Air Force One Had to Intercept Some Inadvertent Flyers / How?

"Dave Stadt" wrote in message
et...

"Chris Schmelzer" wrote in message
...
In article ,
Larry Dighera wrote:

On Fri, 10 Feb 2006 21:13:11 -0500, Ronald Gardner
wrote in ::

I suspect gear and flaps down speed of a F15 to be around 110 or 120
knots.

Unfortunately, that doesn't prevent F-15s from endangering the public
by exceeding the 250 knot speed limit below 10,000'.


Umm, military has never been restricted to the 250knot speed. You really
think they are 'endangering the public' when they do this? Do you think
they don't know where YOUR aircraft is long before you see them?

--
Chris Schmelzer, MD

The guy in Florida in a 172 that got hit by a military hot shot that broke
every rule in the book would agree that they are 'endangering the public'
except he is dead. To add insult to murder he was given partial blame for
not seeing and avoiding a military fighter traveling at well over 250
knots that came up on him from behind.


That was a ****ty deal in deed. I can't speak for what happened in that
case, but I know for a fact that this accident is a case study that every
new pilot must study and several new regulations were put into place after
this to prevent it from happening again.

It is definitely not the norm for how the USAF conducts daily training
missions.

"John Doe" wrote:
It is definitely not the norm for how the USAF conducts daily training
missions.

The Marines have had their problems too...
http://www.cnn.com/US/9902/26/marines.cable.car.02/

And the final verdict didn't go over well...
http://news.bbc.co.uk/1/hi/world/americas/290850.stm

Which final verdict? Despite, the Courts Martial finding that the
accident wasn't the result of criminal acts by the pilots, four careers
went down the toilet. The CO and ops officer had already been relieved.
The two pilots left the Corps.

"Jim Logajan" wrote in message
...
"John Doe" wrote:
It is definitely not the norm for how the USAF conducts daily
training
missions.

The Marines have had their problems too...
http://www.cnn.com/US/9902/26/marines.cable.car.02/

And the final verdict didn't go over well...
http://news.bbc.co.uk/1/hi/world/americas/290850.stm

"sfb" wrote in message news:C2uIf.6041$3V4.3661@trnddc06...
Which final verdict? Despite, the Courts Martial finding that the accident
wasn't the result of criminal acts by the pilots, four careers went down
the toilet. The CO and ops officer had already been relieved. The two
pilots left the Corps.

A case of the fox watching the henhouse. A lot more that 4 careers should
have gone down the toilet. Far as I know murdering 20 people typically
requires considerable jail time.

On Tue, 14 Feb 2006 23:34:02 -0000, Jim Logajan
wrote in ::

"John Doe" wrote:
It is definitely not the norm for how the USAF conducts daily training
missions.

The Marines have had their problems too...
http://www.cnn.com/US/9902/26/marines.cable.car.02/



http://www.s-t.com/daily/03-99/03-30-99/a06wn039.htm
Navigator admits conspiracy, obstruction
By Estes Thompson, Associated Press writer

CAMP LEJEUNE, N.C. -- A Marine navigator pleaded guilty yesterday
to obstruction and conspiracy charges for destroying a videotape
made during the flight of the jet that clipped a ski gondola cable
in Italy.

Capt. Joseph Schweitzer, 31, admitted throwing the tape into a
fire two days after his EA-6B Prowler radar-jamming jet struck the
cable, killing 20 people in February 1998.

"It was a stupid thing to do and I regret that," Schweitzer told
the military judge, Col. Alvin Keller. "It was a rash decision."

The charges carry a maximum of 10 years in prison. A military
panel will be chosen as early as today for a sentencing hearing.
Keller said the victims' relatives can testify about how the
tape's disappearance affected their quest to determine what
happened in the crash.

"Joe is the type of guy who wants to stand up and take
responsibility," said Dave Beck, Schweitzer's attorney. "There
were some bad mistakes made after the accident and they made bad
decisions."

The jet's pilot, Capt. Richard Ashby, 31, of Mission Viejo,
Calif., was acquitted by a military jury at Camp Lejeune of
manslaughter and other charges on March 4, outraging Italian
authorities.

Manslaughter counts against Schweitzer were dismissed after the
acquittal. But Schweitzer and Ashby both faced the obstruction of
justice and conspiracy charges because of the disappearance of the
videotape.

Ashby testified during his trial that Schweitzer filmed the early
part of the flight. After they landed, he gave the tape to
Schweitzer and never saw it again, Ashby testified.

Schweitzer said yesterday that he and Ashby never watched the
videotape. He said one of the reasons he wanted to destroy the
tape was that, at one point during the flight, he turned the
camera on his own face and smiled.

"The video had nothing to do with the mishap," Schweitzer said.
"It wasn't on in the valley. I didn't want it to be an issue."

Neither prosecutors nor defense attorneys would say Monday
whether yesterday will be called to testify at Ashby's
court-martial next month.

Schweitzer's plea was welcomed yesterday by the president of the
Italian province where the accident occurred.

"I appreciate (Capt. Joseph) Schweitzer's honesty," said Lorenzo
Dellai, president of the Province of Trento. "It is a contribution
to clearness, which has always been lacking in this sad story."

John Arthur Eaves Sr., an attorney representing the families of
the German victims in the accident, said Schweitzer's plea raises
more questions.

"I certainly wish we had the desire of Captain Schweitzer to tell
the truth about this destruction of evidence prior to the trial of
Captain Ashby," Eaves said. "This is a tragedy that becomes more
confusing as the evidence is destroyed."


And the final verdict didn't go over well...
http://news.bbc.co.uk/1/hi/world/americas/290850.stm


A military jury in the US cleared Marine Captain Richard Ashby of
all charges relating to the deaths of 20 people killed when his
jet hit sliced through ski-lift cables in the town of Cavalese.

He was found not guilt of involuntary manslaughter and of the
lesser charges of destruction of property and dereliction of duty
over the incident, which happened at the ski resort of Mount
Cermis in February 1998.


More military justice? :-)

On Tue, 14 Feb 2006 17:28:36 -0500, "John Doe"
wrote in yQsIf.30327$Dh.14493@dukeread04::

I know for a fact that this accident is a case study that every
new pilot must study and several new regulations were put into place after
this to prevent it from happening again.

I would be interested to know specifically which "new regulations"
were put into effect as a result of the November 16, 2000 MAC. Are
you able to provide them?

It is definitely not the norm for how the USAF conducts daily training
missions.

Below are the military and NTSB reports on the November 16, 2000 MAC.
Perhaps you can tell me why flight lead Parker was not subjected to a
medical evaluation until 24 November 2000.

-----------------------------------------------------------------------

MIA01FA028A
HISTORY OF FLIGHT

On November 16, 2000, at 1548 eastern standard time, a U.S. Air Force
F-16CG, operated by the 347th Wing, Air Combat Command, collided in
mid air with a Cessna 172, N73829, near Bradenton, Florida. The F-16,
based at Moody Air Force Base (AFB), Valdosta, Georgia, was on a
low-altitude training mission. The Cessna 172, registered to Crystal
Aero Group, was operating as a 14 CFR Part 91 personal flight. The
airline transport (ATP)-rated Cessna pilot was killed. The F-16 pilot,
who held a commercial pilot's certificate, ejected from the airplane
and sustained minor injuries. Visual meteorological conditions
prevailed at the time of the accident. The accident F-16 was part of a
flight of two F-16s. A composite military instrument flight rules
(IFR)/visual flight rules (VFR) flight plan was filed. The two F-16s
departed Moody AFB at 1513. The Cessna 172 departed Sarasota Bradenton
International Airport (SRQ) Sarasota, Florida, about 1541. No flight
plan was filed.

The accident F-16 pilot, who was using call sign Ninja 2, stated that
he was maintaining visual formation with his flight lead, call sign
Ninja 1, when he saw a blur "like a sheet of white" appear in front of
him. He stated that the airplane shuddered violently, and part of the
canopy on the left side was broken away. The accident pilot stated
that wind, smoke, and a strong electrical smell filled the cockpit. He
stated that he called his flight lead several times, but could not
hear a reply. Because the airplane was still controllable, he decided
to try to reach MacDill AFB, and he began a right turn in that
direction. He stated that his primary flight instruments were
shattered and that he could not see them. He stated that the engine
began to spool down and that he realized that he would not be able to
make the airport. He stated that he turned the airplane left toward a
wooded area away from a residential area and attempted an engine
restart, which was not successful. When the airplane cleared the
residential area, it started an uncommanded left roll. When the
airplane went past a 90-degree bank angle, the pilot stated that he
decided to eject. During his parachute descent, he observed the
airplane "pancake" into the ground inverted and explode.

The flight lead stated that the two F-16s were assigned a block
altitude of between 25,000 feet and 26,000 feet en route to the entry
point of visual military training route (MRT) VR-1098. As the flight
approached the SRQ area, Miami Air Route Traffic Control Center
(ARTCC) cleared the F-16s to descend to 13,000 feet. At 1543:39, the
Miami ARTCC controller instructed the flight lead to contact Tampa
Terminal Radar Approach Control (TRACON) controllers. The flight lead
was not successful (because he was given an incorrect frequency), and
he reestablished contact with Miami ARTCC and canceled IFR. Miami
ARTCC advised him of traffic at 10,000 feet, which was acquired on
radar. The controller accepted the cancellation and asked the pilot if
he wished to continue receiving radar traffic advisory services. The
flight lead declined. According to the air traffic control (ATC)
transcripts, the controller then stated, "radar service terminated,
squawk VFR [transponder code 1200], frequency change approved, but
before you go you have traffic ten o'clock about 15 miles northwest
bound, a Beech 1900 at ten thousand [feet]." The flight then began a
VFR descent to enter VR-1098. (For additional information see Air
Traffic Control Group Chairman's Factual Report attachment to this
report.)

The flight lead informed Ninja2 that they were going to perform a "G"
check (G awareness maneuver). They accelerated to 400 knots, made a
right 90-degree turn, followed by a left 90-degree turn back on
course, and continued their descent below 10,000 feet. The flight lead
then instructed the accident pilot to assume the "fighting wing"
formation (with the wingman at the 7 o'clock position behind the
flight lead). They continued to descend through 5,000 feet about 6
miles north of the entry point to VR-1098. The flight lead attempted
to obtain a visual reference to the entry point. The flight lead also
looked at his low-altitude en route chart to reference the class B
airspace at Tampa and the class C airspace at Sarasota.

About 1547, the F-16 flight was heading south and descending through
4,300 feet on a converging course with N73829. Radar data indicated
that the flight had overshot its intended entry point to VR-1098 and
was several miles southwest of the MTR. The flight had also
inadvertently passed through Tampa class B airspace without the
required ATC clearance and was about to enter the Sarasota class C
airspace without establishing communications with ATC, which is
required by Federal regulations.

After continuing to descend, the flight lead looked back to the left
and observed the accident F-16 slightly below him at the 7 o' clock
position and about 4,000 feet to 5,000 feet behind him. The flight
lead also observed a white, high-wing white airplane (the Cessna) in a
30 to 45-degree right turn. The Cessna and the accident F-16 collided
in a left-to-left impact at the flight lead's 10 o' clock position, he
stated. After the collision, the flight lead observed vaporizing fuel
on the F-16's right side. The flight lead did not see the Cessna. The
flight lead called the accident pilot and stated, "it appears you have
had a mid air and are streaming fuel." There was no response. The
flight lead began a left turn to keep the accident F-16 in sight. The
flight lead saw the accident pilot bail out and the airplane collide
with the ground. At 15:48:55, the flight lead stated, "mayday mayday."
At 15:49:11, the flight leader stated, "mayday mayday mayday F sixteen
down." At 15:50:00, the flight lead stated, "yes this is Ninja one we
have an F sixteen down there is a light aircraft may have also gone
down sir I am not sure." The collision occurred about 2,000 feet msl,
about 6 miles southwest of the entry point for VR-1098.

A review of ATC transcripts of communications between N73829 and Tampa
TRACON and communication between Miami ARTCC and Tampa TRACON
indicated that N73829 contacted Tampa TRACON at 15:45:19 stating he
was off Sarasota-Bradenton at 1,600 feet. At 15:45:23, Tampa TRACON
told N73829 to maintain 1,600 feet. N73829 acknowledged the
transmission at 15:45:30. At 15:46:59, Tampa TRACON informed N73829 to
turn left to heading 320 and to follow the shoreline northbound. At
15:47:10, Tampa TRACON instructed N73829 to climb and maintain 3,500
feet, which was acknowledged by N73829 at 15:47:15.

The Miami ARTCC controller contacted Tampa TRACON at 15:47:55 and
asked Tampa TRACON for the flight lead's altitude because he had lost
radar contact with the lead F-16 (only the flight lead had his
transponder activated because formation flights are handled as a
single aircraft by ATC). Tampa TRACON replied at 20:48:00, stating
"ahh hang on I see him down at two thousand." At 15:48:09, Tampa
TRACON informed N73829 that he had traffic off his left side at 2,000
feet. N73829 did not respond. (For additional information see the ATC
transcript attachment to this report.)

A review of altitude data and ground track data (and airspace
boundaries) determined that Tampa TRACON's intruder conflict detection
software noted a conflict between the flight lead and the Cessna, and
generated an aural conflict alert in the TRACON facility at 1547:39
that continued until 1548:03. The controller receiving instruction at
the time of the accident told Safety Board investigators that he heard
an alarm (conflict alert), but that he could not recall where it was.
The controller providing instruction at the time of the accident
stated that he didn't remember whether he saw an alert on his radar
display or if he heard an aural conflict alert. He added that conflict
alerts occur frequently, and that many were false. The conflict
detection system did not account for the accident F-16, or a possible
conflict, because it's transponder was in the standby mode. (For
additional information see the NTSB Recorded Radar Study and the Air
Traffic Control Group Chairman's Factual Report attached to this
report.)

Witnesses stated that they heard the sound of approaching jets. They
observed the first jet flying south, followed by the second jet
located to the left and slightly lower than the first. They also
observed a small civilian airplane flying from west to east,
perpendicular to the military jets. The second jet collided with the
civilian airplane and initially continued southbound, according to
witness statements. The second jet was observed to make a right turn,
followed by a left turn. A parachute was observed, and the airplane
was observed to enter a flat spin to the left before it disappeared
from view below the trees. An explosion was heard, followed by heavy
dark smoke rising above the terrain. (For additional information see
NTSB Group Chairman's Field Report, Ninja 1 and Ninja 2 pilot
statements, and witness statements.)

PERSONNEL INFORMATION

Air Force training, flight evaluations and flight records indicated
that the accident F-16 pilot, age 31, completed undergraduate pilot
training on September 27, 1996. He was qualified in the F-16 on March
3, 1997, and graduated from the F-16 basic course on July 22, 1997.
His most recent instrument/qualification examination was completed on
October 22, 1999. His most recent mission examination was completed on
June 21, 2000. He was qualified as a 2-airplane flight lead on March
19, 1999, and as a 4-airplane flight lead on January 11, 2000. He held
a current military flight physical completed on May 30, 2000, with the
restriction, "required to wear vision correction devices while
performing flying or special operational duty." The pilot indicated on
AF Form 1042 that he wore contact lenses while performing flying or
special operational duty.

A review of FAA records indicated that the accident pilot held a
commercial pilot certificate issued on September 9, 1999, with ratings
for airplane single-engine land, airplane multi-engine land, and
instrument airplane. In addition, he held a flight instructor
certificate with ratings for airplane single-engine land, airplane
multi-engine land, and instrument airplane. The pilot's FAA
second-class medical certificate was issued on December 21, 1998, with
no restrictions. He had accumulated a total of 1,279 flying hours.

Air Force training, flight evaluations and flight records indicated
that the flight lead completed undergraduate pilot training on May 16,
1980. He was qualified in the F-16 on December 20, 1988, and graduated
from the F-16 basic course in March 1989. Following a non-flying tour
he completed the F-16 re-qualification course on June 8, 1998. His
most recent instrument/qualification examination was completed on
September 29, 2000. His most recent mission examination was completed
on December 29, 1999. He was qualified as a 4-airplane flight lead on
February 10, 2000. He held a current military flight physical
completed on August 30, 2000, with the restriction "required to wear
vision correction devices while performing flying or special
operational duty." The pilot indicated on Air Force form 1042 that he
did not wear contact lenses while performing flying or special
operational duty.

A review of FAA records indicated that the flight lead held an ATP
certificate issued on May 18, 2000, with ratings for airplane
single-engine land, airplane multi-engine land, and instrument
airplane. The flight lead held a first-class medical certificate
issued on October 30, 2000, with the restriction "must wear corrective
lenses."

The Cessna 172 pilot, age 57, held an ATP certificate issued on
December 15, 1999, with ratings for airplane single-engine land,
multi-engine land, and instrument airplane. In addition, he held a
flight instructor certificate with ratings for airplane single-engine
and multi-engine land, instrument airplane, and a ground instructor
certificate for basic and advanced instruments. His first-class
medical certificate was issued on September 14, 2000, with the
restriction "must wear corrective lenses and possess glasses for near
and distant vision." The pilot's logbook was destroyed in the crash.
The pilot indicated on his last medical certificate application that
he had accumulated 2,020 flight hours.

AIRCRAFT INFORMATION

The accident F-16 was equipped with a General Electric turbofan
F110-GE-100 engine. The engine was overhauled by Tinker AFB Oklahoma,
Air Logistics Center, on December 17, 1998. The engine operating time
was 2,537.5 hours, with 5,610 engine total accumulated cycles (TACs).
The engine had accumulated 640 operating hours since overhaul. The
airframe had accumulated 3,243.7 total flight hours. All time
compliance technical orders pertaining to the airframe and engine
assembly had been accomplished.

A Safety Board review of N73829's airplane logbooks indicated that the
last recorded altimeter, static, and transponder system checks were
completed on November 11, 1999. The last annual inspection was
conducted on April 7, 2000. The last 100-hour inspection was conducted
on November 13, 2000.

METEOROLOGICAL INFORMATION

The nearest weather reporting facility at the time of the accident was
Sarasota-Bradenton Airport. The 1553 surface weather observation
indicated the following: clear, visibility 10 miles, temperature 80
degrees Fahrenheit, dew point 64 degrees Fahrenheit, wind 210 degrees
at 11 knots, altimeter 29.97 Hg.

WRECKAGE AND IMPACT INFORMATION

The F-16's wreckage was located in a wooded area near Sarasota. The
wreckage was about 4 miles southwest of the Cessna 172 crash site on a
bearing of 187 degrees magnetic.

Examination of the F-16 crash site revealed that the airplane collided
with the ground in a left flat spin on a heading of 170 degrees. The
right wing was found inverted and had evidence of an impact 81 inches
inboard of the wing tip in the vicinity of the SUU-20 (bomb and rocket
training dispenser). A aluminum fuel line from the Cessna 172 was
found wedged between the lower wing surface and the SUU-20 attachment
point. The Air Combat Maneuvering Instrumentation (ACMI) pod, with the
associated missile rail launcher (MRL), was separated from the right
wing tip at station 9. A faint transfer of red paint was present on
the upper aft surface of the MRL. The ACMI pod exhibited scarring
discoloration on the upper aft surface. A segment of one of the Cessna
172's flight control cables was found wedged in the F-16's right wing
leading edge. The wing's leading edge was deformed upward and aft.
Scratches were observed on the upper wing surface between the SUU-20
mount point area and the wing tip. The scratches extended from the
wing's leading edge to the trailing edge.

The canopy was located about 640 feet northwest of the main wreckage.
The canopy was shattered on the left side extending from the 11
o'clock position rearward to the 7 o'clock position. Gouging from the
Cessna was present on the canopy rail's leading edge. The gouging
extended aft and over the transparency portion of the canopy, ending
at the 11 o'clock position. A faint paint transfer was present on the
right forward canopy rail.

The SUU-20 was found imbedded tail first in the ground adjacent to the
entrance of Rosedale Golf and Country Club Community. Part of the
Cessna's main landing gear trunnion was found imbedded in the upper
leading structure of the SUU-20.

Visual examination of the airframe revealed no evidence of a precrash
mechanical failure or malfunction. Flight control continuity was
confirmed through data retrieved from the crash survivable memory unit
(CSMU). The engine assembly was not examined because the pilot
reported that he did not experience any engine-related problems before
the collision.

The Cessna wreckage was located in numerous pieces in the southwest
quadrant of the Rosedale Golf and Country Club community on the east
side of Bradenton. Numerous small pieces of F-16 structure and canopy
material were located within the Cessna debris field. Because of
airframe disintegration, verification of flight control continuity was
not possible. No preimpact discrepancies were observed during the
on-site wreckage inspection.

The engine, propeller and forward cabin section were found in one
piece at the edge of the main north-south entry road on the southwest
side of the complex. The propeller was attached to the engine with the
No.2 blade buried in the ground vertically to the hub. Propeller blade
No.1's outer 4 1/2 inches was missing. Gray/white paint transfer was
observed spanwise at the mid span on the forward side of the No.1
blade. Minor scrapes were observed chordwise on the No. 2 blade, which
was imbedded in the dirt.

The engine was attached to the engine mounts and firewall, and came to
rest in about a 20-degree, right-side-low attitude.

The cabin section was separated just forward of the rear seat
location. The front and rear seats were not found in the aircraft
cabin section. Parts of the seats were found in the debris field. The
left front seat belt was found buckled and its length was consistent
with normal use. The inboard attach point was found separated from the
floor structure.

The right wing, including the lift strut, was recovered from a pond. A
portion of the cabin roof (rear seat area) was attached to the right
wing root. The right wing's flap surface was fully retracted. The left
wing was located in the back yard of a nearby residence. The left wing
had impacted the roof of the residence, coming to rest in the back
yard. The left wing fuel tank had evidence of hydraulic deformation
"ballooning," which was more pronounced at the root. The left wing
root structure had evidence of span-wise compression damage. A leading
edge deformation, semicircular five to six inches in diameter, started
at the broken upper wing strut attachment and was oriented forward and
outward through the leading edge at a 45-degree angle.

An empennage section (baggage area to rear flight surfaces) was
removed from the pond about 100 feet south of the right wing location.
The bottom side of the empennage section had impact marks, which were
oriented approximately 38 degrees from the empennage centerline. The
impact marks originated from the right front of the empennage and
progressed to the left rear.

MEDICAL AND PATHOLOGICAL INFORMATION

Toxicology samples from the F-16 accident pilot and flight lead were
forwarded to the Armed Forces Institute of Pathology, Washington, DC,
for analysis. The results were negative for carbon monoxide, major
drugs of abuse and prescription and over-the-counter medications.

An autopsy determined that the Cessna pilot was killed by blunt force
trauma. The FAA's Forensic Toxicology Research Section in Oklahoma
City performed a postmortem toxicology analysis of tissue and fluid
specimens from the pilot. The results were negative for major drugs of
abuse and prescription and over-the-counter medications.
Traces of ethanol were detected, but the toxicology reported noted
that "ethanol found in this case may be potentially be from postmortem
ethanol formation and not from the ingestion of ethanol."

FLIGHT RECORDERS

The accident F-16 was equipped with a General Dynamics seat data
recorder (SDR). The unit was forwarded to Lockheed-Martin, Fort Worth,
Texas, for examination.

The flight lead F-16's SDR was downloaded at Moody AFB. The data were
forwarded to Lockheed-Martin for further analysis. However, due to a
recoding anomaly with the flight lead F-16's SDR, no useful data was
recovered. (For additional information see the NTSB F-16 Recorded Data
Study attached to this report.)

The CSMUs (crash survivable memory units) were forwarded to the U. S.
Air Force Safety Center in Albuquerque, New Mexico, for readout and
evaluation. The data were forwarded to the Safety Board for further
analysis. (For additional information see the NTSB F-16 Recorded Data
Study attached to this report.)

In addition, the F-16s were equipped with 8mm audio airborne video
tape recorders (AVTRs). The tapes were also forwarded to the Air Force
Safety Center for analysis. Examination determined that accident
airplane's tapes were destroyed by fire.

The tapes from the flight lead F-16 were found to have good quality
voice and video. The recorded data of the accident sortie covered
about 25 minutes, and began about two minutes before the midair
collision.

Lockheed Martin examined the download data from the crash survivable
flight data recorder (CSFDR), the SDR, data printouts from the general
avionics computer (GAC), the global positioning system (GPS), the
inertia navigation system (INS) and the AVTR tapes from the flight
lead's airplane. Lockheed Martin's examination report stated that M
Aero stated that GPS "was removed from the navigation solution at some
time prior to the midair. It cannot be determined from the data why
the GPS was removed from the navigation solution." The report added:
"A position error of approximately 9-11 nm was entered into the
navigation system at some time on the mishap flight prior to the video
recording. It can not be determined from the data what caused this
position error." (For additional information see the Lockheed Martin
Aeronautics Company Report of F-16C 89-2104 Mishap Investigation and
the NTSB F-16 Recorded Data Study attached to this report.)

The flight lead stated during an interview conducted by the Air Force
Accident Investigation Board that he did not perform an INS update
before the accident flight. He stated that navigation along their
planned route was conducted in the NAV mode and that they were
steering off INS steer points. He added that no INS en route updates
were accomplished. The flight lead stated that he not detect any NAV
problems on the return flight to Moody Air Force Base after the
accident. He stated that he thought the navigation system was
functioning correctly and giving him accurate information. He stated,
"I had no suspicion at all that there was a navigation system
problem."

TEST AND RESEARCH

Radar data from the FAA's Sarasota-Bradenton ASR7 facility and radar
data from the Air Force's 84th Radar Evaluation Squadron (84th RADES)
were used to determine the airplane flight paths, speeds and
altitudes. (The radar tracks for the three aircraft are shown in the
plots included in the recorded radar study.)

The F-16 flight entered the top of the class B airspace about 380
knots airspeed and left the airspace at 6,000 feet about a minute
later at 360 knots. Speeds of up to 450 knots were noted during the
descent. The airspace between Tampa class B airspace and Sarasota
class C airspace is Class E airspace, with a lower floor at 700 feet.
About 30 seconds after leaving the Tampa class B airspace, the flight
entered the Sarasota class C airspace at 380 knots. The flight
remained in the Sarasota class C airspace where the midair collision
took place. The flight lead's speed remained above 300 knots until the
accident F-16's collision with the Cessna.

OTHER INFORMATION

The Department of Defense's (DoD's) Flight Information Publication
General Planning GP, Section E-Supplementary Information, Para 5-35,
"Aircraft Speed Below 10,000 Feet Mean Sea Level" states:

"(Exemption to Federal Air Regulations 91.177 issued to DOD, May 18,
1978)-Operations below 10,000 feet Mean Sea Level at Indicated Air
Speed in excess of 250 knots, in noncompliance with Federal Air
Regulations 91.117 (a), are authorized for military aircraft,
including Reserve and Air National Guard components, only under the
following conditions:...

"g. If the airspeed required or recommended in the airplane flight
manual to maintain safe maneuverability is greater than the maximum
speed described in Federal Air regulations 91.117, the airplane may be
operated at that speed."

The F-16C/D flight manual, in Section VI, "Flight Characteristics,"
recommends "a minimum of 300 knots during normal cruise operation
below 10,000 MSL." The Air Force Instruction 11-2f-16, F-16 Operations
Procedures states in Chapter 5, "Air to Air Weapons Employment," Para
5.3.2, that the "minimum airspeed during low altitude offensive or
defensive maneuvering is 350 KIAS."

The DoD's Flight Information Publication Area Planning AP/1B, Military
Training Routes, North and South America states (in Chapter 2, "VFR
Military Training Routes (VR)," Para I, General) that "VRs are
developed by DoD to provide for military operational and training
requirements that cannot be met under terms of FAR 91.117 (Aircraft
Speed). Accordingly, the FAA has issued a waiver to DoD to permit
operation of an aircraft below 10,000 feet MSL in excess of 250 knots
indicated airspeed along DOD developed and published VFR routes." It
further states (in Para IV, Flight Plans) that "operations to and from
VRs should be conducted on an IFR flight plan. Pilots operating on an
IFR flight plan to a VR shall file to the fix/radial/distance (FRD) of
their entry/alternate entry point."

The DoD's Flight Information Publication Area Planning AP/1, North and
South America notes (in Chapter 3, "Flight Planning 3 f. Class B
Airspace") that "generally that airspace from the surface to 10,000'
surrounding the nation's busiest airports in terms of IFR operations
or passenger enplanements. The configuration of each Class B Airspace
area is individually tailored and consists of a surface area and two
or more layers and is designed to contain all published instrument
procedures once an aircraft enters the airspace. An ATC clearance is
required for all aircraft to operate in the area and all aircraft that
are so cleared receive separation services within the airspace."

CFR Part 91.113, Right-of-way rules (Paragraph (b), General), states:

"When weather conditions permit, regardless of weather an operation is
conducted instrument flight rules or visual flight rules, vigilance
shall be maintained by each person operating an aircraft so as to see
and avoid other aircraft. When a rule of this section gives another
aircraft the right-of-way, the pilot shall give way to that aircraft
and may not pass over, under, or ahead of it unless well clear. (f)
Overtaking. Each aircraft that is being overtaken has the right-of-way
and each pilot of an overtaking aircraft shall alter course to the
right to pass well clear. (g) Landing. Aircraft while on final
approach to land or while landing, have the right-of-way over other
aircraft in flight operating on the surface, except that they shall
not take advantage of this rule to force an aircraft off the runway
surface which has already landing is attempting to make way for an
aircraft on final approach. When two or more aircraft are approaching
an airport for the purpose of landing, the aircraft at the lower
altitude has the right-of-way, but it shall not take advantage of this
rule to cut in front of another which is on final approach to land or
to overtake that aircraft."

The FAA's Aeronautical Information Manual, Section 3-2-4, Class C
Airspace, states that "two-way radio communication must be established
with the ATC facility providing ATC services prior to entry" and that
pilots must "thereafter maintain those communications while in Class C
airspace." The manual adds that "radio contact should be initiated far
enough from the Class C airspace boundary to preclude entering Class C
airspace before two-way communications are established."

The wreckage of the accident F-16 was released to the Air Force Safety
Investigation Board. The Cessna 172 wreckage was released to the
owner's agent.


------------------------------------------------------------------------
Summary of the USAF's report:



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


------------------------------------------------------------------------
Here's some information about ATC's contribution:

http://www.flysouth.co.za/news/Archi...2015-12-00.htm

PILOTS WARNED BEFORE FLORIDA MID-AIR

Air traffic controllers in Miami and Tampa tried to warn converging
pilots seconds before their aircraft -- an F-16 fighter jet and a
Cessna 172 -- collided in midair over Bradenton, Florida, USA, a
preliminary government report says.

The Nov. 16 collision killed the Cessna pilot, Jacques Olivier, 57,
of Hernando County. Air Force Capt. John Kreuder, 31, guided the jet
to a wooded area before ejecting to safety on a fairway at Rosedale
Golf & Country Club.

The Miami air traffic controllers tried unsuccessfully to get two
fighter pilots to contact Tampa air traffic control for landing
instructions just seconds before the crash. At the same time,
controllers in Tampa were warning Olivier to ascend. Olivier was en
route to Albert Whitted Airport in St. Petersburg.

Before either could do so, the left wing of Olivier's Cessna
collided with the left wing of one of the two approaching F-16s. The
National Transportation Safety Board report shows that two F-16s
departed Moody Air Force Base in Valdosta, Ga., at 3:13 p.m., just 35
minutes before the collision, on their way to MacDill Air Force Base
in Tampa. Olivier piloted his Cessna 172 from Sarasota-Bradenton
International Airport only three minutes before the accident.

According to the report, after trying but failing to get in contact
with Tampa, the fighter pilot radioed back to Miami, which then told
him to descend to 13,000 feet and said there was traffic in the area.

The report says the two fighter jets reached a level between 3,000
and 5,000 feet, when one of the pilots picked up the Cessna on radar
-- but not in time to warn the other, who hit it.

The Tampa controllers had originally told Olivier to fly up the
shoreline at 1,600 feet, then two minutes later he was cleared
to reach his fatal altitude of 3,500 feet.

At 3:48 p.m., the Tampa controllers alerted Olivier to aircraft on
his left at 2,000 feet. Only seconds later, Miami radar lost contact
with one of the F-16s. The control tower asked Tampa controllers if
they knew the jet's altitude. ``Ah, hang on, I see him down at
2,000,'' a Tampa controller said.

Nine seconds later, Tampa controllers tried to warn Olivier there was
aircraft on his left. There was no reply. The report says that shortly
before the accident, the pilot of the first F-16 looked back to check
on the other and saw the white Cessna, but not in time to issue a
warning. The two aircraft collided, left side to left side.

Kreuder told investigators he saw a blur he described as ``a sheet of
white'' directly in front of him. The impact, he said, caused the jet
to shudder, knocked his visor off his helmet and tore away part of the
canopy's left side. Kreuder also said the cockpit filled with smoke
and there was a strong electrical smell in the air. Thinking he could
still make it to MacDill, Kreuder began a right turn, but the engine
shut down and he had to abandon the plane.

Shortly before the collision, the two jets were in a maneuver called
a G-check, in which the two planes make identical 90-degree turns to
the right, then to the left at a speed of nearly 500 mph. The move
gives pilots experience flying with high-gravity forces.


--------------------------------------------------------------------
http://www.naplesnews.com/01/08/florida/d669110a.htm

Probe reports trainee was at radar screen during air collision

Saturday, August 11, 2001
Associated Press

BRADENTON — A trainee was at the radar screen when an Air Force jet
collided with a private plane in November, said a Federal Aviation
Administration report made public Friday.

The Sarasota Herald-Tribune reported that documents obtained from the
agency said the trainee was at the screen at a Tampa air control tower
at the same time controllers in Miami were trying to warn the pilots
off their collision course.

The civilian pilot of the Cessna, Jacques Olivier of Hernando, was
killed in the collision. The Air Force F-16 pilot parachuted to
safety, but the jet was destroyed when it crashed into a wooded area.

Two Air Force pilots were flying 480 mph — 180 mph faster than federal
and Air Force guidelines allow in that urban area — on a practice
bombing run to rural Avon Park.

Out of radar contact, the jet pilots were miles off course when the
jet sliced through Olivier's Cessna near Interstate 75.

The FAA documents said the trainer for the unidentified novice
controller was on the telephone to the Miami controllers at the time
of the collision over Manatee County.

The FAA's report includes signed statements by the trainer and trainee
assigned to Tampa's south satellite, known as "S" position on Nov. 16.

The two F-16s over Manatee County were designated Ninja 1 and Ninja 2.

"I was working the 'S' position. The traffic was moderate to heavy. I
took the automated hand-off on Ninja 1. My trainee plugged in, to
train, at about this time," wrote air traffic controller Mark Allen.

Miami controllers had directed the F-16s to an outdated radio
frequency and they were unable to initiate contact with Tampa.

"I answered a phone call from MIA regarding Ninja 1's altitude. I saw
a fast moving target, southbound, and figured it was Ninja. I pointed
to the radar scope and told my trainee to issue traffic to N829
(Olivier)," he continued.

"I saw the fast moving target and N829 merge. When N829 did not
respond, I took the position from the trainee," Allen wrote.

The trainee, whose name has not been released, wrote that when Miami
controllers called, he "didn't know what they were talking about."

After hearing a "Mayday" call, he wrote he was ordered to leave the
controls.

According to Allen's report, Miami controllers or an Air Force radar
man telephoned to ask for the proper Tampa frequency. By that time, it
was too late to save Olivier.

The FAA report details the contact between controllers in Miami and
Tampa in the moments before and after the crash.

"Can you tell me what the altitude is on that Ninja 1? I lost the
target on him," asked one Miami controller.

"Ahh. Hang on. I see him down at 2,000 (feet)," responded the Tampa
trainee.

Nine seconds later, the trainee attempted to make a radio call to
Olivier: Traffic off your left side. Ahh. Two thousand."

There was no response. After Allen took back the controls and made
three more attempts to contact Olivier, Ninja 1 sent out a distress
signal.

Ten minutes after the crash, the Air Force pilots and Tampa
controllers were still trying to figure out what happened, the report
shows.
--------------------------------------------------------------------
http://www.naplesnews.com/01/03/florida/d608794a.htm


Tampa air controllers denounce military investigation of crash

Friday, March 9, 2001
Associated Press

TAMPA — Air traffic controllers could not have prevented a deadly
collision between an Air Force fighter and a Cessna, say local
officials who say the military is completely at fault.

An Air Force report said the controllers were partly at fault.

"If the F-16s had called us and talked to us and gotten permission to
be in our airspace ... those two planes never would have gotten
together," said Joe Formoso, president of the Tampa local of the
National Air Traffic Controllers Association.

Killed in the Nov. 16 crash near Bradenton was Cessna pilot Jacques
Olivier. F-16 pilot Capt Greg. Kreuder ejected safely before his met
crashed into a wooded area.

A second F-16 on the training mission was not involved in the
collision.

An Air Force investigation released earlier this week partially blames
its own pilots and air traffic controllers. The Air Force said that
air traffic controllers had time to move the Cessna out of the way
when they received a 30-second warning that the aircraft were on a
collision course.

Air traffic controllers refused to cooperate with the Air Force in its
review, but are cooperating with a National Transportation Safety
Board investigation.

Formoso disputed the conclusion that controllers could have warned
Olivier of the approaching war jets. Formoso said the alarm sounded
only 19 seconds before the crash and the F-16 was traveling at 550
mph.

An Air Force spokesman said he was unaware there was a dispute over
when controllers were alerted and said the military's investigation of
the crash was thorough.

Meanwhile, documents released by the Air Force indicate that Kreuder
had concerns about flying a training mission that ventured so close to
where civilian planes might be flying. The two pilots had not before
flown that route from Moody Air Force Base in Georgia to a bombing
range in Avon Park in south-central Florida.

Well into their flight, both pilots began suspecting that Miami and
Tampa air traffic controllers were miscommunication about where the
pilots were and where they were heading, the documents said.

Kreuder told investigators he started to feel uncertain after the two
jets came within 10 miles of a low-flying Beechcraft south of
Gainesville and after Miami air-route controllers asked where and why
they were flying.

When the F-16 pilots neared the range covered by Tampa controllers,
the two were directed by Miami to set their radios to a frequency that
had not been used by Tampa controllers for more than a year.

When the pilots could not reach Tampa controllers, they switched their
frequencies back to Miami.

To add to the problems, the military report said the two F-16 pilots
had no idea they were only miles away from Sarasota-Bradenton Airport.

Lead pilot Lt. Col. James Parker's on-board computer led the F-16s off
course, about nine to 11 miles south of where they should have been.


--------------------------------------------------------------------

HIDDEN MILITARY AIRWAYS
What military pilots need to know!

During the time period between 1986 and 1995, there have been three
midair collisions and 51 known near midair collisions between civilian
and military aircraft operating on or near Military Training Routes
(MTRs)--VR and IR routes. In 45 of the near midair collisions
(NMACs), the military pilots spotted the civilian aircraft and managed
to avoid an accident. In November of 2000, a F-16 collided with a
Cessna 172 while descending through controlled airspace at 480
knots-this accident currently under investigation. In addition, since
1986 NASA’s Aviation Safety Reporting System (ASRS) has documented 46
close encounters between aircraft operating near MTRs. The actual
number of midair collisions between military and general aviation
aircraft is relatively low considering the thousands of sorties flown
each year by military aircraft. However, 80 percent of reported
military near misses occur with general aviation aircraft.
I personally know of multiple unreported close encounters and you
probably have too!

So, what can we do to avert a near mid-air collision?
Effective Mission Planning
Complying with the Rules
Report all close encounters

It begins with mission planning! Many near misses can be averted if
we effectively plan and utilize all available resources. Have you
ever used a civilian sectional chart to plan your low level? The
sectional chart has all the MTRs printed on the chart. These thin
gray lines quickly get lost in all the clutter that is printed on a
chart. Innocuous as they may seem, the gray lines represent the
centerline of your route. Be aware that civilian aviator may not be
aware that you could be off your centerline. A sectional chart can
also be used an airspace reference for the actual boundaries of
airfields, accurate location of special use airspace, boundaries of
Class B, C, and D airspace. The typical TPC chart used by the
military does not provide this information. When is the last time you
really CHUMed a map? The sectional chart is updated every 56 days and
depicts new obstructions and airspace data. Another reason to use the
sectional chart.

Have you ever flown a MTR without booking the route or flown outside
the booked time?
Many of us have probably done one of the above due to forgetting to or
unable to get through on the phone line. It’s VFR and it’s see and
avoid, right? Yes, it is see and avoid but AP1/B (that thick book in
your flight planning room with dust on it) requires pilots to schedule
the route through the designated “scheduling activity” listed in the
route description. If a civilian pilot is not aware the route is
active, then you increase your chance for a near miss with the “slow
mover.” The bottom line is to schedule the route and meet your entry
time--if you can’t, then rely the information to FSS. It is difficult
as it is for all pilots (both civil and military) to obtain accurate
information on active MTRs.
Don’t exacerbate the situation!
How many of you annotate the conflicting MTRs on your route? This can
be a tedious and time consuming activity that is usually disregarded
(unless you utilize standardize route booklets). Here is where a
sectional chart can assist as well.
Remember, most routes are only deconflicted at the entry time by the
“scheduling agency.” Several bases are now utilizing computer
programs to deconflict routes owned by that “scheduling agency.” But,
deconfliction with routes owned by others is not common.

Intercepting civilian aircraft--have you ever locked and intercepted a
civilian aircraft while in a MOA or on a MTR? This is not the
“big”one! I suggest you stay at least one NM away from aircraft that
are not participating in your mission. The last thing the military
needs is a NMAC or TCAS alert due to a fighter pilot with a cowboy
attitude.

Complying with FAR speed restrictions. How many times have you
exceeded the speed restrictions below 10,000 feet when not on a MTR?
Civilians and most military aircraft are prohibited from exceeding 250
KIAS below 10,000 feet. Airlines pilots are frequently disciplined if
they are violated for breaking this rule. Military pilots are
sometimes “Teflon coated” and get away with breaking some of the FARs
especially the speed restrictions below 10,000 feet. Fighter and
T-38s can fly at 350 knots below 10,000 feet on an IFR flight plan and
300 knots while VFR. Recent newspaper reports cite the F-16 pilot who
collided with the Cessna 172 near Tampa was flying 480 knots below
10,000 feet while VFR and not on an MTR. This accident is still under
investigation so check with your safety office to review the report.
The bottom line is that many of us have busted the speed restriction
below 10,000 feet and we need to be more careful. We can not afford
accidents with civilians or FAR violations.

Should I report that near miss? Definitely YES. If we are to fix the
problems associated with airspace and training routes, we have to
report the information via the proper channels. See your flight
safety officer for the proper forms to fill out.

The bottom line is that civilians and the military have to share the
same airspace. If you mission plan effectively, abide by the
procedures and report all close encounters the hidden military routes
can be seen by others sharing the same airspace.

Copyright 1999 by JetSafety. All rights reserved.


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Friends say a final adieu to pilot

Rotarians and others recall the dedication and humor of Jacques
Olivier, who died Thursday in a midair plane crash.

By Times staff writer
© St. Petersburg Times, published November 22, 2000


INVERNESS -- With generous donations to a scholarship fund and a
mournful playing of taps, the Rotary Club of Inverness bid farewell to
former president Jacques Olivier, who died Thursday in a midair
collision.

Current club president Randy Val Alstine read a proclamation from the
city of Inverness that named the week of Nov. 12-18 Jacques Olivier
week in the city to note the many hours of community service that
Olivier performed. The council is expected to make the formal
dedication at its Dec. 5 meeting.

Olivier, 57, was killed when an Air Force F-16 fighter jet collided
with the single-engine Cessna airplane that he was piloting over
Manatee County. The Air Force pilot ejected from his crippled craft
and landed safely. The investigation into the crash is continuing.

At the Rotary Club's regular meeting on Tuesday, members took turns
standing to recall special moments they had shared with Olivier. Sonny
Hunt remembered when Olivier volunteered to help with the club's
annual fundraising golf tournament, despite not having any idea how to
play golf. "He rode around with me in a cart and had no clue what was
going on," Hunt chuckled. John O'Donnell noted that he nicknamed
Olivier, a native of France, the club's French Connection. "He was an
asset to our country and the world," he said.

Other members recalled his opinions on world events, which Olivier was
never shy about sharing, and his penchant for chasing his wife,
Danielle, out of the kitchen so he could prepare gourmet meals.

His most memorable trait, all agreed, was his sense of humor,
evidenced by an almost constant smile. "A fitting tribute to Jacques
would be for us to carry on what he stood for, his interest in youth
and public service, and for all of us to take that one attribute of
sharing a smile and continue it," said the Rev. Craig Davies. It's a
comfort, Davies added, to know that "he's piloting a plane in heaven
above."

After Lionel King played taps in honor of Olivier, Hunt rose with
tears in his eyes to make a final announcement.

Each week, the club collects money from members for its scholarship
fund, and the amount typically is about $100. On Tuesday, Hunt said,
fueled by a $500 donation from Jewel Lamb, the collection topped $730.


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Notice how the NTSB failed to find the military pilot to have
contributed to the cause of this civil/military MAC:


NTSB Identification: LAX86MA186A. The docket is stored on NTSB
microfiche number 31421.

Accident occurred Sunday, April 20, 1986 at WARNER SPRINGS, CA
Aircraft:LTV AEROSPACE INDUSTRIES A7E, registration: USN
Injuries: 2 Uninjured.

A ROLLADEN-SCHNEIDER LS-4 GLIDER AND AN LTV A7E JET COLLIDED OVER HOT
SPRINGS MTN, NEAR WARNER SPRINGS, CA. THE A7E WAS ATTEMPTING A RAPID
PULL UP AND THE GLIDER WAS ATTEMPTING A NOSE DOWN, 30 DEG RIGHT TURN
WHEN THEY COLLIDED. BOTH AIRCRAFT WERE OPERATING UNDER VISUAL FLT
RULES AND LANDED WITHOUT FURTHER INCIDENT. NEITHER PILOT WAS INJURED.
THE GLIDER LEFT WING OUTBD 3 FT SECTION WAS SEVERED. THE A7E NOSE
COWLING WAS SUBSTANTIALLY DAMAGED AND THE ENGINE INGESTED EXTENSIVE
FIBERGLASS MATERIAL. THE COLLISION OCCURRED AS THE A7E WAS EXECUTING A
SOUTHBOUND TURN ON VR 1257 AND WAS WITHIN THE ROUTE WIDTH (4 NM); THE
GLIDER WAS ATTEMPTING TO GAIN LIFT ON THE WEST SIDE OF HOT SPRINGS MTN
AND WAS WITHIN VR 1257 ROUTE STRUCTURE. THE A7E PLT HAD INFORMED THE
NECESSARY FLT SERV STATIONS THAT THE ROUTE WAS ACTIVE; THE GLIDER PLT
HAD NOT CONTACTED THE FLT SERV STATIONS TO DETERMINE IF THE ROUTE WAS
ACTIVE.

The National Transportation Safety Board determines the probable
cause(s) of this accident as follows.

PREFLIGHT PLANNING/PREPARATION..IMPROPER..PILOT OF OTHER AIRCRAFT
IN-FLIGHT PLANNING/DECISION..IMPROPER..PILOT OF OTHER AIRCRAFT
CHECKLIST..POOR..PILOT OF OTHER AIRCRAFT


Contributing Factors

TERRAIN CONDITION..MOUNTAINOUS/HILLY


Full narrative is not available

Index for Apr1986 | Index of months

----------


NTSB Identification: LAX86MA186B. The docket is stored on NTSB
microfiche number 31421.

Accident occurred Sunday, April 20, 1986 at WARNER SPRINGS, CA
Aircraft:ROLADEN-SCHNIDEN LS-4, registration: N50EH
Injuries: 2 Uninjured.

A ROLLADEN-SCHNEIDER LS-4 GLIDER AND AN LTV A7E JET COLLIDED OVER HOT
SPRINGS MTN, NEAR WARNER SPRINGS, CA. THE A7E WAS ATTEMPTING A RAPID
PULL UP AND THE GLIDER WAS ATTEMPTING A NOSE DOWN, 30 DEG RIGHT TURN
WHEN THEY COLLIDED. BOTH AIRCRAFT WERE OPERATING UNDER VISUAL FLT
RULES AND LANDED WITHOUT FURTHER INCIDENT. NEITHER PILOT WAS INJURED.
THE GLIDER LEFT WING OUTBD 3 FT SECTION WAS SEVERED. THE A7E NOSE
COWLING WAS SUBSTANTIALLY DAMAGED AND THE ENGINE INGESTED EXTENSIVE
FIBERGLASS MATERIAL. THE COLLISION OCCURRED AS THE A7E WAS EXECUTING A
SOUTHBOUND TURN ON VR 1257 AND WAS WITHIN THE ROUTE WIDTH (4NM); THE
GLIDER WAS ATTEMPTING TO GAIN LIFT ON THE WEST SIDE OF HOT SPRINGS MTN
AND WAS WITHIN VR 1257 ROUTE STRUCTURE. THE A7E PLT HAD INFORMED THE
NECESSARY FLT SERV STATIONS THAT THE ROUTE WAS ACTIVE; THE GLIDER PLT
HAD NOT CONTACTED THE FLT SERV STATIONS TO DETERMINE IF THE ROUTE WAS
ACTIVE.

The National Transportation Safety Board determines the probable
cause(s) of this accident as follows.

PREFLIGHT PLANNING/PREPARATION..IMPROPER..PILOT IN COMMAND
IN-FLIGHT PLANNING/DECISION..IMPROPER..PILOT IN COMMAND
CHECKLIST..POOR..PILOT IN COMMAND


Contributing Factors

TERRAIN CONDITION..MOUNTAINOUS/HILLY


Full narrative is not available

Index for Apr1986 | Index of months

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