Air Force Final Report on F-16/Cessna 172 Midair Collision November 16, 2000 (long)
Larry Dighera
172 Midair Collision November 16, 2000. I received the report in MS
Word format. If anyone would like a copy, just e-mail your request.
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SUMMARY OF FACTS AND STATEMENT OF OPINION
F-16CG/CESSNA 172 MIDAIR COLLISION ACCIDENT
16 NOVEMBER 2000
TABLE OF CONTENTS
TABLE OF CONTENTS i
COMMONLY USED ACRONYMS & ABBREVIATIONS iii
GLOSSARY AND TERMS iv
SUMMARY OF FACTS 1
1. AUTHORITY, PURPOSE, AND CIRCUMSTANCES 1
a. Authority 1
b. Purpose. 1
c. Circumstances. 1
2. ACCIDENT SUMMARY 1
3. BACKGROUND 2
4. SEQUENCE OF EVENTS 2
a. Mission. 2
b. Planning. 2
c. Preflight. 3
d. Flight. 3
e. Impact. 7
f. Life Support Equipment, Egress and Survival. 7
g. Search and Rescue. 7
h. Recovery of Remains. 7
5. MAINTENANCE 8
a. Forms Documentation. 8
b. Inspections. 8
c. Maintenance Procedures. 8
d. Maintenance Personnel and Supervision: 8
e. Fuel, Hydraulic and Oil Inspection Analysis. 9
f. Unscheduled Maintenance. 9
6. AIRCRAFT AND AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS
9
a. Condition of Systems. 9
b. Testing. 10
7. WEATHER 10
a. Forecast Weather. 10
b. Observed Weather. 10
c. Space Environment. 10
d. Conclusions. 10
8. CREW QUALIFICATIONS 11
a. Ninja 1, Flight Lead 11
b. Ninja 2, Mishap Pilot 11
c. Cessna 829, Mishap Pilot 11
9. MEDICAL 12
a. Qualifications. 12
b. Health. 12
c. Pathology. 12
d. Lifestyle. 13
e. Crew Rest and Crew Duty Time. 13
10. OPERATIONS AND SUPERVISION 13
a. Operations. 13
b. Supervision. 13
11. HUMAN FACTORS ANALYSIS 13
a. Lieutenant Colonel Parker, Ninja 1 13
b. Captain Kreuder, Ninja 2 14
c. Mr. Olivier, Cessna 829 14
12. AIRSPACE AND AIR TRAFFIC CONTROL ANALYSIS 15
a. Class B Airspace 15
b. Class C Airspace 15
c. VR-1098 16
d. Air Traffic Control 16
e. Airspeed Requirements 17
13. GOVERNING DIRECTIVES AND PUBLICATIONS 17
a. Primary Operations Directives and Publications. 17
b. Maintenance Directives and Publications. 18
c. Known or Suspected Deviations from Directives or Publications.
18
(1) Mishap Pilots . 18
(2) Lead Pilot 18
(3) Air Traffic Control. 18
14. NEWS MEDIA INVOLVEMENT 18
STATEMENT OF OPINION 18
COMMONLY USED ACRONYMS & ABBREVIATIONS
AB After Burner
ACC Air Combat Command
ACES-II Air Crew Ejection System-II
ACM Air Combat Maneuvering
ACMI Air Combat Maneuvering Instrumentation
AF Air Force
AFB Air Force Base
AFI Air Force Instruction
AFM Air Force Manual
AFTO Air Force Technical Order
AFTTP Air Force Tactics, Techniques, and Procedures
AGL Above Ground Level
AIM Aeronautical Information Manual
AIM-9 Air Intercept Missile-9
ALE-50 Active towed decoy
ATC Air Traffic Control
ATIS Automatic Terminal Information Service
ATP Airline Transport Pilot
BAM Bird Avoidance Model
BDU Bomb Dummy Unit
BSA Basic Surface Attack
CAMS Core Automated Maintenance System
CAP Critical Action Procedure
CBU Cluster Bomb Unit
CCIP Continuously Computed Impact Point
CCRP Continuously Computed Release Point
CFPS Combat Flight Planning System
CJs F-16CJ Aircraft
COMACC Commander, Air Combat Command
CSMU Crash Survivable Memory Unit
CT Continuation Training
DED Data Entry Display
DLO Desired Learning Objective
DME Distance Measuring Equipment
DMPI Desired Munitions Point of Impact
DoD Department of Defense
EMS Emergency Medical Service
EOR End of Runway
EP Emergency Procedure
EPU Emergency Power Unit
EST Eastern Standard Time
FAA Federal Aviation Administration
FAAO Federal Aviation Administration Order
FAR Federal Aviation Regulation
FCC Fire Control Computer
FLIP Flight Information Publication
FOD Foreign Object Damage
FS Fighter Squadron
Ft Feet
G Gravitational
GAC General Avionics Computer
GeoRef Geographic Reference
G-Suit Anti-gravity suit
GP General Planning
GPS Global Positioning System
HSD Horizontal Situation Display
HSI Horizontal Situation Indicator
HUD Heads Up Display
IAW In Accordance With
IFF Identification Friend or Foe
IFR Instrument Flight Rules
IMC Instrument Meteorological Conditions
INS Inertial Navigation System
INU Inertial Navigation Unit
IP Initial Point or Instructor Pilot
JFS Jet Fuel Starter
JOAP Joint Oil Analysis Program
KIAS Knots Indicated Airspeed
KCAS Knots Calibrated Airspeed
KTAS Knots True Airspeed
L Local
LANTIRN Low Altitude Navigation Targeting Infrared for Night
LPU Life Preserver Unit
MANTIRN Medium Altitude Navigation Targeting Infrared for Night
MANT Short for MANTIRN
MARSA Military Authority Assumes Responsibility for Separation of
Aircraft
MAU Miscellaneous Armament Unit
MIA Miami Center
MFD Multi-function Display
MOA Military Operations Area
MPS Mission Planning Software
MSL Mean Sea Level
MTR Moving Target Reject
NM Nautical Mile
NOTAM Notice to Airmen
OCA Offensive Counter-Air
PA-2000 Phoenix Aviator-2000
PCS Permanent Change of Station
PFPS Portable Flight Planning System
PLF Parachute Landing Fall
PRC-90 Survival Communication Radio
RALT Radar Altimeter
RAP Ready Aircrew Program
RCC Rescue Coordination Center
RPM Revolutions per Minute
RTB Return to Base
SA Situational Awareness
SA-3 Surface-to-Air Missile
SAR Search and Rescue
SAT Surface Attack Tactics
SDR Seat Data Recorder
SEC Secondary Engine Control
SFO Simulated Flame Out
SIB Safety Investigation Board
SII Special Interest Item
S/N Serial Number
SOF Supervisor of Flying
SUU-20 Suspension Utility Unit
SRQ Sarasota-Bradenton International Airport
SWA Southwest Asia
TAC Tactical
TACAN Tactical Air Navigation
TCI Time Change Item
TCTO Time Compliance Technical Order
TPA Tampa Approach Control
TD Target Designator
TDY Temporary Duty
T.O. Technical Order
UFC Up-Front Controls
USAF United States Air Force
U.S.C. United States Code
VFR Visual Flight Rules
VMC Visual Meteorological Conditions
VORTAC Very High Frequency Omnidirectional Range/Tactical Air
Navigation
VR Visual Route
Z Zulu or Greenwich Meridian Time (GMT)
ZVEL Zero Velocity
The above list was compiled from the Summary of Facts, the Statement
of Opinion, the Index of Tabs, and witness testimony (Tab V).
GLOSSARY AND TERMS
Class A accident: A mishap in which there is loss of life, permanent
total disability, destruction of a USAF aircraft, or at least
$1,000,000 property damage or loss.
Cursor slew: An adjustment to the aircraft General Avionics Computer
(GAC) navigational solution normally used to correct small position
errors and refine attack steering. These refinements are typically
used to aid in target acquisition and on-board sensor cueing.
Cursor slew bias: A change to the navigational guidance symbology
resulting from a cursor slew input.
Fence check: A cockpit procedure used to ensure all switches and
avionics are set up properly for entry into a tactical environment.
The actions accomplished in the fence check are threat/scenario
dependent.
Fighting wing formation: A two-ship formation which gives the wingman
a maneuvering cone from 30 to 70 degrees aft of line abreast and
lateral spacing between 500 feet (ft) and 3000 ft from lead’s
aircraft.
G-awareness exercise: Moderate increased G maneuvers used to
determine aircraft and pilot capabilities in terms of tolerance for
increased G maneuvering on a given day.
Hot-pit refueling: Aircraft refueling that is accomplished on the
ground with aircraft engine running.
HUD/INS steering cue: The steering symbology displayed in the HUD
that shows the direction of turn necessary to follow the most direct
route to the selected INS steer point.
Mark 82/Mark 84: General purpose bombs.
Mode C: Automatic altitude reporting equipment.
Mode III: Four-digit beacon code equipment used to identify aircraft
in the National Airspace System.
Motherhood items: Non-tactical, administrative items in a pre-flight
briefing that are required for mission completion.
Radar in the notch: Positioning the radar elevation search in such a
manner that the radar scan pattern is oriented in the direction of the
aircraft’s flight path.
Sensor of interest: The avionics system that the pilot has selected
for hands-on control (e.g., radar, targeting pod, HUD, Maverick
missile, etc.).
Situational Awareness: The continuous perception of self and aircraft
in relation to the dynamic environment of flight, threats, and
mission, and the ability to forecast, then execute tasks based on that
perception.
Spin entry: The initial stages of an aircraft departing controlled
flight.
Stereo flight plan/Stereo route: A pre-coordinated flight plan.
10/10 trap attack: A tactical element air-to-ground attack.
Top-3: Squadron operations officer or designated representative
responsible for oversight of daily flying operations at the squadron
level.
VAD-2: Moody AFB stereo departure route.
VAD-25: Moody AFB stereo departure route.
Windscreen: Aircraft canopy or windshield.
SUMMARY OF FACTS
AUTHORITY, PURPOSE, AND CIRCUMSTANCES
Authority.
On 12 December 2000 General John P. Jumper, Commander, Air
Combat Command (COMACC), appointed Brigadier General Robin E. Scott to
conduct an aircraft accident investigation of the midair collision
involving an Air Force F-16 fighter and civilian Cessna 172 that
occurred near Bradenton, Florida on 16 November 2000. The
investigation was conducted at MacDill Air Force Base (AFB), Florida,
and Moody AFB, Georgia, from 15 December 2000 through 19 January 2001.
Technical advisors were Lieutenant Colonel Robert B. Tauchen (Legal),
Lieutenant Colonel Marcel V. Dionne (Medical), Captain Jay T. Stull
(Air Traffic Control), Captain John R. Fountain (Maintenance), and
Captain Todd A. Robbins (Pilot) (Tabs Y-2, Y-3).
Purpose.
This aircraft accident investigation was convened under Air Force
Instruction (AFI) 51-503. The primary purpose was to gather and
preserve evidence for claims, litigation, and disciplinary and
administrative actions. In addition to setting forth factual
information concerning the accident, the board president is also
required to state his opinion as to the cause of the accident or the
existence of factors, if any, that substantially contributed to the
accident. This investigation was separate and apart from the safety
investigation, which was conducted pursuant to AFI 91-204 for the
purpose of mishap prevention. This report is available for public
dissemination under the Freedom of Information Act (5 United States
Code (U.S.C.) §552) and AFI 37-131.
Circumstances.
This accident board was convened to investigate the Class A accident
involving an F-16CG aircraft, serial number (S/N) 89-2104, assigned to
the 69th Fighter Squadron (FS), 347th Wing, Moody AFB, Georgia, which
crashed on 16 November 2000, after a midair collision with a Cessna
172, registration number N73829.
ACCIDENT SUMMARY
Aircraft F-16CG, S/N 89-2104 (Ninja 2), and a Cessna 172,
N73829 (Cessna 829), collided in midair near Bradenton, Florida. The
F-16 was part of a two-ship low-level, Surface Attack Tactics (SAT)
sortie. The F-16 pilot, Captain Gregory Kreuder of 69 FS, ejected
safely less than a minute after the collision. The Cessna 172,
registered to Crystal Aero Group, had taken off from the
Sarasota-Bradenton International Airport. The pilot, Mr. Jacques
Olivier of Hernando, Florida, was killed in the mishap (Tabs, A-2,
B-2-4). The F-16 crashed in an unpopulated area, causing fire damage
to surrounding vegetation, but there was no damage to any structures.
The Cessna 172 broke up in midair, with the major portions of the
wreckage impacting a golf course and surrounding homes causing minor
damage. There were no injuries to civilians on the ground (Tab P-2).
Both aircraft were totally destroyed in the accident. The loss of the
F-16 was valued at $24,592,070.94 (Tab M-2). Media interest was
initially high, with queries from local, regional, and national news
outlets. Air Combat Command (ACC) Public Affairs handled media
inquiries with support from the 347th Wing Public Affairs, Moody AFB,
Georgia, and 6th Air Refueling Wing Public Affairs, MacDill AFB,
Florida.
BACKGROUND
The 347th Wing, stationed at Moody AFB, Georgia, is host to
two operational F-16C/D fighter squadrons, one HH-60G rescue squadron,
one HC-130P rescue squadron, 17 additional squadrons, and several
tenant units. The Wing has operational control over Avon Park Air
Force Range in central Florida and a deployed unit complex at MacDill
AFB, Florida. The mission of the 347th Wing is to rapidly mobilize,
deploy and employ combat power in support of theater commanders. The
69th FS is an F-16 fighter squadron assigned to the 347th Wing,
capable of employing aircraft in conventional surface attack and
counter-air roles. The wing and its subordinate units are all
components of ACC (Tab CC-4).
SEQUENCE OF EVENTS
Mission.
The mishap mission was scheduled and planned as the second of
two SAT sorties, with hot-pit refueling between the sorties. The
first sortie was scheduled for the local training areas around Moody
AFB. The mishap sortie profile included a medium altitude cruise to
Lakeland, Florida, an enroute descent for low-level tactical
navigation on the published low-level visual route VR-1098, simulated
air-to-surface attacks on the Avon Park Air Force Range, and climbout
to medium altitude for return to Moody AFB (Tab V-6.21-22).
Lieutenant Colonel James Parker was the flight lead (Ninja 1) for both
sorties, and Captain Gregory Kreuder was the wingman (Ninja 2). The
sorties were continuation training for both pilots (Tab V-6.16).
Lieutenant Colonel Mark Picton, 69 FS Director of Operations,
authorized the flight (Tab K-2).
Planning.
(1) Most of the mission planning was accomplished the
evening prior to the mishap (Tabs
V-6.9, V-8.7). Based on fuel considerations, the pilots determined
that VR-1098 would be the best low-level route for their mission.
Lieutenant Colonel Parker tasked Captain Kreuder to produce a
low-level route map and schedule the route with the appropriate
scheduling agency (Tabs V-6.10, V-8.7, V-8.8, V-8.9, V-8.13, CC-10).
Neither pilot had flown VR-1098 before (Tabs V-6.24, V-8.12). As part
of his mission planning, Lieutenant Colonel Parker referred to a FLIP
L-19 Instrument Flight Rules (IFR) Enroute Low Altitude Chart and
determined that their planned route of flight would keep them clear of
the Tampa Class B and the Sarasota-Bradenton Class C airspace
(hereafter referred to as Sarasota Class C airspace) (Tabs V-6.11,
V-6.59). Lieutenant Colonel Parker also planned the simulated attack
for the Avon Park targets and prepared the briefing room for the next
day’s mission. The next morning, Captain Kreuder reviewed the weather
and NOTAMs prior to the flight briefing and filed a composite
IFR/VFR/IFR flight plan in accordance with unit procedures (Tabs K-2,
K-5, V-8.13). He also checked the Bird Avoidance Model (BAM) for
forecast bird activity in the Florida area (Tab
V-8.13).
(2) The mission briefing included a mission overview,
scenario of simulated threats for the mission, routing to the
low-level entry point, and possible divert airfields along the route
of flight. Additionally, the flight lead covered wingman
responsibilities and formation positions. The pilots discussed the
specific details of VR-1098, the planned attacks on Avon Park, and
tactical considerations during the simulated attacks (Tab V-6.19).
Lieutenant Colonel Parker did not specifically brief Class B and Class
C airspace restrictions in the Tampa area during the flight briefing
(Tab V-6.28). Air Force directives require the flight lead to brief
applicable airspace restrictions (Tabs BB-2.2, BB-2.7). Although
Lieutenant Colonel Parker checked to make sure their planned route to
the low-level would not enter these areas, they would be flying in
close proximity to them. This information would have enhanced the
wingman’s awareness of the boundaries of these controlled airspaces
and their accompanying altitude restrictions (Tabs R-2, V-6.11,
V-8.14, V-8.15). All other appropriate items were covered in adequate
detail in accordance with Air Force directives (Tabs V-6.19-6.28,
BB-2.2, BB-2.6). According to Captain Kreuder, the briefing was
thorough and understood by him (Tab V-8.15).
Preflight.
(1) After the mission briefing, the pilots gathered their
flight equipment and assembled at the 68th FS duty desk, where they
received a final update from squadron operations system management
personnel before proceeding to the aircraft (Tabs V-6.29, V-8.19,
V-8.22). Aircraft pre-flight inspections, engine starts, before taxi
checks, taxi, and end-of-runway inspections were all uneventful (Tabs
V-6.29, V-8.19).
(2) Both aircraft were configured with two 370-gallon
wing tanks, a training Maverick air-to-ground missile, a training
heat-seeking Air Intercept Missile-9 (AIM-9), an Air Crew Maneuvering
Instrumentation (ACMI) pod, a Suspension Utility Unit-20 (SUU-20), and
a targeting pod (Tab M-2). The SUU-20 was empty for the mishap flight
because the training ordnance had been expended during the first
sortie of the day (Tabs V-6.30, V-8.19).
Flight.
(1) The first sortie was flown uneventfully and both
aircraft landed with no noted discrepancies (Tabs V-6.36-6.37,
V-8.19). Ninja 2 landed first and proceeded to the hot-pit for
refueling. Ninja 1 landed shortly thereafter, completed hot-pit
refueling, and taxied to the departure end of the runway (Tabs V-6.30,
V-8.19).
(2) Ninja flight took off for their second sortie at 1513
(Tab CC-11). The takeoff, rejoin, and climbout to 25,000 ft mean sea
level (MSL) were uneventful (Tabs V-6.38, V-8.23). Ninja 2
accomplished a targeting pod check on the Taylor TACAN and confirmed
that the flight was navigating correctly to that steer point (Tab
V-8.30). With the exception of Ninja 2’s check on the Taylor TACAN,
neither flight member recalled confirming their INS system accuracy
with ground based navigational aids (Tabs V-6.41, V-8.28). Enroute to
the Lakeland TACAN, Ninja flight was cleared direct to the VR-1098
start route point by Miami Center (Tab V-7). The flight then received
step-down altitude clearances for their descent to low level (Tabs
N-18, CC-3.2).
(3) At some time, between when Ninja 1’s aircraft tape
recorder was turned off on the first sortie to when the aircraft tape
was turned on during the second sortie, Ninja 1’s Inertial Navigation
System (INS) had developed a 9-11 NM error (Tab J-15). The true
extent of the INS position error could only be determined in
post-mishap flight review of aircraft components and tapes (Tab J-13).
The error was such that following INS steering to a selected point
would place the aircraft 9-11 NM south of the desired location (Tab
J-13). Ground radar plots of the flight’s ground track during the
medium altitude cruise revealed no significant course deviations. (Tab
CC-5.4). Ninja 1 pointed out landmarks to Ninja 2 during the medium
altitude portion of the flight, reinforcing the fact that Ninja flight
seemed to be navigating properly (Tab V-8.24).
(4) Also during this time period, a cursor slew of
approximately 26 NM and 20-30 degrees of right bias had been input to
the General Avionics Computer (Tab J-14). In certain ground-attack
steering modes, this cursor bias is added to the current INS steer
point and repositions various avionics symbology, including the Heads
Up Display (HUD) steering cues. In short, the cursor bias adjusts
navigation symbology. Normally, cursor inputs are used to correct for
small position errors, refine attack steering, and aid in target
acquisition. It is possible, however to inadvertently enter cursor
biases (Tab V-6.62). The cursor switch is a multifunction switch
dependent on the specific avionics mode and location of the sensor of
interest. Therefore, it is possible to enter unintentional cursor
slews when changing between modes and sensors (Tab
V-6.62). A crosscheck of system indications is required so that
unintentional slews are recognized and zeroed out. These errors came
into play later when Ninja flight began maneuvering for low-level
entry.
(5) Miami Center cleared Ninja flight to 13,000 ft and
directed them to contact Tampa Approach on radio frequency 362.3 (Tab
N-18, CC-3.2). The use of this frequency for Tampa Approach was
discontinued in August 2000 (Tabs N-18, CC-9). Ninja 1 thought he was
given frequency 362.35 and attempted contact there. (Tab V-6.40). In
either case, Ninja 1 would have been on the wrong frequency for Tampa
Approach. After his unsuccessful attempt to contact Tampa Approach,
Ninja 1 returned to the previous Miami Center frequency (Tabs N-19,
CC-3.2). Ninja 1 then determined that the flight was rapidly
approaching the low-level route start point and they needed to descend
soon for low-level entry (Tab V-6.40). At 1544:34, Ninja 1 cancelled
IFR with Miami Center. Miami Center acknowledged the IFR cancellation
and asked if he wanted flight following service, which Ninja 1
declined. Miami Center then terminated radar service and directed
Ninja 1 to change his Mode III transponder code to a VFR 1200 code
(Tabs J-38, N-19, CC-3.3, CC-5.1). Miami Center also gave Ninja
flight a traffic advisory on a Beech aircraft 15 NM away at 10,000 ft
MSL, which Ninja acknowledged. Ninja flight started a descent and
maneuvered to the west in order to de-conflict with that traffic (Tabs
N-19, V-6.41, V-8.26, CC-3.3). Ninja 1 was above the Class B airspace
at the time he cancelled IFR (Tabs J-38, CC-2, CC-5).
(6) At 1540:59, Sarasota Tower cleared Cessna 829 for
takeoff. The pilot, Mr. Jacques Olivier, was the only person onboard
the aircraft (Tab CC-3.2, CC-6.2). The Cessna’s planned profile was a
VFR flight at 2,500 ft MSL to Crystal River Airport (Tab N-3).
Shortly after departure, Cessna 829 contacted Tampa Approach, and the
controller called Cessna 829 radar contact at 1545:23 (Tabs N-6,
CC-3.3).
(7) At 1545:42, Ninja flight descended into Tampa Class B
airspace, approximately 15 NM northeast of Sarasota-Bradenton
International Airport, without clearance from Tampa Approach (Tabs
J-38, CC-5.1). Since Ninja 1 had already cancelled IFR and was
unaware that he was in Tampa airspace, he directed the flight to
change to UHF channel 20 (frequency 255.4, Flight Service Station) in
preparation for entry into VR-1098 (Tabs AA-2.2, BB-3.2, CC-3.3).
Ninja flight then accomplished a G-awareness exercise. This exercise
involves maneuvering the aircraft under moderate gravitational (G)
loads for 90-180 degrees of turn to ensure pilots are prepared to
sustain the G forces that will be encountered during the tactical
portion of the mission (Tabs BB-2.3, BB-4.2, BB-6.6, BB-13.3). Ninja
flight accelerated to approximately 440 knots calibrated airspeed
(KCAS) and accomplished two 90-degree turns while continuing their
descent (Tab CC-3.3). Following the G-awareness exercise, Ninja 1
directed his wingman to a fighting wing position (Tabs V-8.32,
CC-3.3).
(8) At 1547, Ninja 1 turned the flight to center up the INS
steering cues for the low-level start route point. As previously
mentioned, the INS had a 9-11 NM position error. (Tab J-15). Ninja
1’s airspeed was decreasing through approximately 390 KCAS (Tab
CC-3.4). Ninja 1 thought he was due north and within 9 NM of the
start route point, which was Manatee Dam. In reality, he was
approximately 5 NM west of the steer point (Tabs V-6.47, J-38,
CC-5.1). Also at 1547, Tampa Approach directed Cessna 829 to turn
left to a heading of 320-degrees and then follow the shoreline
northbound. Tampa also directed a climb to 3,500 ft MSL. Cessna 829
acknowledged and complied with the instructions (Tabs N-7, CC-3.4).
(9) Ninja 1 next called for a “fence check,” directing the
flight to set up the appropriate switches and onboard avionic systems
for the tactical phase of the mission (Tab CC-3.4). Shortly after
calling “fence check,” Ninja 1 entered Sarasota Class C airspace in a
descent through 4,000 ft MSL. During the descent, Ninja 1 called
“heads up, birds,” alerting his wingman of birds flying in their
vicinity (Tabs V-6.48, V-8.37, CC-3.5). As part of his “fence check,”
Ninja 1 changed from a navigational mode to an air-to-ground attack
mode (Tabs
V-6.46, CC-3.4). This mode adjusted the system steering 20 degrees
right, commanding a new heading of approximately 180-degrees (Tab
CC-3.4). This steering was the result of the cursor slew bias that
had previously been input to the system (Tab J-12). The HUD also
displayed a range of approximately 35 NM (Tabs J-10, CC-3.4). Ninja
1 turned to follow the steering cues (Tabs J-37, J-38, CC-2, CC 3.5,
CC-5.1).
(10) In addition, this air-to-ground mode displays a metric of
navigational system accuracy when the system determines anything less
than “high” accuracy (Tab J-11). When Ninja 1 switched to this mode,
the system showed a navigational system accuracy of “medium”, which
eventually degraded to “low” prior to the collision (Tab J-13). Ninja
1 did not notice this degradation in system accuracy (Tab V-6.49).
Ninja 2 thought they were on course and close to the start route
point. However, he did not recall specifically checking his own INS
steering to confirm they were on track to the point (Tabs V-8.34,
V-8.35, V-8.36).
(11) At 1547:39, approximately 30 seconds prior to the
midair collision, the Tampa Approach radar system generated an initial
Mode C Intruder (Conflict) Alert between Cessna 829 and Ninja 1’s 1200
code (Tab CC-8.2). Between 1547:55 and 1548:05, Tampa Approach
communicated with Miami Center and discussed the altitude of Ninja 1
(Tabs N-7, CC-3.5). No safety alert was ever transmitted to Cessna
829 (Tabs N-7, CC-3.5).
(12) At 1548:09, Ninja 2 and Cessna 829 collided near
Bradenton, Florida (Tabs U-5.1,
CC-3.5). The collision happened approximately 6 NM from the
Sarasota-Bradenton International Airport at approximately 2000 ft,
within the confines of the Sarasota Class C airspace (Tabs J-36, J-37,
J-40, R-2, BB-7.2, CC-2, CC-5.1). Ninja 1 was not aware that the
flight was in Class C airspace when the collision occurred (Tab
V-6.69). Ninja 1’s displayed airspeed at the time of the midair was
356 KCAS with a heading of 178 degrees (Tab CC-3.5). Ninja 1’s
attention was focused on finding the start route point and looking
where the HUD steering was pointed (Tab V-6.51). Again, these
indications were incorrect due to the INS position error and cursor
slew, neither of which was recognized by the pilot. Ninja 1 was
unable to find the start route in front of his aircraft because it was
actually about 5 NM at his left eight-o’clock (Tabs J-38, V-6.47,
CC-2). Ninja 1 looked over his left shoulder at approximately one
second prior to impact and saw the Cessna in a turn just in front of
his wingman (Tab V- 6-52).
(13) Ninja 2 was looking in the direction of Ninja 1,
anticipating a left turn for entry into the low-level route. He was
clearing his flight path visually, primarily looking for birds (Tabs
V-8.37, V-8.38). He was flying about 60-degrees aft of his flight
lead and 3,000-5,000 feet in trail (Tab V-8.38). Ninja 2 saw a white
flash that appeared to travel from low left ten- to eleven-o’clock and
simultaneously felt a violent impact (Tab V-8.38). There are
conflicting witness statements about the flight attitude of Cessna 829
immediately prior to the midair (Tabs V-2,
V-3, V-4, V-5, V-6.53). The nearest witnesses on the ground stated
that they saw no evasive maneuvering by the Cessna immediately prior
to the collision (Tabs V-2, V-3, V-4). Other witnesses, including
Ninja 1, perceived that Cessna 829 turned or banked immediately prior
to the collision (Tabs V-5, V-6.53).
(14) Also at 1548:09, Tampa Approach issued Cessna 829 a
traffic advisory on Ninja 1’s position (Tabs N-7, CC-3.5).
(15) The collision created a large hole in the left side of
Ninja 2’s canopy and there was accompanying airflow noise (Tab S-5).
The impact disabled all of his primary flight instruments, and there
was nothing displayed in the HUD (Tab V-8.39). Ninja 2 initially
turned the jet right to the west in an attempt to recover at MacDill
AFB. The aircraft then decelerated and the engine began to spool
down. A few moments later, he determined he would be unable to fly
the aircraft to MacDill AFB, based on its current altitude and
airspeed. Ninja 2 then began a turn back to the left, looking for an
unpopulated area in the event he had to eject (Tabs V-8.39, V-8.40,
V-8.41). Ninja 2 initiated the critical action procedures to restart
the engine, which was unsuccessful due to foreign object ingestion
(Tabs J-24, V-8.40, V-8.41). As altitude and airspeed continued to
decrease, he maneuvered his aircraft towards an uninhabited area (Tab
V-8.42). The aircraft then began an uncontrollable roll to the left
and Ninja 2 ejected (Tabs
V-8.2, V-8.43).
Impact.
After ejection, the aircraft continued to roll left and
transitioned to what appeared to be a spin entry (Tabs V-8.43,
V-8.44). It impacted the terrain at approximately 1549, at
coordinates N 27 23.5, W 82 27.5 (Tabs U-5.1, R-2). The aircraft
impacted the ground in a level attitude, pointing to the north (Tab
V-8.43). It crashed in an uninhabited area in a sparsely wooded
location (Tab S-3). Aside from fire damage to the surrounding
vegetation, there was little damage to the area surrounding the crash
site (Tab S-4).
Life Support Equipment, Egress and Survival.
(1) Upon impact with the Cessna, the left side of Ninja
2’s canopy was shattered, and Ninja 2’s helmet visor was lost (Tab
V-8.39). Ninja 2 safely ejected from his disabled aircraft in a
low-speed, nose-low, approximate 135-degree left-bank at an altitude
of approximately 700 ft (Tab V-8.43).
(2) The helmet, aviator mask, G-suit, Air Crew Ejection
System-II (ACES-II) seat, parachute and seat-kit functioned normally
(Tabs V-8.43, V-8.44, V-8.45). There was a twist in the parachute
risers after the chute opened, but Ninja 2 was able to untwist them
before he reached the ground (Tab V-8.44). Ninja 2 stated that his
PRC-90 radio had marginal reception during his communications with
Ninja 1, who was orbiting overhead the crash site (Tab V-8.45). All
life support and egress equipment had current inspections (Tab U-3).
Life support and egress equipment were not factors in the mishap.
Search and Rescue.
Within moments of his parachute landing, Captain Kreuder was
approached by a civilian who loaned him a cell-phone to call the
operations desk at Moody AFB (Tab V-8.44). Ninja 2 was evaluated by
civilian Emergency Medical Service (EMS) personnel at the crash site.
Within a couple hours of the crash, he was flown by helicopter to the
6th Medical Group Hospital at MacDill AFB (Tabs X-2, V-8.45).
Recovery of Remains.
The remains of the Cessna pilot were recovered in the vicinity of the
Rosedale Golf and Country Club. An autopsy was performed on 18
November 2000 at the District Twelve Medical Examiner Facility (Tab
X-4).
MAINTENANCE
Forms Documentation.
(1) A complete review was performed of active Air Force
Technical Order (AFTO) 781 series forms along with automated
maintenance/equipment history stored in the Core Automated Maintenance
System (CAMS) for both F-16 aircraft involved. This review covered
the time period from the last major phase inspection to the mishap
sortie and yielded no indication of any pending mechanical, electrical
or jet engine failure (Tabs H-2, H-3, H-4, H-5).
(2) A detailed listing of open items in both the AFTO 781
series forms and CAMS is included at Tab H. There is no evidence that
any of the open items were factors in the mishap (Tabs H-2, H-3).
(3) A detailed review of the AFTO Form 781K and the
automated history report showed no airframe or equipment Time
Compliance Technical Orders (TCTO) overdue at the time of the mishap
(Tabs H-2, H-3).
Inspections.
All required scheduled inspections and Time Change Items (TCI)
for aircraft 89-2104 were properly completed and documented (Tabs H-2,
H-3). There was an overdue 50-hour throttle inspection on aircraft
89-2058 (Tab H-4). This overdue inspection was not a factor in the
mishap (Tabs H-4, H-5).
Maintenance Procedures.
There is no evidence that maintenance procedures or practices
with respect to daily operations of aircraft 89-2058 and aircraft
89-2104 were factors in this mishap (Tabs H-2, H-3, H-4, H-5, U-2,
U-3, U-4, U-6).
Maintenance Personnel and Supervision:
(1) All personnel involved with servicing, inspections
(pre-flight and thru-flight), and aircraft launches were adequately
trained to complete all of these tasks, as documented in their AF Form
623s, On the Job Training Records, and AF Form 797s, Job Qualification
Standard Continuation/Command Job Qualification Standard (Tab U-2).
(2) Quality Verification Inspection and Personnel
Evaluation results for the four months prior to the mishap, provided
by the 347th Wing Quality Assurance section, demonstrated a trend of
quality job performance in the 69th FS (Tab U-2).
Fuel, Hydraulic and Oil Inspection Analysis.
(1) Joint Oil Analysis Program (JOAP) samples taken from
the mishap aircraft prior to the last sortie revealed no engine oil
abnormalities (Tab U-7.1). Aircraft 89-2104 was destroyed upon impact
with the ground and post-impact fire; thus, no post-flight JOAP
samples were taken (Tab D-3).
(2) The JOAP Lab at Moody AFB, GA noted no deficiencies in
fuel taken from fuel storage tank samples (Tabs U-8.1, U-8.2, U-8.3,
U-8.4, U-8.5, U-8.6, U-8.7).
(3) Sample results from the oil-servicing, liquid nitrogen
and liquid oxygen carts met required limits (Tabs U-7.3, U-7.4, U-7.5,
U-7.6, U-7.7, U-9, U-10).
Unscheduled Maintenance.
(1) A review of the Maintenance History Report for
aircraft 89-2104, covering the period from 14 January 2000 to 16
November 2000, revealed 192 unscheduled on-equipment maintenance
events. Maintenance History Report review revealed no evidence that
unscheduled maintenance was a factor in the mishap (Tab U-4).
(2) A review of the Maintenance History Report for
aircraft 89-2058, covering the period from 15 May 2000 to 16 November
2000, revealed 194 unscheduled on-equipment maintenance events.
Maintenance History Report review revealed no evidence that
unscheduled maintenance was a factor in the mishap (Tab U-4).
(3) Maintenance personnel working both aircraft the day of
the mishap were unaware of any undocumented discrepancies (Tabs V-11,
V-12). A hot-pit crewmember indicated that both aircraft were
functioning properly at the completion of all launch procedures (Tab
V-11). Lockheed Martin analysis of Crash Survivable Memory Unit
(CSMU), Seat Data Recorder (SDR), Global Positioning System (GPS),
General Avionics Computer (GAC) and INS data, as well as both pilots’
testimony, show no evidence of system performance outside of normal
operating parameters (Tabs J-12, J-13, J-14, V-6.29, V-6.32, V-8.19,
V-8.20).
AIRCRAFT AND AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS
Condition of Systems.
(1) Aircraft 89-2104 was completely destroyed by ground impact
and post-impact fire (Tabs M-2, S-3, S-4).
(2) Prior to the midair collision, aircraft 89-2104 had all
required equipment (Tab H-2). The equipment was functioning properly
and not a factor in the mishap (Tabs J-14, U-4, V-8.19,
V-8.20).
Testing.
(1) The CSMU and SDR from aircraft 89-2104 were
successfully retrieved and sent to Lockheed Martin Flight and System
Safety, Fort Worth, Texas, for analysis (Tab J-2). The HUD and
Multi-Function Display (MFD) recording tapes were destroyed in the
post impact fire (Tab J-3.31). Components retrieved from aircraft
89-2058 included: GAC, Inertial Navigation Unit (INU), GPS receiver
and recorded HUD and MFD tapes. All components were sent to Lockheed
Martin Flight and System Safety, Fort Worth, Texas for analysis (Tab
J-2).
(2) Analysis of data received from Lockheed Martin Flight
and System Safety of component downloads from both aircraft 89-2058
and 89-2104 substantiate that all systems were functional and
operating within design parameters (Tabs J-14, J-15). Evaluation of
system operation showed that aircraft 89-2058’s INS had a 9-11 NM
steering error on the mishap sortie (Tab
J-15). There is no indication that any other system operations of
either aircraft were a factor in this mishap.
WEATHER
Forecast Weather.
Forecast weather for MacDill AFB, Florida, located
approximately 27 nautical miles north of Sarasota, received on 16
November 2000, at 1217L (1717Z), was wind 160 degrees at 8 knots and
unlimited visibility. Sky condition forecast was few clouds at 5,000
ft. After 1500L, wind was forecasted to be 250 degrees at 10 knots.
No turbulence was forecasted at the time of the mishap (Tab K-6).
Observed Weather.
Observations were taken for Sarasota, Florida, at 1453L and
1553L. Observed winds were 210 degrees at 9-11 knots. Reported
visibility was 10 statute miles and sky condition was clear (Tab K-7).
Ninja 2 observed visibility to be better than 5 statute miles and sky
condition better than 3,000 ft, with “typical Florida haze” (Tabs
V-8.36, V-8.37). Ninja 2 also stated that the sun was in his
two-o’clock position (southwest) and not a factor in the mishap (Tabs
V-8.37,
V-8.38).
Space Environment.
There were no space weather-related events affecting the GPS
during the time of the mishap (Tab J-27).
Conclusions.
The flight was conducted during the day in visual
meteorological conditions (VMC). Weather conditions were good, and
there is no evidence that weather was a factor in the mishap.
CREW QUALIFICATIONS
Ninja 1, Flight Lead
(1) Lieutenant Colonel Parker was a qualified four-ship
flight lead. He completed his four-ship flight lead qualification in
February 2000 (Tab T-3). He had previously finished two-ship flight
lead upgrade in September 1999 (Tab T- 3). Lieutenant Colonel Parker
had a total of 2865.1 hours in USAF aircraft to include 991.9 hours in
the F-16, 701.4 hours in the F-106, and 954.5 in the T-33 (Tab G-3).
He also had 36.6 hours as an instructor in the F-106 and 80.5 hours as
an instructor in the T-33 (Tab G-3). He was current and qualified in
all areas of the briefed mission.
(2) Recent flight time is as follows (Tab G-2):
Ninja 2, Mishap Pilot
(1) Captain Kreuder was a qualified four-ship flight lead,
mission commander, functional check flight pilot and Supervisor of
Flying (SOF). He finished his mission commander upgrade on 21 August
2000 and had been a four-ship flight lead since 11 January 2000. He
was initially certified as a two-ship flight lead in March 1999. He
was certified combat mission ready at Moody AFB in December 1998 (Tab
T-2). Captain Kreuder had 706.3 hours in the F-16 (Tab G-9). He was
current and qualified in all areas of the briefed mission.
(2) Recent flight time is as follows (Tab G-7):
c. Cessna 829, Mishap Pilot
Mr. Jacques Olivier was a qualified Airline Transport Pilot
(ATP). He was issued his ATP qualification on 15 December 1999 (Tab
T-4).
MEDICAL
Qualifications.
(1) The medical and dental records of Lieutenant Colonel
Parker (Ninja 1) and Captain Kreuder (Ninja 2) were reviewed. Both
pilots were medically qualified for flight duties and had current USAF
class II flight physicals at the time of the mishap (Tabs X-2, X-3).
(2) The Cessna pilot (Mr. Olivier) was medically qualified
and had a current 1st class Federal Aviation Administration (FAA)
airman medical certificate at the time of the mishap (Tab X-2).
Health.
(1) Lieutenant Colonel Parker sustained no injuries from
the mishap and did not seek medical attention. He had a normal
post-mishap physical examination on 24 November 2000 (Tab X-4).
(2) On the day of the mishap, Captain Kreuder was
hospitalized overnight for observation and evaluation. The only
significant findings on exam were a small superficial skin abrasion on
the left leg and a minor scratch on the right forearm. There was no
evidence of other injury, and full spine x-rays did not reveal any
acute abnormality or fracture (Tab X-4).
(3) Mr. Olivier sustained fatal injuries from the mishap
(Tab X-4).
(4) Neither the F-16 pilots nor the Cessna pilot appeared
to have any pre-existing medical condition that may have been a factor
in this mishap (Tab X-2).
Pathology.
(1) Blood and urine samples from Lieutenant Colonel Parker
and Captain Kreuder were submitted to the Armed Forces Institute of
Pathology for toxicological analysis. Carbon monoxide levels for both
pilots were within normal limits. No ethanol was detected in the
urine or blood samples. Furthermore, no amphetamines, barbiturates,
benzodiazepines, cannabinoids, cocaine, opiates or phencyclidine were
detected in the urine samples of either pilot (Tabs X-2,
X-5).
(2) Mr. Olivier’s autopsy report from the District Twelve
Medical Examiner Office in Sarasota, Florida was reviewed. He died
instantly in the midair collision as a result of blunt force trauma
(Tab X-4). Post-mortem comprehensive toxicological analysis was
negative (Tab X-2).
Lifestyle.
Based on the 72-hour history questionnaires and interviews
with both Lieutenant Colonel Parker and Captain Kreuder, there is no
evidence that unusual habits, behavior, or stress were a factor in the
mishap (Tabs V-6.5, V-6.6, V-6.7, V-8.5, V-8.6, X-6).
Crew Rest and Crew Duty Time.
Both Lieutenant Colonel Parker and Captain Kreuder had
adequate crew rest and were within maximum aircrew duty limitations
when the mishap occurred (Tabs V-6.7, V-8.5, X-6, BB-10.3, BB-10.4).
OPERATIONS AND SUPERVISION
Operations.
The operations tempo at the time of the mishap was moderate
for an F-16 fighter squadron. The squadron had last deployed in
August 2000, when it participated in a Green Flag Exercise (Tabs V-9,
V-10). The squadron was in the process of deactivating. The
deactivation was going according to plan and morale in the unit
remained high. As personnel left the unit, those who remained were
picking up some additional duties. However, the unit had not received
any new pilots for some time; thus, there was minimum additional
upgrade training. The paperwork load continued to decrease as
personnel left the unit (Tab V-10). The experience level of the
pilots was higher than a typical operational fighter squadron.
Operations tempo was not a factor in this mishap (Tab V-10).
Supervision.
The squadron commander and the operations officer both felt
that Lieutenant Colonel Parker and Captain Kreuder were very
professional, disciplined and competent aviators (Tabs V-9,
V-10). The squadron leadership applied the proper supervisory role
for the experience level of the pilots involved. Due to the
deactivation of the 69th FS, they had combined duty desk operations
with the 68th FS. The 68th FS Top-3 was not available for the
step-brief because he was giving a mass brief. He did, however, tell
the Squadron Operations Systems Manager to pass along to the pilots
that he had no additional words for them (Tab V-6.29). Squadron
supervision was not a factor in this mishap.
HUMAN FACTORS ANALYSIS
a. Lieutenant Colonel Parker, Ninja 1
(1) Mis-prioritization of tasks: Lieutenant Colonel
Parker was navigating VFR and focusing his attention on the ground in
an attempt to find the Manatee Dam (Tabs V-6.46,
V-6.48). This focus on locating the low-level entry point likely
detracted from his flight path deconfliction responsibilities. He did
not see the collision threat in sufficient time to warn his wingman
(Tab V-6.52).
(2) Lost situational awareness: Lieutenant Colonel Parker
did not have proper situational awareness, as demonstrated by his
failure to recognize INS inaccuracies and cursor slew biases, and
flying through Class B and Class C airspace without proper clearance
or communications. As a result of his loss of SA, he ultimately
navigated his flight onto a collision course with Cessna 829.
b. Captain Kreuder, Ninja 2
(1) Mis-prioritization of tasks: In the moments prior to
the mishap, Ninja 2 was in fighting wing formation, slightly low and
to the left, 3,000-5,000 ft behind his flight lead. Captain Kreuder
was looking out for birds and expecting Ninja 1 to turn onto the
low-level route at any moment (Tab V-8.34). His immediate focus was
to “see and avoid” Ninja 1, since he expected him to turn sharply
across his flight path. However, Captain Kreuder did not properly
prioritize his visual lookout for other aircraft, as evidenced by his
failure to see Cessna 829, who was on a collision course to his left.
Captain Kreuder does not recall where he was looking at the instant of
impact, but reported that he saw a white flash at his ten- to
eleven-o’clock position just a split second prior to collision (Tab
V-8.38).
(2) Failure to adequately deconflict flight path: If two
aircraft are on a collision course, the flight geometry results in
little to no relative movement of the other aircraft on their
respective windscreens. The peripheral visual acuity of the average
human eye with 20/20 central vision is in the range of 20/200 to
20/400 (Tabs X-7.3, X-7.4). The eye relies more heavily on an
object’s relative motion and less on visual acuity in the peripheral
field of vision to detect oncoming threats. Cessna 829’s contrast and
small size against a featureless sky with very little or no relative
motion in Ninja 2’s left windscreen would render the collision threat
difficult to detect in the pilot’s peripheral vision. Therefore, a
disciplined and methodical visual scan of all forward sectors is
critical for acquiring flight path conflicts.
c. Mr. Jacques Olivier, Cessna 829
No historical human factors information was available on the
Cessna 829 pilot. However, it is reasonable to conclude that Mr.
Olivier did not perceive the collision threat in time to avoid the
collision. He would have faced the same visual perception problems as
Ninja flight: a small aircraft in a featureless sky with little or no
relative movement across his windscreen.
AIRSPACE AND AIR TRAFFIC CONTROL ANALYSIS
Class B Airspace.
(1) The airspace surrounding Tampa International Airport
is categorized as Class B airspace. Class B airspace normally extends
upward from the surface to 10,000 ft MSL surrounding the nation’s
busiest airports. The configuration of each Class B airspace area is
individually tailored and consists of a surface area and two or more
layers. For the specific dimensions of the Tampa Class B airspace,
refer to the legal description contained in Federal Aviation
Administration Order 7400.9H (Tab BB-7.2). For a visual depiction of
the southeast corner of this airspace, refer to the Tampa/Orlando VFR
Terminal Area Chart (Tab R-2).
(2) Aircraft operating in Class B airspace are required to
obtain Air Traffic Control (ATC) clearance, have an operable two-way
radio capable of communications with ATC on appropriate frequencies,
and be equipped with an operating transponder and automatic altitude
reporting equipment (Tabs BB-8.6, BB-9.10).
(3) Ninja 1 entered the Tampa Class B airspace approximately
15 NM northeast of Sarasota without clearance from Tampa Approach. On
17 November 2000, Tampa Approach filed a Preliminary Pilot Deviation
Report against Ninja 1 for this violation (Tab CC-7.1).
Class C Airspace.
(1) The airspace surrounding Sarasota-Bradenton
International Airport is categorized as Class C airspace. This
airspace extends from the surface up to and including 4,000 ft MSL
within a 5-mile radius of the Sarasota-Bradenton International
Airport. It also includes the airspace extending from 1,200 ft MSL up
to and including 4,000 ft MSL within a 10-mile radius of the airport
(Tabs R-2, BB-7.3).
(2) Aircraft operating in Class C airspace are required to
establish two-way radio communications with ATC before entering the
airspace and have an operational transponder (Tabs BB-8.5, BB-9.8).
(3) Ninja 1 entered the Sarasota Class C airspace 9 NM
northeast of Sarasota without establishing two-way radio
communications with Tampa Approach. On 17 November 2000, Tampa
Approach filed a Preliminary Pilot Deviation Report against Ninja 1
for this violation (Tab CC-7.1).
VR-1098.
VR-1098 is a military training route used for flights entering
the Avon Park Bombing Range (R-2901). The entry point (Point A) for
VR-1098 is located approximately 12 NM northeast of the
Sarasota-Bradenton International Airport at an altitude between 500 ft
above ground level (AGL) and 1,500 ft AGL. At Point A, the route
extends 3 NM southwest (right) of centerline, slightly penetrating the
Sarasota Class C airspace, and 8 NM northeast (left) of centerline,
underlying the Tampa Class B airspace (Tabs R-2, BB-3.3).
Air Traffic Control.
(1) According to Federal Aviation Administration
directives, the primary purpose of the Air Traffic Control (ATC)
system is to prevent a collision between aircraft operating in the
system and to organize and expedite the flow of traffic. An air
traffic controller’s first duty priority is to separate aircraft and
issue safety alerts. Controllers also have the regulatory
responsibility to issue mandatory traffic advisories and safety alerts
to VFR aircraft operating in Class C airspace (Tabs BB-9.3, BB-9.8).
(2) An air traffic controller receives a Mode C Intruder
Alert when the ATC automated radar system identifies an existing or
pending situation between a tracked radar target and an untracked
radar target that requires immediate attention or action by the
controller. Once a controller observes and recognizes this situation,
his or her first priority is to issue a safety alert. A safety alert
is issued to an aircraft if the controller is aware the aircraft is in
a position which, in the controller’s judgment, places it in unsafe
proximity to other aircraft (Tabs BB-9.4, BB-9.5,
BB-9.6, BB-9.15, BB-9.16).
(3) At the time of the mishap, Cessna 829 was operating
in the Sarasota Class C airspace under the control of Tampa Approach.
At 1547:39, Tampa Approach’s radar system generated the first of a
series of five Mode C Intruder Alerts between Cessna 829 and Ninja 1.
The Mode C Intruder Alerts continued for 19 seconds, until 1547:58,
when the automated radar system no longer identified a conflict
between these two aircraft (Tabs CC-8.2, CC-8.3, CC-8.4). The system
did not identify a conflict between Cessna 829 and Ninja 2 because
Ninja 2 was not squawking a Mode III beacon code. In accordance with
Air Force directives, a wingman in standard formation does not squawk
a Mode III beacon code since the lead aircraft is already squawking a
code for the flight (Tab V-6.39, V-8.25, BB-10.5).
(4) Tampa Approach never issued a safety alert to Cessna
829, despite receiving the first Mode C Intruder Alert approximately
30 seconds before the mishap. The written transcripts do not show any
radio or landline communications by Tampa Approach when the Conflict
Alert activated. Tampa Approach also failed to issue a timely traffic
advisory to Cessna 829, with the first and only traffic advisory being
issued at the approximate time of impact (Tabs N-7,
CC-3.5). This traffic advisory was actually on Ninja 1, who had
already passed in front of Cessna 829.
(5) The accident board was unable to determine why Tampa
Approach failed to issue a safety alert to Cessna 829 because the air
traffic controllers involved in the mishap declined our request for
interviews (Tab CC-12).
e. Airspeed Requirements.
(1) Federal Aviation Regulation Part 91 states “no person may
operate an aircraft below 10,000 feet MSL at an indicated airspeed of
more than 250 knots.” However, it also states that “[i]f the minimum
safe airspeed for any particular operation is greater than the maximum
speed prescribed in this section, the aircraft may be operated at that
minimum speed” (Tab BB-8.4).
(2) According to Air Force T.O. 1F-16CG-1 Flight Manual,
page 6-3, the F-16CG should be operated at a minimum airspeed of 300
KIAS during normal cruise operations below 10,000 ft. The closure
rate of Cessna 829 and Ninja 1 based on radar-measured conflict alert
data just prior to the collision was approximately 480 KTAS (Tabs
CC-8.3, CC-13).
GOVERNING DIRECTIVES AND PUBLICATIONS
Primary Operations Directives and Publications.
(1) AFI 11-2F-16 Volume 3, F-16 Flight Operations, 1
July 1999 (Tab BB-2).
(2) Area Planning Military Training Routes North and South
America (AP/1B), 5 October 2000 (Tab BB-3).
(3) AFI 11-2F-16 Volume 3, Chapter 8 Moody AFB Supplement
1, 15 October 2000
(Tab BB-4).
(4) AFI 11-214, Aircrew, Weapons Director, and Terminal
Attack Controller
Procedures for Air Operations, 25 February 1997 (Tab BB-5).
(5) AFTTP 3-3 Volume 5, Combat Aircraft Fundamentals -
F-16, 9 April 1999 (Tab
BB-6).
(6) FAAO 7400.9H, Airspace Designations and Reporting
Points, 1 September 2000
(Tab BB-7).
(7) FAR Part 91, General Operating and Flight Rules, 25 April 2000
(Tab BB-8).
(8) FAAO 7110.65M, Air Traffic Control, 24
February 2000 (Tab BB-9).
(9) AFI 11-202 Volume 3, General Flight Rules, 1
June 1998 (Tab BB-10).
(10) General Planning (GP), 18 May 2000 (Tab
BB-11).
(11) AIM, 10 August 2000 (Tab BB-12). (Advisory only).
(12) 347th Wing F-16 Employment Standards, March 1999 (Tab
BB-13).
(13) T.O. 1F-16CG-1, Flight Manual, 27 May 1996.
Maintenance Directives and Publications.
AFM 37-139, Records Disposition Schedule, 1 March 1996.
Known or Suspected Deviations from Directives or Publications.
Ninja 2 and Cessna 829: Failure to See and Avoid
AFI 11-202 Volume 3, Paragraph 5.2, See and Avoid (Tab BB-10.2)
General Planning, Page 2-42, See and Avoid (Tab BB-11.4)
AIM, Paragraph 5-5-8, See and Avoid (Tab BB-12.2) (Advisory only).
FAR Part 91, Section 91.111, Operating near other aircraft; and FAR
Part 91 Section 91.113, Right-of-way rules (Tabs BB-8.2, BB-8.3)
Tampa Approach: Failure to issue a safety alert to Cessna 829
FAAO 7110.65M, Paragraph 2-1-6, Safety Alert (Tab BB-9.4)
Ninja Flight: Failure to establish two-way radio communications with
Tampa Approach prior to entering Sarasota Class C airspace
FAR Part 91, Section 91.130, Operations in Class C airspace (Tab
BB-8.5)
(4) Ninja Flight: Failure to obtain ATC clearance with Tampa
Approach for entry into the Tampa Class B airspace
FAR Part 91, Section 91.131, Operations in Class B airspace (Tab
BB-8.6).
NEWS MEDIA INVOLVEMENT
News media outlets in the area around the crash site covered
this mishap extensively. Air Force officials conducted several press
conferences on-scene, and numerous television, radio, and print
reporters visited the crash site. Several live interviews were
conducted. In addition, the National Transportation Safety Board held
press conferences and gave interviews.
18 January 2001 ROBIN E. SCOTT, Brigadier
General, USAF
President, Accident
Investigation Board
STATEMENT OF OPINION
F-16CG/Cessna 172
16 November 2000
1. Under 10 U.S.C. 2254(d) any opinion of the accident investigators
as to the cause of, or the factors contributing to, the accident set
forth in the accident investigation report may not be considered as
evidence in any civil or criminal proceeding arising from an aircraft
accident, nor may such information be considered an admission of
liability of the United States or by any person referred to in those
conclusions or statements.
2. OPINION SUMMARY.
There were two causes of the midair collision between an Air
Force F-16 and civilian Cessna aircraft near Bradenton, Florida, on 16
November 2000, both supported by clear and convincing evidence.
First, Ninja 2 and Cessna 829 failed to “see and avoid” each other in
sufficient time to prevent the mishap. Second, Tampa Approach failed
to transmit a safety alert to Cessna 829 when their radar system
generated “Conflict Alert” warnings.
In addition, there were three factors that substantially
contributed to the mishap, all supported by substantial evidence.
First, Ninja 1 lost situational awareness (SA) and descended under
Visual Flight Rules (VFR) into Tampa Class B airspace without
clearance. Second, Ninja 1 failed to recognize a significant position
error in his aircraft’s Inertial Navigation System (INS) and
unknowingly navigated the flight into Sarasota Class C airspace
without the required communications with Tampa Approach. Third, Ninja
1 failed to recognize a cursor slew bias in his ground attack steering
and unknowingly navigated the flight onto a collision course with
Cessna 829.
I base my opinion of these causes and contributing factors on
review and analysis of the following evidence: data released by the
Air Force Safety Investigation Board (SIB), interviews with the two
Air Force pilots, other military personnel from the mishap pilots’
unit, individuals on the ground who witnessed the mishap, applicable
Air Force and FAA directives, videotapes from the lead F-16 aircraft,
radar plots from various ground radar facilities, surveys and
photographs of the crash scenes, and examination of the F-16 wreckage.
3. DISCUSSION OF OPINION.
Three important conditions must be met in order for a midair
collision to occur. First, two aircraft must be in close proximity to
each other in time and space. Second, their flight paths must place
the aircraft on a collision course. Finally, the pilots must fail to
see each other in sufficient time and/or fail to alter their flight
paths enough to avoid the collision. In order to determine the causes
and significant factors that contributed to this mishap, it is
important to understand the circumstances surrounding the critical
chain of events that led to the midair collision.
The First Link in the Chain: The critical chain of events
began at 1544 when Ninja 1 elected to cancel Instrument Flight Rules
(IFR). He based this decision on his determination that the low-level
entry point was fast approaching and he needed to continue the
descent, as well as complete numerous tasks (G-awareness exercise,
fence check, and deploying his wingman to fighting wing position)
before they entered the low-level route. Earlier in the flight, Miami
Center had cleared Ninja 1 to proceed direct to the VR-1098 start
point with a descent to 13,000 ft mean sea level (MSL). When Ninja 1
cancelled IFR, the flight was well inside the lateral confines of
Tampa Class B airspace but still 3,000 ft above its upper limit.
Ninja 1 was not aware of this fact (i.e., he had lost his SA) and
descended the flight into controlled airspace without the required
clearance.
Ninja 1’s loss of SA during his VFR descent was a
substantially contributing factor to this mishap. While proceeding
VFR was permissible under the rules, he was still required to either
avoid entry into the Class B airspace or contact Tampa Approach for
clearance to enter. This loss of SA is the first critical link in the
mishap chain of events.
In Close Proximity: The midair collision occurred within the
confines of Sarasota Class C airspace. Cessna 829 had taken off from
Sarasota-Bradenton International Airport on a VFR flight to Crystal
River Airport and was on a radar-vector climbout with Tampa Approach.
Meanwhile, Ninja flight was still in their VFR descent proceeding to
the low-level start route point, located just northeast of the Class C
airspace. By this time, Ninja 1’s INS had developed a 9-11 nautical
mile (NM) position error that went unnoticed by the pilot. He had
experienced no problems with the INS on the first sortie of the day
and assumed it was still accurate. He did not crosscheck the INS
accuracy with other systems during the medium-altitude portion of the
mishap sortie. However, a review of ground radar plots depicting his
actual ground track on the first three legs of the sortie revealed no
apparent deviations. As he began his descent, the next opportunity to
check his INS accuracy was at the start route point.
Approximately one minute prior to the midair collision, Ninja
1 centered his INS steering and started looking for the start route
ground reference, Manatee Dam. Since both pilots in Ninja flight were
flying VR-1098 for the first time, neither had seen the actual ground
references or local terrain features before. Ninja 1’s INS was
steering him 9-11 NM south of the actual turn point so Manatee Dam
was, in reality, several miles to his left. Consequently, Ninja 1
would never visually acquire the ground reference that could have
clued him in to the INS error.
During this time, Ninja 2 was focused on maintaining his
fighting wing position and looking for birds in the vicinity of his
flight path. His impression was that they were close to the start
route point, and he was anticipating a turn onto the route at any
moment. However, he could not recall checking his own navigation
indications to confirm that their course to the start route point was
correct. Although Ninja 2’s primary non-critical task was to maintain
proper formation, he also had the responsibility to back up his flight
lead on navigation tasks. An opportunity to help his flight lead
regain situational awareness and break the mishap chain of events was
lost.
The INS position error, combined with Ninja 1’s failure to
detect the discrepancy, was another substantially contributing factor
to the mishap. By following this erroneous steering,
Ninja 1 violated Sarasota Class C airspace without the required
communications with Tampa Approach and navigated the flight into the
same airspace with Cessna 829.
On a Collision Course: As stated above, Cessna 829 was under
control of Tampa Approach on a radar-vector climbout. Tampa Approach
issued Cessna 829 a left turn to a 320-degree heading and climb to
3,500 ft MSL at about the time Ninja flight was descending through
4,000 ft MSL and entering the Class C airspace. Ninja 1 directed the
flight to conduct a “fence check” and switched his navigation system
to a ground-attack steering mode. This new mode shifted the steering
indications in the HUD, showing a 180-degree bearing for 35 NM to the
start route point. This shift in the steering indications was the
result of an unintentional cursor slew bias by the pilot. Ninja 1
failed to note this bias, turned the flight south to center up the new
steering, and continued looking for the start route ground reference.
Combined with the Cessna’s 320-degree vector, the collision geometry
for the mishap was complete.
Ninja 1’s failure to recognize and correct the unintentional
cursor slew bias was a substantially contributing factor to the
mishap. Even with the existing INS position error in the system, if
Ninja 1 had noted the cursor bias and zeroed it out, the flight would
still have flown in close proximity to Cessna 829 but would likely not
have ended up on a collision course.
Failure to “See and Avoid”: One cause of this mishap was the
failure of Ninja 2 and Cessna 829 to see each other in sufficient time
to maneuver their aircraft and avoid the midair collision. Both Ninja
flight and Cessna 829 were operating VFR in visual meteorological
conditions (VMC). Under VFR, all pilots are charged with the
responsibility to observe the presence of other aircraft and to
maneuver their aircraft as required to avoid a collision. In aviation
parlance, this responsibility is known as “see and avoid.” Air Force
training manuals emphasize that flight path deconfliction is a
critical task, one that can never be ignored without catastrophic
consequences.
The geometry of a collision intercept and associated visual
perceptions require pilots to conduct a disciplined visual scan in
order to effectively spot potential conflicts. When two aircraft are
on a collision course, there is little to no relative movement of the
other aircraft on their respective windscreens. Therefore, pilots
must constantly scan the airspace around their aircraft in a
disciplined, methodical manner in order to effectively “see and
avoid.”
Visual lookout is a priority task for all flight members,
flight leads as well as wingmen.
In this mishap, Ninja 2 failed to effectively accomplish his visual
lookout responsibilities. His attention, just prior to the mishap,
was on maintaining formation position and looking out for birds in the
vicinity of his aircraft. When the collision occurred, he was focused
on the flight lead’s aircraft at his right one- to two-o’clock
position and anticipating Ninja 1’s left turn onto the low-level
route. Just prior to the midair collision, Ninja 2 saw a white flash
at his ten- to eleven-o’clock position. He thought he had hit a bird.
Nor did Ninja 1’s own visual lookout provide his wingman
effective mutual support in flight path deconfliction. As the flight
leveled off at 2,000 ft MSL, Ninja 1 was focused on navigation tasks,
and his visual scan was towards the ground, looking for Manatee Dam.
Just prior to impact, Ninja 1 looked over his left shoulder to check
his wingman’s position and saw Cessna 829 for the first time. There
was insufficient time for him to warn his wingman before the two
aircraft collided.
There is conflicting testimony as to whether Cessna 829 saw
the impending midair collision at the last moment and attempted to
maneuver his aircraft or whether his aircraft was in wings level
flight at the time of impact. In either case, Cessna 829 failed to
“see and avoid” Ninja 2 in sufficient time to avoid the midair
collision.
Failure to Issue a Warning: ATC directives state that the
primary purpose of the ATC system is to prevent a collision between
aircraft operating in the system. Additionally, controllers are to
give first priority to separating aircraft and issuing safety alerts,
as required.
Approximately 30 seconds prior to the midair collision, Tampa
Approach’s ATC radar computer system recorded a series of Mode C
Intruder Alert warnings that lasted for 19 seconds. Air Traffic
Control is supposed to issue a safety alert to aircraft under their
control if they are aware of an aircraft that is not under their
control at an altitude that, in the controller’s judgment, places both
aircraft in close proximity to each other. At the time of the
Intruder Alerts, Cessna 829 was under the control of Tampa Approach
while Ninja flight was flying VFR. Ninja 1 had a 1200 Mode III squawk
in his transponder. All three aircraft were at approximately 2,000 ft
MSL.
In the event of a safety alert, Air Traffic Control is
supposed to offer the pilot an alternate course of action when
feasible (e.g., “Traffic alert, advise you turn right heading zero
niner zero or climb to eight thousand feet”). The only transmission
Tampa Approach gave Cessna 829 was a normal traffic advisory at the
approximate time of the midair collision. This advisory was actually
on Ninja 1, who had already passed in front of Cessna 829. Ninja 2
was still behind his flight lead in a fighting wing position to the
left and approximately 3000-6000 ft in trail. The accident board was
unable to determine why no safety alert was issued to Cessna 829. The
controllers on duty at the time of the mishap declined our request for
interviews.
The failure of Tampa Approach to issue a safety alert to
Cessna 829 was also a cause of this mishap. If Tampa Approach had
issued a safety alert to Cessna 829 when the first Conflict Alerts
began, it is likely the pilot would have had sufficient time to
maneuver his aircraft and avoid Ninja 2.
4. CONCLUSION.
Technological advances, improvements in training, and
refinements in the airspace structure over the past several decades
have served to improve both civilian and military aviation safety
records. Redundancy is designed into the aviation “system,” with
overlapping responsibilities between pilots and air traffic
controllers. On occasion, though, equipment will malfunction and
competent professionals will make mistakes. These are normally
isolated events that are quickly rectified with little or no impact on
the safe conduct of flying operations. There are, however, times when
several such events occur in close sequence to each other and in a
synergistic way to produce tragic results--this mishap is one such
case.
The critical chain of events began when Ninja 1 elected to
cancel IFR and ended three and a half minutes later with a midair
collision between Ninja 2 and Cessna 829, resulting in the death of
the Cessna pilot and the total destruction of two aircraft. The
evidence shows that a combination of avionics anomalies, procedural
errors, and individual mistakes, both on the ground and in the air,
led to this midair collision.
Media interest in this mishap was high. One of the issues
raised in the press concerned the speed of the fighters. Ninja flight
did, in fact, accelerate to 441 KCAS to start their G-awareness
exercise in Class B airspace and then slowly decelerated to
approximately 350 KCAS just prior to the mishap. These are speeds
normally used by fighter aircraft to safely perform tactical
maneuvering, but not appropriate for controlled airspace around busy
airports. Ninja flight’s mistake was in transitioning to the tactical
portion of their flight too early, unaware that they were in
controlled airspace. That being said, it is my opinion that speed was
not a factor in this mishap. Based on their closure rate of
approximately 480 knots, if neither pilot had seen the other until
they were only 1 NM apart, they would have still had seven seconds to
react and maneuver their aircraft enough to avoid the collision.
Both F-16 pilots were experienced aviators and qualified
four-ship flight leads with proven track records of competency in the
air. There is no evidence to suggest either of them acted with a
deliberate disregard for the safety of others. The mishap sortie
began to unravel when Ninja 1 lost situational awareness and descended
into Tampa Class B airspace without clearance. Although training and
experience minimize one’s susceptibility to losing SA, it does not
make you immune. There is an aviator expression, “you never know
you’ve lost your SA until you get it back.” In this case, Ninja
flight did not realize they had lost SA, and the other substantially
contributing factors quickly led to this midair collision before they
could they could get it back.
18 January 2001 ROBIN E. SCOTT, Brigadier
General, USAF
President, Accident
Investigation Board
Dr. Anthony J. Lomenzo
Larry Dighera wrote:
> Below is a (poor) copy of the Air Force Final Report on F-16/Cessna
> 172 Midair Collision November 16, 2000. I received the report in MS
> Word format. If anyone would like a copy, just e-mail your request.
>
> =====================================================================
>
REFER TO THE INITIATING THREAD FOR THE GOVERNMENT REPORT ON THE
"MISHAP"....
Various readers who may suffer instances of rapid rise in BP [Blood
Pressure] are warned forthwith 'before' they read the cited government
report. It's a veritable classic of government mish-mosh at its finest!
But then, YOU be the judge!
Comment after the read :
My first thought in reading the thing was a retro to the old aircraft
carrier back in time flick and that very calm ship's doc telling the
senator that he and the lady [and Charlie the dog] "don't look any worse
for wear from their "MISHAP" and then the senator angrily says that having
a boat shot out from under you and 3 people killed is hardly a "mishap."
But that was Hollywood. This is the real thing.
It is astounding to me that the Cessna pilot who knows from nothing that a
fighter jet is IN FACT violating both speed restrictions [440 KCAS [!]
and then subsequent 356 KCAS (Knots Calibrated Air Speed] at the time of
the G-force 'exercise' WITHIN Class B airspace!] , violating airspace
itself [Both B and C---Tampa registered the jet as a "Mode C Intruder"--in
effect, the didn't know who the hell it was!!] without prior ATC approval
and knowledge [See the report! 'Ninja 1'--the F-16-- descended into Class
B airspace...TAMPA...without clearance from Tampa approach! ] as well as
FAA mandated communication requirements [NO contact with Tampa ATC] and
then the report has the audacity to say, among other things, that if the
CESSNA PILOT had practiced 'see and avoid' techniques, well, HE could
have avoided the whole "mishap"! Wot' the ..... .!
Here's a guy [Cessna pilot] within controlled airspace doing, what, Cessna
specs and speeds while following Class B and C dictums as 'any' pilot is
mandated to do and suddenly jet fighterS enter the airspace on a military
exercise at speeds close to 4 times the Cessna during the G-force
'exercises' and in direct contravention to the FARS in re mandated speed
restrictions below 10 thou', NO contact with Tampa ATC control [In B or C
airspace] to even be there to begin with and the "Cessna" pilot "fails"
to "see and avoid" ? See WHAT, for crissakes? A blink of an eye just
moments before impact? When is the last time YOU saw or, better yet, even
'expected' an F-16 fighter to zoom by your wing as if you were standing
still .... in Class B CONTROLLED airspace?
This, mind you, and again, in 'controlled' airspace with the FARS being
definitively clear as to what can and what can NOT occur in controlled
airspace and speed restrictions under 10 thousand feet? In one area, the
'innuendo' of the report is that the fault lies with Tampa Approach! In
effect, they saw the fighter 'blip' and should have said something to the
Cessna pilot although the report was rather light on comment as to the
distance a Cessna can travel who is within the regs versus some fighter
jet doing, among other things inclusive of the housing complex serving as
the simulated 'target', G-force exercises within controlled airspace.
Although the report does say that 'Ninja 1' in the F-16 lost SA
[Situational Awareness], miscalculated navigation and cited other multiple
violationS [*although the wordage tap dancing is painfully noted], hey,
bottom line---I do NOT see the Cessna pilot being in any way culpable
whatsoever on some sort of government 'finding' that the Cessna pilot must
apparently 'share' some of the 'blame' [?!] in re the Cessna pilot's
'failure' to 'see and avoid.' Again I say, see WHAT , for crissakes? And
again, some blink of an eye 'see and avoid' at such horrendously
mismatched speeds just before final impact? What do you think? Do you
really share the government's view that the Cessna pilot also must 'share'
[?] in the fatal 'mishap' ???
Doc Tony
DFWJeff
accelerate that speck to 480 knots.......
Hogwash!
"Larry Dighera" <LDig...@socal.rr.com> wrote in message
news:TEeG6.291$EP.2...@typhoon.we.rr.com...
RT
> 172 Midair Collision November 16, 2000
Thanks for the post.
A typical accident - a chain of events/mistakes... <sigh>
Razor
part I have trouble with is the degree to which they point at the
controllers for failing to issue an alert, and the claims that the 172
pilot failed to see and avoid. 30 seconds is not a lot of time to react.
By the time the controller found the alert on his screen, and figured out
which aircraft were involved, he could easily have lost 5 to 10 seconds of
that time. Then he had to break-in on his frequency to issue the alert.
I'm sure his task was further complicated by trying to decide if the F-16
was talking to anybody (which it wasn't). Likewise, by the time the
Cessna pilot saw the camo-gray colored F-16 rushing toward him, he would
have had very little time to react. Also, changing the vector of a 172 is
harder than changing the vector of an F16 (with higher G capability).
In my opinion, the number one cause of this collision was the decision of
the F-16 flight lead to cancel IFR and run silent. He could have gotten
back to Miami Center and asked for clarification of the approach control
frequency. Most of us have had to do that at one time or another. Being
in contact with a controller who had them on radar would have allowed them
to maintain separation from traffic and to avoid violating the airspace
boundaries. Not having a chart with the airspace boundaries in their
possession seems highly irresponsible on the part of the F-16 pilots. If
he was lost, that was even more reason to be on the radio asking for help.
Making excuses about failure to see and avoid, INS innacuracies, and
controller response times are pretty lame. Yes, they were contributing
factors, but not the primary cause. The real problem was that the F-16
lead pilot got lost, shut up, and started wallowing around the sky looking
for ground references to help him get back on course while relying too
much on his moving map.
Larry Dighera
>
>Larry Dighera <LDig...@socal.rr.com> wrote in message
>news:TEeG6.291$EP.2...@typhoon.we.rr.com...
>> Below is a (poor) copy of the Air Force Final Report on F-16/Cessna
>> 172 Midair Collision November 16, 2000
>
>Thanks for the post.
You're welcome.
>A typical accident - a chain of events/mistakes... <sigh>
True. But, it could have been prevented if the high-speed military
fighters were _required_ to employ radar for collision avoidance.
Seems reasonable to me in this technologically advanced 12st century;
see-and-avoid at 480 knots is obviously not reasonable.
What bothers me is that Lockheed published the minimum descent speed
below 10,000 feet for the F-16 is 300 knots. I'd really like to know
the engineering behind that entry in the flight manual.
But, what bothers me most is the fact that the Flight Lead was at ~400
knots at 2,000 feet, and the Air Force investigation failed to find
the fact that the F-16s were operating 100 knots (or 33%) over the
published minimum descent speed to even qualify as a _factor_ in this
"mishap" [sic], let alone as a violation of FAR 91.117(d):
(d) If the minimum safe airspeed for any particular operation is
greater than the maximum speed prescribed in this section, the
aircraft may be operated at that minimum speed.
Notice that 91.117(d) doesn't say 133% faster than the minimum speed;
is _AT_ "that minimum speed."
The Air Force investigation also failed to find the Flight Lead,
Lieutenant Colonel James Parker's wanton disregard for FARs
constituted reckless operation.
Hopefully, the NTSB investigation will be more impartial.
Graham Shevlin
2001 American Science Fiction-disguised-as-truth award (HINT: The most
famous past winner of this award was the Warren Commission Report).
This document is a pile of poorly-argued cack riddled with
doublespeak. Although I don't as a rule approve of letting lawyers
near the scene of an aircrash, part of me hopes that the relatives of
the Cessna pilot engage a sharp lawyer and take the government to the
cleaners...
RT
Even the AF report, which seems fairly thorough, sort of lays it at the feet
of the hotdoggers.
The major question is, will the gummint do anything about it? If not,
youse blokes join Indonesia (eg) as a country where the military can do as
they like.
Your problem - sort it.
HLAviation
>really share the government's view that the Cessna pilot also must 'share'
>[?] in the fatal 'mishap' ???
>
>Doc Tony
Yes, under the rules of VFR it is every pilots duty to see and avoid. That
said, I believe his "share" of the blame is a slight fraction of a share, even
less than ATCs. On a 10 share scale, my assignment would be, 6 shares flight
lead, 3 shares ATC, 0.9 shares wingman, 0.1 Cessna pilot.
One comment I found interesting was: "The loss of the F-16 was valued at
$24,592,070.94" The .94 shows the level of bean counting in todays military.
HLAviation
>fighters were _required_ to employ radar for collision avoidance.
>Seems reasonable to me in this technologically advanced 12st century;
Not only that, but why doesn't the INS backup/correct on a GPS signal?
>What bothers me is that Lockheed published the minimum descent speed
>below 10,000 feet for the F-16 is 300 knots. I'd really like to know
>the engineering behind that entry in the flight manual.
>
Probably has something to do with stall speed at elevated Gs. F-16s manuver at
9Gs pretty regularly.
>But, what bothers me most is the fact that the Flight Lead was at ~400
>knots at 2,000 feet, and the Air Force investigation failed to find
>the fact that the F-16s were operating 100 knots (or 33%) over the
>published minimum descent speed to even qualify as a _factor_ in this
>"mishap" [sic],
I found that in the report when I read it.
>
>The Air Force investigation also failed to find the Flight Lead,
>Lieutenant Colonel James Parker's wanton disregard for FARs
>constituted reckless operation.
>
I don't think this qualifies for "Wanton Disregard".
HLAviation
>part I have trouble with is the degree to which they point at the
>controllers for failing to issue an alert, and the claims that the 172
>pilot failed to see and avoid. 30 seconds is not a lot of time to react.
>By the time the controller found the alert on his screen, and figured out
>which aircraft were involved, he could easily have lost 5 to 10 seconds of
>that time. Then he had to break-in on his frequency to issue the alert.
>I'm sure his task was further complicated by trying to decide if the F-16
>was talking to anybody (which it wasn't). Likewise, by the time the
>Cessna pilot saw the camo-gray colored F-16 rushing toward him, he would
>have had very little time to react. Also, changing the vector of a 172 is
>harder than changing the vector of an F16 (with higher G capability).
>
Ok, so the pilot gets a 20 second notice to expedite a decent, by the time he
gets the message and processes it and shoves the yoke forward we're down to 15
seconds, if he limits the decent to 2000 fpm that puts 500 ft between him and
the F-16. When you need to seperate yourself from another plane quickly, shove
it forward, don't try to turn. Also from the description of of the movement
from 10-11 o-clock, that tells me that the Cessna approached the F-16's from
the left (port, redlight) side, which would also put the see and avoid burden
on the Cessna. He is not totally without fault here.
Richard Tilton
Larry Dighera wrote:
<Much appreciated report snipped ...>
> That being said, it is my opinion that speed was
> not a factor in this mishap. Based on their closure rate of
> approximately 480 knots, if neither pilot had seen the other until
> they were only 1 NM apart, they would have still had seven seconds to
> react and maneuver their aircraft enough to avoid the collision.
>
> 18 January 2001 ROBIN E. SCOTT, Brigadier
> General, USAF
> President, Accident
> Investigation Board
Perhaps General Scott, and the other members of the Accident Investigation
Board should have conducted a carefully planned exercise in which they are
placed in a cessna, flying in class B airspace and have a pair of F-16s
intercept at 350 knots and see if they successfully see-and-avoid with a 7
second heads-up over the radio. I bet even if they knew they would be
intercepted, but didn't know which heading the F-16s would be flying at
intercept, they would still need a diaper change after the intercept, and
the report would be totally different.
I fly out of Hicks (T67), which is very close to Carswell (NFW), and I
have not had any problem seeing the C-130s or even the B-1s when they were
here last year, but the F-16s and F/A-18s are very difficult to see, even
when they are in the pattern. This doesn't prove anything, of course, but
this accident has really upset me.
Just venting,
Richard
Richard Tilton
DFWJeff wrote:
> Have YOU ever seen an F-16 at one mile? Nothing but a speck! Now
> accelerate that speck to 480 knots.......
>
>
Especially if it is on a collision course!!!
Dean Wilkinson
moment of impact. That was no help at all.
I was simply stating that the BEST case was that he saw the F-16 at 1 mile (not
easy to do, F-16s are hard to see) and had 7.5 seconds to react. Even pushing the
yoke forward would not have made a big difference (he might have been able to lose
8 feet of altitude in that amount of time at 500 fpm average).
Steven P. McNicoll
"Richard Tilton" <rwti...@swbell.net> wrote in message
news:3AEB943B...@swbell.net...
>
> Perhaps General Scott, and the other members of the Accident Investigation
> Board should have conducted a carefully planned exercise in which they are
> placed in a cessna, flying in class B airspace and have a pair of F-16s
> intercept at 350 knots and see if they successfully see-and-avoid with a 7
> second heads-up over the radio.
>
Why in Class B airspace?
Ash Wyllie
>>True. But, it could have been prevented if the high-speed military
>>fighters were _required_ to employ radar for collision avoidance.
>>Seems reasonable to me in this technologically advanced 12st century;
>Not only that, but why doesn't the INS backup/correct on a GPS signal?
Because CCongress hasn't budgeted any money to do so.
-ash
for assistance dial MYCROFTXXX
HLAviation
>at the
>moment of impact. That was no help at all.
The issue was that the ATC guys had a signal a full 30 seconds before impact,
figure 10 seconds (a long time really) for them to see the situation and
advise.
>I was simply stating that the BEST case was that he saw the F-16 at 1 mile
>(not
>easy to do, F-16s are hard to see) and had 7.5 seconds to react. Even
>pushing the
>yoke forward would not have made a big difference (he might have been able to
>lose
>8 feet of altitude in that amount of time at 500 fpm average).
>
8 ft would have made it a near(very near) miss rather than a collision. Shove
the yoke forward and you drop faster than 500 fpm nearly instantly. I
routinely drop 200 ft in 4-5 seconds when doing ag work.
Dr. Anthony J. Lomenzo
HLAviation wrote:
> >What do you think? Do you
> >really share the government's view that the Cessna pilot also must 'share'
> >[?] in the fatal 'mishap' ???
> >
> >Doc Tony
>
> Yes, under the rules of VFR it is every pilots duty to see and avoid. That
> said, I believe his "share" of the blame is a slight fraction of a share, even
> less than ATCs. On a 10 share scale, my assignment would be, 6 shares flight
> lead, 3 shares ATC, 0.9 shares wingman, 0.1 Cessna pilot.
>
Well, IF the USAF "Mode C Intruder" [on Tampa scopes] A/C had been some lumbering
albeit SAME SPEED prop job, I 'might' consider your 0.1 assessment under the old
see and be seen axiom ['Uncle' terming it 'see and avoid' ] BUT an F-16 fighter
clearly over the limit and not even a warning of the 'intruder' [sic!] to other
uses of Class B airspace --and-- zipping along the tune of 446 KAIS [or 'KCAS' as
Uncle says it] ....nahhh.
>
> One comment I found interesting was: "The loss of the F-16 was valued at
> $24,592,070.94" The .94 shows the level of bean counting in todays military.
Indeed, HL....shades of that DoD [Department of Defense] and GAO [Government
Accounting Office] 'finding' {!} some years back when they 'discovered' and duly
informed the taxpaying public of those $278.00 HAMMERS! But then, retro one of
the moon walks, remember?....and that tripod video camera refusing to budge
whereupon, in full view of the watching world, the astronaut [I forget which one
it was] took an on-board hammer to the thing...[the $278 one per chance? ;-)..]
but damn if the video camera began to function forthwith...at least for awhile!
;-)
Doc Tony
Dean Wilkinson
judge where something that fast is going to pass you (above or below). Diving is
the right thing to do, but still might not help. The F-16 pilot was the one who
could have done the most to avoid the collision.
Richard Tilton
F-16s would be very difficult to spot, especially with the element of surprise
on their side, and I believe the report would have placed more responsibility on
the F-16 drivers.
Richard
Steven P. McNicoll
>
> You're right, it could be done anywhere. The point is that the
intercepting
> F-16s would be very difficult to spot, especially with the element of
surprise
> on their side, and I believe the report would have placed more
responsibility on
> the F-16 drivers.
>
Agreed.
HLAviation
>lumbering
>albeit SAME SPEED prop job, I 'might' consider your 0.1 assessment under the
>old
>see and be seen axiom ['Uncle' terming it 'see and avoid' ] BUT an F-16
>fighter
>clearly over the limit and not even a warning of the 'intruder' [sic!] to
>other
>uses of Class B airspace --and-- zipping along the tune of 446 KAIS [or
>'KCAS' as
>Uncle says it] ....nahhh.
>
I don't buy that reasoning. Where I fly pipeline and spray fields, I deal with
low level T-38s, F-16s, B-1Bs and occassional F-15s all flying at low
altitudes. I have seen and avoided all of these as they fly at HIGH speed
through their MOAs and such where they don't have their 300 kt restriction. It
IS possible to spot an F-16 clipping along at you before he hits you. If you
couldn't I would have died years ago. I often don't have a radio, or am not on
any frequency, as I am operating below radar coverage much of the time.
Anything moving catches the eye. See and avoid is everyones responsability
under VFR. The problem here was compound fixation, The Flight lead was fixated
on finding the dam, the wing man was fixated on finding the birds and watching
for his leads turn clue, and I bet the Cessna was fixated on navigation in the
class B (or did it actually happen in class C) relying on ATC for seperation.
If you let somebody hit you, you have to shoulder at least a fraction of the
blame. Even when I'm 5' off the ground on a spray run, I'm glancing up and
around for anything that will possibly interfere with my turn, same when flying
pipeline. You should have a VFR scan thats just as disciplined as your
instrument scan. One thing that was drilled into me early on in flying, was
"Keep your head on a swivel." That methodology has always served me well.
Complacency on all parts is what caused this accident in my opinion.
Larry Dighera
>Complacency on all parts is what caused this accident in my opinion.
It was incompetence, carelessness, and a reckless disregard for
civilian life that caused this grim "mishap" [sic]. The Flight Lead,
"Ninja 1" Lieutenant Colonel James Parker, should be court martialed
and jailed like any felon. Here is a partial list of the fatal errors
Parker committed on this flight:
1. Erroneously thought he was given frequency 362.35 by
Miami Center and attempted contact there.
2. Failure to obtain ATC clearance with Tampa Approach for
entry into the Tampa Class B airspace.
3. Failure to establish two-way radio communications with
Tampa Approach prior to entering Sarasota Class C airspace.
4. Failure to adequately deconflict flight path (Air Force
training manuals emphasize that flight path deconfliction is a
critical task, one that can never be ignored without
catastrophic consequences.)
5. Lost situational awareness.
6. Failed to recognize a significant 9-11 nautical mile
position error in his aircraft's Inertial Navigation System.
7. Did not crosscheck the INS accuracy with other systems.
8. The system showed a navigational system accuracy of
'medium', which eventually degraded to 'low' prior to the
collision. Ninja 1 failed to notice this degradation in
system accuracy.
9. Failed to recognize a cursor slew bias in his ground
attack steering.
10. Unintentional cursor slew bias by the pilot.
11. Mis-prioritization of tasks.
And, these are only the faults found and _reported_ by the Air Force.
But, the true core cause of this "mishap" [sic] is the military's
high-speed operation below 10,000 feet. That MUST CHANGE!
Larry Dighera
>The major question is, will the gummint do anything about it? If not,
>youse blokes join Indonesia (eg) as a country where the military can do as
>they like.
>
>Your problem - sort it.
Exactly. It is time we civil pilots did "sort it." Mr. Jacques
Oliver shall not have given his life in vain.
It's time we drafted an initiative requiring the military to take
_full_ _responsibility_ for the hazards caused by its high-speed
low-level operations, and military flights should be _required_ to
employ the radar the citizens of this country have paid to install in
their aircraft to assist them in seeing and avoiding other aircraft.
Larry Dighera
>>But, what bothers me most is the fact that the Flight Lead was at ~400
>>knots at 2,000 feet, and the Air Force investigation failed to find
>>the fact that the F-16s were operating 100 knots (or 33%) over the
>>published minimum descent speed to even qualify as a _factor_ in this
>>"mishap" [sic],
>
>I found that in the report when I read it.
Found what?
FAR 91.117 (d) states:
(d) If the minimum safe airspeed for any particular operation
is greater than the maximum speed prescribed in this section,
the aircraft may be operated at that minimum speed.
And, the AF report states:
(2) According to Air Force T.O. 1F-16CG-1 Flight Manual,
page 6-3, the F-16CG should be operated at a minimum airspeed
of 300 KIAS during normal cruise operations below 10,000 ft.
So, a thinking individual might construe this to mean that F-16s
should be operated at ~300 KIAS to comply with FAR 91.117.
But, the Air Force found:
The closure rate of Cessna 829 and Ninja 1 based on
radar-measured conflict alert data just prior to the collision
was approximately 480 KTAS.
That places the F-16s near ~400 knots (and 2,000 feet) at the time of
the collision. If exceeding the speed mandated in FAR 91.117 by 33%
is not adequate to qualify as a factor in this fatal "mishap," how
fast must one exceed the speeds mandated in the FARs to have the Air
Force deem it a factor?
>>The Air Force investigation also failed to find the Flight Lead,
>>Lieutenant Colonel James Parker's wanton disregard for FARs
>>constituted reckless operation.
>
>I don't think this qualifies for "Wanton Disregard".
Huh? Parker was presumably aware of the speed and altitude of his
aircraft at the time of the "mishap". If Parker's decision to
illegally operate his flight in violation of FAR 91.117 fails to
constitute malice in your opinion, perhaps Parker's decision to wander
around congested airspace at ~400 knots while lost, or failure to
crosscheck the INS accuracy, or failure to notice a navigational
system accuracy of 'low', or failure to deconflict their flight path,
or loss of situational awareness, or ..., might qualify as "Wanton
Disregard". If none of these qualify in your mind, surely, the sum of
Parkers fatal decisions qualify as "Wanton Disregard".
Larry Dighera
<wdcjN...@qwest.net> wrote:
>The F-16 pilot was the one who
>could have done the most to avoid the collision.
Oh, you mean like using the radar installed in his $24,592,070.94
fighter? Nah, the military isn't responsible for the hazards they
cause. They blame the pilot they killed and ATC for the lethal
"mishap" [sic]. The military is above the law; they can commandeer
>50% of the nation's airspace, and fly with a reckless disregard for
civil laws and the lives of the civilians they've sworn to protect.
I say, if the military want's to fly so fast as to effectively become
invisible, they should take FULL RESPONSIBILITY for the hazard they
create to civil aviation. Anything less could be construed as the FAA
shirking its duty to keep the skies safe.
al...@mindhelicalwire.com
>On 30 Apr 2001 05:35:24 GMT, hlavi...@aol.com (HLAviation) wrote:
>
>>Complacency on all parts is what caused this accident in my opinion.
>
>It was incompetence, carelessness, and a reckless disregard for
>civilian life that caused this grim "mishap" [sic]. The Flight Lead,
>"Ninja 1" Lieutenant Colonel James Parker, should be court martialed
probably
>and jailed
or at least drummed out of the service, if the facts are found to be
as you stated
>like any felon.
Well, I don't know about that. Is incompetence or gross negligence a
felony?
--
Alex
Make the obvious change in the return address to reply by email.
Larry Dighera
>Is incompetence or gross negligence a felony?
If your negligence causes a homicide, it is at least Manslaughter
which is a felony.
Surely Lieutenant Colonel James Parker was aware that he was at ~380
knots and 2,000 feet, so he was aware that he was in violation of FAR
91.117, and deliberately chose to continue to operate his flight at
that speed, and endanger the safety other flights in the area, instead
of slowing down.
Steven P. McNicoll
"HLAviation" <hlavi...@aol.com> wrote in message
news:20010430013524...@ng-ms1.aol.com...
>
> I don't buy that reasoning. Where I fly pipeline and spray fields, I
> deal with low level T-38s, F-16s, B-1Bs and occassional F-15s all
> flying at low altitudes. I have seen and avoided all of these as they
> fly at HIGH speed through their MOAs and such where they don't
> have their 300 kt restriction. It IS possible to spot an F-16 clipping
> along at you before he hits you. If you couldn't I would have died
> years ago. I often don't have a radio, or am not on any frequency,
> as I am operating below radar coverage much of the time. Anything
> moving catches the eye. See and avoid is everyones responsability
> under VFR.
>
Yes, but when you're operating in a hot MOA or crossing an active MTR you
expect to encounter high speed military aircraft. The Cessna wasn't in
either of those and quite reasonably didn't expect to encounter any such
traffic.
>
> The problem here was compound fixation, The Flight lead was fixated
> on finding the dam, the wing man was fixated on finding the birds and
> watching for his leads turn clue, and I bet the Cessna was fixated on
> navigation in the class B (or did it actually happen in class C) relying
> on ATC for seperation.
>
It happened in the Sarasota Class C airspace. Even if the F-16s were
communicating with ATC, as they should have been, both parties were VFR and
ATC doesn't separate VFR traffic in Class C airspace.
>
> If you let somebody hit you, you have to shoulder at least a fraction of
> the blame.
>
Agreed, but the key word here is "fraction". The Air Force report suggests
most of the blame goes to ATC and the Cessna pilot.