation was the pilot's self-induced pressure to arrive at class with enough time to take a final examination.

I'm sure that that's something that we've all been involved in at one time or another. Late for a meeting, wife or husband waiting, girlfriend, boyfriend at the airport to pick us up, you know. We need to get there, no matter what.

Quite often in my job, people always talk about idiot-proofing the system. What does that really mean? Well, a lot of the accidents that we see from day to day are not just inexperienced pilots. This was what I would class as a reasonably experienced pilot who had an ATP pilot certificate, valid medical certificate, as we've already heard, with no limitations or waivers.

She had all the ratings that she should have had, was also instrument rated, and had 4,300 hours total time, which I think is a reasonably good amount of time.

The real issue, I think, is pilot judgment, and I think that probably is going to be something that you'll see underlying a lot of the things that we're going to be discussing here over the next two days.

I know from my own perspective, it's too frequently we hear of aircraft accidents that stem from what essentially breaks down into poor pilot judgment. Pilots run out of fuel. They don't flight plan properly. They knowingly overload the aircraft and expect them to fly just the same as they're within normal limits, and more often than not, they fly into known adverse weather conditions and continue to do that.

So, what is judgment? We hear a lot about aeronautical decision-making and decision-making and all the pros and cons regarding that, but one of the factors that feeds into aeronautical decision-making is judgment.

I sort of described it here as pilot judgment can be termed as a mental process that we use in making decisions about what we're going to do, and if we hone in on the term "process", then that definition tells us that process requires a series of steps to complete in order to complete it satisfactorily.

Stan Trollop and Richard Jansen, in their book, "Human Factors For General Aviation", outlined a judgment process, what goes into making good decisions and judgment, and they come up with vigilance, which is look for expected problems, problem discovery, change something that's discovered that may affect the safety of flight, but change it to the right thing, problem diagnosis, you know, discovering that there's a problem in the first place.

Alternatives. What alternatives do I have to get myself out of this situation?

One of the things I was taught when I was first learning to fly was never let the back door close behind you. In other words, don't let the weather get you into such a state that you don't have an out. You can't do a 180-degree as Rudy termed it and head in the other direction.

Risk analysis. What are the risks associated with the various decisions that I have to make and the various outcomes that I have to come to get myself out of this situation I now find myself in?

Underlying problems, and this refers to in this lady's case having the pressure of making a class that happens to be her final examination. I guess if she didn't make it, she wasn't going to receive a passing grade.

So, that was a real underlying problem that did affect the safety of flight obviously.

The decision. The pilot decides on a course of action, and rather than fly the route that was typically flown by this company, she chose to, I guess, take a route that was over higher terrain into deteriorating weather conditions and hoped to successfully conclude the flight, which of course she didn't, and then the pilot acts on that decision, which is the action.

So, can we learn good judgment? Some people say yes, some people say no. I say yes, we can, but it's all to do with education and training, like a lot of other things.

Well, how do we typically learn good judgment? Most of it is through our life experiences, but in the case of a student just starting out flight training, 17-18-19 years old, they really don't have the life experiences that some of us that are more older than that have to relate to and to keep us out of trouble necessarily.

How can we then learn those life experiences if we don't possess them? Well, I say at the bottom here of the slide, as you can see, they can be learned more quickly and more safely through a systematic training program than through a traditional trial and error method.

I know in my job sometimes, when I have an event report that comes into me to look at, to investigate, often it's a flight-training-related activity, you know, why did you let the student go that far, and the reply will be "how else do they learn? They've got to learn by their mistakes."

Well, pretty much we're in an environment now where I don't think that you can really attack it from that direction. It's sort of an old school way of doing things.

What hampers being able to learn good judgment? Well, one of the facts is that bad judgment is frequently reinforced because it doesn't result in a bad outcome. We get away with it. We push the envelope, we get away with it, and more often than not, we can make a bad decision, and we will get away with it, and there will be absolutely no repercussions whatsoever.

So, what's the next thing human nature's going to tell us to do? We'll try it again. If we get caught in an exactly similar situation, but this time, we may not have the same luck, and an accident results.

In the past, the traditional path to flight training taught us that if we included aircraft flight characteristics and capabilities, the national air space system that we had to fly in, the ATC system, meteorology regulations, emergency procedures, and stick and rudder skills, if we possessed that kind of information, then we will be able to exercise good judgment, and therefore the result will be safe flight.

But we're now finding obviously through investigating accident after accident that that really isn't necessarily so, and we need to do something about it.

So, in conclusion to what my presentation is about, I think we should employ a more systematic and deliberate approach, particularly in flight training, but not just in flight training, throughout the whole flight training spectrum, of teaching judgment as a specific and essential skill just like any of the other skills we're going to need to fly an aircraft.

We must also understand that judgment is learned through the experience of making as many decisions as possible. So, we've got to get these people into environment where they can gain this experience in a classroom or simulator-type situation where they're not going to run out of altitude, as we heard in some of the spin discussions, but not in the air, where some of those decisions, the student gets beyond the capabilities of the instructor, and I think that's a basis of a lot of flight training-related accidents. The student just gets too far, the instructor can now not recover the situation, and, unfortunately, accidents occur.

A closing thought for all of you was the outcome does not dictate whether a decision was good or bad since a decision can be good or bad irrespective of the outcome. It's not very good English, but it made sense as I was writing it.

Thank you very much.

(Applause)

MR. KAPUSTIN: Thank you very much.

Before I introduce John King, when Grant spoke about judgment, a case just happens to come to mind.

When I was in the Chicago Field Office, we investigated -- remember Patsy Cline and Hawksaw Hawkins? They were killed in a Comanche. They were on a tour for the governor in the campaign tour, you know, doing performances. They were ready to go back, and the pilot checked the weather, and it looked pretty bad en route. He called his wife and said we're not going to be home tonight, weather's pretty bad. Wife says, look, get your butt home, you've been gone for a week now, the weather looks fine here. He says okay, honey, that's it. Next thing, we've got a big hole in the ground. Judgment.

I would introduce Mr. John King, and his bio should be a lot longer than that, but in compliance with Dennis's request, he shortened it.

John King, along with his wife Martha, is Co-Chairman of King Schools, Incorporated. King Schools provides training, videos and multimedia CD-ROM training courses to pilots throughout the world.

King Schools has recently completed a new multimedia training system for use by Cessna pilot centers which utilizes a high level of engaged training with emphasis on judgment and decision-making, judgment, and he's got a tremendous web site that I found the other day.

Mr. King. John.

(Applause)

MR. KING: Thank you very much, Rudy, and, Grant, I'm going to agree with a lot of things you said, and he's frantically looking around for my talk right now, and holy mackerel, we found it. I'm so sorry.

Basically, what I'm going to say is we need to create a cultural sea change in aviation. I think we need to do things dramatically and fundamentally different than we are.

I'll have to tell you that this accident makes me very, very sad. I think all accidents make me very sad, but this one does. Here was a very, very capable person, who was working hard to advance herself in life, got an ATP, was taking college classes, obviously a very competent person, and who wound up dead on a hillside in California, and it seems so senseless and so wrong that that happens, and it happens all the time to all sorts of general aviation pilots whom I think are a very special group of people, yet they wind up being dead in many, many ways, and you have to ask why does this happen time after time, and why is it so predictable?

As you know, flying into VFR and worsening weather conditions for cross-country flying is the most frequent cause of fatalities in general aviation aircraft, and a very sad thing about those is that they are so terribly, terribly predictable.

We had some bad weather the other day in the San Diego area, where we live, and I was thinking, wow, the clouds are right down on the mountains, and we got to the airport, and there was a lot of activity buzzing around, and sure enough, someone had taken off and flown into those mountains and killed themselves.

You have to ask why does this happen, and I think 85 percent of accidents are caused by pilots, not by aircraft, and they are caused for the very large part on pilots making bad decisions, as Grant says.

So, I think we want to get down to the root if we're in the flight training business, those of us who can effect and influence pilots, these magnificent people that they are, yet they go out and do this to themselves, how can we keep that from happening?

I think one of the problems is that pilots grossly underestimated the risks they are taking. One of the causes of accidents is this continuing VFR and bad weather and low-time pilots, according to the study by the Office of Aviation Medicine, are more comfortable with this idea of flying continuing VFR in worsening weather conditions.

Non-instrument-rated pilots are more comfortable with it than IFR-rated pilots. So, why do we so grossly underestimate the risk as general aviation pilots in all phases of flying, and we do, and the reason I think we do, and I'm so sorry to put it this way, is I think we in aviation for a long, long time have been telling the big lie, and we have been doing it for so long, that we all believe it, and, sadly, it's just not true.

We want pilots to feel that aviation is safe, and we want them to be comfortable, and we want them to start flying and continue flying. So, therefore, we tell them aviation is safe. In fact, the old saw is the most dangerous part of your trip will be the drive to the airport.

I'm sorry. It's just patently not true. You're seven times more likely to have a fatality in a general aviation airplane than you are in a car. We tell people that. It's not true. It's patently not true, and we've done it for so long, that many of us in general aviation believe it.

In fact, you go talk to general aviation pilots and tell them that there are risks associated with general aviation, and they will tell you no, no. They will tell you exactly what I just said here. The most dangerous part of the trip was the drive to the airport. It's false. It's not correct. It's intellectually dishonest, and we have to quit doing that.

So, the truth is, it is totally irresponsible to view aviation as an entirely safe activity. I said that you're seven times more likely to have a fatality in a general aviation airplane than you are in a car, but you are 49 times more likely to have a fatality in a general aviation airplane than you are riding in the airlines.

It is true about the airlines, that the airlines are an incredibly safe form of transportation. The airlines have such consistency and standardization and such capable equipment and such training, and all of those things make them very, very safe, but it's just not true in general aviation.

So, there is something we can do that I think is dramatically -- that we can do that will make a dramatic difference -- I guess I got way behind here. Am I just -- yeah. Here I am.

There is one thing that I think we, each of us who are involved in general aviation, can do to dramatically improve the accident rate, and that is quit lying to folks. I think we must make a cultural sea change. We must change everything about the culture of general aviation.

Right now, we are in denial. What we need to do in the future is tell people, yes, there are risks associated with general aviation. We must emphasize risks. We must start talking about risks, because until we start talking about risks, we won't identify risks, and we won't manage risks.

So, I think we have to tell general aviation pilots this is a risky activity. Now, we're all afraid to do that, those of us in the flight training business, because we're afraid we're going to lose customers, but Martha and I went horseback riding the other day, and they made us sign a three-page form that said that we're probably going to die, and if we didn't die, at the least we'd be maimed for the rest of our lives, and if that happened to us, it was our own damn fault anyway for wanting to do such a damn fool thing as riding on a horse.

We don't do that in general aviation. We tell them, oh, it's safe. We need to do the equivalent. We need to say yes, there are risks associated with general aviation, and your job is to manage those risks, and that's what you're going to do as you learn to fly.

We must tell them that their most important job that they can do is risk management. We must help them assess risks and identify them, and we must give them very clear and simple tools to deal with risks.

The failure to manage risk is the Number 1 cause of accidents, and the key is to assess the risk properly. You know, if there's low risk, you can continue. Moderate risk, you modify your plans. High risk, you abandon your mission, and there is, of course, a constant tension between risk management and mission completion.

This particular pilot that we're talking about did have a problem. This pilot said that they were supposed to go to a class, and they might have failed that class. She might have failed that class if she didn't go to it.

So, how do we get this pilot to recognize that it's not worth dying for? She didn't think she was going to die for it. In fact, she went on a day when the weather was just horrible. It was dark conditions. She took the most direct route over the mountains instead of going along a highway where it would be lower. She could have gone IFR. She was instrument-rated and equipped, chose to go VFR.

Why did she do that? She failed to assess the risk properly, and what I'm suggesting to you is the reason she didn't assess the risk properly is culturally all of us about aviation have -- I'm going to go through some of these because these keep moving. Culturally have been lying to people about the risk, and it's ingrained in the entire culture of general aviation, and we just need to change that.

So, what I'm saying is -- and I'm going to catch up with myself here in just a second -- we need to start working with risk and give people simple tools to deal with risk, clearer things.

In a complicated situation, people -- in a risky situation, a dangerous situation people won't remember something risky. So, we need to give people clear simple tools, memory aids, guidelines, things that when they get in a situation, they can pull out of their hat and use.

And by the way, if you're worried about these slides that you're missing, they're in the book, and you can read them, but we're behind time, and I don't want to spend more time on it.

The majority of aviation accidents are caused by lapses in risk management. However, our flight training still continues to fill -- focus on skill and precision, and what I'm saying is we need to change everything that surrounds the envelope of learning to fly in general aviation. We need to change the environment. We need to change the cultural approach to it.

We also need to emphasize decision-making and evaluation of risk. We need to talk about judgment, and we need to do it now because we are -- can no longer continue this accident rate that we have in general aviation.

Society won't accept it. The public won't accept it. The insurance companies won't accept it. We must change it, and to do that right off, the first thing we need to do is quit lying to ourselves and identify and manage risk.

Thank you very much.

(Applause)

MR. KAPUSTIN: Thank you, John. Our next distinguished guest is Ken Ibold. Ken is the Editor-in-Chief of Aviation Safety Magazine. It's not Air Safety Week. I almost misread that. Sorry. Aviation Safety Magazine, a monthly publication devoted to improving the safety of general aviation.

Aviation Safety Week is primarily a general aviation pilots, although military and airline pilots also make up the ranks of the readership.

Mr. Ibold is an award-winning journalist whose work covers the aviation, defense and technology fields. He's a former investigative reporter for several large newspapers in the Southeast with credits in the areas of illegal immigration and African famine.

Mr. Ibold is a 1983 graduate of the University of Wisconsin at Madison with a degree in Journalism, but his academic background is also strong in psychology, mathematics and chemistry. He's been a pilot since 1988 and currently owns and flies a Piper Lance.

Ken, it's all yours.

MR. IBOLD: Thank you, Rudy. Well, about three weeks ago, as I was preparing to be here with you today, an associate of mine was flying his Mooney from Caldwell, New Jersey, to Oxford, Connecticut, and he went VFR in an attempt to get more direct routing.

As he flew, he encountered lowering ceilings, and these are his words, he said, "I was basically scud-running at about 1,200 feet. The cloud bases were ragged. So, I was weaving around a bit to try to stay clear. Fortunately, I know that area really well, and I knew where there were some towers that might have been a problem, and I could avoid those.

Still, after awhile, I started thinking to myself, well, I don't know, and I started thinking about airports nearby with an ILS where I could divert, but I kept going and eventually the airport came into view."

Now, this guy's an ATP. He's a CFII. He's got several thousand hours. He was flying a Mooney 201, and I guess after what we've heard from Mr. Pollack today, this is a pretty familiar story.

The aviation industry is well known for identifying problems and fixing them, and sometimes it seems those solutions come before most people even know a problem exists. But all too often, those fixes come only after there's a crash and an unnecessary death or 200.

There are two kinds of fixes that generally apply, technology and training. But, unfortunately, those fixes are generally focused on the airline industry with some trickle-down into corporate jets and Part 135.

Sadly enough, general aviation pilots are left with the admonishment to just try a little harder. Well, admittedly, pilots bring some of this on themselves by fighting initiatives that would require equipment to be added to their airplanes or otherwise increase the cost of flying.

This accident at hand is just another in a very, very long string of reminders that things go wrong when the weather goes bad. The Chieftain and the pilot were very well qualified for the flight, and if you look at the airplane and the pilot, you come to the conclusion that the weather wasn't really all that bad considering the tools at their disposal.

Of course, that hindsight is 20/20. I think everybody in this room can see that if the pilot's route had been just a little more to the east or if she had just a little more altitude for a little longer, then we wouldn't be discussing this accident right now.

How close was it? Well, the radar return showed about a 1,000-per-minute descent in the last 30 seconds of the flight. If that descent had started 10 seconds later, she would have cleared the peak.

So, you have to ask yourself why she did it. Surely she was aware on some level that VFR flight into IMC remains one of the most dangerous acts a general aviation pilot can make.

Let's play the human factors tune for a minute. There are three primary factors that I see. One was that it was a short flight. The weather was VFR at the point of origin, and it was a familiar route.

Now, it's well known that most pilots don't prepare for short flights with the same level of care that they employ on longer flights. There's no regulatory solution we can apply to this. Short hops lead pilots to cut all kinds of corners in preflight planning and in preflighting their airplanes.

The weather was marginal VMC at the point of origin. She decided to forego a weather briefing, and this is probably why. After all, how different can the weather be 50 miles away? Well, it's possible that she got some weather information from an FBO computer or from AS broadcasts along the way, but still I think she knew to a large extent what she was getting herself into.

This was a familiar route. She'd flown it a 100 to 150 times in the past two years. That is, she'd flown from one airport to the other that many times, but this route, as we've said, was a little bit different.

Her more direct route would have shaved about three minutes from the time of the flight. Now, because this actual time savings was so small, it indicates to me that the rest of her preflight was probably just as superficial or non-existent.

Once she got into this situation, you have to ask yourself why don't you turn around? Let's put ourselves in that woman's seat for a second. You can't see the ground, but you can see the sky closing in on top of you. You think the terrain is higher here, but you're not really sure just how high it goes.

Your drive to make it to your final exam is so strong, it has cut off the possibility of turning around. Hey, besides, you're a high-time pilot. You got a nice airplane. You can handle a simple weather problem like this.

But even so, your heart is pounding, and you notice you've got a death grip on the yoke. You vaguely realize that your mouth is dry, and that your hand is slick with sweat. Your scan outside gets just a little more frantic, and you even punch into the cloud bases a couple of times.

Suddenly you become aware of a lead weight in the pit of your stomach, and you don't want to go any lower, but somewhere in the back of your brain, you're worrying about a violation or possibly icing in the clouds, and the clouds are going down.

Okay. It's decision time. Do you climb and confess? Do you turn around? Miss class, fail your exam, fail your class? Do you press on? It's only a little bit farther. Well, at 200 knots, that moment takes an eternity.

It's tempting to assume the obvious in that she began her descent to stay below the clouds, and she never saw the ground rising up to meet her flight path, but in the strange world of aviation reality, no matter how likely that may be, it may also be faulty.

The accident site was about 1,500 feet, and the chart does mark the peak at about 1,600 feet. Winds were almost a direct headwind. So, there may have been some down drafts present as she neared the crest of the hill.

Now, the winds were relatively light. So, it's unlikely that a down draft could have caused the descent, but maybe it came at a time when she was flipping the sectional chart, which divides from front to back just north of the accident site. Maybe she was scanning an instrument chart looking for a frequency to call to get a clearance. Maybe she was briefing herself on an approach plate for the upcoming approach into Oakland.

There are a bunch of other unknowns, too. Did she even have a VFR chart that showed the hill? A lot of pilots who fly familiar routes don't have their charts out. Did she have instrument charts and approach plates on board? Were they out? Was the auto-pilot on? Was she hand-flying? What frequencies were in the standby positions of the NAVCOMs?

All of these pieces of evidence were destroyed by the crash, but they could have painted a better picture of her mental state.

There's some other realities of flying that probably also played a factor. Pop-up clearances are sometimes very hard to get. If you compound that with the relatively short flight at hand, it probably didn't seem worthwhile to file IFR, especially if she figured filing would have led to a longer vectored approach which ran counter to her desire to shorten the trip as much as possible.

Second is that icing forecasts are notoriously unreliable. If she had gotten some weather information through some source, she would have learned about the air mets that called for the possibility of icing.

In any event, she could see the clouds out the window. She probably had an outside air temperature gauge, and she probably knew the score on that count.

The rising terrain and the lowering ceilings put the squeeze on her. Now, why didn't she just climb and fess up? Fear of enforcement? Fear of a black mark on that aviation record she was working so hard to develop and that were key to her career?

Well, maybe, but maybe not. Pilots are, after all, a fiercely independent lot who hate to admit even to themselves when they screw up. So, we found a number of problems, but we need to also find solutions.

This accident was actually caused by three things. There was the pilot, to be sure, but there were also shortcomings in the airplane and regulations that not only -- that the status quo not only encourages or not only tolerates but it also encourages, and correcting any one of them could have prevented the premature ending to this flight.

When it comes to pilot training, we've begun to reach a point of diminishing returns. There are so many demands placed on general aviation pilots by complex air space, sophisticated avionics, escalating numbers of regulations, that all compete for the pilot's attention and, more importantly, their priority.

You can use training to try to instill discipline in decision-making, and you can regulate information-gathering all you want, but from the pilot's standpoint, knowing what you ought to do is a far different thing from actually doing it.

Avionics designers could develop a cheap GPS and altimeter-based terrain warning system for pilots who fly in mountainous areas, and in fact some systems are beginning to have features like this. This technology is readily available, and the avionics companies can create a GPS with a terrain database that they sell to hikers for less than 200 bucks.

Why can't that same capability be added to a $10,000 aviation GPS? FAA certification requirements would need to be kept lenient to encourage manufacturers to adapt off-the-shelf technology or to provide it as an add-on to current GPS receivers. This might help keep the costs low enough that pilots would consider it a worthwhile expense.

Finally, the FAA could help by making it clear that pilots climbing into IMC, confessing and getting a clearance would not get a violation or other enforcement action, unless it was clearly negligent or intentional.

Now, if necessary, they could separate minor infractions into a new class of violations, like traffic offenses, that wouldn't need to be revealed to employers, unless there was some sort of a pattern of abuse.

Now, to an extent, this already exists in NASA's Aviation Safety Reporting Program, and I think maybe we can do a better job of letting pilots know just when and why this constitutes a get-out-of-jail free card.

You can require general aviation to carry a financially-impossible load of technology. You can ask pilots to have a thousand hours of dual instruction. You can study decision-making until it's pension time, but after all the psychobabble and maintenance bills, you're still going to have accidents, and it's our job to minimize them.

That means removing obstacles to making the right decision wherever possible. It means lowering the costs of technological solutions. It means reducing the fear of negative repercussions for correcting a mistake, and most of all, it means reminding pilots that once again, that they have an out if only they'll use it.

Thank you.

(Applause)

MR. KAPUSTIN: Thank you, Ken. Anybody from AOPA here?

(No response)

MR. KAPUSTIN: I just can't resist, despite the time constraints, carelessness, poor judgment, whatever causes some of these general aviation accidents, unfortunately, it's not confined to general aviation.

Air carriers. Airlines spent millions and millions of dollars on CRM, simulators, all kinds of sophisticated training. Air carriers. They fly. They try to land in Level 5 thunderstorms. They get lost. They don't know where they are. They fly into the side of mountains. They run out of fuel. They take off without a preflight. Cowlings fly off the airplane. All kinds of -- they fly hundreds of feet below MDA, fly through trees.

So, I just wanted to kind of put a plug in for general aviation since this is a general aviation seminar.

Our next distinguished guest is Paul Fiduccia. Did I pronounce it right, Paul?

MR. FIDUCCIA: You did.

MR. KAPUSTIN: Paul is President of the Small Aircraft Manufacturers Association, acronym SAMA. SAMA is the national trade association representing the leading producers of experimental kit-built and new design-certified small aircraft.

SAMA also represents manufacturers of engines, propellers, avionics, ground systems, and other equipment for services for small airplanes flown for personal and business use.

SAMA's goal is to expand the market for small aircraft.

For the last two years, Mr. Fiduccia has served the FAA's Safer Skies Agenda -- that's a mouthful. I've got to read it again. Safer Skies Agendas, General Aviation Joint Safety Analysis Team, wow, and Joint Safety Implementation Team for Weather.

He's a member of the FAA's Research Engineering Development Advisory Committee, and he's chairman of its Small Aircraft Transportation System Subcommittee.

Mr. Fiduccia has a Mechanical Engineering degree from Purdue University and has worked as an R&D engineer. He also has a law degree from Georgetown University.

Before founding SAMA in 1990, he was a partner in the national law firm of Winston and Strong, where he specialized in federal relations for 10 years. Mr. Fiduccia is an active pilot with commercial, instrument, multiengine and seaplane ratings. He began flying over 35 years ago.

Paul, it's all yours.

(Applause)

MR. FIDUCCIA: Thank you. Chairman Hall mentioned the Safer Skies Initiative in his introductory remarks, said he was waiting for the products, and as one of those who's been working on Safer Skies for over two and a half years, we're very anxious to get these products out.

VFR and IMC has been mentioned before as the Number 1 cause of fatal general aviation weather accidents. What I'm going to do is two things today, describe very quickly the General Aviation Safer Skies Weather effort, so that people in the audience can know how they might be able to use the products from that effort which I think are very useful, and also to ask you to participate in monitoring the implementation of that because unless the recommendations are implemented, all the work will have been for nothing.

Secondly, I want to comment on the accident discussed today as it relates to the Safer Skies findings. I think there's some very important lessons to be learned from this accident.

I would also like to mention that in addition to the general aviation weather effort, there was a general aviation CFIT effort, controlled flight into terrain. This was a CFIT accident. GAMA was the GA Chair, Industry Chair for that. Lowell Foster, who spoke earlier this morning, was the FAA chair on the Analysis portion of that.

I'm going to -- you've got this in your books. I'm not going to read everything that's on here. There are two phases -- actually three phases of Safer Skies. One is analysis, two is implementation and planning, three is actual implementation.

The analysis phase involved a number of FAA persons who had very much knowledge about aviation operations. We had a spectrum of pilots with varying degrees of experience. We spent eight months reviewing all the fatal weather accidents for a year, 22 of them in very much detail. We reviewed 22 because those were about the only ones where there was an adequate NTSB report that you could really get to the root causes of the accident.

We divided the root causes into several categories, pilot/aircraft information, ATC and so on. We then identified interventions for all these root causes. Root cause analysis involved about one day per case for 20 people, and we took these interventions. We grouped them. We threw out the ones that were less effective and less feasible. We prioritized them into five major recommendations with 20 elements.

Those five recommendations were as follows. Number 1, better information to pilots on the location and severity of weather hazard areas, so the pilot would know how and when he could complete the flight safely. This involved new weather graphics that could be used by flight service stations to provide briefings over computers. The pilot can access them by home or by data link.

Improved pilot reports. Implementation of the data link system that was mentioned earlier. Improved ATC information. The controllers, so they can disseminate it to pilots, and then a model flight operations manual, which is intended to be a risk assessment guide along the lines of what I think John King may have had in mind, where the pilot has a mechanism for assessing all the different risk factors in the flight and accurately determining whether it should be made or not.

The other four recommendations were better weather training materials, mechanisms for disseminating them, things on mountain and low altitude flights. As this accident highlights, there are particular dangers to be had when you've got mountainous terrain.

Better technology, including for rotorcraft and small airplanes and weather, and improved regulations, and the previous speaker mentioned things that pilots would be encouraged to give a pilot report when they're in weather they shouldn't be in or encouraged to fess up, climb up, and get into the system if they can, and this airplane, of course, could have.

The next process after the analysis was implementation. We had 30 FAA people, Weather Service, NASA, six trade association staff. We reached unanimous agreement on everything in this report. If we couldn't get everybody to agree, it was not in there. It was not easy, and we had an interesting time for six months.

We ended up with what was a several-hundred page report that's available on CD-ROM. If you're interested, Roger Baker is the only person from the office that I'm aware of, in the audience here. You might want to contact Roger.

We put it on a CD-ROM because of its length. We did this in this level of detail because we wanted it to be clear to the FAA and the industry exactly what had to be done. So, the report contains very detailed implementation plans that go office-by-office, year-by-year, what are the deliverables, what are the dates, what kind of resources are required to actually pull this off?

We didn't come up with very much that's new. After we did the analysis task, we looked at all the previous recommendations to the FAA on weather safety improvements and found that most of them had been made multiple times before.

We submitted this report in January, and we spent the last nine months for the FAA to decide which of these things they're going to do, and actually next week or week after next, we're supposed to get the final word on agreements from the FAA on which of these recommendations they're going to put the resources into and go forward with. The industry's already made its commitments.

The recommendations in the report are, Number 1, operational graphics. We didn't change that from the JSAT. We looked at IMC conditions, icing, thunderstorms, turbulence. The other items are the same again from the JSAT recommendations. We saw no reason to deviate from those, and what we did was explain what specific things had to be done in order to make those things happen.

The conclusion on this is that we spent two and three-quarters year process to get the FAA to approve what would be taken on their part, and also the Weather Service and NASA to a lesser extent and the industry on what needed to be done. It was a very resource-intensive process. It was a data-driven process. We can track back from any implementation plan all the way back to an accident that we reviewed.

This had the unintended consequence perhaps of delaying some previously-recommended actions when we all went back to ground zero and did this analysis, and lately, there's been kind of a shift in priorities as runway incursion seems to be the only thing the FAA's interested in in the safety area.

In addition to that, we found the FAA never set aside funding in the beginning to do these things. Now we're scrambling to try and reprogram funds to get the work done.

Nevertheless, the FAA in the end agreed to do the vast majority of the things that were recommended a little bit more delayed than we would have liked, and now we have begun initiating a monitoring process to make sure these things happen.

I'd like to talk about this case now. I take this very seriously. I'm in the aviation business. I lose multiple friends every year flying, most of them in experimental flight test accidents.

Earlier this year, one of my friends died in a VFR/IMC accident, a company pilot on the way to an airshow. We mentioned before this is really about real people and real friends and real family members.

I think this case is about factors mainly that were not covered very well in the NTSB report. I agree with the statements made, particularly by John King, about the risk assessment, and I'd say the Safer Skies' main conclusion was pilots are unable to accurately assess the risk of an operation because they don't have sufficient, accurate and precise weather information. They don't have ways of judging that weather information, and that the vast majority of accidents are caused by that.

However, I think this case is really about a lack of professional ethics on the part of the pilot and the accident airplane, the pilot and the lead plane, and the operator, among others.

Let's look at the facts here. We've got an ATP/CFII pilot with lots of hours, lots of currency, flown this trip somewhere between 2 and 300 times in the last couple of years, knew every square inch of this real estate over there. If you're a pilot, you can -- you know, what else are you going to do on the trip? You're looking down at the ground most of the time.

The mission. 55 nautical miles. The accident's 15 minutes, about halfway through the trip. The aircraft. Navajo Chieftain, 10 seats, 700 horsepower, probably 5,000 pounds weight that day, high-performance airplane, IFR capable, tooling along at a couple hundred knots.

Operation. Well, it was under Part 91, but it was really a 135 operator doing this, to reposition the aircraft.

Let's look at the NTSB report. Seven pages of narrative, three and a half are about the wreckage, had nothing to do with the cause of the accident. Very short section on what the weather situation was. What's relevant to this accident? What weather information the pilot had, the pilot, the lead pilot, the operator. What information was available that she did or didn't have? What were the real conditions?

There's nothing in this report on the lead pilot. Was that her boss? Was it the chief pilot? Nothing in here about the standard operating procedures of the company. Why wasn't this an IFR flight? What about fatigue? Nothing in there about what she'd flown earlier in the day.

We've got a 200-knot+ airplane navigating by dead reckoning and pilotage at night, under an overcast, in rain, light rain, at an altitude, the lead pilot's at 1,200 feet, terrain's at 1,600 feet. Why isn't there anything in there about this whole operation? What in any event is remotely safe?

The lead pilot made it because he had the sense to follow the road apparently. So, let's look at what's the root cause of this for a pilot with Safer Skies knowledge. Well, the immediate cause is a CFIT because of failure to navigate. She didn't know where she was when she started letting down or else she was dodging around the bases and ran into the mountain. She must have thought she was further east than she was or because of the headwind, she was further south than she was.

But this case isn't about judgment really, although that's a problem in a lot of cases, and it's not about risk assessment, although that's the problem in most cases, and it's not about lack of experience. This case is about, in my view, professional ethics of the principal decision-makers involved in this.

The pilot had to take a course. We've heard that. What about the job pressures? They had to position these two airplanes over to Oakland International. They weren't doing that for fun. They had to get there. She was under job pressures as well.

What about the operator pressures, the financial pressures, that they were operating under? If you look at the relevant information that was not in the NTSB report, I think that was probably the most important information and what would have helped us understand this accident.

One of the things I'll say this was, it wasn't about data link, which is one of the things we've been pushing real hard. The flight was too short for that.

What do I mean by professional ethics here? The definition of a professional applies to doctors, applies to lawyers, most times it doesn't seem to. They have access to a body of knowledge the layman doesn't have, and their clients are supposed to -- are not able to make decisions in their own welfare. So, if a doctor says you've got to take out your liver, you want assurance because you've got a diseased liver, not because the guy wants a new BMW.

Ethics. They have to do with the set of rules that restrain the professionals from abusing their clients. On occasion, professionals get booted out of their professions. They take courses on it. They take continuing legal and medical education courses on it.

I believe the pilots have professional responsibilities and so do operators because their passengers are relying on them totally to make the decisions necessary that are life and death for them. Should that operation be launched, should it be completed? Is that airplane being maintained properly? Are the people hired properly? Are they trained properly? Is everything else in the operation done properly?

I was up in Alaska last month, and there's an organization up there called the Alaska Aviation Safety Foundation, and the gentleman by the name of Tom Worthy, who's been flying since about the time I was born, is a very wise old fellow, who, in a discussion with him, said -- he gave me an example of an accident that's very similar to this one.

Last month, in Alaska, two airplanes, same route, one turns around, the other pilot says, "I've got to keep my schedule." His last words. Splattered himself into the mountain, killing a bunch of passengers, and this flight, by the way, in the Chieftain, this had nine passenger seats in it. There could have been 10 people killed instead of one.

Well, Alaska's a good place to look for some, I think, insight into this. He had bad weather. He had bad terrain. He had little time in the surveillance support for pilot decision-making. There was financial pressure to operate.

You probably have more commercial VFR operations in the Alaska than the rest of the country combined. There's lots of competition up there. You can go down the line at any airport and say, hey, I want you to fly me to X, and the weather's really bad, and they'll say, by the way, if you don't, I'm going to go to your competitor next door and give him the money and fly to X.

So, there's lots of reasons to -- it makes it hard on the operators and the pilots to make the decision, and it comes down to that professional decision of money in your pocket or completing your course versus the safety of your charges, your passengers. In this case, it was just an airplane.

The Safer Skies Weather JSAT Conclusion Number 1 was inadequate weather information. We had things in there on risk assessment, but in this case, it's not really about that, I don't think.

I think it's about a failure of the professional ethics of all the actors involved. The pilot in the lead plane was doing something equally unsafe as the pilot in the following plane. He just was a little better, a little luckier, and he may have in fact been more of a cause than she was. She may have been directed to follow him as chief pilot and said we're taking this airplane to Oakland, just stay behind me. He asked her, hey, you still back there?

The operator. What kind of procedures did they have? What kind of pressures were they under to reposition this airplane? Why wasn't -- why weren't they doing this regularly as an IFR flight over there?

Now, let's get to some other actors in this. How about the FAA? Safer Skies recommended that they make some changes in the way they do enforcement, so pilots -- it makes it easier for them to make the right decisions. They didn't really want to do that.

What about the VFR not recommended kind of forecast? Totally useless to anybody except the brand-new student pilot. What about the National Weather Service in delivering more precise forecasts of ceiling and visibility conditions?

Assuming visibility is not a high priority of the FAA's Weather Research Program in terms of area forecasts. It should be.

What about the NTSB? Relevant information isn't in this report. If we had this one in our Weather JSAT, we would have discarded it on the grounds that we don't have enough information to really understand what happened here.

What about the industry? John King points out the big lie. Well, it's true. SAMA's Number 1 objective in terms of expanding the market for a small aircraft is to enable pilots of small aircraft to deal with weather. It's the biggest problem, lack of utility or, I should say, lack of safe utility.

And in order for pilots to safely use small airplanes for transportation, you have to be instrument rated and capable. I think that's what we ought to reflect upon with this accident, and professional ethics is not trained anywhere that I'm aware of.

When we talk about a pilot being professional, we mean in the very narrow sense that he's technically competent. He has knowledge, skill and judgment, judgment in kind of a narrow sense, being able to assess the risk, and that's very important, but in this case, the pilot knew the risks completely and still undertook the flight, and that happens a lot, and I think for the industry, we've all got an ethical responsibility as a matter of professionalism to deal with a certain number of these accidents that are caused like this.

Thank you.

(Applause)

MR. KAPUSTIN: Thank you very much, Paul. We have time for just a few quick questions. Dennis, not too much, huh? While we wait for the questions to come up, before we get any rhetorical questions, any accident report -- Paul's comments on the NTSB report, there are things in there that probably didn't need to be there and some that maybe should have been in there.

Based on my experience, no matter who investigates an accident, any other investigator, professional investigator can come along behind you and find different set of facts, possibly different outcome of the investigation, different recommendations.

So, it's not a hundred percent precise science. You do the best you can and come up with corrective -- whatever corrective actions you come up with.

Let's see the questions. This is for Mr. King. Do you currently have a video for operational risk management for general aviation pilots?

Mr. King?

MR. KING: Yeah. I wasn't trying to sell a video. Can you hear me now? Okay. I wasn't trying to sell a video, but, yes, we have two things.

We developed in conjunction with the FAA and Ohio State University a video called "Making Your Own Rules", and it identifies the four major risk factors of a flight, pilot, aircraft, the environment you're flying in, and what we call the external pressures, the reasons you're making the flight, the things that pressure you to complete the flight.

We do have a video that covers that, and I think it's very good, and it gives you a checklist to assess the risks of your flight before you go, and then the second thing we have is "How to Avoid Unwanted Adventure", which basically sets some rules of safe flying.

So, yeah, we do have some videos on the subject, and probably because of my passion on this subject.

MR. KAPUSTIN: The other question is -- thank you, John. I don't know if this is yours or not. What does JSAT stand for? How do you get the CD-ROM?

MR. FIDUCCIA: The FAA made these acronyms up, but they're Joint, which means FAA and industry, Safety Analysis Team. That's the JSAT. The other one is Joint Safety Implementation Team, and, so, these are different groups with some overlap that were between joint FAA/NASA/NWS, Weather Service, and industry to analyze and prescribe implementation steps on the safety program.

MR. KAPUSTIN: Okay. Is there a CD, and how do we get it?

MR. FIDUCCIA: Yeah. There's a CD, and Roger Baker from FAA over here, if you contact him, he can get to the right person there, and the FAA can provide them.

MR. KAPUSTIN: Okay. Thank you. No more questions?

(No response)

MR. KAPUSTIN: Dennis, I'll give it back to you. Thank you.

MR. JONES: And I'm not going to talk about Roger Baker.

Could you please join me with a line of applause for this group here? Very, very good.

(Applause)

MR. JONES: Well, thank you very much for your patience. We've got a little behind schedule. We were planning to break a little earlier, but I think the issues that this panel raised warranted our time here, and I want to thank you very much, panel, for providing this discussion.

We're going to have a little slight program change. We're going to try to get back here a little earlier than we planned. So, we will try to return back by about 1:40. Approximately 1:40, we'll return and reconvene.

There are a lot of eating establishments within short walking distance from here, but please, there is a lot of food available tonight at our banquet, and we're encouraging you, we're encouraging you to come to our banquet this evening. We have a lot in store for you. So, don't eat too much, save it for this evening. Thanks a lot. We'll see you back at about 1:40.

(Whereupon, at 12:54 p.m., the meeting was recessed, to reconvene this same day, Thursday, September 21st, 2000, at 1:40 p.m.)

A F T E R N O O N S E S S I O N

1:40 p.m.

MR. JONES: Thanks for returning, and we're going to start our afternoon session. Our first panel this afternoon will be on Helicopter Operations, and the presentation will be done by our Regional Investigator Clint Johnson.

Clint Johnson is of our Northwest Field Office up in Anchorage, Alaska. It's kind of a unique place, and I had a chance to go up there last year with the Chairman and to learn a little bit about the operations up there and how a lot of the remote villages depend on aviation to -- for transportation.

In fact, I received one story where this one village relies on aircraft to bring in Pizza Hut. So, it is a unique place, and I thought we would have a good perspective and an interesting insight into what goes on in that part of the world.

Also on the panel will be our moderator, Roy Resavage, and he will introduce the other panel members as they start.

With that, Clint.

Helicopter Accident

MR. JOHNSON: Thank you, Dennis. Appreciate it very much. It's great to be here. It's good to get out of Alaska for a couple of days here and come down to Washington. It's not very often they let me out of Alaska, have to talk to them about that.

I have an accident today that took place on

-- see if we can get the first slide up here. It actually took place in Juneau, Alaska, which is our capitol city, which is down in Southeast Alaska, took place on September 10th, 1999, and this was an interesting accident, especially with my background in the helicopter industry. This was definitely an interesting accident for myself.

This accident was different for a couple of different reasons. Number 1, and most importantly, when this accident took place, not one, not two but three AS-350s were destroyed in the process, all owned by the same operator, and all within about a five-mile radius, up at the 5,000-foot level of the Juneau Ice Field.

To give you an idea of what type of aircraft we're dealing with here, it's known as an AS-350B-2. It's known in the industry as an A-Star, better known as an A-Star. It commonly is used in tour operations throughout the world. It seats six to seven people, depending on the configuration that it's set up for. The speed is about a 120 knots, relatively quick for a machine of that size. Excellent visibility and average cost of one of these babies off the showroom floor about $1.3 million.

As a result of these accidents, we had one serious injury, we had five minor injuries, we had 10 people stranded at about the 5,200-foot level of the Juneau Ice Field overnight, which is not a good thing by all means, and it resulted in about $4 million in hull losses as far as the aircraft is concerned.

Juneau, just to give you an idea, a little bit of a background on Juneau. Juneau is down in the southeast portion of our state. It is our capitol city. The interesting thing about Juneau is it is our capitol, and there are no roads to Juneau. The only way to get there is either by flying or by boat.

To give you an idea of one of the biggest attractions for Juneau is the Juneau Ice Field. That's what everybody wants to see. To give you an idea of how -- what size this is, it's about 1,500 square miles of ice and snow. In some areas, it can be up to 1,500 to 2,000 feet deep, tremendous amount of ice and snow. It's a hundred miles long and about 45 miles wide, and it's the fifth largest ice field in North America.

To give you an idea as far as why Juneau lends itself so well to helicopter tours is the hull distance. In the foreground, you can see the runways of Juneau, the airport, the international airport. In the background is the Menden Hall Glacier. Menden Hall Glacier eventually hooks up with the Juneau Ice Field, and that's what everybody comes to see.

To give you an idea of the volume that goes through Juneau as far as tourists goes, last year or actually in 1999, when this accident took place, there was an estimated 650,000 people that actually went through Juneau. 600,000 of those, it's estimated, arrived by cruise ship, 85,000 of those folks went on tours, helicopter tours.

Now, if you look at those numbers and relate those to the Grand Canyon markets and the Hawaiian markets, it may not seem that impressive, but keep in mind our season is very short, roughly three months at the max long, from June to September.

I need to set the scenario here for you for just a moment. Unfortunately, the accident history in Juneau for 1999 was not the first time that we had been to Juneau when the three accidents took place.

June 9th, 1999, an AS-350B-2, an A-Star, departs on a program tour of the Juneau Ice Field, very close to the same place that these three helicopters ended up crashing, also.

On board that machine was six cruise ship passengers, one pilot, total of seven occupants on board. As they made their way up the Juneau Ice Field and eventually reached the upper level elevation of the Juneau Ice Field, the last radio position was normal. These folks, what they'll do is they'll report in where they are, what their progress is with their base and other machines in the area. There were no problems reported. There was no distress call, and there was no ELT.

Unfortunately, a machine that was about five minutes behind came across this accident scene. Just some bullets about this real quick. It resulted in seven fatalities. Obviously the aircraft was destroyed, but the interesting thing is in 18 years of helicopter tours in the Juneau area, this was the first fatal helicopter accident.

It was a devastating accident not only for Juneau but also for the tour industry in Southeast Alaska.

You might ask, why would I add this, and why would we want to even cloud the issue here? Well, one of the biggest reasons is the fact this was actually the helicopter that was about five minutes behind this helicopter before he came down, this is what he told me in an interview.

He indicated that flat light made it very, very difficult to discern where the terrain was and where the clouds started, very, very tough. Now, to give you an idea as far as flat light, it's a little tough to explain, but basically this is the area. This is the top of the Juneau Ice Field. It's very, very flat, and it's very, very featureless at this point.

Now, keep in mind that there has been a light snow, dusting of snow, that is going to hide any of the topographical features of the ice. As you're moving over the ice, your depth perception is basically null at this point. You may still have a horizon or a vertical reference as far as the horizon goes, but as far as your vertical or your vertical reference and how high you are actually off the ground, it's really, really tough to see.

This might be a little bit more of an idea. Once you lose that horizon, you cannot tell how high you are off the ground, and I know this from personal experience.

Okay. This is the first accident or the beginning of the first accident here. This is on September 10th, roughly three months, three and a half months after the Coastal helicopter accident. It's a little later in the afternoon or actually just early -- late morning, that is.

Six people -- five people, excuse me, arrive for a helicopter tour. This is a little bit different. This is not a program tour. This is what's referred to as a pilot's choice. Now, basically what this does, this allows the pilot to pick his route, depending on weather and also ice conditions at the time.

The tour itself is programmed to last roughly one and a half hours after its departure. It's supposed to return back to Juneau, and it also includes two landings, which is a real thrill for anybody that has never done that.

Weather conditions at the time excellent as far as Juneau goes. It was a high overcast, very light winds and great temperature-wise. When I had a chance to interview the pilot of the first accident helicopter, he indicated he flew up the Menden Hall Glacier, over the cravassed area of the Menden Hall Glacier, and finally ended up on top of the Juneau Ice Field, had no problem getting up there.

He actually cruised around and even went ahead and completed both landings as advertised. This is when things went a bit awry. He indicated to me that he had always been taught or always been told not to cut across the wide open expanse of the Juneau Ice Field for obvious reasons. He said he couldn't tell me why he didn't do it this time. He just thought that the light conditions and the weather conditions would warrant a crossing.

He indicated that as he was crossing the ice field, he encountered a light snow shower, very light. He indicated he still had at least three miles as far as visibility. He indicated that he slowed the helicopter down to transition through the snow showers, and an interesting fact that I came up with here is he had no real sense of danger. He didn't think that there was going to be any problem.

He indicated to me that he was 500 -- he was sure he was at least 500 feet off the ice. Passenger seated in the left rear said pretty much the same thing, said he was just enjoying the view, actually felt a little bit of a power change as the pilot lowered the collective and slowed down, and he said pretty much the same thing, that he thought that they were maybe 300 feet off the ice.

He indicated just about 20 seconds before the impact, he took this photo for us, which was nice, and you can see that as far as the horizontal or horizontal visibility, it's not as bad as you would think.

The next thing happens, they hit -- the machine hits skids level, flips over, slides for about a 150 feet, and ends up inverted on its back. The next thing the passengers knew is they were hanging from their seatbelts.

As far as the injuries sustained, for the most part to the front seat occupants and the pilot. The pilot sustained a minor head injury, and both of the front seat passengers had -- one sustained a broken ankle, and the other one a wrenched knee, but nothing that was life-threatening at this point.

Now, Accident Number 1 has taken place up at the 5,200-foot level of the Juneau Ice Field, roughly 16 miles to the north of Juneau.

The pilot at that point, after assessing the passengers, and this -- I should mention that this is also a passenger photo. This was literally a couple of minutes after the accident took place, and it was a pretty devastating impact, as you can see.

Now, there's a couple of problems here. Obviously the pilot's first intuition was to go ahead and try and get help to their location, other machines in the area or else directly back to their base.

There was a problem there. This area right here, this is the instrument panel. So, as far as any COM or any FM communication, that was completely out of the question.

The second thing is the rotor blade in the accident sequence had been disabled or destroyed ELT. So, they were in essence completely isolated from the outside world, and at this point in time, the weather was coming down, and for the most part it was IMC at this -- after about 45 minutes of being on the ice field.

The pilot assured each one of the passengers that help would be on the way as soon as they were reported overdue, and that was in fact the case. So, at that point, he settled in, made sure -- tried to make the passengers as comfortable as possible, and this is another passenger photo here that was taken.

At this point, it's coming up on 12:30, and the helicopter is definitely considered overdue now from the operations folks. The base manager is advised by the dispatcher that they have an overdue helicopter. The base manager that was there elected to go ahead and take an observer and jump in their own A-Star and go out and see if they can find these folks.

He indicated as he climbed up the Menden Hall Glacier, up towards the ice field, he encountered low overcast and flat light-like conditions, and he was not able to get up on to the area where he suspected the helicopter was.

After searching for roughly an hour, his fuel reserves were exhausted, and he requested another helicopter from the base of operations be readied and sent to his location so he could return for fuel.

This is where Helicopter Number 2 comes into play. Helicopter Number 2 is the second machine that was actually dispatched out of the Juneau Heliport. He searched the upper ice fields. They actually passed each other on the way up the ice field. The base manager indicated to him where he had left off as far as his search, and he was actually able to get up on to the ice field.

Approximately half an hour had gone by from the time that they swapped places there, and he was actually able to get up in the ice field. He observed a ceiling of roughly 700 feet. He said the visibility was again three miles, and he was using a mountain range on the right side of the helicopter as far as reference goes, and the same thing.

He indicated to me that he was sure that he was 500 feet above the ice before the impact happened. Same exact scenario. This one slid for roughly 75 feet and ultimately rolled over on its side and was destroyed.

Both the pilot and the passenger, the observer here, reported no injuries, and we now have Number 2. This is roughly probably three miles from the original helicopter accident, again up at about the 5,300-foot level of the Juneau Ice Field.

Unfortunately, they were not within visual contact of each other because of a mountain range in between them, but they were very, very close as far as their proximity goes.

At this point in time, the base manager, after receiving or topping off with fuel, he comes back into the area where Helicopter Number 2 is. Helicopter Number 2 still has COM and is able to communicate to the base manager, and he informs him that he has crashed and no injuries but they do need a ride.

Helicopter Number 3 comes into play. This machine was actually returning from Petersburg, which is down to the south of Juneau, on a swing job down there. He overhears all the conversation going on, and the search is still going on for the tour helicopter.

He offers to go ahead and join in the search. His offer is taken up by the base manager. He's dispatched to go pick up the helicopter pilot and passenger of Helicopter Number 2.

He gets into the area, and the weather conditions are not going to allow him to get in. So, you can see as far as the weather patterns here, they're going up and down on a regular basis. He tells Helicopter Pilot Number 2 that he is going to return for fuel, allow for the weather to return -- to improve, and then he would return to pick them up.

That's exactly what he does. He actually hot refuels in Juneau and returns immediately back to the area and lands next to the Helicopter Number 2 with no real problems.

Now, this is a pivotal point. This is where the four employees are all company employees. They have a quick meeting. Instead of going back to Juneau and taking these folks back, they elect to go ahead and keep on looking for the missing helicopter. The problem is, is they still haven't heard, and there's still no word, and at this point, I was in the loop and trying to figure out exactly what the situation was that we had.

Now, this is actually a picture. This was taken from one of the search helicopters. At this point in time, other operators in the area, Coastal Helicopters and also Northstar Helicopters, had dropped everything that they were doing, and they were up assisting in the search at this point.

This is actually taken from one of the Coastal helicopters, looking up to the north from the south, and this is what they were able to see. Now, basically the comment that that pilot told me, he says, "I didn't want to go in there because I didn't want to end up like everybody else", which was probably a pretty good move at this point.

Now, what the intent was is this was -- this is the area where Helicopter Accident Number 2 is on this side. The intent of Helicopter Number 3 is to come around this mountain range, head southbound, where the weather was actually a little bit better, and this is where the accident helicopter, the tour helicopter, was located at the present time, and that's exactly what he did.

He indicated to me that the ceiling was about a thousand feet, had six miles visibility, and the tour -- missing tour helicopter was sighted in less than probably a mile and a half to two miles away. He indicated that he slowed the air speed to 30 knots for a nice gradual closure rate and used the mountains on the left-hand side as reference, and the same thing.

He said he was sure that he was at least 500 feet off the ice, and in full view of the passengers, same thing happened, hit the ground, hit the ice, rolled over the side, obviously destroyed the machine.

Now, the interesting fact is here, two of these guys, both pilots, had been in two helicopter accidents in probably about the last two hours, which is pretty amazing in itself.

But nobody was injured at this point in time. We now have Accident Number 3, and this is all within about a four to five mile radius, not within walking distance because of the cravasses between the two accident sites, and now it's a critical situation.

So, just for a second, let's go ahead and recap what we have here. We have three helicopters that have been destroyed, one serious injury as a result. We have five minor injuries, 10 people stranded at the 5,300-foot level and 5,200-foot level of the Juneau Ice Field. Weather was hampering the rescue efforts, and the problem was, it was now about 7:00 at night, and night time was rapidly approaching.

That's where these folks came into play. These are members of the Juneau Mountain Rescue Team. They are a non-profit volunteer organization based in Juneau, and I want to mention that one of our investigators, Mr. Scott Erickson, up in Anchorage is also a member of the Anchorage arm of that same type of an organization. He volunteers his own time to go out and help folks out like this. So, I definitely wanted to mention that.

The weather conditions at this point had deteriorated where there was no way that they were going to be able to reach them by aerial means. They were going to have to be able to be taken in by helicopter, as far in as possible, again Arrow, Coastal and the Coast Guard at this point in time, took these folks in to the lower levels, but the problem was, there was a thousand-foot ice wall in between the upper level and the lower level where the helicopters were able to land and drop off the rescuers.

So, the feat that was in front of these folks at this time, this nine-member team, was to scale this thousand-foot ice wall at night while it was snowing with all their gear up to the top, and they finally made it, and it was pretty amazing.

Once they reached the top, the next feat was to be able to find the helicopter, and this was literally like finding a needle in a haystack because there was no electronic devices to lead them to the helicopter. It was snowing, ankle-deep or actually knee-deep snow at this point, but miraculously and luckily, they just happened to stumble across them.

Now, the interesting thing is here, is the passengers and also the pilot took it upon themselves to build an ice igloo, and you can see around the helicopter here, they've actually built one heck of a little shelter, and I was pretty proud of that, and they didn't just give up. They actually took it upon themselves to build a shelter up there, and it took me a long time to be able to knock that thing down. So, they built it pretty well.

At that point in time, obviously the rescue folks, they had ample gear on board or brought the gear up as far as medical supplies, tents, and at this time, they were able to stabilize everybody, and it was looking a little bit better.

The next morning, roughly 11:00 in the morning, HH-60 Coast Guard machine came in and actually hoisted everybody out. They were unable to land there because of the visibility conditions and ended up hoisting all of the occupants out.

As far as our findings that we came up with when looking at this accident here, visibility restricted, flat light conditions were obviously encountered, radar altimeters were not installed on all three of these machines nor were they required, mind you, and the FSDO or the Flight Standards District Office failed to require the operator to conduct instrument proficiency training and check rides as per their internal FAA order.

Probable cause. Helicopter Pilot Number 1 or Accident Helicopter Number 1, the pilot continued flight into IMC or instrument meteorological conditions, inadequate altitude clearance.

Helicopter 2 and Number 3, both the same, pilot's failure to maintain altitude and clearance.

That concludes my presentation, and I'll go ahead and hand it over to Mr. Resavage.

(Applause)

MR. RESAVAGE: Good afternoon. Can you hear me? How about now? All right.

My name is Roy Resavage. I'm with the Helicopter Association International.

When I first found out they were going to brief this particular case, of all the cases we've had over the last who knows how long, I was kind of perplexed as to why they would pick this because in one sense, as they go through, as Clint went through it, and I think he did an excellent job, it kind of has a key-steering cop routine aspect to it, you know. You sit there, and you say how could they do that? You know, when are they going to learn, you know? Surely this is going to end sooner or later.

But in fact, this is really a deadly serious problem, and at first, I wondered, you know, this is really not the right type of case to present, but in reflection, I think it is. I think we can learn a lot from this case. There's a lot of good teaching points from this, and even though it might seem outrageous that you could crash three aircraft at one incident, it highlights the problem that we have, and I think you're going to hear everyone talking essentially the teaching point of this, is although there are sidelines to it, the teaching point is how do you handle flat light conditions, and, you know, is it possible and safe to operate in flat light conditions?

The first slide here. I've got it on my machine here, but I don't have it up on the big one. Could I get some tech support maybe? Maybe not.

I'm about the most technically-inept person in this room, I can assure you, but there's only two buttons for me to hit, and, so, chances are that I'll be able to progress through this thing here.

The first slide. I wanted to spend a little bit of time and talk to you about helicopter statistics because I would think that most of the people in this room are not as familiar with the helicopter component of GA as they are with most of the other aspects, and I kind of wanted to show you where we fall out in the grand scheme of things, and also show you where tour aircraft fall out in the grand scheme of things, and that's what I'm attempting to do here.

You can see back in 1970, we flew about 870,000 hours a year, and now we're up to just under two and a half million flight hours a year. If you look to the left, you'll also see that we started out with an accident rate of approximately 30, and now we're down to an accident rate of eight, roughly eight. So, there's been great strides made from the early days when the industry was in its embryonic stage.

Unfortunately, from about 1990 on, we've kind of hit a plateau, and we're holding ground there.

Here we just list some of the reasons why we think there has been improvement. Again, the industry has really matured. There's a very professional aspect to all the different sectors that we're involved with, and, of course, there's been a lot of good regulation, a lot of good oversight and proper training that I think have all fed into the situation here.

Here, I would like to show you where helicopters stand relative to the GA community, and you can see that we roughly parallel the general aviation community, although we are a little bit higher, as you can see.

You know, we are working harder to get down there. We need to work even harder than we are obviously, but this is where we are in relation to the overall general aviation community.

I would like to add, though, that the vast majority of the helicopters that are out there are not used for pleasure. If you look at the number of GA aircraft, and you look at the percentage that are used for pleasure as opposed to commerce, and you compare that to the helicopter industry, the amount that are used for commerce is the predominant number. Almost all helicopters are used for commerce, and some of that commerce requires a challenging scenario. It's not just a question of flying around and enjoying the sights as you go.

This slide here, we're trying to show that often the exposure to risk is proportional to how many times you take off and land, and that was brought out in some of the earlier cases today.

The vast majority of the incidents take place in the landing environment. Helicopters on average throughout all the different type of work they do take off and land about three times an hour as opposed to approximately once an hour for fixed wing. So, if you factor in the exposure to risk into our flight hours, you can see that the numbers come down quite a bit.

We have certain segments of the industry where there may be six take-off and landings per hour. So, it varies.

In the tour industry that we're talking about now, you can see where Clint was talking roughly about the flight hours that are involved in the rotorcraft industry and air tour, commercial air tour, and a little under a million people a year are flown, and the numbers speak for themselves.

This is an overall slide again to give you an idea of the accidents in the GA community, the helicopter community, and the air tour industry, and you can see that even though it sounds like at the rate that we were going here, that we should probably have 40 or 50 accidents a year, that in fact is not the case.

As he correctly pointed out in 1999, the accident in Juneau was the first fatal accident they had had, and as a matter of fact, it was the first fatal air tour accident by professional air tour operators that there had been in two years.

Going down a little bit further in the slide, you can again see the accident rates of the GA and the helicopter and also the subset of the air tour operators.

I'm going to go through these slides very fast because Clinton handled them a whole lot better than I could, and what I'm going to do from here on in is I'm briefly going to cover a couple points, and then I'm going to pass it to the panel and let them go on.

Again, I think Clinton did an outstanding job on this accident report, and I think they really have brought out a lot of the salient points, and I don't want to take all the good stuff and stick my colleagues here with nothing to say.

So, I do want to just highlight a few things. The pilot operating this aircraft, although he was a relatively experienced pilot, I believe he had about 2,400 hours, and he had close to 1,200 hours in type, had no instrument rating, and that's not unusual. He was flying VFR. Probably 95 percent of the rotary wing operations are VFR.

He was not required to have an instrument rating, but he was required to have basic instrument training in his commercial certification. So, he should have had at minimum 10 hours of basic instrument training.

Also, as was brought out in the brief, there was no flat light training by his employer, and there was no inadvertent IMC training. The aircraft was not certified for IFR flight. He was not certified for IFR flight, but it would seem prudent to be able to rely on basic instruments to at least do a course reversal to extricate yourself from a situation like that.

The VFR panel before lunch, I think, handled this very well.

In the proficiency check, the pilot never had to demonstrate his ability to fly on basic instruments and to perform some type of escape maneuver to show that he was capable of doing that in this tough flat light situation that is often encountered in the glacier situation.

And, of course, as was brought out, the aircraft had no radar altimeters. Again, I'd like to emphasize the fact that the radar altimeters are not required. It would again seem prudent when operating in that type of environment where you have a changing landscape that's not necessarily discernible by the naked eye to have a radar altimeter and perhaps some other type of ground proximity warning system to give you aid in a situation like that.

Subsequent to this accident, TEMSCO has made those changes to put in a radar altimeter, and I'll again let the other people speak to some of the different training programs that are going on.

Again, I would like to emphasize how dangerous the flat light situation is. It's very, very difficult, and it's very insidious at its onset. One minute, the pilot believes he has visual reference. He's flying along, he can see a mountain or whatever he is using as his check point, and then the next thing he knows, the horizon and the surface basically join, perhaps snow is falling out of a cloud that's up in front of him, he's not aware of that. All of a sudden, they're in -- from the flat light situation, they're going to a white-out situation, which is again very insidious and very dangerous.

We tried to find out what type of tools are available for the people out there to be prepared for this. Should this be part of their training? Is it something you would expect someone to get on their own in the course of their training? The answer is no.

The Airman's Information Manual and the Rotorcraft Flying Handbook do not even address the flat light conditions. So, you know, there's, you know, possible room for improvement there.

One of the things that we at HAI believe that we could possibly do to help alleviate this in the future is we are going to -- we are talking with Roger Baker today. I know his name's being used in vain over and over today, throughout the course of this, but he's so easy, you know, you have to grab him while you can.

But in conjunction with FAA, HAI would like to put together a video that basically talks to some of these points, where we could get experts and actually come up with a program that would be available for people to look at.

Obviously the operators need to have this in their operating manuals and their instructions, and there should be training, and there should be recurrent training on this, but we also are going to, in conjunction with the FAA, produce a product that will also help some of the operators that may not be in that situation.

So, with that, I think I've used up all of my time, and I'll leave the other recommendations to the panel, and I would like to introduce Dick Bunker, who is with Massachusetts Aeronautical Commission. He has been a long-time accident investigator. He's got tons of flight hours, got about 8,000 flight hours, about half of which are in helicopters, and I'll let him carry on.

Dick.

(Applause)

MR. BUNKER: Okay. Can everybody hear me all right? All right.

Well, I've got to say one thing to follow on Roy. It's kind of tough, and, of course, in my case, I'm one of these flat landers from the East Coast. So, we don't get involved in mountain flying. I think the highest mountain I've got in the state of Massachusetts anyway is a little over 3,000 feet.

Ice and snow fields aren't a problem either. Again, this is something that we just don't have, and, frankly, I've never flown in any of these type of conditions, other than bringing our helicopter back from Arizona in 1986 and coming across the Rockies.

Having talked to Clint about this and some of the other folks here on our distinguished panel, I think we all got pretty much the same thing out of this particular incident, and the sad part about it in my mind is why did it take the loss of three helicopters before they started implementing some of these training procedures that they now have set up?

Why did it take the loss of three helicopters before they put radar altimeters in the aircraft, which they have done. So, obviously they learned from their mistakes, to their credit, but my feeling is that it shouldn't have taken that long, and I think everyone here would agree with that.

Unfortunately, I see this quite often, and I'm just talking one state in this country that I deal with on a regular basis, and we are busy. Don't get me wrong. I'm one person, and so far this year, we've had three fatal accidents as opposed to five last year and 11 the year before, but we're brought up on the -- what I call the fender-bender accidents, and we're up to -- I did Number 31 last week.

The problem is we get the statistics. We put everything together. We give it to the legislators, whatever it may take, but it's reactionary. We should be doing this before these accidents happen. We should be getting this information out to these people.

I don't know what the answer is, but that's my opinion.

The investigations to me is not just a matter of gathering data for statistics, for the files, and we all have to do it. However, I think the whole idea of this is to learn from our mistakes, learn from past mistakes, and I just feel that it takes too long a time to go from the accident stage to implementing a procedure to fix the problem. It shouldn't take that long. We've got to do a little better than that, I think.

I thank you very much.

(Applause)

MR. RESAVAGE: Next, I would like to introduce George Conway, who is an epidemiologist, I'm not sure I pronounced that right, and he's had a long-standing interest in safety in transportation-related practices.

Since September, he's been -- this is the longest title I think I have ever read in my life. His current assignment is Chief, Alaska Field Station, Division of Safety Research, National Institute of Occupational Safety and Health, Centers for Disease Control, in Anchorage.

So, I would like -- it would have to be a very big door to get all of that on there, but Dr. Conway has been very active in all modes of transportation safety. He has helped set up some safety prevention centers, and I'm very interested to hear what he has to say.

DR. CONWAY: Thanks, Roy. Well, maybe Uncle Sam will buy me a door after all, huh? Let's see if I can get this thing on.

So, it's a tough job, you know, speaking after lunch, and people are getting kind of sleepy and what not, and it's humbling, too, to follow speakers like Grant Brophy and John King, and, you know, I was listening to John talk earlier, and it was amazing seeing him as something more than his virtual self on the computer screen. Sure, probably the same thing for a lot of us.

I was thinking, what on earth am I going to say that will add to anything to what these guys have said, and then, over lunch time, I was thinking about what the center of this issue is, and I think it was Mark Twain wrote or Samuel Clemens, that the thing about judgment is it comes from experience, and the only bad thing about experience is that you typically get experience following bad judgment.

So, with that, I'd like to talk about these three events. I have one -- there's one figure. My judgment -- there it is. Okay. Trying to think over my preference to plow through many slides. I'm actually mostly going to stick to some prepared remarks which are in your little packet.

These three rotorcraft crashes that took place just about a year ago this week provide examples of undesired outcomes in a rapidly-growing portion of our tourism industry.

During 1999, U.S. Forest Service recorded almost 17,000 glacier landings in the Juneau area. So, that's during daylight hours. There's about a hundred days or so in our tourist season, and that was a take-off and landing roughly every five minutes for these tours, which is really a striking figure.

You can see this graph shows the current usage and the volume for these tours starting in `84, which is when they started gathering information. I think there were 640. `99, there were about 17,000, and the operators have requested leave or permission from the Forest Service to do 40,000 landings a year within the next five years, which would be a take-off and landing during daylight hours of about one every minute in Juneau.

Juneau's a small town, about -- by Alaskan standards, it's a city, but by most other U.S. standards, it's a small town. It's got about 30,000 people in it, except when the cruise ships land, and then the population goes up very substantially.

Now, most of the press attention that surrounded this in Juneau hasn't been on safety hazard, it's been the environmental concerns and noise. This is a really big issue, and there's some local ordinances to making some attempts to limit the noise that this creates.

Rotorcraft have accounted for a substantial number of deaths in Alaska during the last decade. The first of these related -- as Mr. Johnson mentioned, the first of these didn't occur until 1999, in our tourism industry, and that was a few months and a few miles away from these three events.

The majority of Alaska's severe rotorcraft crashes have occurred during helicopter and heavy-lift load operations and also business transport operations, and the great majority of those deaths have been occupational, hence our own agency's concern with those.

While most of our work historically has been centered with rotorcraft on lift load operations, there are certain features of those operations which are common to these rotorcraft operations in the tourism industry as well.

Both of them involve frequent short trips, rapid take-off and landing cycles, and then repetitively and potentially very monotonous routings. They both involve multiple complex tasks, although I must say in lift load, I think it is probably an order of magnitude more complex than tourism.

In addition to the demands of flying rotorcraft, and, of course, rotorcraft not being self-trimming, require a great deal of vigilance just while flying. So, the additional distraction of having to deal with passengers and play tour guide and answer people's questions may on occasion saturate the operator's attention.

Any additional stimuli or demands, such as can readily occur in an emergency, can rapidly lead to the operator being overloaded with tasks. Both types of operations have to contend with our climate which can be very harsh, and which often provides marginal or worse flying conditions.

They're also both very competitive businesses. They operate on very narrow margin. Depending upon the company, some of the operators pay on a wage, some of them pay based on piecework. If you're paid by piecework, if you don't fly, you don't earn.

Both operations are very heavily dependent upon good planning and management oversight for their safety, and there was a collaborative intervention by industry and government in helicopter logging in Southeast Alaska in the early `90s with really a tremendous beneficial outcome, where there have been very few crashes since then.

The distinctive features of Southeast Alaska air tour operators or operations are that they range rapidly from relatively temporate urban airports to otherwise remote and inaccessible glaciers within minutes. On these glaciers, as I think all the speakers have mentioned, flat lighting conditions are often encountered, thus operators anticipating offering any regular service should probably train their pilots in flat light techniques and probably at a minimum equip their aircraft with radar altimeters.

Some or all of the componentry of -- there's a suite of microelectronics that's been designed for initial testing in Southwest Alaska and the Yukon Cuscoquin Delta by a collaborative effort by FAA Flight Standards-Alaska and the University of Alaska Aviation Technology Center and the Institute of Socioeconomic Research in Alaska, called CAPSTONE, which is a really innovative suite of avionics in a microcomputer format adaptable to use in small aircraft, and some of these devices may also be useful in industry, such as this. There's some material in your handouts about that.

Comparison of these crashes to the tragic events in June of last year, when the pilot and the six passengers died, may be informative. At least in the three accidents discussed here, the pilots were experienced enough to realize that they'd gotten into very bad lighting conditions with marginal visibility, and they had decelerated substantially prior to impact. So, even though their vehicles were destroyed, there was adequate survival space in the vehicles on impact.

Nonetheless, the fact that these three crashes occurred, especially that they occurred serially, really raises to my mind three questions.

One. Could these events all have been avoided if the pilots had been better trained for the characteristic conditions that they encountered?

The second. Would application of operational risk management have been helpful in preventing these events, and then, third, would better and more suitable avionics have helped?

Better organization and a systematic approach to safety should be helpful in preventing these events, too. Since the parallel experience of rapid growth in air tours in the Grand Canyon with the catastrophic mid-air collision in 1986, and in Hawaii, where the culmination of that was there were two serious crashes in one day in 1994, there have been increases in oversight of this industry in those locales, both by regulation as well as by voluntary efforts, and I had expected Mr. Resavage would have talked about TOPS or the Tour Operators Program of Safety of the Helicopter Association International, which is a voluntary program by operators willing to adhere to a higher safety standard for their operations.

This program extends to management, pilots, maintenance, ground support, aircraft in each of these operations, and it includes voluntary annual audits and formalization of each corporate safety program. It will be interesting to see if this promising program helps out in the long run.

What are the recent developments that may mitigate these events in the future? In late 1999, Congress mandated four federal agencies in Alaska, the FAA, NTSB, National Weather Service and our own agency, to collaborate on a three-year joint interagency safety initiative.

One of the major focal points of the initiative is on better understanding and preventing the series of events which lead to controlled flight into terrain accidents, particularly those due to continuation errors in the face of deteriorating weather conditions and/or visibility.

These government agencies hope to collaborate with industry in developing effective strategies with the hope actually of developing and collaborating on voluntary standards at a higher level of practice to avoid these events while maintaining the viability of the aviation industry in Alaska, and just to close, I will add that despite our safety concerns, anybody that hasn't tried flying on glaciers in Alaska should. It's a real kick.

Thanks.

(Applause)

MR. RESAVAGE: Thank you very much, Doctor. Our next speaker will be Major Joe Blackburn. He's the Chief of Aeronautics Branch of the Aviation Systems and Accident Investigation Division in the United States Army Safety Center, located at Fort Rucker.

He has served as president on numerous accident investigation boards. He's qualified in many different type of aircraft, and I'll turn my mike over to him.

MAJOR BLACKBURN: I think I'm on. Good afternoon. First, let me say I feel somewhat disadvantaged. Nobody else is dressed like I am, and that is -- first of all, let me say this. I'm excited to be part of this effort to prevent accidents.

While we may be different, we may speak differently, we have different organizations, we have different respective bottom lines, I believe we all share the similar objective, and that is to accomplish our missions and do it safely.

To that end, I'd like to spend my few minutes discussing the risk management process as it applies to accident prevention. Mr. King made some reference to that. Certainly not coordinated, but I'm glad he did mention that. He kind of focused at the individual pilot level, and my intent is to kind of broaden that a little bit and talk to it at higher levels and how risk management can help us all prevent accidents.

As you may have read in the paper, General Reimer stated some time ago that proper risk management is a combat multiplier that we can ill afford to squander. I would suggest that it's also a business multiplier that business can ill afford to squander.

Private business already uses risk management to maximize efficiency and profit while minimizing costs associated with accidental loss, and in aviation, whether it be military or civil, simple mistakes can result in catastrophic losses. Therefore, effective risk management is critical.

So, what is it? Simply put, it's a process of identifying and controlling hazards. This process applies to every level. Again, Mr. King addressed it at the pilot level. I would suggest that it is appropriately applied at every level.

We expect our privates, our sergeants, our warrant officers, our junior officers, our highest-ranking generals, to all be proactive risk managers, and I would think that would apply in the civilian sector as well.

The five steps in the process are, first, to identify hazards, to assess hazards to determine risks, develop controls, implement controls, supervise and evaluate, and, of course, the three accidents in Juneau provide an opportunity to look at this process as it can be applied to preventing future accidents up there.

First, identifying hazards. Sometimes not so easy. Often it is fairly easy to identify. A hazard is an actual or potential condition that can result in injury or death or damage or destruction of equipment.

We all use personal experience, unit history, external evaluations, focused analysis to identify hazards. I think we'd all agree that helicopter operations in the unique and challenging flight environments of glacier ice fields poses some pretty obvious hazards.

I'll limit my discussion to two of them. First is simply the obvious flight into degraded visual environments may result in loss of situational awareness and spacial disorientation.

Secondly, hasty search and rescue operations for downed aircraft by similar-type aircraft may result in these rescue aircraft encountering the same conditions that precipitated the original accident, and I kind of liken it to sending a reconnaissance aircraft out to figure out what's happening somewhere around the front lines and being shot down by a SAM, a surface air missile. We probably wouldn't send another one out to find out what happened to the first one, unless we had some better information.

So, once we've identified risk, we will then assess -- excuse me -- the hazard, we'll assess the hazard to determine the risks of it. Risk is simply the chance of a hazard or bad consequence occurring, expressed in terms of probability and severity.

First, it must be credible, and it must have a reasonable expectation of occurring. It's clear in this case that sufficient historical data exists to verify the hazards associated with this type of flight in the glacier ice fields.

Given that these, as we've seen, volumes of flights are increasing and will continue to increase as the industry experiences growth, and that the environmental conditions will probably not change any time soon, the potential for future accidents remains high.

I think it's a valid assumption that the demand for air tours coincides with the arrival of cruise ships, and therefore the operator's kind of tied to the customer schedule instead of the customer tied to the operator's schedule.

Simply, they can't wait for optimal weather to conduct these flights, and the result is a requirement to conduct these air tours even during periods of marginal weather.

Secondly, even with optimal controls in place, accidents, we can assume, will continue to happen. Due to the harsh environmental conditions where they fly, there is clearly an increased sense of urgency in locating downed aircraft and crews in the event of an accident, and therefore I think we can assume that the operator will continue to at least conduct initial search and rescue operations with his organic aircraft because of the urgency to find the crews.

The third step is to develop controls and make risk decisions, and because after we identify hazards, and we develop one or more controls that either eliminate the hazard or reduce the severity or probability of it happening, and then after control measures have been identified, appropriate decision authorities examine the residual risk and compare that to the anticipated benefits of the operation or the mission.

We can't completely get rid of risk. The question becomes, is the risk worth the reward, and in the Army, obviously the commanders are empowered to make those decisions.

So, in discussing these controls, we'll take a look at the first hazard. Basically, aircraft -- the pilots flew their aircraft into the ground as a result of poor visibility and an inability to identify the surface of the earth, boiled down to that.

I'd recommend that these controls be considered in trying to mitigate this risk. First of all, standardization training. I have not read the company training program. I know they do have one. I don't have benefit to that, but let me just say that one of the tenets of Army aviation is standardization, and we accomplish that through the establishment of specific task, conditions and standards, for required events.

Through this method, we ensure the appropriate training has been conducted, that pilots have been evaluated, and pilots are certified to fly in those conditions.

Again without having seen the program, I don't know how effective their program is, but I would suggest to you that that is probably an area that deserves some analysis, and it's one of the areas that we investigate or we look very closely at during any investigation, and I'll just pose these questions to you.

Did the pilots receive adequate training in the area? And did that training include operating in that area under less-than-optimal conditions? We've talked about the flat light phenomena. Does the present training program adequately prepare pilots to conduct their mission in that flat light condition? And, finally, are there any requirements for recurring evaluations?

We all are aware that skills and knowledge erode over time. Is this something -- simply a one-time certification or is this specific unique area training something that is evaluated over a period of time? Simply a tool to verify that the pilots are still proficient in those particular tasks.

The second control is weather forecasting and reporting. Now, clearly the weather in the ice field differed significantly than the forecast weather in Juneau, not unusual, and that happens lots of places.

I would suggest that the addition of an automated remote weather-reporting system that's placed where the volume of traffic is concentrated in the ice field providing information to both operators to make decisions, if I can launch my aircraft, and also to forewarn pilots if there are different conditions at least and the decision is made to fly in those conditions, at least the pilots are aware of that before they take off, and also pilot reports.

I know there's lots of different operators that are conducting flights in that area. Frequent pilot reports are just another way to supplement that weather information.

Instrument certification. All Army pilots are -- receive their instrument certifications. So, I kind of assume that, and that's obviously not the case in the civilian world. So, this may be an easy thing for me to say and a hard thing to do on the outside, but pilots should be required to hold instrument ratings.

This is particularly relevant where often you have marginal weather conditions that require complete or at least some reliance on aircraft systems, and when you have a situation where this marginal weather flat light conditions, etc., that result in loss of visual cues, and the rapid onset of possible spacial disorientation and loss of situational awareness, it's even more critical.

Weather minimums. I assume that there are some company-specific weather minimums. I would suggest to you that a comprehensive procedure or policy ought to be developed that pays particular attention to pilot -- individual pilot experience levels.

An experienced ice field pilot may have a set of weather minimums, and the inexperienced pilot may have a different set of weather minimums. There may be occasion where we still need to fly the mission. We need two pilots to do it.

Bottom line is a comprehensive policy should be developed to provide clear guidance to address these factors that elevate the risk of otherwise routine missions.

Aircraft should be certified for IFR flight, and I won't get too much into that, and, finally, obstacle avoidance equipment. We've talked about radar altimeters already and ground proximity warning systems, surely a control.

We do realize and recognize that the operator of -- this particular operator has installed that equipment and is considering others, but should that not be a requirement for everybody operating in this environment? A requirement versus a decision or company decision to install those.

Let me shift to the second identified hazard, that of hasty search and rescue operations. In the absence of a clearly-defined, well-rehearsed plan, the execution of these hasty search and rescue operations clearly elevates the risk dramatically.

How would we control that? First of all, again because I'm in the Army, I go back to standard procedures, standard operating procedures, to conduct search and rescue. The decision ought to be made at the appropriate level. I'm assuming it was in this case, but the appropriate authority making the decision certainly needs to go through a checklist of considerations before that decision is made.

It can't simply be I've got an overdue aircraft, let's send somebody out to find out what happened. Crew availability ought to be considered for experience levels, weather conditions, the urgency of the situation.

Secondly, use of the ELTs. Again, I applaud the operator in making the shift and position of where he puts that. Probably ought to be something implemented at a higher level so that other operators benefit from this unfortunate accident.

Additionally, there are ought to be coordination conducted to identify those agencies that can provide position fix information to these operators and means of communication identified and established to access that information rapidly.

Finally, handheld radios and GPS. We didn't discuss much about the survival aspect of this, but in again another case where the operator has already decided to issue handheld radios to their pilots, all operators ought to do that.

I also would recommend that all pilots carry handheld GPS in the event aircraft power is lost, and they can't use the systems on board. They still have the means to talk to and report their situation, and the means to relay exactly where they are.

The fourth step in the process is to implement these controls, and that's done through a number of ways, policies, procedures, regulations, the addition of equipment, exploration of technology, etc.

In some cases, these controls, particularly when they're complex, require implementation by one or more organizations, either laterally or vertically, and, finally, fifth step, supervise and evaluate, again done by a number of organizations from the FAA down to the operator, but during operations, prior to operations, after operations, these controls that we've identified need to be continuously assessed and updated as required.

Obviously these controls will not eliminate all hazards. I think you may agree, though, that using a process such as this, both at the individual pilot level and in the broad arena of aviation operations, we can develop some controls that, if we don't eliminate the risk, at least we will have reduced it or managed the risk.

Finally, risk management is not a one-time exercise. It continues. It is never-ending. It's done by everybody associated with the operation. It's critical to conserving people, resources and equipment.

I think the flying public, pilots, operators, everybody stands to benefit from effective risk management programs, and I'm sure that we'd all agree that they deserve nothing less.

Thank you.

(Applause)

MR. RESAVAGE: Thank you, Major. Our next speaker is Jim Brandt, who is the current President of the Airborne Law Enforcement Association. He's just recently retired from the FBI after 29 years. So, he probably has a dossier on each and every one of you out there.

He holds about every airman certificate you can hold and is also an instructor in almost every type of aircraft you could fly, including gliders.

So, my pleasure to introduce Jim Brandt.

MR. BRANDT: Thank you very much.

I'm a little uncomfortable speaking in front of an audience of my peers that know as much or more than I do about aviation. So, I felt a little uncomfortable coming up here.

Roy saw me this morning, said, "Hey, Jim, you're wearing your power tie. That's great." I had to follow Dr. Conway with his power brain. If you read the handouts that he did, he could have spent an hour up here. They were just terrific, and then I followed Joe with his power uniform, and then Dennis is going I need a bigger tie.

There's very little information available on flat light conditions. Our review of major aircraft accidents revealed on November 28th, 1979, an Air New Zealand DC-10-30 was involved in a fatal crash at Ross Island near Mount Everest in Antarctica with a loss of 257 people. The aircraft descended to 1,500 feet above an ice field for a photo shoot. It was a chartered aircraft for tourists to view the Antarctic Ice Fields.

Basically, they found a hole. They went down through the hole to about an 8,000 feet ceiling, then popped below it, and ended up at 1,500 feet. They were scud running in a DC-10 over the Antarctic. Had to be fun.

As the aircraft passed over the edge of Ross Island, both pilots were unable to distinguish the horizon from the ground or the sky. There was some confusion in the cockpit. The captain stated, "You can see Ross Island, right? Fine." Then the co-pilot said, "Yes, you're cleared to turn to the right. There's no high", and the flight engineer interrupted him. He said, "I don't like this."

When cockpit resource management -- you know, there's a clue that there's a problem if somebody in the cockpit doesn't feel comfortable. Then somebody stated, "Is it? It is", and then somebody else said, "Yes." Then the captain said, "No, negative." So, there's another clue. The captain doesn't like what's going on in his cockpit.

The co-pilot said, "There's no high ground. You can do a 180." The above conversation lasted for 14 seconds. Six seconds later, the ground proximity warning indicator went off, saying "pull up, pull up". 6.5 seconds later, they hit the ground, killed everybody on board.

The aircraft was crewed by two ATP pilots who were current and well trained. There was also a flight engineer in the cockpit who was visually scanning the horizon, also. The aircraft had two radar altimeters and the ground proximity warning system. The GPWS operated within its designed parameters and gave them six and a half seconds warning before they hit the ground.

The crew responded expeditiously to the warning. Simulator trials proved conclusively that if they did everything perfectly, when the warning went off, they could not have avoided impact with the ground.

The accident report said that white-out conditions are snow surface features which cannot be identified. Loss of horizon occurs when the snow merges with the whiteness of the sky. No shadows or contrast exists. Dark-colored objects appear to float in the air. The sun is totally obscured through the overcast but may exhibit considerable glare from the sky, reflection from the ground, and from the horizon. It's equally bright from all directions.

I contacted a number of law enforcement officers who fly in Alaska, and they said that expecting white-out conditions near landing in loose snow is expected, and it's really no problem, but flying into flat light conditions is very insidious as you're looking at a prominent fixture or feature as you're flying forward, say a mountain range. When you lose sight of the mountain range, then you execute a 180, if there's an ice field behind you, there's nothing you can do. You have to be instrument-rated or instrument-proficient, and the aircraft has to be instrument-certified. It's just not a viable option in every instance.

One of the investigators that was there asked some of the tour pilots what do you do if you go to -- into inadvertent IMC, and half of them said you do a descending 180-degree turn. Well, that doesn't sound right if you have an instrument rating or if your aircraft's instrument-certified, but they don't. So, they rely on contact with the ground. If they can't see in front of them, they think they're at 500 feet. They make the turn, but they turn into the ground in these type of conditions.

I talked to one of the Alaska State Troopers. I said, "How do you guys train for flat light?" I think this is Alaskan humor, but he said, "We don't because it's really scary." He said, "Although they have instrument ratings, the aircraft are not instrument-certified, and if you don't have an instrument-certified aircraft when you get into flat light conditions, you're in big trouble." So, they don't train for it.

I reviewed the Airman's Information Manual, AC-006A, Aviation Weather, and other publications. I failed to find anything of significant information regarding flat light conditions.

After consulting with law enforcement pilots in Alaska, aircraft accident investigators who were at the scene of this accident, and others in the aviation field, the consensus among most was reached that additional information needs to be developed about flat light conditions, possibly in an FAA circular or some type of -- I forget what they call it. The yellow information that the FSDOs pass out. I don't remember what they're called now, and training needs to be developed for these people that fly in areas where they're going to run into flat light conditions.

Unless you have an instrument rating and the aircraft is instrument-certified in flat light conditions, as we've seen here, you're going to have a problem. So, awareness of the tour operators to not get into these conditions is probably the best thing they can do.

I appreciate your time. Thank you.

(Applause)

MR. RESAVAGE: Thanks you, Jim. Well, at this time, I'd like to entertain any questions, if you have any. If you'd please send them up here, we will try to answer them as best we can.

This is for Major Blackburn. Regarding standardization, it seems as they were so standardized, they all had the same exact crash. So, it's like that old joke, there's something to be said for consistency, except they were consistently bad, I know.

Please describe the characteristic of flat light conditions. Does this occur with any frequency outside of an environment like Alaska? What would flat light conditions training involve? Doesn't the radar altimeter decrease -- I'm not sure what the last two words are.

Flat light conditions, as I understand them, again it's very -- as we've all said, it's very difficult to find this chronicled in any book or information manual. It's kind of passed down. In some instances, obviously in this instance, it wasn't passed down, but there are operators up there that do have operational manuals that do address flat light and these white-out conditions.

What I have been able to read preparing for this is that it's -- flat light is a situation that doesn't have to be just in Alaska with snow, but it's any -- that's the most prevalent, but any situation where you have indiscernible difference between the surface and the sky, whether that's caused by an overcast, the position of the sun and the reflectivity of the surface, the absence of regular features that would break up the visual cues for you.

So, it doesn't have to be in a white-out condition. It could also occur on water. If you're coming in to do a landing in a seaplane, you might experience the same type of phenomena.

So, this is where it's most commonly thought of, but I think there are other places that it is applicable to.

Is there anyone else who would like to add anything to that?

(No response)

MR. RESAVAGE: Could you comment to the aspect of running out of fuel in a fuel versus payload trade-off? What is the basis or origin of the pilot's basis for believing that they were at 500 feet? I guess that's two different questions.

I think on the fuel trade-off, if I remember right from reading this accident report, the pilot had 55 percent fuel, and he was well under max gross weight. Obviously there's a trade-off as in any aircraft, as to what the weight limitations are, how you can use the power that's available to you.

In this case, the pilot felt that he had more than enough fuel to do the mission.

Is there again anyone that wants to add anything to that? I don't believe that that was a factor in this case. I don't -- there was nothing to indicate that they had -- it had anything to do with the outcome.

What was the basis or origin of the pilots believing that they were at 500 feet?

I could only speculate, and then someone else will have to answer. My speculation is again they're working with bar-outs. It's an MSL situation. There's a gradual slope to the glacier. The pilot -- again, you're over a 45-mile by a 100-mile wide expanse where one part of the glacier looks exactly like the other part of the glacier. They didn't know exactly what the real elevation was, and again without having a radar altimeter, they may have been reading 6,000 feet on their bar-out, thinking that the glacier was at 5,500 feet, and when in fact there was an obvious discrepancy.

Is there any other explanation that -- okay. Let me try to get through some of these real quickly because I know we want to move on to the next.

Would early assistance from the Coast Guard made for a safer rescue effort? Trained professionals versus assistance from tour pilots.

I'll pass that off to Major Blackburn. Is there -- I think we know he has a view on this.

MAJOR BLACKBURN: I think clearly the formal trained search and rescue operation that was available -- and I do not know why it wasn't available sooner. I know they have limited assets there. I'm not sure if that was the case or it simply did not meet the criteria yet for the Coast Guard to launch on a search and rescue, and maybe Clint can talk to that. I don't know.

But clearly if they had launched the Coast Guard aircraft, I believe it would have at least affected the operator's decision to continue his own internal search and rescue. I think that's kind of speculative, but I believe that would be the case.

MR. RESAVAGE: I have two more questions here. One was, why was this accident selected as representative for helicopters?

As I stated at the beginning of my talk, I questioned that as well. As you can see from the statistics that I put up, in 1999, there were three air tour accidents for the whole year, and we had, unfortunately, about a 180 some or a 190 accidents that year.

But I think the teaching point was the flat light situation here, and obviously there were a lot of other issues that have been brought up, but I think they were trying to bring that to a head. Is there anything else?

Okay. Besides the equipment upgrades, did the operator publish a formal preaccident plan for the company, and I would have to defer this to Clinton because I don't know, and he said yes, they did.

And again, in my preparation for this, we looked at several different operators, and, you know, there is not in the commercial world absolute standardization across the board, but a number of the operators do address this. They do have different criteria as to how experienced a pilot has to be, and what parameters they can operate in, and the training that's involved before they can go out, the recurrent training that's required.

So, there are individual differences in their operating manual and their ops specs.

Does anyone else have anything they want to add before we conclude?

(No response)

MR. RESAVAGE: Well, thank you very much.

(Applause)

MR. JONES: Thanks, Roy. At this time, we'll take a 10-minute break, so you can get together and talk about how you're going to be coming to the dinner banquet this evening, and then we'll return in approximately 10 minutes. Thank you.

(Whereupon, a recess was taken.)

MR. JONES: Okay. Our final panel for today will be about the dinner banquet this evening in the Grand Ballroom.

By the way, a couple of questions came up. This place is very secure, and you can leave your manuals here overnight, if you so desire.

Also, there was a couple of questions about bringing luggage down tomorrow morning for those who want to leave their luggage here when they check out. We have adequate room here to bring your luggage.

And we now have a current list for the attendees that's up at the registration desk that's available for everyone here.

Okay. Our next panel will be on Maintenance-Related Accident. The presentation will be by our accident investigator from our South Central Region, Nicole Charnon.

Nicole is one of our rising stars and has been thrilling us and exhilarating us with her style, and I think you'll appreciate her over the next 10 or 15 minutes.

The panel will be moderated by Doug Macnair of the Professional Aircraft Maintenance Association.

Let's get started.

Maintenance-Related Accident

MS. CHARNON: Can you hear me? Okay. I don't know if this is going, but we're ready. All right.

Good afternoon. Like Dennis said, my name is Nicole Charnon, and it is my pleasure to be presenting you with a case study involving an in-flight separation of a propeller from the maintenance portion of this GA Symposium.

I'm going to start off this case study with an accident introduction, followed by our on-scene actions. I will then follow up with our Materials Laboratory findings, some supplemental type certificate and service difficulty reports that pertain to this matter.

I will follow or finish this presentation with some of our findings and then the NTSB's probable cause.

On May 8th, 1999, I received a call informing me that a Grumman AA-5B, otherwise known as a Grumman Tiger, had an in-flight separation of its propeller and was forced to make an emergency landing in Claremore, Oklahoma.

The pilot, who was a U.S. Senator, was flying his airplane from Ketchum, Oklahoma, to Oklahoma City, where he was to meet with the President of the United States to survey the destruction caused by one of the most severe tornadoes to hit the area just a few days prior to the accident.

The aircraft, November 4546 Juliette, was manufactured in 1979 by the Gulfstream American Corporation and had a 180-horsepower Lycoming 0-360-A4K engine installed.

The propeller that had separated was a two-blade fixed-pitch propeller, manufactured by Sensenich.

Once we arrived on scene, we interviewed the pilot, documented the accident site, and then examined the propeller and then moved the aircraft into a local hangar for the next day's examination.

During the interview with the pilot, he stated that while at 2,500 feet MSL, the airplane started to vibrate. He stated that the vibration worsened and soon the propeller separated from the engine, and the engine rpm exceeded its red line limits.

The pilot set up for an emergency landing in a field. However, after noticing his increased glide ratio, he elected instead to land at the Claremore Municipal Airport.

On final approach, the airplane started to porpoise. So, the pilot elected to land on the grass area next to the runway, and upon touchdown, the nose landing gear collapsed, the aircraft slid across the runway and came to rest as we see it here on its main landing gear and nose cowling.

Fortunately, for the investigation, the propeller assembly was located approximately three miles from the airport on a rural road and was brought over to the airport.

This is a photograph of the crankshaft flange at the accident site. As we documented the accident site, we noticed that the crankshaft flange remained intact. As we could see here, the entire propeller assembly and the starter ring gear are missing. The starter ring gear, however, was located approximately 60 feet from where the airplane came to rest.

The fractured propeller bolt ends were still installed on the flange's propeller mounting bushings and were fractured in the threaded section down inside the bushings, and I don't know if you can see here with this cursor. These are the bushings that I'm referring to around -- there's six of them around the crankshaft flange.

The Sensenich propeller assembly that had separated consisted of the following items. Number 9, we have the crankshaft flange with the six bushings. Number 8, we had the starter ring gear. We start the propeller assembly with Number 7, which is our aft spinner bulkhead, followed by the propeller spacer, the propeller, the forward bulkhead, a doubler, and then the spinner cone.

We examined the propeller assembly after it was brought to the airport. The Sensenich propeller assembly remained intact with the exception of six inches of propeller blade tip that was missing from one of its blades.

We later found that missing section of the propeller blade tip in the lower engine cowling and determined that as the propeller separated from the aircraft while still rotating at near cruise rpm, the one propeller blade sliced through the lower cowling, tearing off that six inches of blade tip, leaving it behind as the propeller assembly to the ground.

The propeller spinner cone, viewed here, displayed a puncture near its apex from the inside out. This is a view of the aft spinner bulkhead while still attached to the propeller assembly.

The aft spinner bulkhead displayed a peened or dimpled appearance. It also appeared that the propeller fell to and impacted the ground with the aft spinner bulkhead first, as you can see with the black asphalt marks here in this photo.

We concluded our first day of on-scene examination and started up the following morning. The next day, we examined the maintenance records and finished our on-scene examination of the aircraft.

Examination of the maintenance records revealed that the airplane's last annual was completed on 5/8/1998, exactly one year prior to the accident. The airplane's total time at the time of the accident was 1,734 hours.

On July 15th, 1983, the pilot had purchased a supplemental type certificate, otherwise known as an STC, to allow for the installation of a Sensenich propeller on the Grumman Tiger.

On October 27th, 1995, a new Sensenich propeller was installed on November 4546 Juliette. This was accomplished just 151 hours prior to the accident, and this was the last time this propeller assembly had been installed on this aircraft, according to the maintenance records.

After examining the airplane engine, cowling and maintenance records, we focused our attention back on the propeller assembly and removed the spinner cone.

All of the bolts remained with the propeller assembly, with the exception of one, which more than likely made that puncture hole near the spinner cone's apex as it departed the propeller assembly. Remnants of safety wire were still present on four of the bolt heads.

This is a photograph of the forward face of the aft spinner bulkhead. We noted at first what appeared to be elongated holes in the aft spinner bulkhead. As you can see, two of the holes, two of the six holes here, seemed to have relatively little damage, this one here, and this one up here, where the other four definitely displayed an elongated appearance.

This aft spinner bulkhead is going to play a pivotal role later on in this presentation. So, keep this photograph in mind for future reference.

The propeller assembly was then shipped to and examined at the NTSB Materials Laboratory here in Washington, D.C. During our examination, it was learned that the six propeller bolts failed as a result of fatigue cracking.

This is a close-up view of one of the propeller bushings with the fractured bolt still installed. As we could see here on this lower right side, we've got some good beach marks, indicative of fatigue fracture. All of the bolts displayed similar characteristics as this one.

We then examined the safety wire on our scanning electron microscope. You can see highlighted in this photo that magnification of the safety wire's flat fracture surface displayed fine striations which were typical of fatigue fracture.

The manufacturer specifications for hardness values and dimensions were then referenced, and all the bolts were found to be within those manufacturer specifications.

The bolt holes in the aft spinner bulkhead were examined. Four of the six bolt holes displayed a crescent-shaped sheared-off arc area. The elongation of the bolt holes appeared to be a result of being cut or punctured instead of being deformed into elongation.

There was a reason why two of the bolt holes did not display that sheared-off crescent-shaped area, which I will get into later on in the presentation.

Here's a close-up view of one of the aft spinner bulkheads bolt holes that have displayed the sheared-off crescent-shaped area highlighted here with the brace. As you can see, the metal around the hole had not been deformed into elongation but rather had been cut or punched out.

All the mating surfaces of the propeller assembly, including the crankshaft flange, the starter ring gear, the aft spinner bulkhead and the propeller spacer, displayed a severe peened appearance, indicating that the mating surfaces of the propeller assembly were subjected to considerable relative motion.

Up here in the upper left, we have the aft spinner bulkhead. On the upper right, we have the starter ring gear, and then on the lower left, we have the propeller spacer.

As we can see in all these photos, the peening damage that I talked about just a little bit ago on all the mating surfaces.

The STC used on the accident airplane instructed the mechanics to install the Sensenich propeller in accordance with the installation drawing provided by the STC and the manufacturer's service manual.

The Grumman Service Manual instructed the mechanic to temporarily secure the aft spinner bulkhead over the propeller mounting bushings during the assembly process.

A caution followed this instruction which warned the mechanics to the potential of damaging the aft spinner bulkhead if it was not held securely in place during the propeller assembly.

This is the installation illustration which was referenced in the STC. We have the crankshaft flange like I said before, with the six propeller mounting bushings. We have the starter ring gear which slides over top of those propeller mounting bushings and comes to rest against the crankshaft flange, and then we have the aft spinner bulkhead which also slides over the propeller mounting bushings and comes to rest against the starter ring gear.

This Number 7 here, this aft spinner bulkhead, is what the Grumman Service Manual is instructing the mechanic to temporarily secure during the propeller assembly process.

An additional STC, which also applied to the installation of the Sensenich propeller on the Grumman Tiger, is described here. It warns that the aft spinner bulkhead can slide off the propeller mounting bushings and come to rest against the bolts.

The mechanic does not detect that the aft spinner bulkhead has slid down against the bolts and continues on with the installation process. This particular STC recommended that someone either hold that aft spinner bulkhead in place or another option would be to replace two bushings with two longer bushings, so that they would be able to support the aft spinner bulkhead during the installation process.

We then searched the Service Difficulty Reports Database and found one report pertaining to this installation issue, and we can read here, it said that the aft spinner bulkhead was found with elongated mounting holes due to the crankshaft bushings not being long enough to support the bulkhead during installation. Mounting the bulkhead misaligned was causing cracking due to vibration.

The corrective procedures are illustrated above here on the left. This is a profile view of the propeller assembly and the crankshaft flange. Where is my cursor? There it is. Okay. We -- in white here, we have the crankshaft flange. In blue, we have the propeller mounting bushing. In red, we have the starter ring gear. In orange, we have the aft spinner bulkhead, and in white, the propeller spacer.

In front of that would be the propeller, and, of course, all this would be held together with the propeller bolt. Ideally, the aft spinner bulkhead would be temporarily secured over the propeller mounting bushings while the rest of the propeller assembly was being installed.

However, it appears that during the installation process, the aft spinner bulkhead is sliding off of the propeller mounting bushings and coming to rest against the propeller bolts, as we can see here on the illustration to the right.

We now have the aft spinner bulkhead resting against the bolt, and now we now have a space between the aft spinner bulkhead and the starter ring gear.

As illustrated on the drawing on the left, the mechanic continues with the installation process by torquing the propeller bolts and pinching the aft spinner bulkhead between the propeller mounting bushing and the propeller spacer.

Eventually, those crescent-shaped sheared-off arc areas are worn through the aft spinner bulkhead, and the propeller becomes loose. The propeller's bolts, of course, lose their torque. The propeller starts to vibrate, and eventually we have a fatigue fracture of the propeller bolts.

I explained earlier that four of the six aft spinner bulkheads bolt holes contained those crescent-shaped sheared-off arc areas, and that's because two of the propeller bushings are considerably shorter than the others, and that's for propeller indexing purposes during the installation process.

The remaining four longer bushings are really not all that long themselves because after we have this starter ring gear in place, we don't have enough propeller bushing to independently support that aft spinner bulkhead during the propeller assembly, and therefore it slides off and comes to rest on the bolts.

So, therefore we need a temporary means of securing that aft spinner bulkhead in place.

The problem is that most general aviation mechanics do not have reference to the maintenance manuals or the STC information and are not aware of this potential installation error.

The mechanics see this as a typical fixed-pitch two-bladed propeller and install it in the opposite manner in which it was disassembled. It is apparent that more than one mechanic has performed this installation error.

Both STC owners indicated that this is not an uncommon occurrence, and that they had found numerous aft spinner bulkheads with loose propellers due to the same issue.

The one STC owner estimated that nearly 40 percent of all the Grumman Tigers that pass through his shop have loose propellers because of this installation problem.

The owner of that particular STC owner sent the NTSB three exemplar aft spinner bulkheads and the FAA three additional aft spinner bulkheads that displayed similar characteristics as the one that we had found on this accident airplane.

This is a photo of the three exemplar bulkheads that were sent to me, and as we can see here on this close-up view of the aft spinner bulkhead, the bolt heads were damaged in a similar manner to November 4546 Juliette's. The bolt hole in this lower left corner still has that crescent-shaped arc that hasn't quite yet been punched out, where the one over here and up here has.

In some cases, not only were these bulkheads damaged once, but sometimes they were installed improperly two or three times as we could see in these other photos. It looks like this one's been punched out twice, and this one looks like it's been punched out maybe even three times.

Some of our findings on this particular accident was that the installation of this propeller seemed straightforward. However, it was not. Also, the maintenance manuals and STC information are generally not made available to the general aviation mechanic by their facility, and another problem is, is that the mechanics are not requesting or using the instructions that are provided to them.

The NTSB determined the probable cause of this accident to be the fatigue fracture of the propeller bolts resulting from the improper installation of the propeller assembly.

That concludes my case study. I brought along the accident propeller assembly and the three exemplar bulkheads for any of you who are interested in looking at it later.

I'd like now to turn this over to the panel, and I thank you.

(Applause)

MR. MACNAIR: Good afternoon. My name is Doug Macnair. I'm Vice President of the Professional Aviation Maintenance Association and was fingered to moderate this gathering here this afternoon.

I'm pleased to have these gentlemen here. I'm not going to focus particularly heavily on this particular accident because these folks are so much better qualified to do so than I am.

However, I would like to set the stage a little bit for the environment in which this type of activity goes on because this case in particular brings out several very notable, I guess, failings or shortcomings that we as an industry, I think, have across the board.

First of all, aviation maintenance and particularly general aviation maintenance is somewhat lived in the shadows of our industry. Maintenance has never been the highest priority or the highest, most visible entity within the industry, and it tends to receive the least attention.

As we listened to Paul Fiduccia and some of the other speakers earlier today talking about the JSAT and the JSIT, you find that maintenance doesn't even really make the agenda, which is actually a good thing because, in reality, a relative minority of the accidents out there have a cause or contributing factor that is maintenance-related. So, consequently, we don't make the large-scale agendas, such as JSAT and JSIT.

As we look at the future of general aviation, and we see some of the projected growth that was talked about earlier today, and we overlay that over discussions of late of a pending shortage in aircraft mechanics, and we think of that in terms of general aviation, we see perhaps a situation arising where we see more and more qualitative problems arising, particularly for general aviation. I'll expand on that.

General aviation offers as a rule the lowest-paying maintenance-related employment opportunities in our industry. Those result in relatively high turnover for general aviation as people move on to regional air carrier, business aviation, major flag carrier positions that pay substantially more.

As we see the explosive growth, particularly in the commercial and business aviation sectors, we see this turnover increasing. At the same time, we are in fact producing fewer and fewer certificated A&P mechanics.

While we have not seen any real quantitative shortage of warm bodies in our industry yet, people are still getting work done. There is a growing concern that there may be a qualitative problem that will be rather insidious creeping in, and it most likely to creep in first at the general aviation level because that is the place where the talent is being robbed from.

When we see things like this accident, where maintenance manuals are not followed, where specific instructions for continued airworthiness are not followed, those are qualitative issues. There are rules out there that say you must have the data to do the work. You must have done the job before or done it under the supervision of someone who has.

The regulations and policies are all there to prevent this very type of occurrence, but again it's still happening.

So, as the panel begins to examine this accident, I want you to think about the chain of events that led to this, not just the mechanic installing the propeller improperly and not using the proper technical data, but to think about the entire chain going back to the certification of these STCs, going back to the certification of the aircraft, the data that's passed along, the systems that we employ in general aviation, to ensure that data is available and used by our people.

We talked about earlier our cultural sea change. John King was using that. Risk management. When was the last time we as an industry thought about risk management in our maintenance practices?

General aviation, let's face it, is a little bit different than the air carriers when it comes to maintenance. There is that constant struggle between cost effectiveness of individual aircraft ownership particularly and safety. Doing the right thing all the time to the highest possible standard.

No where else in our industry is that struggle more difficult than between the individual consumer aircraft owner and that person's mechanic or maintenance facility. People try in the maintenance profession to accommodate the customer as best they can. They don't want to lose that customer, but at the same time, they don't want to jeopardize safety, put people's lives in danger.

We need to think about how we approach this. What level of safety is the most acceptable? Is acceptable? How do we manage the risks inherent in that cost/safety struggle? And how do we do that particularly as we see some of our talent moving on to other segments of the industry?

So, as we talk about this particular case, think about the chain, the entire chain, not just individual who does the job improperly, think about the human factors elements, the economic elements, the data elements, the certification elements, that all led to this occurrence.

Furthermore, we need to think about what we do as an industry to solve these problems once we find out about them. For example, a recommendation has come out of this accident that would call for an airworthiness directive to inspect these.

We have an STC holder that says yes, we know that 40 percent out there of these installations are probably bad, but what didn't come out in the presentation from Nicole is that that deficiency in the installation can exist whether it's an STC propeller or the original MaCauley installation that was on the aircraft when it was produced.

You can install the propeller wrong no matter how you do it or which propeller is on there, and obviously a large proportion of the people doing the work on these aircraft are not aware that this is not a routine installation. There is something special about this. So, how do we draw attention to that?

We have a distinguished group of panelists here today. I'm going to let them speak to the real issues here. I'd first like to introduce Mike Mertens.

Mike is the Quality Assurance Manager and Chief Inspector for Duncan Aviation, located in Lincoln, Nebraska. They are a major repair station, and Mike has been involved in the aviation industry for 25 years, including primarily, I guess, in general aviation, and he even did two years in Mozambique involved in maintaining aircraft during the famine relief over there.

In his copious spare time, he is apparently in the process of converting his Piper Tripacer to a standard Pacer by STC. So, he's eminently qualified to discuss this type of maintenance.

Thanks, Mike.

(Applause)

MR. MERTENS: All right. Obviously I can't be a real good mechanic, I can't figure out these electrical things. Okay. All right. Now I'm here. All right.

Well, thank you for allowing me to be a part of this today. As a mechanic for years, there's certain things in our industry that are what we call "gotchas", and this is a classic example of that.

As a mechanic, you are doing your best to get an airplane done quickly and repaired quickly, get back in the air quickly for the customer as inexpensively as you possibly can, but there are certain things that in the design and the operation and in the actual maintenance of it that puts you in the position where you can make a mistake even though you're doing your best to do the right thing, and this is one of those.

This combination of propeller, spinner and aircraft installation is one of those things that will get you, no matter what you want to do. There's been some statements made that this was avoidable. With the information that was available, even with the concept of if you tape this propeller spinner in place before you install the propeller, this will fix it, even at that point, I don't think at that point, you'd be able to say this is good.

Right now, after reading the accident report, listening to what we've heard today and what we'll hear from the rest of the panel, I cannot say with confidence that when I got done with this job, that propeller and spinner is totally accurately put in place because there's no way to ensure that this is totally in the right position.

So, it is a gotcha. It's there, and it's ready for us to make a mistake as a mechanic doing our best to make this pilot have the safest airplane possible and get out the door, and yet we can still make a mistake.

My feeling is the only way to really fix this issue with this specific propeller installation is with an airworthiness directive, and that could be handled two different ways.

One, you can take the example of adding the two longer bushings to hold it all in place, and no matter if the propeller's greasy or all that kind of fun stuff that you have with the propeller, that it would be held in place totally when you install a propeller. You could do it with one person or two persons at that point. There's not always two people around when you need to install a propeller.

The other thing you could do is to install some way to make sure that the spinner bulkhead is attached actually to the propeller as they do with later model of aircraft or with automatic propellers that are constant speed and non-fixed pitch, but that is really the only way you can fix this particular problem.

Somebody that's out there in the industry that is going to maintain that way until there's something taken out of the ordinary, this is exactly the reason why there's airworthiness directives for maintenance issues.

There are other opportunities probably that could have affected this accident to make it not happen. The first was maybe the pilot preflight. When I got my pilot's license, the first thing they told us to do in a preflight is you grab hold of the propeller and you yank on it before you go fly the airplane to make sure it's still attached in its correct position.

As bad as this propeller looked when I looked at the pictures, that thing had been worn and loose for quite awhile. So, surely there should have been some way for that pilot to feel or see that there was a problem with the installation.

There could have been a little bit of vibration earlier than what he felt at that time. There's also a possibility, though, that it happened over a long period of time, and it didn't feel not normal to the pilot at that moment. So, that is one thing, the preflight.

Then we talked about the annuals being accomplished. Two annuals before the one that was done before this accident occurred, there's one that said it followed the maintenance manual checklist for inspection of this propeller. That means you cut the safety wire, you check the torque on the bolts, and then you resafety the propeller at the end. That would have caught this as well.

Well, two annuals ago, it happened. It was done per the checklist, and the three annuals ago, it was done that way. The last annual, the entry just says complied with the annual inspection, no mention was done of how it was done. So, if it was accomplished by Appendix D out of Part 43, you don't know if the mechanic actually took the time to check the torque of the propellers or not.

The STC holder, the TC holder, or even the FAA Certification Office all has a little bit of chance to stop this from happening. There is a rule for instructions for continued airworthiness to happen when you have either a field approval for a modification to an aircraft or for a type certificate -- hello? All right. I'm back again.

A type certificate or an STC. Any one of those issues was the time it went through FAA certification, and it has an opportunity for them to say, wait a minute, something's wrong with this propeller, this installation. There's not things right, especially when you get the warning notes and suggestions in the STC procedure, but again it was not stopped at that point and mandated that the longer bushings were put in place.

So, the FARs are there, and if we followed the FARs, that would not have -- I mean, we would not have had this issue probably if we'd have followed them all the way through.

That's enough for just this accident. When you look at the aviation maintenance as a whole, one thing we have to remember is no matter how professional these mechanics are, which they are -- they're a bunch of people who really care. They're not in it for the money, as we've already heard at least once. You're in it because you love aviation, and you love the maintenance that you do, and you love to get these people to have a good safe airplane when they fly.

These customers most of the time are your friends, and if they're not, you hope that they will be eventually as they come through your facility.

The A&P license is just a license to learn. There is no way that all these little specific minutiae that we have in these gotchas can be taught to anybody at any one time, and again this is one airplane, but it is only one small segment and the one small model part of the maintenance industry that we have.

There's a gotcha in almost every one of them. Maybe what we need instead of new teaching and training is maybe somebody to review the maintenance manual after the airplane's been done by the manufacturer for awhile, and it's been manufactured, that gets some of these service conditions actually put in the manuals in the correct and immediate hurry.

So, the A&P license is a license to learn. They won't know every issue and every specific maintenance issue for every opportunity that's out there. There is a high need for mechanics and maybe in the shortage coming down the road, that will mean there's even less experience working on the aircraft that you bring to the facility.

The STC holder actually did the installation. So, in this instance, there isn't even an opportunity for not having an installation instruction or not knowing it. The person who did the STC, who helped design it or owned it at that point, was the one who installed this propeller. You can't ask for better knowledge on this specific instance, and yet he still departed the aircraft.

Recurrent training. We talked for years in the industry that maybe we need to have just recurrent training. How can you recurrent train this issue on every single airplane? So, we talk about the Grumman Tiger. What about my Piper Tripacer? I'm sure there's little gotchas in that airplane, too, that I don't even know about yet.

When was the last time we had a manual revision for Piper Tripacer? That's an interesting thought.

It is possible to train people for -- to look out for gotchas, but there's not a way to train out every possible gotcha that's in the industry.

Where are the instructions for continued airworthiness information kept? If we actually had a set of continuous airworthiness instructions for this aircraft, where are they kept? Is it with the aircraft records that the customer has? He comes into your facility. He or she comes into the facility and brings you the airplane, says, hey, I need to have this propeller fixed. Okay. Where are they going to have the instructions to continue the airworthiness? It's not going to be in the maintenance manual because this is put on by an STC. The maintenance manual is not written by the STC holder.

So, where are they kept? You have to have them. I'm thinking that maybe they ought to be with the pilot operating handbook or the flight manual because that is supposed to be on every airplane when they fly. If they're with the log books, not every customer or not every pilot flies around with their log books in their airplane. Where does the mechanic know where to look at?

The fan belt breaks on an airplane. A Grumman Tiger. It stops in Lincoln, Nebraska. I need to be somewhere quick. Do you have a belt? Yes. Can you replace it for me? Sure. You go to the maintenance manual. You open up there. You figure out how to take this thing off, and you put it back on because you think it's just a normal manual. Just like I said, it looks normal, but it's not normal.

Where are you going to find the issues of continued airworthiness? They're probably at the customer's home base. So, I think that they ought to be put in the flight manual. At least that way, it will always be on board.

Are maintenance manuals always available? I sure hope so. We spend over $200,000 a year just keeping our manuals current and in place, and there's always the Internet. There's always all kinds of opportunities to get this. However, do we always have the time to go look them up and find them? Not always.

Is it always accurate? Is the FTC information available? Almost all this stuff is available, but it's always for a price, and, of course, we want things done cheap.

Economic pressures on the mechanic. They want to make a living. If you're an individual IA, and you're trying to make a living at this business, you're probably not going to be rich, but you need to at least make some money, and if you're going to charge twice as much because you have all this information, and somebody down the street doesn't, a lot of times, the aircraft owner will go to where it's really cheap to get it done, not necessarily where it's done properly.

You're supposed to fix it fast, fix it cheap, but fix it perfect.

The thought that this is a normal fix, a normal repair, like was said already twice, you think it's really an easy repair, but yet it's not. It has that little gotcha with it. Until you have experience and have worked in some place like Mozambique, where you have nothing, you know that you have to look for outside the normal.

Is this really right? How come this spinner bulkhead is loose on here? How come it's not sitting still while I'm putting on this propeller and trying to torque up these bolts? Something is wrong here, and it should set off warning bells. I don't know how you teach that to somebody, except for years of experience, and having somebody else look at it when you're done.

So, in conclusion, this is a gotcha. The gotchas are what the AD system is about. Go fix the gotchas so you can't set up the mechanic to fail and set up the aircraft to crash. Make sure that's taken care of. We don't need new rules. We do need to follow the ones that are in place.

Thanks.

(Applause)

MR. MACNAIR: Thank you, Mike. Everybody hear me? A little bit? Okay.

Next up, we're going to have Dean Thompson, who is the Manager of Air Safety Investigation for the Raytheon Aircraft Company, formerly Beechcraft.

Mike has been with Beech since 1985. Prior to that, he was with the Boeing Military Airplane Company in Wichita, Kansas. Mike is a commercial pilot. Excuse me. I'm sorry. Dean. You know, you impressed me so much, Mike. I'm sorry.

Dean Thompson is a commercial pilot, certificated flight instructor. He holds the A&P mechanic's certificate, and he is currently with GAMA's Safety Affairs Committee and Co-Chairman of their Accident Investigation Subcommittee.

So, with that, Dean.

MR. THOMPSON: Thank you, Doug. Good afternoon, everyone. We'll get going here in a minute. There we go.

When the publication materials for this symposium went out, one of the things that was stressed was that this should be an opportunity to identify shared responsibilities of everyone in the general aviation industry, and that's what I want to concentrate on today, is some of those shared responsibilities.

I don't plan to get into many of the nuts and bolts of the details of the accident. There are many issues that could be picked out and talked about, but time constraints limit that. So, what I do want to talk about are these issues that you see in front of you here, the content of the maintenance information, the use of the maintenance information, some service difficulty report aspects, and then talk about some implications of those.

I want to point out that none of the things that I have to talk about involve much high-tech or cutting edge technology. It doesn't require building any new boxes, doesn't require buying anything for your airplane. It's fundamental stuff that we should be doing right now, and that we can be doing right now, inexpensively.

There we go. Get the right direction. All right. As you'll recall, Nicole presented Finding Number 1, the installation appears straightforward. However, it is not. It points out a need for those of us in manufacturing, those of us who are involved in preparing some of these instructions, that the instructions need to be properly prepared.

As Mike pointed out, the proper information needs to be there, and it needs to be there in a form that can be used. It needs to be concisely presented. We can overrun the technician with an abundance of information that just gets in the way of his understanding what it is he needs to be doing. So, we need to prepare it in a form that he can use and will want to use.

On the other hand, those of us who prepare these things have to take into account the audience that we're speaking to. You have a technician who is or should be considered to be a licensed expert in the field, have some fairly high level of baseline knowledge and know some of these standard techniques and so on.

On the other hand, sometimes that definition of that baseline seems to be changing as we go through the years. What once was considered to be a standard baseline may no longer be. So, we have to keep juggling all the time what is the proper amount of information, and what is the proper kind of information to provide.

You look at Findings 2 and 3 together. Maintenance manuals and STC information generally not available to GA mechanics, and mechanics not requesting or using installation instructions. In this case, not available, meaning that the shop and particularly the smaller shops apparently not providing the information to their technicians, and then beyond that, the various technicians in many cases not requiring that they be provided with that information or not demanding that they be provided, or sometimes if it is available not using the information.

Technicians have a professional responsibility to use this information, and we should be able to expect them to use it. Sometimes a habit develops where a new air mechanic will ask Joe over here to show him the way to do it, and Joe will do that, but maybe Joe has never read the instruction, has never really known the precisely-proper way to do it, maybe he was shown by Charlie, maybe Charlie was shown by Ed some years ago. Who knows where Ed got it?

There is this responsibility to determine what the procedure is and then abide by that procedure. That's a bit of an education job for all of us. It's not so long ago that Chairman Hall hosted another symposium that dealt with the issue of corporate culture in transportation safety. That symposium dealt with mainly the cultures involved with operators, but those of us in the industry as well, in the maintenance and the manufacturing end, training, what have you, we also have the responsibility to develop this corporate culture of safety.

All of us, academia, manufacturing, technicians, etc., should constantly work to develop this culture of use that I have quoted here. We need to make sure that the prevailing attitude in the industry is that the information will be sought out, and the information will be used.

We cannot afford to have an industry that depends on tribal knowledge. It has to be the precisely-proper information, and it's up to us not only as organizations but each of us individually to instill that attitude, that culture, within the industry.

Even owners and operators, many times, we find that in localized areas, a mechanic or technician of some sort who is held in high regard by the local community because he's been working on these airplanes for so many years, that he probably knows more than the factory knows. Why, he could write the book on how to maintain that airplane, but then you look closer, and you find that he doesn't have any books himself. It's been whatever he's come up with over the years.

Even owners and operators need to arrive at this point individually of demanding that their FBO, their maintenance technician, whoever, be using these proper procedures.

I've shamelessly stolen this first bullet from Christopher Hart's presentation on the Global Aviation Information Network, and I do that to point out one of his main points is that "we all knew about that problem when in fact many of us did not know about that problem", and that takes us into the issue of the STCs.

Nicole pointed out that the STC owner said that he has replaced hundreds of aft spinner bulkheads over the years, and then she also pointed out that when she did an SDR search, she returned one report of such a condition.

We don't have to wait for the game program to reach its conclusion to use some of the tools that are available to us right now. This aspect of the STCs is both a problem right now and an opportunity. The problem is that the SDR system is somewhat less than totally useful because of the information it contains, and that information is spotty at best.

If you look at reporting requirements on the part of 121 operators, that SDR information is quite good because they have a requirement to submit that information. Part 91 operators do not have such a requirement, and therefore the Part 91 type SDR information is very ragged.

Nonetheless, that information is used. Some people feel that when you submit an SDR, it somehow disappears into a black hole, never to be seen again, and therefore why should they bother with submitting one? The real matter is that those are used.

We at Raytheon get a monthly dump of those SDRs, and they're routed to various organizations within our company. Sometimes those SDRs will result in us taking some action, sometimes it will result in the FAA raising a question that we need to answer. Many times, we'll use that SDR history, such as it is, for research when it comes time to investigate an accident or to investigate an issue that we're considering for service bulletin. Many things generate a need to go search that SDR database.

It's now easier than it has ever been to both submit an SDR and to query the SDR database. That should be part of our culture, is to demand that data systems like the SDRs be used, used more fully.

Now, with regard to implications raised by these issues, for the Tiger fleet, obviously we have the opportunity with this pending recommendation to inspect the propellers and make sure that any loose ones out there are corrected, but we also have an opportunity to educate the universe of technicians who work on the Tigers themselves as to this problem, this condition.

We also have the opportunity to educate them that even though this is a simple procedure, as Mike pointed out, even simple procedures can have aspects that, if not understood, can be gotchas. It's an opportunity to publicize to them the need to be careful even with simple procedures, not only this particular procedure but also the airplane in general.

Sometimes airplanes in this class are considered to be very simple, and therefore a level of complacency is generated, and they're not paid attention to as closely as "more complex airplanes are".

Those points are not limited to the Tiger fleet, but we can extend them to all of general aviation. All technicians need to understand the importance of using proper procedures. All shops, repair stations, etc., need to understand the importance of providing their technicians with that good information. Training and educational organizations need to instill the importance of using these procedures.

We manufacturers need to make sure that we provide the right information, and then for everyone, when these anomalies are discovered, they need to be gotten into the system so that those of us who have some responsibility, some involvement in changing procedures can work with that information.

If all of these are done, then we can also create an opportunity to enhance overall general aviation safety, and implications with regard to the flying public at large. I've quoted some information here from the 1999 GAMA Statistical Data Book that says for 1998, the industry flew 27 million flight hours, which is about twice the number of hours flown by the airlines, carried a 145 million passengers, and points out that 5,400 communities rely exclusively on GA for air transportation. That 145 million passengers represents a sizable chunk of the flying public.

As was pointed out, as these maintenance technicians move up through the ranks of GA into airline operations and other places, they need to have these habits, this culture, already in place for that move. They need to have that sense of professionalism that is reinforced by the rest of us in the industry, encouraging and demanding that.

It's also for the reason of these mechanics and pilots moving up through the ranks that it becomes valuable for the NTSB to investigate these types of occurrences, and Nicole did a fine job of nailing down the situation here, the chain of events that led to this.

This is the kind of detail that's extremely valuable in coming up with the proper fix, not just a fix, to address not only the problem at hand but also the broader problems within the industry.

We're all aware that organizations, such as fractional ownership programs, are increasing the number of airplanes operating in the GA fleet, increasing the number of passengers that are being carried in the GA fleet.

We might expect that some of the current dissatisfaction with the airlines would translate into additional traffic within GA. That flying public and that oncoming flying public needs to be able to look to GA and say that that is a safe operation, and that's yet more reason we need to instill this culture of doing things the right way. That's really the end-all of why we should do this, is the flying public, the safety of the flying public, and not least of all the safety of ourselves who use the system.

Thank you.

(Applause)

MR. MACNAIR: Thank you, Dean. Appreciate that. Next, we have comments from Jay Wickham, who is currently the Vice President and General Manager of Mattituck Aviation, a company that was started by his father way back in 1945.

Jay has been with the company since 1968, where he's held a variety of positions, from the disassembly of engines and component overhaul right up through analytical examinations and safety programs and rapid response system implementation and so forth.

He is currently CEO of Mattituck Aviation, and just to show that he is involved deeply in general aviation, he was one of the first to bring on an after-market cylinder program, design program, back in 1990, and for those of us who are pilots in general aviation, we appreciate this.

He implemented an engine school that occurs at most of the major airshows to allow hands-on assembly and disassembly of popular kit plane power plants.

With that, comments from Jay Wickham.

MR. WICKHAM: Does it work? Good afternoon. I promise, Dennis, I won't do it. Private joke, but later on at the banquet.

We have an STC, and we have a warning on an STC. That's not very uncommon. We have lots of documents that have warnings, and that's what we do to help people to put things together and take them apart without hurting anybody. Nobody in this room, myself and anybody here, wants to hurt anybody doing things, but some things are very, very difficult with documentation.

In the stall/spin this morning, when we had that, there were implications in there that people were going to try to redo some flight characteristics of airplanes to make things easier for the pilot.

To go right along with that, this STC is a hard one, and maybe we could do something about some of this type of documentation that would help the technician do his job a little easier. He doesn't know everything that he should. He can't know everything that he should. He has to refer to documentation and manuals, and if we can do one thing to help him, maybe something like this can be avoided.

We were all lucky in this one. Somebody walked away, but sometimes they don't.

Listen to this warning. It says if not properly installed as per the approved STC data, damage to the spinner bulkhead will occur, can occur/will occur. We know it will occur.

Now, there's one thing that might have been put in this thing, and I think we knew this in the beginning. If damage occurs to this spinner bulkhead, that means that the torque integrity on the bolts that hold the propeller assembly on has been breached, and we also know from M&Ds and service difficulty reports that when propeller bolts are left loose, they fatigue, and they break, and this allows the propeller to precede the occupants in the aircraft to the ground. This is not a scenario that we're really looking for.

Would it have been bad if we had known this, to put something in there a little more blatant and tell people that, yes, this propeller could depart from this aircraft, and if we wrote something like that on a piece of paper and reviewed it, would we not think that maybe a little bit more in-depth study of the engineering that went into this STC might be prudent? Maybe we shouldn't put this STC out that's quite so easy to form a gotcha, like Mike said.

To go one step further on this, we tell people in this STC that if this spinner bulkhead is damaged by having those little pieces taken out of it and being pinched in the wrong position, we tell them to replace the spinner bulkhead, just the spinner bulkhead, and we know that if that is damaged, that the torque integrity on the bolt has been breached, and we know what happens when it stays that way, and how do we know?

When we tell him to replace the damaged bulkhead, how do we know in what condition the bolts are internally? We can look at the outside. We can look at the threads, and, yeah, they have threads, but how do we know how long that torque has been breached? Wouldn't it be prudent to replace those at the same time?

There is an option in this, and Mike brought that up. Why weren't the long dowels put in in the first place, so that this couldn't happen? Why did it even have to go along with a warning? You could still put a warning in there, but if you had the long dowels in there, this -- there would be no comment here.

I have heard, and I don't know whether this is true or not, that they were not put in and not mandated to be put in because if you return the airplane to the MaCauley Propeller, you would have trouble with installation there. Maybe that's a possibility, I don't know. I'd rather have them there. I can't see too many people going back to the MaCauley Propeller and having the rpm restriction that this AD -- I mean that this took care of.

We know what happened here. We know the prop came off. We know why. We know the bolts broke. We know why the bolts broke, because of fatigue failure. We know what caused the fatigue failure, and we know who did it. We know that this was an improper installation. We know who did it. The STC holder did it. Something's wrong with that scenario.

We know the technician did it, and I think we know why. I think it's very difficult to make this installation, and I think that it's something that we probably ought to be thinking about, and why does it take so long?

It's been almost a year and a half, and the STC holder tells us that 40 percent of the airplanes flying around out there have loose propellers, and we're going to a banquet tonight. That's too long, I think, and maybe we can do something in the community, maybe anybody that worked on this Grumman American should be notified, and they should go out to the people that they work on and tell them while the regulatory issues get resolved.

I think it's too long for something like this. I mean, this can cause a crash that may not get away so easy as this one. Why does it take so long? That's a concern.

I just have one more thing to say, and I think this opportunity that we have to be in this room with these people is a very, very good one. I think it's an opportunity to interface with the governing bodies that dictate aviation safety, and if you go away from this room knowing one thing, that you have an opportunity to respond to where you were these last two days, and you do respond to that, even if you didn't like the symposium, and if we go away, and we write back, and we say we got this out of it, we didn't like this, maybe we'll do this again and maybe we'll have this opportunity to say something because we need to.

I mean, all these people need to work together to do something and stop these accidents or prevent them, if we can. I don't think you'll ever stop them, but maybe we can prevent them.

So, I thank you for having me here, and I hope this goes again next year.

(Applause)

MR. MACNAIR: Thank you, Jay. Finally on the panel, we have a distinguished analyst from the Federal Aviation Administration, Thomas A. Winston. He's been with the FAA for -- excuse me -- he's been in the federal service for 30 years, served in the United States Army from 1969 to 1976, and has been employed by the FAA since 1976.

He's worked in the Flight Standards Division, Airways Facilities Division, and is currently the Deputy Flight Standards Division Manager for the FAA Great Lakes Region.

Mr. Winston has also served as Chairman of the Safety Performance and Analysis System Team for Repair Stations since August of this year.

MR. WINSTON: Well, for the last 10 years.

MR. MACNAIR: 10 years? All right. So, please welcome Thomas Winston.

(Applause)

MR. WINSTON: Thank you. Good afternoon. Dennis, I thank you for inviting me here.

The FAA and the NTSB has, I call it, a good relationship. I think the NTSB is the check and balance of what the FAA does. They continually recommend corrections or improvements on aviation products based on their investigation, and they do a fine job of doing what they do, and I really appreciate taking the opportunity or being invited here and me taking the opportunity to look at this.

You know, this accident here is -- you know, when I first looked at it, I said it's an open and shut case. We have a situation where something was improperly installed, which resulted in a propeller coming off of an American Grumman aircraft. The aircraft sustained damage. There were no fatalities, but -- and then I think about, well, why? I think that comes to everybody's mind.

Why did it happen? We've talked a little bit here about documentation. Was the STC documentation clear enough, that the STC holder in this case could have installed the propeller aft bulkhead assembly properly?

I asked if the person was trained? What was the training of a particular person doing the work? And then I think about what were the pressures, you know? What was -- was he pushed? Was the owner pushing to get the propeller installed? Were there issues of finance? What was it?

And, so, even though out of all the incidents and accidents that we've talked about here, we haven't really hit on, well, what happened? I mean, from the spin accident this morning, we were able to say, well, you know, if he would have done this, this wouldn't have happened or if the pilot would have had more hours, or if the mechanic would have had more experience, but I think in order for us to make a difference in accident investigations, what we're going to have to do is start looking at the environment a person is actually in.

I mean, you can write documents all day. You can come up with all kinds of training programs and everything else, but we're going to have to start focusing on who's the person affected? I mean, who's that mechanic? Just like in this case, you have a situation where you have a person who liked to work on single engine and multiengine recip airplanes, and they only work for an FBO. They don't have a big shop. They don't have a lot of manuals.

How do we reach those people? When you go to the seminars, are they the ones that actually show up, so they can get the information? No. Is it the ones that the manufacturers target? No. Because these are the people who are out there by themselves trying to make a living.

What I would like to do is from here just kind of move into some areas, and as I go through them, I will talk about, and I'll get in depth a little bit more. First of all, we've talked a little bit about the FAA. Who's the FAA? Why do they do things?

I think the who is pretty easy, but what does the FAA do when they do a parallel investigation with the NTSB? I'll talk a little bit about that. I'll talk a little bit about the mechanical and maintenance accidents and the 1998 data for it.

I'll talk a little bit about the Grumman American, which I think is pretty straightforward. It's been pretty much articulated, the causes and the concerns with that already, and then I'll talk a little bit about the Safer Skies, and then what's ahead.

The FAA accident investigations start off with was there a violation of the Federal Aviation Regulations, and most people would say, well, the FAA is looking to violate somebody. They're looking to come out and find -- to find a particular mechanic, revoke his certificate and all that, but it goes a little bit further than that.

I think, first of all, whenever you talk about was there a violation of the regulations, I think you have to look at why did it happen. A lot of times, we find that mechanics, pilots, everybody in aviation, they want to do a good job. It's not our business to try to take punitive actions on them.

I think the FAA right now is looking at non-punitive actions. We know that in order to lower the accident rate in commercial aviation and general aviation, that we're going to have to do business different than what we're doing it now. So, we're working with NASA Reports. We're working with counseling people and doing the non-punitive things.

It's more important for us to find out why something happened versus taking punitive actions to actually hurt the person.

Another area is the FAA's facilities involvement, performance of FAA facilities, and that will include issues, such as air traffic, NASA facilities, and things like that. That's normally the behind-the-scenes investigations, but every time an aircraft accident happens, we send out our airways facilities people to certify the facility, if it was like on approach, was a VOR or something like that. So, we look at it that way.

We look at the air traffic. Was there any issues concerning air traffic and other issues concerning that? We also looked at the airworthiness of the certificated aircraft involved. I noticed this morning that all of the aircraft that was involved in the accidents, there was nothing that anybody identified to the airworthiness being a cause of it, but there was some question about the spin accident, of the flaps not being properly rigged, and also that the yoke had some issues there about what it actually controlled.

We do look at those. We investigate it and find out if the product meets its type design and things like that. If it was an STC issue, was the STC properly installed, and so forth.

And also, the FAA looks at the competency of the FAA-certificated airman, air agency, commercial operator, or air carrier involved, and again that kind of gets into what we've talked about here. We've talked about training. We've talked about documentation. We've talked about what's a person's authority as a mechanic, repair station or 121 certificate holder, etc.

Now, even though the FAA -- and that was only a few of the main responsibilities, but even though the FAA does do that, we don't determine probable cause. The cause of an accident, which has been very clearly articulated here by the NTSB, is their responsibility. The FAA does work hand-in-hand with that.

If you -- I was looking at some data concerning aircraft accidents as it relates to maintenance, and there wasn't a lot of information there. For the most part, and as we've seen this morning, that 80 percent or 85 percent of accidents is caused by pilot error, pilot-induced-type issues.

So, now you have another 15 percent. What's there, and how many of those pertain to maintenance? Well, AOPA publishes a NOL report, and I know this data's kind of old, but this is just for the sake of talking about what's there, and like the quantitative measures here, but in 1998, there were something like 236 total accidents that could be attributed to maintenance, and with those, 19 of them resulted in fatalities.

One of the biggest areas whenever we talked about maintenance, which this case kind of falls right into, is that the largest percentage of accidents that were maintenance is caused in the engine propeller area. 44.5 percent or a 105 of those particular accidents.

This Grumman American. We basically know the aircraft departed. The aircraft sustained substantial damage and the possible improper maintenance and all that.

Could it have been avoided? Yes and no. I don't know. If it were to happen again or if the situation were to present itself again under the same circumstances, would it have happened? I would say probably so because of the hidden risk involved with it.

Another issue that we talked about, and it was covered quite thoroughly, but I'll cover a little bit of it, is the service difficulty reporting information.

I went into the FAA's database, and I wanted to pull up all the SDRs that concerned Grumman A5-Bs in the FAA database, and what I found was 13 records, and of those 13 records, two were propeller-related. There was a 1989 aircraft using a spinner kit, SK-143-2, was found with elongated holes, and I think that was the one that the NTSB investigator-in-charge mentioned, and then there was another service difficulty report that noted the unit misaligned, suggest using longer -- oh, okay. I'm sorry. I got out of -- but the suggestion of the submitter of that was saying that the longer crankshaft bushings would have been a fix for actually correcting the problem.

The next one was reported in 1989, when the propeller was removed for compliance with an AD, and here, cracks were found in the face of the hub, and it goes on to explain what those were. But those were the only two out of the SDRs that were in there.

So, what came to mind? I said, well, why isn't more of these propellers being reported? I think that kind of leads right to some of the issues that was discussed earlier.

For the people who recognize -- just like the manufacturer, the STC holder said there's a 40 percent of the STCs out there, they have this problem. Well, we only knew about this after the accident, and, first of all, if it was 40 percent of them, why wasn't more of them reported? I don't know the answer to that, but I think that's something we should try to look at and actually consider.

We know that there's some regulatory requirements for reporting for different operators, 121, some 65 technicians, also, but what I would think is that we need to do more to try to get people to report information so that information can get to the right people, and I think there's not enough of that going on.

What were some of the FAA's concerns here? I mentioned this before. It was the training and competency of the maintenance technician, the clarity and correctness of the installation documentation, compliance of the Federal Aviation Regulations and improved SDR reporting.

The FAA, even though these are mostly issues that are centered around operating the aircraft, but the FAA in partnership with industry, which is called the Safer Skies Agenda, that's from the Administrator Garvey's initiatives, will use the latest technology to help analyze general aviation accidents and determine the best actions to break the chain of events that lead to accidents.

Most Safer Skies issues are controlled flight into terrain, weather, loss of control, survivability, aeronautical decision-making, etc. Now, many of you will probably say how does that relate to maintenance? I think that from the maintenance standpoint, we are going to have to start looking at maintenance as an issue in a more detailed fashion.

I think this addresses the 80 percent of general aviation accidents, but what about the other 20 percent? What could we be doing? What initiatives can we put forth to try to help the mechanic out there, the repair stations, etc.?

Recently, with the FAA, we've started working with a lot of the repair stations, the technicians, the carriers, and we have what we call an airworthiness safety program manager, and their specific function is to start identifying issues with the maintenance-related issues in the industry, put out pamphlets, get the ACs out there.

I know it was mentioned this morning about advisory circular information, to get that information out, and we're also mining the databases within the FAA. When I say mining the databases, the FAA, from the inspector's reports to SDRs, service difficulty reports, there's all kind of information and data that's stored throughout the Federal Government, including the FAA, and the information is sitting here in a dormant situation.

We are right now looking at ways of mining that information, trying to find out what are some of the risks, what are some of the issues out there, and then actually bringing that information out and actually briefing people on what some of the risks are out there.

What's ahead? I think that together with industry, that in order for us to lower the number of accidents, it's not an FAA issue, but it's an FAA and the industry issue, I think organizations, such as PAMA, the repair stations, the technicians out there, that we're going to have to start exchanging more information in order to identify what the risks are.

There's really no reason why this information about this propeller and that bulkhead being a high probability of failure, of being installed wrong, shouldn't have been able to get out to the right people, but I think together with PAMA, the FAA, and everybody -- and every other element of the aviation industry, we can get the job done.

Thank you.

(Applause)

MR. MACNAIR: Thanks, Tom. We've heard a lot of information here from the panel.

Just to summarize some of the thoughts that came out in relation to this accident and other events that could come up similar to this in the future, we've talked about SDR reporting. We've talked about data and documentation and making that available to maintenance personnel.

We talked about compliance systems and ensuring that people do in fact follow the current FAA rules and policies. We've talked about culture, both corporate and industry. We've talked about environment. It really comes down to discussions of human factors and maintenance resource management, things that we have somewhat neglected perhaps in our end of the industry.

Thank you. We've talked about the need for comprehensive and on-going general aviation accident investigations. Sometimes general aviation accidents take a low priority over certainly air carrier and other commercial accidents, and certainly what happens in the general aviation industry can serve as a precursor for what could happen elsewhere in the industry.

We've talked about training. All of these things are long-term opportunities for improvement, but if we do nothing else, as Jay said, if we get nothing else out of this discussion today, we know, we know that 40 percent of the Grumman Tigers out there potentially have this very problem, and they're flying right now.

I would -- after we handle the question and answer session, I would invite you to come up and take a look at the parts from Senator Inhofe's airplane and some other of the bulkheads that were submitted that demonstrate the same problems.

If we do nothing else, let's address this at a minimum.

We have quite a stack of questions here for the panel, and this one is for Mike. Comments on the fundamental conflict in the parachute accident. The owner-operator was also performing the maintenance. Is this situation wise?

MR. MERTENS: That's a pretty loaded gun. Hello? Okay. Whatever. I may have to shout really loud.

The FAA does allow for owner-operator maintenance, and with the owner-operator maintenance, they can perform certain things under their certificate as a pilot even for preventive maintenance.

In this issue with this accident here, this is beyond the scope of what would be a minor maintenance, preventive maintenance that the owner-operator can do, but it does come to maybe even a deeper subject, is the partnership between the owner-operator and also the maintenance facility or the maintenance provider for providing good, safe maintenance.

We can't ground a person's airplane. We can't stop them from flying it away if it's wrong. We can't do any of that kind of stuff as a mechanic. That is the owner-operator's responsibility to allow us to do the job.

If I have a Grumman Tiger today to come in and wanted to have their propeller installed or changed or whatever, I would strongly encourage them to put in the bushings, but I couldn't make them do it.

So, there is a real conflict between what the owner-operator will allow us to do and what we can do and would like to do as mechanics. A lot of times, we'd like to do more than we can.

The answer to the question there is just basically the owner-operator can do some of their own maintenance, and as a maintenance provider, we can only do what we are contracted and allowed to do by the owner-operator. We can't force them to do things they don't want to do.

MR. MACNAIR: Thank you, Mike. This question may be directed to the NTSB. The question is, -- or the FAA. The question, was anything done when the 1989 SDR came out, and if not, how come?

MR. WINSTON: Well, I would say that as far as the SDR information, it was mentioned earlier that the manufacturers do look at the information, and if you have a situation where there's a preponderance of SDRs, and I think it actually raises the level of concern with it, and being that it was only one, and I would probably suspect that that's why something wasn't done with it.

If we would have probably seen more of them or even over a longer period of time, then I think that would have probably raised the concern, but right now, the information just is being used basically to -- for the manufacturers and for the FAA to try to determine any hot spots out there.

Thank you.

MR. MACNAIR: Tom, keep the mike close.

MR. WINSTON: Okay.

MR. MACNAIR: Two more questions. The general aviation alerts were virtually stopped due to budgetary concerns. As a very valuable tool to inform the maintenance community, how can we get money to facilitate these publications and get them out to the A&Ps?

MR. WINSTON: Okay. Roger Baker's gone, isn't he? But --

MR. MACNAIR: Boy, he snuck out quick, didn't he? He was just there.

MR. WINSTON: What I would do is take an IOU on the general aviation alerts because I'm not prepared to talk about that, but if I can get the name of the person who asked the question, I will get back with them.

Thank you.

MR. MACNAIR: Just for the record, the GA alerts are currently available on the FAA's web site. So, they are not totally suspended. They're just not being distributed in printed form currently.

Also for Tom. Does the FAA have the ways and means to put the SDR data entry, data search and data download on the Internet?

MR. WINSTON: Again, that would have to be reviewed by our SDR office in Oklahoma City to see the viability of that actually happening.

Again, I can take that question forward because it actually deals with that program office, and as an inspector, that's really not within our main area of responsibility. So, I will take that question on, also.

MR. MACNAIR: I believe that at least some of the SDR data is available through the web site, but it's not the most user-friendly database in the world, if you've ever tried to search for anything. It's hard to extrapolate what exactly you're looking for or extract what you're looking for out of that database.

So, there's certainly room for some improvement.

MR. WINSTON: Okay. Doug, make sure I get those, and I'll make --

MR. MACNAIR: Okay. Thank you. The AMT Awards Program is a vehicle to get to and reach the AMT, but how can we increase the professionalism within our industry and discipline? I guess I'll take that one.

One of the things that we as a community, the entire maintenance industry, need to start thinking about in my opinion and in the opinion of PAMA is that we need to start thinking about going beyond the FAA's minimum standards, which is their mandate after all. They are here to set the minimum safe standards for the industry, but if we want to talk about things like professionalism and discipline, that does not come from federal regulations. That comes from us. That comes from the industry and from all of us as individuals in our careers.

It means things like life-time learning, professional standards, like professional certification, on-going training. These are things that we can't turn to the FAA and beg them to solve for us.

Attempts have been made to do that through the Part 66 rulemaking and some other activities over recent years, but if we really want to talk about professionalism in our industry, we have to bring it on ourselves.

I'm going to put this question out to the entire panel because this could spark some debate. Wouldn't it be safer to require every STC to be approved by the original equipment manufacturer? Is it cocktail hour? Anybody want to bite?

MR. MERTENS: Well, I'll start off a little bit with that at least. I'm not sure safer would be the right word. When you contemplate doing an STC on an aircraft, you are going to amend or supplement the type certificate that the manufacturer's already put in place, for maybe a special reason or maybe to do a produce improvement that the manufacturer may not feel is correct themselves.

It doesn't make it an unsafe airplane by itself. In a lot of ways, the accident we talked about today, the STC gave the aircraft back some usefulness it did not have before because of some speed restrictions and rpm restrictions.

However, the actual fault may lie in the actual installation of the spinner bulkhead which actually came from the manufacturer. So, I can't just out of hand say that everything has to go to back to the manufacturer. Sometimes there's a real conflict between what the STC wants to put out and what the manufacturer wants to have, and they both can come at a situation from different angles and different directions.

So, to just say everything has to go through the manufacturer, that's not right because they may not have all the data that the STC holder has. On the other hand, the STC holder may not have all the information that the manufacturer has.

So, I don't think that would solve all your issues, and it may slow up a lot of product improvements that the manufacturer may not want to even apply to, and if you want to take my airplane, for example, the old Piper Tripacer, Piper kind of wishes it'd go away, but there are lots of product improvements that can happen through STCs that Piper wouldn't even want to deal with, and they don't have the money to deal with them either. So, that might be another issue where the STC holder can come up with that information.

Anybody else want a swing at that?

MR. THOMPSON: There are a number of issues involved with type certificate holders dealing with supplemental type certificates, not least of which would be the issue of a type certificate holder attempting to modify a type certificated product using a supplemental type certificate. That's generally viewed with disfavor.

Beyond that, there are a number of issues involved with STCs that type certificate holders have some difficulty with. If an STC does in fact represent a genuine safety improvement, it's really something that the type certificate holder would look at as a change to his type certificate and not use the vehicle of a supplemental.

There are occasions where STC information has been brought to the attention of manufacturers, and ultimately at least the gist of that STC winds up being a part of the product, but I think the major issue is that it's really not proper for a TC to be changed using an STC by the TC holder.

MR. MACNAIR: Thanks, Dean. From a maintenance standpoint, I would like to add that as the general aviation fleet in the aggregate continues to age, and there are fewer and fewer manufacturers supporting the products, the need for STCs over time is probably going to increase, and there are not necessarily original equipment manufacturers there to produce those.

From -- as it relates to this topic and this accident and this discussion today, with the proliferation of STCs to support these aircraft, we stand to have even greater instances of documentation problems and compliance problems through the installation and maintenance inspection and so forth of these STCs.

As a follow-on question to this was, does the FAA have adequate resources and expertise to continue approving STCs?

MR. WINSTON: The FAA, like most organizations, has gone through quite a bit of change, and we do have some limitation on our resources.

As far as the STCs are concerned, that is normally controlled by our Aircraft Certification Office, and that is a different organization than Flight Standards, where I belong.

As far as -- and probably what prompted that question is that the time that it takes to get an STC approved. From when I've experienced, heard, etc., without being within that office, is that there is a limited amount of aircraft certification people to support the STCs.

I don't know what the plans are on increasing that number or maybe even changing the processes, but that's something that will have to be answered by them. So, again, I can refer that question. Sorry about that.

MR. MACNAIR: That's fair enough. There are some efforts underway to look at additional designations for engineering and engineering organizations that would offload some of the work effort from the FAA to designees, but that is still in process and by no means going to be a final rule or final activity any time very soon.

Another question is, how do you know that 40 percent of the A-85 props are loose? That's a good question. I believe from the presentation, it was one of the STC -- okay. Okay. That was one of the STC holders that estimated that 40 percent of the aircraft that go through that particular facility showed evidence of being loose.

Again, we don't know for certain. All the more reason perhaps to have an inspection to find out if in fact they are.

Last question is, how can we encourage young adults to come into our profession?

Image is everything. We were talking over lunch, some folks from the FAA and I, about this very topic, and the idea of recruiting young people to our industry, and it is very important, and it's something that PAMA and certainly our Foundation are very interested in getting involved with and really stepping up on an industry basis.

However, that's a big however, some of the recent statistics I've seen from A&P schools that actually track the progress, career progress of their graduates are a bit startling, certainly to me, and I think they should be to you.

Nearly 90 to 95 percent of the graduates from A&P schools actually do go into our industry as aircraft maintenance professionals. However, after five years, if you go back and look at those same graduates and see where they are, we have seen statistics as low as 15 percent remaining in the industry.

We can recruit young people to our industry day in and day out and by the tens of thousands, but if we only retain 15 percent of them, we're not going to make any progress.

So, again, I would encourage us all to walk away from here and look within ourselves at what we do as an industry and what we provide the very people we want to attract and retain. Are we paying them a wage that's competitive for the skill sets and knowledge, intellectual capabilities that we seek? Do we give them a career path? Do we give them that opportunity for growth? Do we stimulate them and make them want to stay? Something beyond the passion of aviation. That works for awhile.

So, there are lots of ways we can recruit young people. We can get to the guidance counselors in the schools. We can make them aware of this as a career path. We can go to school fairs and career days. We can promote this industry. We can rah-rah a lot, but getting them here is only half the story. We have to keep them.

Thanks for letting me get on my soapbox, whoever asked the question.

We thank you all very much for coming.

(Applause)

MR. JONES: Thanks, Doug, for a great presentation. It was very insightful and profound, and there's a certain person on the panel who didn't spill the beans on me. I think he'll talk about it this evening.

We're getting towards the end of our day, and I think we've had a lot of interesting discussions today, and it will hold us through dinner.

As an instructor, I used to go up with a lot of student pilots that sometimes were not quite bright, and I had this one student that I was up on a flight with, and we were flying, and it was a presolo stage, and I was feeling pretty good about this student.

I said, "I think on the next flight, I'm going to solo him." The air traffic controller called us and said, "Can you tell us what the visibility is?" The student looked at me and says, "What should I say?" I said, "Well, look around, make an estimate and tell him what you think the visibility is."

So, he looked around, and he got this smile on his face, and he said, "Well, I can see the sun. So, it must be 93 million miles." Now, I've often said that I know they're required to take physicals, and they have to keep current, but sometimes I think they ought to take a saliva test, too.

Well, we have reached -- we've covered a lot of distance ourselves today, and I want to thank you for your patience and for the lively discussion.

Now, we've reached the point we're going to conclude the day. Tomorrow, it gets even better. So, I hope you join us again for tomorrow.

This evening, we have a reception and a dinner banquet which will be in the Ballroom at the L'Enfant Plaza Hotel. We're looking forward to all of you joining us.

So, thank you very much, and we'll see you at the dinner banquet.

(Applause)

(Whereupon, at 5:03 p.m., the meeting was adjourned, to reconvene tomorrow morning, Friday, September 22nd, 2000, at 8:00 a.m.)

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