NTSB GAAP Symposium
September 22, 2000

Day 2, of 2
day 1

A G E N D A

AGENDA ITEM:

Spacial Disorientation Device Demonstration
Roger Shaw
Civil Aeromedical Institute

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

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

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

Closing Remarks

P R O C E E D I N G S

(8:04 a.m.)

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

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

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

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

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

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

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

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

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

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

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

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

(Applause)

Spacial Disorientation Device Demonstration

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(No response)

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

(Applause)

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

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

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

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

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

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

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

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

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

So, please join me in welcoming David Muzio.

(Applause)

In-Flight Loss of Control Accident

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

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

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

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

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

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

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

So, if you could go ahead and start that.

(Audio recording)

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

(Audio recording)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Applause)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Canfield.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

I'm just saying that you really-when you

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you.

(Applause)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you very much.

(Applause)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you very much.

(Applause)

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

Phil.

MR. POYNOR: Thank you, Dick.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you.

(Applause)

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

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

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

Martha?

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

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

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

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

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

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

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

MR. COLLINS: All right.

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

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

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

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

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

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

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

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

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

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

Phil?

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

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

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

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

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

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

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

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

MR. MENCONI: I agree.

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

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

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

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

MR. JONES: No.

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

(Applause)

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

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

(Whereupon, a recess was taken.)

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

Steve.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That concludes my presentation. Thank you.

(Applause)

MR. OLCOTT: Thank you very much, Steve.

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

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

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

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

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

(Applause)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Applause)

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

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

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

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

Clay Lacy.

(Applause)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Okay. Thank you.

(Applause)

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

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

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

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

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

Bob Agostino.

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

(Applause)

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

MR. OLCOTT: Can you hear Bob?

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

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

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

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

A lot of good examples. Sioux City, hopeless situation, amazing example of how people communicate, listen, interface and produce extraordinary events. We can even go further to the Apollo 13. They had a malfunction. Great example of how human factors can be positive.

But what we're really talking about is how do we affect the minority situation that gets the press, that causes the accidents? The negative side, the dark side, if you will, of human factors.

Standing in a place not too far from here many years ago, Thomas Jefferson said, "The price of freedom is eternal vigilance." I think that's a direct overlay to a flight crew. I believe the price of safety is eternal vigilance.

Why did this accident happen? I mean, why did it really happen? How do we take an aircraft that's manufactured to the highest FAA standards, an aircraft that had all the bells and whistles, was Category 2-capable, had GPWS, TCAS, wind shear protection, wind shear warning, I'm sorry, how can this aircraft arrive at its destination with approximately a three-hour fuel reserve, with gear that's confirmed to be down and locked, with flaps set for approach, approximately 20 degrees, with perfectly-operating flight controls and two good engines, how could this aircraft end up going through a chainlink fence at the departure end of a runway when there were two suitable airports within 50 nautical miles, there were nine suitable airports within 200 nautical miles?

Now, the captain, not a low-time pilot, he's not a rookie. He has 7,806 total flight hours, of which 975 hours were pilot-in-command in type. He received simulator training from a very reputable institution, Flight Safety, and he checked favorably.

Now, this event had the potential of being a very good barroom story. There I was on short final with no hydraulics, surrounded by Migs, didn't happen that way. Didn't happen that way. Ended up being an accident.

Mr. King and many of the other speakers who have preceded me, I believe, I truly do believe, had the right approach, tell the truth, it's time to get naked. We need to stop dancing around the problem. This flight crew failed. The pilot-in-command failed. They failed to execute, to request, to review, to even consider the hydraulic failure checklist. If they had, they would have seen that the first line item was take your landing distance that you have tabulated, and you multiply it by three. There was no evidence on the CVR that any of the checklists were asked for or executed.

Now, Mr. Chairman, I'm not making fun of the fact that you're from Tennessee, but you may say this or you may have said this at one time. I am not the sharpest tack in the box, but I do get in town once in awhile, and it doesn't take me a long time to figure out that 3,600 multiplied by three does not equal 5,425 feet of runway that they had available to them.

We still had the accident. The crew failed. I believe that the crew failed to act in a professional and responsible manner. I believe, based on the facts, that they failed to use any of the abnormal or emergency checklists as prescribed in the approved aircraft flight manual. They failed to use their own company policies and procedures set forth by FlexJet.

They failed their passengers. Their passengers. They also failed themselves, ultimately.

If we skip back just a little while, just to reflect on a couple of other accidents that are fairly representative of Hyannis, we won't go into great detail, but think about them because we've all studied them. We've all read about them.

What about Captain Van Zanten? KLM. He was Mr. 747. He was Mr. KLM. Perfectly good airplane. Operating under 121 requirements. What happened there? We could talk about Major Hammond, the United States Air Force, Fairchild Air Force Base, Flight 52. There was no malfunction with that aircraft, but what happened there? Operating under military requirement, under military regulations.

In each of these three events, all the necessary regulations to keep the aircraft and the crew and the passengers safe were in place. The crews in each case failed to act in a responsible and professional manner.

At the end of the day, it simply didn't matter what regulations they were operating to. It really didn't matter. The accidents still occurred. We have limited resources. NTSB clearly has limited resources. We need to pick our target, and we need to aim well, if we plan on addressing this problem in the future.

I believe that the largest part of the situation path that we must take is improving education and training of our pilots. Mr. King, Congressman Oberstar yesterday, spoke about the 80 to 85 percent pilot error probable cause, human failure. We need to fix that.

Now, if we're flying in a brand-new business jet at 51,000 feet or 37,000 feet, and just by luck some rock decides to deorbit, and the only place on this beautiful blue planet it can land is my cockpit, well, it just stinks to be me, and we are not going to fix that problem ever.

But if we can reduce that 85 to 80 percent pilot error factor, crew failure, I think we've contributed a lot in our time. We must develop a joint partnership, I believe, between government, between industry, and between the users.

The NTSB for 33 years has done an outstanding job of identifying and recommending. We know what the answers are. I believe we know how to fix it as an industry. Keep in mind, 33 years. What have we learned in 33 years? The space shuttle's been flying for 25 of 33 years. A lot of information.

I believe that Colonel Tony Kern, who's just retired from the Air Force Academy, I'll try to speed this up, came very close in his last book, "Darker Shades of Blue". I truly do recommend that everybody who has the opportunity to read it do so because it applies to each and every one of us, not just to those of us that are in the front end of the airplane.

Tony bills a model and very quickly the model, imagine the Parthenon or the front end of the Department of Justice, two large foundation steps. The first step is discipline. Think about what profession is not measured by its discipline. Did you ever get pulled over by a cop? I have. I'm sure glad he was a professional.

Do you measure the quality of your position by professionalism? How about our accident investigators? How about our statesmen and politicians? How about our pilots? Discipline holds it all together.

His second step on his foundation is skill-based training, and for 30 years, for 30 years or more, we have focused almost exclusively on skill-based training.

We go into the simulator, light lights up, punch out the light, get a banana. Right? That's part, that is truly part and a significant part. The military of the United States has recognized for many years the value and the quality of simulator training. Our air carriers clearly recognize the value of simulator training, and we in general aviation recognize the quality of simulator training. But are all crews who are flying Part 25 aircraft simulator-trained? I assure you they are not.

Tony builds six columns quickly on top of this foundation. He believes, as I do, as many of you do, that we need to start learning more about ourselves. The first column is knowledge about ourselves, truly about ourselves.

We sent some of our senior pilots, for example, to a Harvard Model on Negotiating Skills. I was not a very popular guy. But what is negotiation? It's the ability to communicate, more importantly to listen, to get what I want to get, what I need, and to give what they want and to give what they need. We're putting all of our pilots through that course now.

Knowledge about ourselves, knowledge about our team. What's our team? My team is my co-pilot, my captain, my flight engineer, my flight attendant, my dispatcher, my mechanic, the fellow who put coffee on the airplane. Knowledge about my team. How are all of these people affecting me? Maybe the boss's secretary, if she's doing the scheduling. She's part of the team, part of our world.

Knowledge about our aircraft. The corporate operators have a very difficult task. They don't have maintenance bases and facilities all over the world that are qualified to work on their aircraft, and they may be in Kokomo, Indiana, and they are finally responsible for the airworthiness of their aircraft by federal regulation. Are the tires inflated properly? By the NTSB's own statistic, 23 to 26 percent of all aborted take-offs are due to tire failure. Number 1 reason, underinflation. Why's it happening?

Knowledge about the environment. When I say the word "environment", the first thing that comes to my mind, and I'm sure many of yours, is the weather. What about our corporate environment? Our cultural environment? What about our relationship with the FAA? What about our relationship with other organizations that affect the people fueling? What is our environment? Are we more worried about being regulated-I'm sorry-violated or are we more worried about being safe?

Risk was mentioned yesterday. This flight departed as a low-risk mission. Clay and Dick clearly bring that out. This was a low-risk mission. Flying two passengers, people, with beating hearts between Point A and Point B. Six to seven miles from the end of the runway, it became a moderate-risk mission.

Jack King, you did a great job with that. But before it got on the ground, it was a high-risk mission, and they did not abort, and they did not change their course of action.

We need to be educated on risk assessment. How do we assess? And the last but not least is mission. What is the mission? Is this person in the back of my airplane going to die because this is a late flight if I don't get him on the ground? Well, that wasn't the case here.

These six columns hold up the beam of the overstructure, which is what? Situational awareness. We elevate it as much as we can, situational awareness, and by doing that, we hope to improve ultimately judgment.

I would submit for your consideration, Mr. Chairman, that a blue ribbon commission be formed for the purpose of investigating what options are available to improve flight crew capability and competency. This, I believe, would vastly improve safety. The challenge is there.

In closing, in 1480, Leonardo da Vinci made this statement, "For progress to take place, three things must occur simultaneously. The idea. There must be the conception. The idea. The technology must be available to support the idea", and God knows we've got the technology, the finest technology in the world, and third of all, "we must have the political will to move forward". The political will.

John Kennedy made the statement, "The United States was not built by those who waited and rested and wished to look behind them. This country was conquered by those who moved forward."

1903, at Kitty Hawk, we conquered our first dragon, and thousands of dragons fell between 1907 and 1927 when Charles Lindbergh conquered the North Atlantic, and dragon after dragon fell till 1947, when Chuck Yeager broke the speed of sound at Morak Air Force Base, and finally in 1969, when Neal Armstrong stepped on the moon in the Sea of Tranquility.

The last dragon is standing before us, the last dragon. In 1961, President Kennedy, prior to Alan Shepard's first suborbital flight, made the commitment that we would go to the moon, and we would return the pilots, occupants, astronauts, safely. Nine years later, that goal was achieved. We repeated that tremendous event five more times.

Would it not be a worthwhile goal to reduce the human failure accident statistic by 90 percent in the next nine years? I believe it is a worthy goal, and I truly believe that it's an achievable goal, and I thank you very much for your time this morning.

(Applause)

MR. OLCOTT: Thank you very much, Bob. You make a very good point, that it all comes down to people, and we need to train those people as effectively as possible. Thank you very much.

I believe we now have questions from the audience. Bob Agostino, would you like to take this one to start with?

Each panelist discussed human factors and shortcomings of the crew. What about the organizational management system failures that allowed the accident to happen, or perhaps we could say contributed to the accident? Do you have a comment on that?

MR. AGOSTINO: Hello? Is this on? Elvis has left the building? Okay.

As we reviewed the accident along with Steve Demko and the members of the investigation team, we did find that the fractional ownership manager clearly had policies and procedures in place that weren't followed. I'm not sure how to answer the question beyond that.

The crew didn't follow the FARs. They didn't follow their company operating procedures, and they didn't follow the aircraft flight manual.

I'm not sure that in every accident, the organizational culture's always a question. We viewed the accident yesterday of the young lady in the Navajo. Were there cultural issues there? There very well may have been. I believe that's the only way I can answer that, Jack.

MR. OLCOTT: Dick Aarons.

MR. AARONS: I've watched this business of the safety culture of the organization, and I've become persuaded over the years that it's much more important than we think at first glance.

In the trenches, the flight crews and the maintenance personnel receive directives and attempt to act on them in a safe and responsible way, but they also get subliminal messages from their management at the upper tiers as to simply how seriously to take this, and it's been my experience in looking at accidents over the years that when you see a lackadaisical attitude or cutting corners at the operational level, you will find at least a subliminal approval for that at ever-higher levels of management.

MR. OLCOTT: Clay, do you have a comment on this?

MR. LACY: Yeah. Is this on? I think so. Well, certainly the organizational aspect administrative of how to conduct a flight operation department is very important.

The goal that Bob talked about is going to be hard to achieve in my opinion, very hard to achieve, for a couple of reasons, and one is, as we all know, we've finally gotten to the pilot shortage that people predicted 15-20 years ago is here, and many of the pilots in general aviation that take jobs on a commuter airline or maybe even a charter company, they're passing through at the moment to try and get enough experience to get a job on a major airline.

So, the experience level is down somewhat, I would say, and it's going to be down, and I think it's going to get less. So, it becomes more important that we have good flight operation department with standard operating procedures to make up for some of the lack of experience that we've had in the past.

MR. OLCOTT: I might just comment that I believe that the organizational structure behind this particular operation was quite responsive and had taken a lot of effort to train their pilots and to do organizationally those things that created the culture of safety.

But when everything is said and done, it comes down to the pilot and the crew and the need for coordination between those two important elements. It comes down to people, the mechanic in this particular situation. The maintenance technician also is one of the people factors in the accident.

The second question, again, Bob, maybe we can go to you for this, under a fractional ownership program with multiple owners, who is responsible for recovery and postaccident clean-up?

MR. AGOSTINO: I'd like to defer that one to you.

MR. OLCOTT: The owner of an aircraft is responsible for that aircraft. I own a Baron. I get my Baron maintained by a very competent organization. If they do not do the job correctly, in the final analysis, I'm responsible because I'm the owner.

In a fractional ownership program, the owners are responsible for the consequences, and they are indeed in the final analysis the responsible party. It's one of the elements that is emphasized in the contractual arrangements of a fractional ownership program, that the owner has responsibility.

We have as a matter of course in our community over the years allowed an owner to buy expertise. We allow an owner to hire a professional pilot. We allow an owner to have his or her Baron maintained.

So, we buy the concept of purchasing professional expertise, but that does not absolve the owner for the ultimate responsibilities.

Anyone else want to make a comment? We're a little short on time. Maybe we should go on to this last question, so we don't interfere with the scheduling of the in-flight accident.

This captain was known to have poor cockpit resource management. Was anything done by management to correct this problem? Please comment on the value of CRM training for this crew considering their failure to use proper procedures.

Clay, do you want to start with that, and then we'll move on to the other panelists?

MR. LACY: Well, I believe that-in fact, I know in the records here that the chief pilot or someone did verbally discuss with the captain that they had had reports of poor cockpit procedures, and I think that they responsibly brought it to his attention and maybe they didn't hear anymore about it after that. I'm not sure. That occurred, oh, about nine months before this accident.

The other thing here that-as Jack said, I think the company had operated responsibly inasmuch as he'd been-the pilots are trained at Flight Safety. Going on a Flight Safety reports they had on the pilots, it was all above average. Everything looked good.

I'm not sure. There are probably some things that the company could have done in this case, but I don't feel that they were negligent. There's only so much monitoring you can do, and at any rate, I think that it's something that everybody-every company has to be concerned about and aware of and more in the future, as I said, because of lower experience.

MR. OLCOTT: Bob, any comment?

MR. AGOSTINO: How many pilots do we have in the room?

(Show of hands)

MR. AGOSTINO: I think it goes back to the old cliche. Fly like you train, train like you fly. There is a disconnect apparently here.

MR. AARONS: I'd have to agree entirely on the disconnect. CRM is a term that we've used so much now in the last 10 years, that I think sometimes it starts losing its definition, it loses meaning.

CRM only makes sense, at least in my view, to the extent that it's combined with practical, workable SOPs that are applied at the appropriate time. As Bob says, we have to train the way we're going to fly, and then fly the way we've been trained.

Also, I think in looking at this, that one of the ways the crew itself should approach this business of CRM is to listen to what the speaker from SAMA yesterday talked about, which is the fact that we have as pilots a professional ethics situation to think about; that is, to respond professionally and ethically, we have to adopt these SOPs and CRMs.

Thank you.

MR. OLCOTT: Well, there's one other question, and, Bob, I believe you're the best person to answer this. Was the emergency brake lever safety wired?

MR. AGOSTINO: No. In fact, on the on-site investigation, Steve, myself and one of our safety officers, Dave Ryan, we went into the cockpit. There was no evidence of any tampering with the normal emergency braking system, and it moved freely and easily.

MR. OLCOTT: And the other question again, did the aircraft have an operable ELT?

MR. AGOSTINO: I can't answer that, Jack. I don't believe it did because they're not required.

MR. OLCOTT: Yeah. I don't think it did either. I don't think they're required in turbine airplanes.

Does anyone have any final question for our panel? Anyone over here has a question for the panel?

(No response)

MR. OLCOTT: Well, thank you very much. Very interesting accident. Also, compliments to the NTSB for putting on this most enlightening seminar.

Thank you.

(Applause)

MR. JONES: Thank you, Jack, and distinguished members of the panel, for a fine discussion on the subject matter.

We will be taking a 15-minute break and return for our last panel which will be on Mid-Air Collisions.

Thank you.

(Whereupon, a recess was taken.)

MR. JONES: Okay. Our last panel today will be on Mid-Air Collisions, and that presentation will be done by Pam Sullivan of our North Central Regional Office, which is in Chicago, Illinois.

The moderator of the panel will be Ed Bolen of the General Aviation Manufacturers Association.

Pam.

Mid-Air Collision Accident

MS. SULLIVAN: Thank you, Dennis.

One comment that I would like to make to start with is that although I worked on this accident in its initial stages, to give credit where credit is due, Mr. Frank Gatlin from our Chicago office was actually the investigator-in-charge on it.

The accident that I'm going to present to you this morning was a mid-air collision which occurred between a Cessna 172, November 5323 Kilo, and a Beech Bonanza A-36, November 2071 Lima.

The accident occurred approximately four miles south of Meigs Field in Chicago, Illinois, on July 17^th, 1997, at 18:06 Central Daylight Time. There was seven people who lost their lives in this accident, four of which were on board the Cessna and three on board the Bonanza.

The weather at the time of the accident was good. It was 25,000 feet scattered with 10 miles visibility. The controller in the tower at Meigs Field at the time stated that there was the usual hazy conditions over the lakefront.

Meigs Field is on the shores of Lake Michigan, in the heart of downtown Chicago, and with the good weather, and it being a Saturday evening, there were quite a few people around who witnessed the accident.

Some of these witnesses reported that the Cessna was flying southbound in the 3 to 500 foot altitude above the water, and it was in a slight climb. The Bonanza was on a northwesterly heading in a 3 to 400 foot per minute descent.

Some of these-one witness actually, who was a pilot, stated that the Bonanza was in landing configuration at the time of the accident. This same pilot stated that the left wing of the Cessna contacted one of the wings of the Bonanza, and that the Cessna was in flames as both aircraft descended into the water. None of the witnesses interviewed described any evasive action by either aircraft.

The Cessna was being operated by AM Corp, which is based at Lansing Municipal Airport in Lansing, Illinois. The purpose of the flight was to take passengers on a sight-seeing flight of the Chicago skyline.

The aircraft was being piloted by a certified flight instructor, who was an employee of AM Corp, and this flight instructor had approximately 773 hours of flight time.

One of the three passengers on board that aircraft happened to be a student pilot, although there was no indication and no reason to believe that there was flight instruction taking place at the time.

The vice president of AM Corp stated that their sight-seeing flights all varied, depending on what the passengers wanted. He said a typical flight, however, was that they would depart Lansing, they would fly north, pass Meigs Field, up past Navy Pier, and they would turn back southbound.

At that time, they would intercept the 360 degree radial off the Chicago Heights VOR and fly that back to the Lansing Municipal Airport.

The Bonanza was on a personal flight at the time of the accident, and there were two pilots on board this aircraft. There was a private instrument pilot who had approximately 1,375 hours of flight time. There was a commercial instrument multiengine-rated pilot who had approximately 2,480 hours of flight time.

It was not determined during the investigation which pilot was actually in which seat or who was in command of the aircraft at the time. In addition to the two pilots, there was one passenger on board this aircraft.

The flight of the Bonanza originated from Michigan City, Indiana. Michigan City, as you can see, sits on the southeastern tip of Lake Michigan, and this airplane was intending on landing at Meigs Field.

Now, I'd like to show you an animation which is a recreation of the flight paths from radar data of both aircraft. This animation was put together by Dan Van of our Aircraft Performance Division, and a couple of notes that I'd like to make before I show the animation is that you will see the Cessna at the top of the screen, descending southbound as depicted by the red track, and the Bonanza's approaching the airport from the south and indicated by the blue track.

In addition, the times that you will see on the screen are in Zulu, although when I talk about the communications, I'll be referencing those in local time.

It also should be noted that both airplanes were in contact with Meigs Tower at the time of the accident, and the ATC transcripts and tapes provided the following information.

At 1750, the pilot of the Cessna made an initial contact with the Meigs Tower, stating that they were 10 miles south of the airport at 1,900 feet. The pilot stated that they were inbound for the transition up north of the lakeshore, and the controller acknowledged the transmission and issued the altimeter setting.

At 1756, the Cessna pilot inquired as to which runway was active. The controller responded that Runway 3-6 was active and asked the pilot what her intentions were. The pilot requested a low approach over Runway 3-6.

The controller then informed the pilot of the Cessna to report turning final for Runway 3-6 and to make a right turn out after the low approach.

At 1758, the Cessna pilot reported turning final for Runway 3-6. The controller cleared the aircraft for the low approach. At 1800, the controller asked the Cessna if they were going to continue northbound. The pilot responded that they wanted to fly north of Navy Pier, make a 180-degree turn southbound. The controller instructed the pilot to report to her prior to starting that turn.

At 1801, the Cessna pilot reported starting the turn to the south. The controller acknowledged this transmission and instructed the pilot to report being abeam of the runway. The Cessna pilot acknowledged this transmission with her N number, and it should be noted that the Cessna pilot did not make this transmission reporting her position when abeam the runway.

In the subsequent interview, the controller stated that she asked pilots to report abeam the runway so she can keep track of their position for the purpose of calling out traffic to other airplanes in the area.

At 1803, the controller called out traffic to the Cessna pilot. The pilot acknowledged this transmission and that was the last communications between the pilot of the Cessna and the controller.

Also at 1803, the pilot of the Bonanza contacted the tower, reporting that they were nine miles south of the airport at 2,600 feet inbound to Meigs.

The controller instructed the pilot to report when four miles south of the airport and to plan on landing Runway 3-6. The controller then advised the pilot of the Bonanza of another aircraft which was holding at 1,700 feet over the south crib with an emergency.

This other aircraft had approached Meigs Field, and they were unable to get their gear down and locked. They were holding over the crib, trying to rectify that situation.

The crib is a water-intake facility in Lake Michigan, approximately four miles southeast of the airport.

At 1805, the Bonanza pilot reported being four miles south of the airport, and the controller cleared the airplane to land. At 1806, the Bonanza pilot acknowledged the landing clearance and reported not having the airplane over the crib in sight. This was the last transmission from the Bonanza.

The last radar hit was a primary return as 1806, which you can see on the screen.

The controller stated that she then saw smoke on the south side of the airport and made several attempts to contact the Bonanza. In addition, she asked the pilot that was holding over the crib to divert to the area where she saw the smoke to see if it could tell what had happened.

She also contacted the fire department which launched their helicopter based at Meigs Field. The fire department boat was already out on the lake because of the other aircraft with the emergency, and they diverted over to the area where the smoke was.

The controller stated that she was not aware that a collision had taken place until some time later when she heard over the police radio that there were possibly two aircraft involved.

Radar data was used to obtain altitude information for both aircraft. The Cessna was in a climb from 1,500 feet to 1,800 feet, and then it descended to 1,600 feet prior to the collision. The Bonanza was in a descent from 2,600 feet to 1,600 feet prior to the collision.

Studies show that it takes a minimum of 12.5 seconds for a pilot to see an object, recognize the threat of a collision and to take an evasive action. A cockpit visibility study was performed for this accident, and it showed that under ideal conditions, the Cessna would have been visible to the Bonanza pilot 27 seconds prior to the collision, and the Bonanza would have been visible to the Cessna pilot 25 seconds prior to the collision.

The wreckage of both airplanes came to rest in Lake Michigan, between 3.5 and 3.9 miles south of the runway. The wreckage path was aligned 30 degrees east of the extended center line of Runway 3-6.

Both airplanes were retrieved from the water over a four-day period following the accident. They were transported by boat to a Coast Guard station on the south side of Chicago, where they were examined and reconstructed.

Examination of the Cessna revealed that the left wing was separated from the fuselage at the wing root. This wing was further separated into two sections at the aileron flap junction. The outboard section of the wing was crushed aft and down and contained paint transfer marks from the Bonanza.

Examination of the Bonanza revealed that the top of the fuselage from the cockpit back to the dorsal fin was crushed inward and to the right. Paint transfer marks from the Cessna were visible along this area.

The left wing was separated and fragmented. Reconstruction of the wing spar indicated that it was bent aft about 15 degrees, and the top of the spar was rotated aft approximately 20 degrees.

Meigs Tower is a Level 1 VFR contract facility. The facility operates between 0600 and 2200 daily, and when operating, the air space is Class D, which is from the surface up to 2,500 feet, and airplanes entering that air space are required to establish and maintain radio contact with the tower.

FAA regulations and ATC procedures state that separation services are not provided to VFR aircraft entering or transiting the air space. The controllers at VFR facilities are to provide sequencing and separation for runway operations only.

The contract for Meigs Tower was awarded in 1994 and was supposed to take effect in 1996. However, that did not happen because the airport was closed in September of 1996. The airport reopened in February of 1997 as a contract facility.

The tower staffing at Meigs at the time of the accident was based on three week day shifts with one controller per shift. One shift was from 0600 to 1400. There was an overlapping shift from 10 to 1800, and an evening shift from 14 to 2200.

On weekends, the overlapping shift was eliminated. This accident occurred on a Saturday, and therefore there was only one full performance level controller in the facility at the time.

A review of ATC transcripts for the 17 minutes between the time the Cessna initially contacted the tower and when the accident occurred revealed that the controller was working five airplanes, in addition to the two accident airplanes. The controller made nine inquiries requesting position reports from those aircraft and called out traffic at least 13 times between the airplanes.

The controller categorized the workload as light with an emergency. The traffic count at Meigs had increased an average of 41 percent for the four months preceding the accident.

It was not equipped with digital bright radar indicator tower equipment, also known as DBRITE. DBRITE is a system that receives primary target information from a direct feed off of a radar antenna.

Our investigation revealed that Meigs was scheduled to get a DBRITE as part of a development program with the new Chicago TRACON facility. The display actually arrived in Chicago in 1990 and was moved to the Meigs Tower. However, it was never installed.

In December of 1992, that equipment was moved to the contract tower in Gary, Indiana, and installed t here.

The FAA stated that the equipment was not installed at Meigs because of concerns regarding signal degradation between Meigs and O'Hare and the possibility that the airport was going to be closing.

The FAA stated that they will report-they will entertain the installation of DBRITE at Level 1 towers if three conditions are met. Those conditions are the tower has to be part of a hub system. There has to be at least 30,000 operations per year, and sufficient low altitude operational radar coverage has to exist.

A terminal automator radar display and information system, also known as TARDIS, was installed at Meigs shortly after this accident. TARDIS is a digitized radar feed that works off of an aircraft's transponder. This system uses a 17-inch computer monitor for display and cannot be used as a primary tool for aircraft separation. It is simply considered to be an extension of the controller's eyes.

As of July 5^th of this year, there are a 194 operational contract towers. 62 of those towers are equipped with DBRITE. 67 of the 194 facilities have been identified as meeting the criteria to have a radar display. However, they currently do not have one.

In addition, there are 20 FAA-controlled VFR facilities that also meet the criteria for having radar installed but do not currently have a display.

The Safety Board has been told that the radar displays for these facilities would most likely be obtained when other facilities get equipment and radar upgrades, and that the FAA is unlikely to support the further installation of any TARDISs.

Significant findings of this accident were both the pilot of the Cessna and the pilot of the Bonanza failed to see and avoid each other. The pilot of the Cessna failed to make the position report as instructed to do so by the controller. No radar was installed at Meigs Tower at the time of the accident, and there was one full performance level controller on duty at the time of the accident.

The National Transportation Safety Board concluded that the cause of this accident was both pilots failed to maintain visual separation between their airplanes. A factor in the accident was that the Cessna pilot did not report her position when abeam the runway as instructed to do so by the controller.

This concludes my presentation, and I'll turn it over to Ed and the panel for discussion.

Thank you.

(Applause)

MR. BOLEN: Well, thank you, Pam. That was an excellent presentation.

I think this is a very interesting accident for us to talk about for a variety of reasons. One, it involves contract towers. Two, it involves an airport that the aviation community really rallied around Meigs Field when it was closed.

It also deals with a mid-air collision, which I think is significant because mid-air collisions generally have a little higher percentage of fatalities than the rest of the accidents in general aviation. About 40 percent involve fatalities.

It's primarily a GA phenomenon. We hear a lot about near-misses with commercial aviation and near-misses with military aviation. The mid-air accidents are primarily confined to general aviation. So, it's a uniquely general aviation phenomenon, and then, finally, mid-air collisions, although they aren't a large percentage of the GA accidents, they certainly draw an inordinate amount of press attention.

So, I think for a variety of factors, it's interesting that we're being able to focus on this particular accident at this time.

I'd like to turn it over to the panel of experts we have assembled here. The first person is going to be Vince Mellone, who is part of NASA's Aviation Safety Reporting System. He's the program manager. In addition to working at NASA, Vince has 32 years of experience at the FAA in air traffic control.

So, Vince.

MR. MELLONE: Thank you, Ed. Thank you, Luke. Can you hear me okay?

I'm going to try to do two things here. One, I want to give you a look at what we saw in the database that involved near-misses and near mid-air collision reports that we've analyzed for general aviation aircraft, and the second thing that I want to do, because of my air traffic control background, I was a former manager at O'Hare and Oakland Center and Bay TRACON. So, I've got a little bit of experience in the ATC field.

I wanted to bring up some points that I don't think were punctuated in the analysis by the NTSB. They're in the report, but I think maybe there should be some additional emphasis.

Let me start out by looking at the SRS Database. As many of you know, the NASA Aviation Safety Reporting System is a partnership with the FAA to encourage incident reporting under the cloak of limited immunity and confidentiality.

25 years now, the SRS has received about 490,000 reports, and we processed and analyzed about 90,000 records into the SRS database. We have the largest aviation incident database in the world. We do not deal with accidents. So, my report is based on incidents.

In this review that we prepared for, since 1988, we've had 92,000 incidents entered into the SRS database, and of that total, over 5,000 involved near mid-air collisions, and from that total, over 3,300 involved near mid-air collisions with at least one GA aircraft.

Then we broke that down because of this accident, where there were two GAs involved, and 760 near mid-air collision incidents are in the SRS database involving two GA.

Then we decided to limit this little effort to January `97 on, and we looked at 96 GA versus GA near-misses that-where there was tower control, local control involvement. So, our data is involved-this little report is involved in that.

I want you to see the flight time experience that-in those 96 incidents, and as you can see, 42 percent involved 501 hours to 2,400 hours, up to 2,000 hours, which one of the pilots had, the 23 Kilo. The 71 Lima pilot had 2,400 hours or thereabouts, but you can see the majority fall in the less-than-500 to the 500 to 2,000, and this, I think, prevailed throughout the GA incidents.

The operator mission was predominantly training or pleasure, and in the mid-air collision, it was training and passenger-carrying. On the flight conditions, most of the incidents are VMC. The lighting conditions on our near-miss incident reports are day light, and then we looked at wing configuration for the near-misses in the data, GA versus GA, and looking at wing configurations, you can see at least one aircraft in these 96 involved low 50 percent of the time, and at least one aircraft involved high wing GA in 29 percent.

Then we took it beyond that, and we looked at high versus high, low versus low, and so forth. Of the 47 incidents where we could determine both aircraft that were involved in the near-miss, 24 of them was low wing versus low wing. 12 were high wing as in this case versus low wing, and 11 of the near-misses were high wing versus high wing. The others, we did not know or it wasn't mentioned/determined what the second aircraft's wing configuration was.

The phase of flight predominantly in descent. The aircraft reporting was in-involved in the near-miss was then the descent phase, and that seemed to be the case in the near-mid-air collision. One of the two aircraft is in descent or making his approach for landing.

The route here again that was flown in our-where we could determine it out of the 96 incidents, 70 incidents were either determined that 18 -- 19 were on a visual approach, 15 occurred in the traffic pattern, and so forth.

The anomalies that prevailed. There were 96 near-misses. In those 96 incidents, it was cited that there was a non-adherence to an FAR 40 times, published procedure and so forth 30 times, and in four of those incidents, the conflict was a very severe near-miss where you're talking about major evasive action, 50 feet, 100 feet, as was identified in the report or in our follow-up research.

The anomaly resolutions, those where there was a resolution, most of them, of the number that we were able to determine, were detected after the fact. In other words, the near-miss occurred, and there was no resolution. It was only detected after the fact. In some cases, the controller intervened and so forth.

The consequences, most of them, none. There was no follow-up, based on our reports received. In over half of the incidents where they mentioned consequence, whether the FAA investigated, whether there was some interview or some contact with the tower, in most of them, there was none. So, a lot of near-misses that we get in the SRS database, there's no follow-up, no apparent follow-up by anybody in an official or unofficial capacity.

What were the human factors involved? Not unlike the near-mid-air collision-the mid-air collision here, vigilance was Number-clearly Number 1 cited repeatedly. Distraction. I've got that word misspelled, unfortunately, and, of course, we mentioned today and yesterday complacency.

Experience level did not appear to be a problem in the mid-air collision accident we have, and workload certainly wasn't a problem. Situational awareness may have been a problem.

That concludes the information that we drew from the SRS database.

Now, I want to step into my second role, if I may, and I argue this from my air traffic control background. I reviewed this package very thoroughly. I went through the transcript, and I went through the radar data.

The first thing that happened here-I mean, we talk about the pilots, and the conclusion that you see in the NTSB report, and I respect that-we work with the NTSB all the time on a first-name basis, and they are the most respected professionals that we have the opportunity to be associated with. I know many of the NTSB staff by first-name basis.

But they lay it on the pilots, and I agree with that. It points out that the see and avoid failed. That's true. But this operation involved a partnership here, and this operation involved a partnership that failed because there's a string of events that are pointed out by the NTSB in the report, in detail, but they led up to this.

For an example, the first and foremost thing that happened from the air traffic-that didn't happen from the air traffic control point of view, and it's not brought out as a factor, is the controller failed to issue traffic. Now, she did a good job of issuing traffic in other activities going on at the time, but not the 23 Kilo and not the 71 Lima.

If you check the transcript, she never told either aircraft about each other. She set up a mindset for 71 Lima on final landing. He asked about other traffic. She checks into it and says, "He's no longer in the air space."

The mindset is there's nobody in his way. Meanwhile, proceeding southbound, descending to his altitude, which, with an FAA controller, if I had been working that aircraft, I would have instructed, and I think other experienced FAA controllers would have instructed 23 Kilo to cross or pass the beam at or above. I wouldn't have just let the aircraft go passing by in a southbound head-on operation to final approach. That didn't happen.

The other thing that didn't happen was there was four minutes and several seconds that went by in the last contact with 23 Kilo, that didn't bother the controller. Yet, 23 Kilo reports over North Pier-I mean Navy Pier, less than a mile from the airport, they reported abeam. Abeam what? She says between the numbers.

Okay. But four minutes went by, and there was no reported beam. An experienced controller in my opinion, that would have bothered them. There would have been a reaction to that. Where are you? So, that didn't happen.

The other thing is, let's talk about the contract tower operation. I was kind of flabbergasted. They get a big hurry-up effort, cold start, gotta get Meigs in operation. We're not going to get controllers from Midway to reopen Meigs. So, they take these three controllers. They do a two-week check-out and certify her and others.

She had been out of active control for six years. I don't even think she spent that much time as a tower controller. It's hard to tell from the package. But six years. Two weeks, less than 80 hours, she's certified. What's so bad about that? As a former manager, no minimum of hours. That's brought up by the NTSB, but it also speaks to the contract operation.

No minimum. Got checked out, turned loose, and in their material, there are no minimums. Most FAA facilities, you have to work so many minimums.

Then the second thing that normally happens, you don't take a rookie and turn them loose and let them work all alone because what's their growth from experience? What's their growth? Who are they working with that's more experienced? Her? Nobody.

The other thing about the contract operation, cold start, three controllers and one manager. That's less than half the staffing that the FAA had at Meigs. That's what they had, and the sad thing about that mid-air that was brought out, she has this accident, and there's no relief, and she continued to work the shift alone, could not locate a relief. They use a pager system. That's astounding. A controller that's involved in a mid-air collision is still working airplanes to the end of the shift, about-Pam, was it four hours? Three and a half-four years?

MS. SULLIVAN: It was very close to the end of the shift.

MR. MELLONE: Yeah. It speaks to staffing a rookie. It speaks to her inexperience and her lack of-what's your professional growth? Who is she going to work with? And these are, in my opinion, some of the dynamics that led up-you can lay it on the pilot, but I'll tell you, there's an ATC-some people think I'm a heretic, but there's an ATC issue here that's very strong, that I think should be one of the factors in this report.

Most importantly, she did not issue traffic, and had traffic been issued, and 71 Lima, if you look at the transcript, was very conscientious about where am I? He's going to be looking out the window. You've got 27 seconds. Wait a minute. I'm on final. You've conveyed to me that the traffic I'm concerned about is low on the air space. So, my mindset is I'm concentrating on landing and coming at me head-on with no altitude restriction, no traffic advisory, is death.

Thank you.

(Applause)

MR. BOLEN: Thank you, Vince. Our next speaker is Dr. Mitsutomi from the University of Redlands in Redlands, California. She's currently working as a trainer in a certification program for Cross-Cultural Language.

In addition to being a professor, Dr. Mitsutomi is also a pilot and a vice president of a flight school. She's working with the FAA currently on a program that deals with English language skills to non-native English-speaking people.

DR. MITSUTOMI: Hi, there. I would like to be working with the FAA on this issue. You can't hear me? I'm not on. All right. I got to dig in here. Help me out.

MR. BOLEN: I'd be more than happy to help you out.

DR. MITSUTOMI: All right. I think we're okay. Thank you.

Greetings from Redlands, and it's a total honor to be here with all of you aviation experts. I have absolutely no claim to aviation fame. I'm a private pilot, brand-new at it, only a hundred hours, five months of time when I've had a license in my pocket. So, I know nothing about flying yet. I only have a license to learn, but I've been interested in language and language teaching and learning almost my whole life, and having married an aviator four years ago who also owns a flight school, my interest in aviation was sparked, and I also wanted to learn to fly and operate the machines, and it's a lot of fun, and a major challenge for a linguist.

But I am here to talk to you today about community of competence in global aviation, and why the global focus? Because we're here to talk about an accident that took place near Chicago, because it is a global issue, and I am very convinced that we need to do something proactively rather sooner than later, and my partner with the FAA is Kathleen O'Brien, who is with the Long Beach Flight Standards District Office, a wonderful, wonderful safety program manager, who's been working with me on the set of standards that I have developed, and I have her and the FSDO's blessing as well as many other FAA people, but they aren't doing anything about this problem yet. So, I'm here to talk to you.

If maybe the NTSB is more likely to take some matters into their own hands-and I can't stand behind the podium. So, excuse me. I have to walk around. This is the teacher in me.

You people need to react when people are talking to you. You are a very difficult audience to talk to. If you are with me, why don't you nod, and if you don't agree, you can shake your head or stand up or do something, but don't just sit there. I know it's been a long time. So, we'll try to get out of here in a hurry.

Are you aware that English is being spoken by about 1.5 billion people all over the world? That's a lot of people, and if you look at the chart that I have on the wall, the little yellow circle in the middle refers to those people for whom English is the first or their native language. That's about 375 million folks, most of you included.

I belong to the green circle that's out there, where people are learning English as a foreign language. I was born and raised in Finland, had to study English at school, and they did a pretty good job, but that's not the case with everybody.

To learn a language, you have to learn to read, write, speak and understand it, right, and you all can do that in English probably-I'm so glad you're nodding. You're getting it. Good, good, good. Keep it up.

But in aviation, what's important? Reading and writing, yes, and from pilots' point of view, you know, we need to write some, but not a whole lot, but most important things in communication between the tower and the pilot is what? Listening and speaking. It's understanding what's being said, and it's being able to say what's being said to you.

What are the aviation English characteristics? What is it that all of us who fly or who work in the tower have to be able to do? We need to be able to make statements, and many times, those are done in very short phrases or fragments. Seldom do you hear complete sentences or paragraphs, and we are supposed to focus on content rather than the grammaticality of things, although teachers would probably like to check off mistakes, but in this situation, it doesn't much matter if people understand what you're saying, and also the focus should be on standardized usage with mutual culture, and by that, what we mean is that the focus is on aviation, on flying, on getting instructions, giving instructions, keeping the communication channels open.

Culture is sort of out of the picture, although it does enter in, and, for example, American culture is to do a lot of small talk. People talk in the grocery store, although you don't know them, right, or you're waiting for the bus, and people start talking to you. That's very nice.

Well, in our accident, looking at the transcript, the communication transcript, somebody-there was some of that chitchat, small talk, American culture going on. Somebody from a plane calls on to 23 Kilo and says is there a Leslie on board? They're looking for a woman by the name of Leslie, and she says no, that's not me, it's somebody else. Okay. Have a nice day, you know, this kind of thing, and it happens a lot, although I don't think it's supposed to, is it?

Like I said, I'm not an aviation expert. I'm still learning about all this, but it sure seems to me like especially when things are busy, and you're talking to the tower, that that type of thing doesn't take place.

So, what is it that you need to be able to do to be successful in aviation communication, whether you are a native speaker or a non-native speaker? Native speakers struggle, right, and those of us who are new native, we struggle.

When I first was learning to fly and having to talk on the radio, it was most intimidating, until the Palm Springs put me at ease because they were nice to me, and I told them that I was a student pilot, and they said, "How can we help you today, student pilot?" Oh, yes. I'm coming back here. They're good to me.

But typically that's not the case. So, we need to be able to talk in the standardized aviation phraseology which is explicit in books. So, we all have to learn that regardless of what our background is, and it's meant for standard situations and for standard procedures.

Well, our Cessna pilot failed to report abeam the tower for whatever reason, and if you remember the description of this incident or accident, she was on a sight-seeing flight. So, my imagination would make me think that perhaps they were talking among themselves on the plane, looking at things that were near and around the airport, rather than paying attention to what was happening outside.

So, standard procedures to be followed, all of us, regardless of why we're out there, have to be able to focus on the immediacy of what's around us because life happens, because things go wrong, and in this case, the worst possible thing happened, which was these two airplanes collided because they didn't know of each other.

So, what is it that we have to be able to do? Speak and understand and communicate in all situations, and here is the difficulty with those who have studied English as a foreign language, who are not maybe all that comfortable with it, that communication in all situations becomes very difficult.

Why? Because language is so tied to who we are. It's part of us. It's our personality. It's everything that we are, and we tend to think and react in our first language. So, if you're still struggling with the language-how many of you here are fluent in some other language besides your first?

(Show of hands)

DR. MITSUTOMI: Okay. Not very many. There are a few hands that went up.

How many of you have studied a language at school, say high school, university?

(Show of hands)

MR. MUZIO: Everybody. How come there are only two or three that are fluent? That's the problem. Because language learning takes time. It takes time, and it depends on the methods that you've been taught whether you're fluent or not.

I'm fluent in three, but I've studied six languages extensively. Why am I not fluent in the others? Because I haven't used them. Maybe I can read and write, but I can't speak all that well, including Swedish, which is my second official language, but I never wanted to, because we have this thing between Finland and Sweden. No, I'm just kidding.

Again, successful aviation communication depends on negotiation of meaning, mutual understanding and knowledge of the ATC's phraseology. It isn't enough that there's two-way communication between the tower and the pilot. That's establishing communication. There has to be understanding, and the other thing-again, I'm new at this. You correct me if I'm wrong.

Our Cessna pilot many times said when the controller gave her instructions, for example, report abeam, she says, "We'll be advised." I don't know. What does that mean? "We will be advised." Does that mean that, okay, she's gotten the advice, but she needs to report it, but did she really understand? She didn't repeat back what she was supposed to do, and, so, I'm not sure that there really was communication.

Do you see what I'm saying? Can you nod? Has anyone ever heard that we'll be advised? Maybe-I don't know where she picked that up, but it was her thing.

So, all of the three up here, negotiation of meaning, understanding and the ATC phraseology, again we all have to master that. Non-native speakers have an extra task. They also have to know basic English language structures and functions, and beyond that, they have to be able to think in English, and that's where there's a problem.

I live in Southern California, and we have a flight school. We have many foreign students who come to our school. Every now and then, I go out there and talk to them, and not all but there are some students who cannot carry on a conversation about anything basic whatsoever, but do they know ATC phraseology? Oh, yes. They're very good at it because they've memorized it. But they cannot tell me whether they have brothers or sisters or where they live or why they want to be a pilot, and at a flight school nearby, in the web site, in the native language of the people they're targeting says no English required. We have people here who speak your language, and we will help get through the test.

I think that's just a crime. That's why I'm out here, to say why don't we put a stop to this, because that's not right. Also, pilots who come with a license from their country, and they transfer it at the FSDO, and if the FSDO official doesn't happen to carry on the conversation further beyond what's your name, where do you come from, hello, bye-bye, they may never know that this person does not speak English, and he or she will be flying in the same skies with us.

I am not saying that everyone doesn't speak English. There are a lot of wonderful people whose native language is something other than English that are very, very good at it, but there are those that try and get by and beat the system, and yet English is the lingual franca of the world as well as aviation as of now, until the political situations will change, but for the near future, that will be the case.

So, look at this art piece over here on the wall. The little flower that is standing there in this pot with no dirt, mind you. There's nothing in there. It's just sitting there, represents aviation English, and that is what everybody has to memorize, native speakers or non-native speakers alike, and when you memorize that, it looks good, and it's fine, and it looks functional.

However, it does not survive because plants need what? They need dirt. They need water, and they need sunshine in order to do well, and those pilots, since I'm talking about pilots specifically, pilots who have memorized only the aviation English and know nothing other than that may not do well. If they are lucky, they will be okay, but if something happens, something non-standard, where they have to explain in their own words, if they have to create an original sentence, they may not be able to do that because there's nothing.

So, you have to have general competency rooted in English in order to do this. You have to know the aviation English as well as basic structures in English, to make questions, to answer statements, to negate statements and so forth.

The basic language skills again, read, write, speak and understand English. What's the problem I'm having? Are you aware of the fact that the FAR does say the pilots have to be able to read, write, speak and understand English, and that is wonderful. Yes, they need to be able to do that, but to what degree?

What do you mean by speak English? Does it mean that you have to be able to do this, stand in front of people and make your agenda known to them or does it mean you simply have to be able to converse in simple conversation about basic topics? What does that mean? Or to understand English, does it mean you have to understand jokes? I wish I had time to tell you one. I don't.

Does it mean that you have to be able to understand university lectures? Maybe not. So, what does that mean? No where is it defined what these standards are, and that's the problem that I'm having. When I talk to the students who say, well, I don't need to know English, other than the ATC, and I'm not going to be tested on it anyway, he's right. He's not going to be tested, and no where does it say what he has to be able to do, and I want to say, look, you have to be able to do X, Y, Z or you're not going to make it because pilots ought to be able to speak English. What a novel thought.

So, I am suggesting, I am suggesting that we put together some standards that might look something like this. This is not the only way to go, but it might look something like this, and I've been in conversation with the Defense Language Institute at Lackland Air Force Base, and their scale that they use for pilots is very similar to this, and I've created it to look sort of like an air space chart for those of you who love air space charts.

So, let me help you with this. The red line that goes from the bottom to the side stands for ground level, and that means ground zero English, no English. Why is it up on the side? Because some people try to function with this. They try to go and fly with the memorized aviation English only, not understanding anything other than that, and it's dangerous. That's why it's in red, and these people should be grounded.

Perhaps there should be a test before you take your pilot-before you go fly solo. Perhaps there could be pilot English check before pilot-in-command. P-E-C before P-I-C. Another acronym for the FAA. Clever, don't you think? I know it's late in the day, but come on, lighten up a little bit.

And then, there's the dialogue box, and that's on the left, and I think minimally, you need to be able to do this dialogue back and forth, even if it's in simple sentences. Doesn't matter if you can't make a complex sentence. As long as you can express your thoughts in simple sentences or simple statements and can understand that, and from there on, we move up the category, which is the green, commercial pilots ought to be able to do more, and the "B", the boundary, is for those folks who, for example, are CFIs.

When you teach others, you have to be-you have to really have a good command of the language, right? So, because you have to explain and explain many times.

So, depending on the task required, I think the language should follow that as well, and what's on the very top is the very formal use of English, which is, for example, the type that we read and write in colleges, which is unnecessary, and the space in between, that word "everywhere" space represents culture, the cultural small talk, that kind of thing.

If someone has a master's, we shouldn't ground them for that reason. So, what do we need? We need clearly-articulated standards, and I would be happy to work with anybody on this. I've been asking for an aviation council to be formed, with representatives from air traffic control, pilot community, FAA, NTSB, ICAO, whoever else, and linguists.

That's the problem that we're having now, that aviators are trying to decide what the language should look like. Why not let the language professionals help with this part? Because it would be so much easier if we would pool our resources and not try to reinvent the system.

When language professionals have been testing foreign speakers for a long time, and we could surely adopt some of those methods to what we need, so that you cannot study and memorize for that test, and I would like to have a test to measure the standards, and this needs to be a systems approach. It needs to be a collaborative effort.

It needs to be cross-disciplined, and it's an important problem, and as someone mentioned yesterday, it would be so good for us to be proactive rather than reactive, trying to fix a problem after it's already happened, and there are many, many anecdotes and stories and things that have happened with language or the lack thereof, and, so, I am asking that we get together and pool our resources and create those standards and go forth with this before we have to be getting together for another meeting to talk about another accident that involved language.

Thank you for your attention. You did a whole lot better towards the end.

(Applause)

MR. BOLEN: Thank you very much. Our next speaker also has an academic connection. He's presently the Director of Aviation Safety at the University of North Dakota. Dana Siewert is recognized throughout the country as a leader in flight instruction, and we're anxious to hear from him now.

MR. SIEWERT: I'm not sure why, but I feel like I've just run a 10-mile marathon. Let me catch my breath.

First of all, Dennis, thank you for the invitation, especially realizing that most of your new up and coming NTSB members are from Embry Riddle, it appears. I appreciate the fact that you have invited someone from North Dakota to come visit with you today.

(Applause)

MR. SIEWERT: Thanks, Dad. I tell you, I've changed my entire format around here in the last few minutes. I think we're at a point now where we kind of need to summarize much of the items that we've talked about.

We've gotten a lot of facts, and we've gotten a lot of figures. It will do me no good or do you no good to talk specifically about this particular mid-air collision. It was very well detailed, and I think certainly the facts are there, and they've been brought out.

What I would like to do is take a few minutes because mid-air collision or the avoidance of mid-airs is certainly very important to us at the University of North Dakota, and for those of you that aren't familiar with that program, you may be wondering how in the world could anyone ever get close to running into another airplane over the plains of North Dakota.

But I can tell you that the University of North Dakota in Grand Forks operates 86 aircraft and will fly about 80,000 hours this year, and at our VFR Level 2 tower on a normal day, we'll run about 17 to 1,800 operations, and that's realizing that most of our airplanes don't do their take-off and landings there, but they do them at satellite airports.

I'd like to kind of break this down into three short areas and start by explaining to you something that we do do. We've talked about a lot of things that we should do. Let me just share with you something that we have done.

I don't have an overhead or a PowerPoint, but if you take a look in your books, if you take a look, there is a tab in your book, it's called "NTSB Information" tab, and if you back up from that tab about seven pages, we've included a standard operating procedure which we've all talked about as being very important, and also a few maps, and like I said, I'd like to just share with you something that someone has done to try to eliminate and reduce the risk of mid-air collisions.

If you take a look, there's a page that just starts out with a 6.5, and it says, "VFR Departure Procedures at Grand Forks for Airplanes", and like I said, if you find the NTSB Information tab, and then you just start going towards the front of the book there about seven pages, I think you'll find that particular document.

Is everyone with me? Do you see the piece of paper that I'm talking about?

One of the things that we have done is we have established specific procedures, and this is a recommendation that I would probably make to all flight schools. I'm not sure if this can be initiated into just general aviation. Perhaps in this particular accident, had there been specific routes for these type of sight-seeing flights, one of the things that I noted is it seems as though the aircraft that are doing sight-seeing around Meigs and in Chicago can primarily do whatever they want to do.

We found that to be a problem at the University of North Dakota with the number of airplanes that we have, allowing those airplanes to do whatever they want to do and to go wherever they want to go. After a number of near mid-air collisions identified by our NMAC reports, we had to take a look at some different types of operations that we were doing there to avoid that conflict, and one of the things that we've done is we do have specific operations for our aircraft.

If you can see, and you don't need to go through the whole page, but something that we've done, if you take a look at 6.5.1, and that's part of our standard operating procedure that requires all of our VFR airplanes, climb to specific altitudes, then initiate a 30-degree turn, and after reaching that particular altitude, they proceed directly to an assigned practice area.

We do not allow the airplanes to go wherever they want to go. They have to go to a certain area. They're assigned to that. We control the number of airplanes that go into those specific practice areas, and if you take a look at another page, if you turn that over, you'll see Practice Area Departure and Arrivals, and while it may be a little bit confusing, just taking a look at the diagram, what this diagram does in our standard operating procedures is it requires that our airplanes go to specific practice areas at certain altitudes and return back to the airport at specific altitudes.

We do have an approach control facility that's run by an Air Force base. It is a tanker base, and in addition to the local traffic that we have at Grand Forks, seven miles away from that, from our airport, is we have the Grand Forks Air Force Base which has KC-135 operations.

In addition to those tanker operations, the Grand Forks Airport has a number of Fedex aircraft that come in and out of there along with a number of the small caravan aircraft as well as a number of Northwest flights that come in and out of there each and every day.

So, it is a high-density airport, even though it's up on the Northern Plains, and for those of you that have been in that area, you'll note that on any of the approach plates that are there, it is so designated as a high-density student training area.

So, this is just something that we will be more than happy to share with anyone that may feel that this is something that they may be able to do or incorporate.

The second thing I'd like to go over is I'd like to kind of get to a point to where we can start summarizing and come up with some specific actions that I think that we need to take, and hopefully the NTSB or the FAA will take these steps after this meeting.

It was an excellent symposium, and we have had a lot of things that people have indicated that we should be doing, and I guess the next question is, who's actually going to do that, and who's actually going to initiate that action?

It seems to me as though there are primarily two areas we get to the end of our two days, and the two areas appear to be technology and training. When we took a look at Accident Number 1, the Stall/Spin Accident, what came out of that was technology and spin-resistant development of aircraft.

When we took a look at Accident Number 2, the Visual Flight into IMC, there was question regarding ground proximity warning systems.

When we took a look at the Helicopter Accidents up in Alaska, the question of radar altimeters became very apparent.

When we took a look at Accident Number 5, the In-Flight Loss of Control, there was a lot of emphasis on training on the use of auto-pilots and GPS.

It seems to me that we're looking at technology as one of the answers to be able to reduce the risk and to reduce the number of accidents that we have.

I agree with that, and I think that industry needs to work very, very diligently in trying to provide a lot of this equipment for the general aviation airplanes.

We've done a marvelous job in commercial aviation in equipping all of these large commercial aircraft with this type of equipment. It is very expensive equipment, and, of course, any time you put this type of equipment into general aviation airplanes, the cost per hour of that aircraft goes up.

But I do think that we need to continue to explore the different areas of technology along with things that are already going on, like the spin-resistant air foils. We do have ground proximity warning systems but very rarely do you find those in small general aviation training airplanes.

We have radar altimeters, but here again rarely do you find those in small general aviation training aircraft.

We have seen more use of auto-pilots and ground proximity-GPS in aircraft. In fact, Mrs. King mentioned this morning that rarely do pilots get taught in global positioning systems.

I have to caution myself in not giving a plug for the University of North Dakota, but in 33 Piper Warriors that the university operates, there are dual-color moving map global positioning systems in those airplanes, and student pilots are required to be able to use those prior to going out on their very first solo cross country flight.

So, I think the technology is extremely important. However, the third and final thing that I feel that we need to discuss and talk about, and we need to come up with some answers for, were brought up by Congressman Oberstar last night.

He made the comment that he's aware that in his district, a company called Seres Aircraft is losing a lot of mechanics to Northwest Airlines because Northwest Airlines pays higher salaries and has a better benefit package.

I think that we also need to take a look at the individuals that are providing flight training to our future regional and corporate and airlines as well. We have kind of a saying at the University of North Dakota, that this year's students are next year's flight instructors, and I think that holds pretty true for many of the flight schools.

It's very unusual these days to see someone who is a professional flight instructor primarily because the salary levels are so low in that particular industry. I have talked to some of the individuals here and even some of the NTSB members who-many of them were flight instructing at FBOs or flight schools that may have wanted to stay there, but because of the low salary and the poor benefits in this area, have had to move on to different types of employment.

Now, we've said that that's a problem, but the concern that I have as I leave here today is trying to understand in my mind exactly where we go after this particular meeting.

This has been an excellent symposium. It has brought out a lot of very valid information and a lot of things that we have discussed and talked about, and there have been many recommendations that have been made on things that we should be doing.

So, I would like to, I guess, challenge all of us, but specifically the NTSB, to not let this be the end of this first symposium, but to continue, and I think I would agree with one of the last panel members by suggesting that there be some type of blue ribbon panel that now is put together after a symposium like this to determine specifically what actions we are going to take, and where we're going to go from after this.

It will do none of us any good to leave here in the next 45 minutes or an hour and go all of our different ways without putting some type of resolution and figuring out where we go specifically after this here.

So, once again, I appreciate the opportunity to come up and speak. This is a good start, but it is only a start, and I think that we need to continue and now get into a point where we are discussing not specifically what happened and recommendations but specifically how we are now going to make changes within industry to try to continue to reduce the risk and get down to that 10 percent pilot error as opposed to that 80 to 90 percent.

Thank you.

(Applause)

MR. BOLEN: Dana, thank you very much. Our final speaker today is Bob White, who brings to the table over 40 years of aviation experience.

Currently, Bob is the Engineering Supervisor for Product Safety at Cessna Aircraft Company in Wichita, Kansas.

Bob.

MR. WHITE: Thank you, Ed, and I'm the one you've all been waiting for. I'm the last of the last forum on the last day.

I want to take a little different approach in talking a bit about the accident at hand. We're involved in a mid-air collision event, and a mid-air collision event occurs because the two airplanes did not avoid each other, and there were occupants in the airplanes that should have been able to do that, and why did they not?

In the process of looking at this accident, I looked back at five, the most recent five events that involved the Cessna product lines. Some were Cessnas with Cessnas and Cessnas with other products, and I noted that in those events, they were very similar to the accident event that we're talking about in Chicago.

Five of the six, and I include that, were VFR, in VCM. There was one night traffic pattern involved, and five were in the airport traffic area, the old term Class D and some Class E air space.

One was en route VFR that I looked at involving our airplanes, and incidentally, neither of those two airplanes saw each other, and one didn't even know he had a mid-air till after he landed. Both of those airplanes landed successfully. They did not see each other in any part of the profile.

It was also interesting to note, following one of our other commentaries, that three of the five, of our own events, were non-standard traffic pattern entries. That's interesting to me.

If we've got to be able to see the airplanes, maybe we need to be a little more standardized. There are traffic patterns, and they are designated, but it is also approved to do a non-traffic pattern entry.

All the events that we're talking about today, ours and the one here, were clear see-and-avoid capability. We should have been able to tell the other airplane was there according to the studies that we have, and with that, I wanted to talk just a little bit about the NTSB investigation in Chicago.

I thought that was very thorough. It covered a number of areas. It covered the air traffic control and crew concept in the air traffic control arena. It included some human factor performance, and it included the NTSB's specialty of report addressing the visual capability of the two airplanes in the Chicago event.

The interesting part, as Pam had mentioned, was that the airplanes were visible to each other 27 and 25 seconds before the impact. The visual criteria showed that the airplanes were in the wind screen of each other, both in the lower half but near the center. So, the visibility criteria was there, and in the five airplanes that I addressed with Cessna, the five events with Cessna, those were all well within the wind screen capability of visual perception, and yet apparently in none of these did one or multiple of the pilots see each other.

There's got to be a better way to understand that. So, I wanted to talk about the possibility of the process of why this is happening. Where do we go from here? We've got the events. We have the capability to see the other airplane. We're in the criteria of air space where that's possible, but we apparently don't see them or we would avoid them.

Well, there's three areas that I'd like to talk about, and on this slide, we're talking a bit about the FAA and the NTSB, and I don't see that on the screen, on our monitor. Why is it on mine? I guess we need help. There we go.

Okay. We have scanning techniques, and we have focal length eye techniques, and we have personal vision capability. Now, the scanning techniques are addressed in the FAA manuals. So, the FAA has recognized this. The military certainly recognized it a long time ago. So, there are scanning techniques addressed in the training process of the manuals.

How much do CFIs teach that, and do they teach a standardized procedure, or do they not? I don't know. How about the follow-on after that time, and scanning techniques? Are these addressed in VFRs? Never been addressed in a VFR I've taken. And how about the human capability of each individual and each individual over their experience of life? That used to be called age, but you're not supposed to say that anymore.

We know that as you get older, your focal length, which is a second subject that is in here, your focal length adaption changes. You don't recognize an object until you see it, and if you are looking at a great distance, then you're not focused on a closer-in distance, and that will be a gray area.

So, the object may be physically there, and it may be within your capability, but you simply are not recognizing that it's there. How many of you have a procedure for focal length adaption during your scans? I don't think that's taught a lot, and that adjusts as you become more experienced with life. It becomes-it takes a lot longer to adjust the focal length.

In the accident we're talking about, there was 12 and a half seconds to recognize and take a corrective action before impact of the 25 and 27 seconds the airplane was there.

If you do not see the aircraft, if you are not at a focal length where you can recognize that, you may have less time than that. High-density area, there was time. Where was the scanning technique? What was the scanning technique, and have you as the individual taken into consideration your capability of dealing with that situation?

I think we need to increase the focus probably on those two areas, so to speak. I've mentioned initial training, initial attention to that when you are initially becoming a pilot, continuation training in the VFRs that come out, and the third continuation training are the safety seminars that are given throughout the nation, and who presents most of those?

Well, we have with us Roger Baker with the FAA who does an excellent job of making every effort to make current information available to pilots through safety seminars. We also have AOPA, and we have other agencies. I'm sure the King folks deal in the same arena, but I'm familiar with the first two because they deal with our GAMA Committee, of which I participate as well as a number of you in the audience now.

There are several ways to do that and continually be up-to-date and jogged through the training and continuation training process and your own individual process.

That's-the reason I talk to that is because we're talking to mostly pilots here right now, and no matter how much ATC may miss what's going on, if the airplane is out there, and you can see it, you have the opportunity to avoid it, and in the cases we have talked about today, we probably haven't.

Now, one last item I have. I had to deal with the NTSB just a little bit here. So, Dennis is aware, and as long as I have been talking, continue to talk and will be doing so, I talk about a 72-hour history of the pilots that are operating the airplanes.

72 hours is kind of an arbitrary number, but history of the individual and what they were doing over a period of time can be significant, not only in collision avoidance but all the accidents, but let's take just the collision avoidance.

We looked into the air traffic control people the last 24 hours, that person had adequate rest, but that was a statement that was made in the report. Often it takes more than that time period to address the subject.

For example, myself, I can often recover the first 24 hours after a long-duty day or a long trip. I can surge and do that, but even with adequate rest, the second day after is my trouble day. So, you need to look at some of those, I think.

The 72-hour history has gone back a long time, and you learn a lot about that, psychological and otherwise, and that may affect if the person is overly tired, depressed, overly thinking about another object. Then that can affect, well, your vision, too. You have to be able-now, how-as Dennis has pointed out to me in the past, well, how do we adjust for that?

I don't know how we adjust for that. How do we fix that? But if we do have that type of history, then we know whether it is a factor, not a factor, and how to factor that into our thinking for the future.

So, I had to talk about my 72-hour history thing. So, there we go.

Now, Dennis gave me 10 minutes, and we are late, and I'm probably on to my 10 minutes.

So, in summary, the visual capability is available for your knowledge of yourself. You must know yourself, and you must know where you are and how you adjust to that. Otherwise, you may not be able to avoid the mid-air collision, and you are the pilot in the airplane. You need to know that. We need to look at that in our excellent investigation process, and there are means to achieve that.

I thank you very much for your time. I thank Chairman Hall and Dennis for allowing me to participate in this symposium.

Thank you.

(Applause)

MR. BOLEN: Okay. We'll now pick up take a few questions before we close. While we're going ahead and picking up the questions, there are a couple points that I would like to make, just some observations that I've made over the two days.

One is that we are very fortunate as a community to have NTSB doing accident investigation for us. I think one thing that's come up over and over again is how professional these people are, how committed they are, and I think we in general aviation are very fortunate to have the NTSB as part of our safety effort.

I think that we also have to recognize that sometimes knowing what did not happen is as important as what did happen, and I think that's something that prevents us from going down blind alleys, and I think we're very fortunate about that as well.

So, my hat's off to the NTSB and all they do for us.

The first question. In light of the fact that general aviation accident rate is 14 times that of scheduled airlines, shouldn't the GA aircraft carrying paying passengers be required to file and follow an IFR flight plan in order to meet the expectations of those passengers for a safe flight?

Anyone want to take that?

MR. WHITE: Well, I think that's a pretty difficult question, and I think that comes under the regulatory considerations and commitments. I'm not sure any of us at this table are prepared to talk about that.

MR. MELLONE: I think one of the concerns will be the workload that would be added to the system. That would be a significant increase in ATC workload, and there'd be some big concerns on that.

MR. BOLEN: The next question. How about pursuing retired airline pilots as the flight instructors for new students? Some have a passion for flying. They're financially secure, and they have a wealth of experience.

Dana, you're a well-known flight instructor. Do you want to make comments on that?

MR. SIEWERT: Is this one on now? We have certainly taken a look at that. However, there's not too many retired airline pilots that want to settle down in Grand Forks, North Dakota.

But that is certainly an alternative, and I think that flight schools and programs such as ours will certainly have to do that. That is something that we're doing, looking at retired military as well as retired airline, and in fact, we do have both of those on our staff right now.

MR. BOLEN: We have a question. Did the mid-air collision involve a foreign-speaking pilot?

DR. MITSUTOMI: No.

MR. BOLEN: For the Bonanza, what was the sun angle relative to the 172? Does anyone have any ideas on how to cope with sun in the eyes?

MR. WHITE: My understanding of the accident, the sun was to the west. This was 6:30 in the afternoon, and the two aircraft were both approaching each other, north to south and south to north, which I don't believe was a factor.

Now, how do you focus in the sun? The only way I've been able to do that is use a shade, and that helps reduce the angle of the sun in your eye. If that airplane's coming right out of the sun, that's pretty difficult.

Anybody else have any comments on that?

(No response)

MR. BOLEN: Well, that's it for the questions. Before I go, I just want to make one last point, and that is, the easy thing to do for the NTSB would have been not to have this GA symposium. It was a lot of effort and a lot of work on their part, and they could have simply ignored it. There's no reason to have the first ever, no one would have thought any different, but they took it upon themselves because the NTSB is not satisfied with the status quo. They brought us all together, and I think they did a lot of hard work that provided a lot of benefits.

So, on behalf of everyone, I think we owe them a debt of recognition. Thank you very much, especially Dennis.

(Applause)

Closing Remarks

CHAIRMAN HALL: This will be brief. I was upstairs, and I wasn't going to say anything else, but all the manufacturers called, said they didn't want Cessna to have the last word. So, they wanted me to come down.

Obviously I want to run a thank you list by you for your attention and for my thanks as well. Last night, we talked at length about the Safety Board's investigators and the level of commitment and professionalism they bring to their jobs, and I would like to recognize those individuals who have participated and helped put this program together.

If you're here, if you would stand, Jeff Kennedy from our Miami Office. Is Jeff here? Wayne Pollack from L.A. Clint Johnson and Nicole Charnon. Dave Muzio. Steve Demko. Pam Sullivan. Beverly Drake. Luke Schiada, and I would appreciate it if you could join me in giving them a round of applause.

(Applause)

CHAIRMAN HALL: In addition, I also want to thank Jill Andrews. Is Jill here? Keith McGuire. Preston Hicks. Carl Dinwiddie. Georgia Snyder. Bob Pearce. George Prellezo. Gene Sundeen, and most importantly, the individual who put this event together, and who had the ultimate responsibility for its success or failure, Dennis Jones. Dennis, if you'd please stand.

(Applause)

CHAIRMAN HALL: If you'll see me upstairs, I'll give you a grade.

I also want to thank our administrative staff, and I don't know if somebody in the back could get whoever's left in the room back there to come in, so I can recognize them.

Is Eunice out there? We have this nice facility, but before we had this nice facility, we had events all over the country, and the person that we looked to to help us on these events is Eunice Bellinger.

Eunice, come on down, with who you have, and your folks that are still here. I'd like to also recognize Seema Patel and Kristy Welch, Monica Stachowiak, Tisha Kincy, Sheryl Christian, Alonzo Johnson, Marcia McBurnett, Sheryl Cook, June Morris and Rosalind Morris, and we have a few of those folks here, and, Eunice, thank you so much on behalf of the Safety Board, and I know I speak for the participants as well.

(Applause)

CHAIRMAN HALL: And other folks from the NTSB that deserve recognition are Jim Arena, Gina John, Ken Allen, Antion Downs, Jim Cash, Ted Lopatkiewicz, Keith Holloway, Carolyn Dargan, and Vince Giuliana, and most especially the person who was the main coordinator and agitator of putting this event together, Julie Beal.

So, Julie, if you would please-

(Applause)

CHAIRMAN HALL: I'd like to acknowledge the assistance we received from three individuals who are here on assignment from other agencies and professional development programs.

Are Craig Flynn, Lea Anne Thorne or Heather Houck in the room? If not, Julie, if you will be sure that they know I extended the thanks, and, finally, to the FAA's Roger Shaw and Larry Brashiers. Are they in the room? Step up here. I really appreciate you all bringing the flight simulator to the conference.

(Applause)

CHAIRMAN HALL: There was some investigators from the Parsippany Office that went out with my staff assistant last night, and I would appreciate it if you could arrange a flight simulator ride for them immediately after we finish.

I hope this-you found this productive. If you did, and you think it ought to continue, and you have changes or suggestions or if you think it shouldn't continue, please express yourselves on the response sheet or what do you call those? The what? Evaluation sheet that's been provided.

But it is a beautiful day outside. We thank all of you for your attendance and support, and this will formally close on behalf of Dennis Jones this General Aviation Symposium.

Thank you for attending.

(Whereupon, at 12:59 p.m., the meeting was concluded.)

Day1 | GAAP Sessions