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  #71  
Old August 18th 03, 11:53 PM
Billy Beck
external usenet poster
 
Posts: n/a
Default


Ed Rasimus wrote:

"Tarver Engineering" wrote:


Ed, go fly an airplane and forget about trying to understand how the system
works.

John p. Tarver, MS/PE
Electrical Engineer

John, since you brandish your MS/PE in your sig, it indicates an
educational accomplishment. Similarly, but not brandished, my
educational accomplishments include MPS (Master of Political
Science--Auburn U. 1978) and MSIR (Master of International
Relations--Troy State U. 1981). I teach Political Science in Colorado
Springs and you are welcome any time you pass through to visit the
college and audit my classes.


You really ought to crawl out there and buy the man a drink,
Tarver.


Billy

http://www.two--four.net/weblog.php
  #72  
Old August 19th 03, 01:34 AM
Ed Rasimus
external usenet poster
 
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Default

Larry Dighera wrote:

On Mon, 18 Aug 2003 16:54:21 GMT, Ed Rasimus
wrote in Message-Id: :

Exceptions, such as operating at higher
speed under 10,000 feet, are well coordinated with FAA


Some times they are, and some times they're not.

Well, the statement I made was with regard to exceptions to FAA
regulations made in the regulations themselves. We shouldn't
reasonably expect realistic training operations in tactical jet
aircraft to be conducted below 250 KIAS and above FL 180, nor should
we expect tactical training to require detailed route of flight
clearances from FAA controllers. Deconfliction takes place through air
space management and when operating under Visual Flight Rules, through
the time-honored practice of "see-and-avoid"

That being said, I've snipped the dross of your accident report and
we'll now jump to the portions that provide an example of the type of
"exceptions" in the FAR's that I refer to:

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."


Now, having read the "exceptions" coordinated between military and FAA
with regard to the operation of tactical aircraft in a training
environment, please return to your original comments--(I've taken the
liberty to paste them here at the end of this lengthy post for easy
access:

Sometimes a renegade military fighter pilot just ignores FAA
Regulations, enters Class B airspace at ~500 knots without a
clearance, leads his wingman into a midair collision, and scatters the
remains of a Cessna 172 ATP rated pilot over 4 acres of golf course,
and retains his pension and rank without being criminally charged for
the death he caused:


How can you characterize this military pilot as "renegade"? The
accident report says nowhere that the intrusion was intentional or
even knowing action. What "criminal charge" would you bring? Certainly
not "murder" which requires intent and pre-meditation. Now for certain
that no military pilot plans to intentionally have a mid-air either
for himself or his wingman. Maybe manslaughter? Reckless endangerment?

Do you really see a case of "just ignore" FARs? Or, have you got some
kind of anti-military axe to grind? Certainly the accident report that
you posted shows nothing in the conclusions to support any portion of
your paragraph.





Ed Rasimus
Fighter Pilot (ret)
***"When Thunder Rolled:
*** An F-105 Pilot Over N. Vietnam"
*** from Smithsonian Books
ISBN: 1588341038
  #73  
Old August 19th 03, 02:46 AM
Tarver Engineering
external usenet poster
 
Posts: n/a
Default


"Ed Rasimus" wrote in message
...
"Tarver Engineering" wrote:


"Ed Rasimus" wrote in message
news
"Tarver Engineering" wrote:

NASA is an extra Constitutional entity, just like US DOT and they are
identical in being Congressional authority delegated to the Executive.


Do you stay up late at night making this stuff up? NASA is an agency
established by the Executive branch to "execute" under the
authorization and appropriations of enabling legislation enacted by
the Legislative branch. There's nothing "extra Constitutional" about
it.


Yes Ed, Congress delegates much of its authority to the Executive. That

way
Administrative Law can enable the spending of money which otherwise would
have to be allocated by Congress directly.


Administrative "Law" is simply the power of "regulation" rather than
"legislation" and is well within the existing Constitutional authority
of the Executive Branch. The "enabling" to spending money is more than
adequately covered by the passage of appropriation bills. That's the
whole of idea of an "Executive" branch--it executes the policy
legislated by the Congress.


Those Federal powers in the Constitution are quite limited and intentionally
so. The three branches of Government and their powers, the military, the
postal service and coining money are eacmples of Constitutional entities.
The Executive Branch is not there to implement the will of congress, but as
a co-equal Branch of governemtn.

Congressional "authority", in other words the power of the Legislative
branch as described in the Constitution cannot be "delegated" to the
Executive.


LOL

Ed, go fly an airplane and forget about trying to understand how the

system
works.

John p. Tarver, MS/PE
Electrical Engineer

John, since you brandish your MS/PE in your sig, it indicates an
educational accomplishment. Similarly, but not brandished, my
educational accomplishments include MPS (Master of Political
Science--Auburn U. 1978) and MSIR (Master of International
Relations--Troy State U. 1981). I teach Political Science in Colorado
Springs and you are welcome any time you pass through to visit the
college and audit my classes.


In that case, Ed, you certainly should be able to disearn what entities are
in the Constitution and which is not. Take for example the department of
Education, which is alternatively praised and then threatened with
disbandment. Limiting Federal powers to those entities that are
Constitutional in nature is at the heart of libertarian thought. Wheras
through republican thinking, one might come to the conclusion that Federal
power should be limited to those things the States are unable to deal with;
under a civil free society. Then there is the democratic idea that Federal
power should be unlimited and seek to satisfy the desires of the masses. I
don't see how you can convey the meaning of this experiment in democracy
without understanding the differences in the basic ideas of our Republic.

Please educate us, educated one.


  #74  
Old August 19th 03, 04:31 AM
Mary Shafer
external usenet poster
 
Posts: n/a
Default

On Sun, 17 Aug 2003 10:49:26 -0400, wrote:

On Sat, 16 Aug 2003 22:40:53 -0700, Mary Shafer
wrote:

snip

We charter-hauled a Federal grant-funded duck-counter (I **** you not)
around in an Aztec for awhile a few years back, 'cause she couldn't do
the "mission" legally in a "public use" aircraft.


If the duck counting were part of the mission of the agency, it should
have been OK. The rule isn't against carrying people, it's against
running a charter airline in disguise. Local flights with pax doing
something agency-charter-related are OK.


This person wasn't a federal employee, just a professorial-type that
had gotten a grant to count ducks from the air. She had tried to find
a public use ride, and had been told that it wasn't possible/legal.


We not only flew contractors in Dryden research aircraft, we even sent
them for training in experimental aircraft. You wouldn't believe the
trouble that caused, mostly because of life insurance and liability,
so we had to have them sign a waiver. As if these young engineers (or
us older engineers) thought they were mortal....

I even managed to put a couple of United pilots into F-18s, looking at
unusual attitude recovery. No contract, no agreement, no nothing. A
duck counter would have been (forgive me, I can't resist) duck soup.

Did I ever tell you guys about bug collecting with the Jetstar? Or
how we simulated dead bug bodies when getting the real thing didn't
work? Nothing to do with ducks or contractors or pax operations,
although I have a story about pax-like operations in turbulence with
the Jetstar.

Mary

--
Mary Shafer Retired aerospace research engineer

  #75  
Old August 19th 03, 05:00 AM
Mary Shafer
external usenet poster
 
Posts: n/a
Default

On Mon, 18 Aug 2003 16:54:21 GMT, Ed Rasimus
wrote:

As for the basic question regarding FAA authority over military
aviation operations, except in special use airspace, the military is
expected to comply fully with FAA direction. The governing regulation
for the USAF (used to be AFM 60-16 "Flight Operating Rules") specifies
that operations "will be conducted to the maximum extent practicable,
under IFR"--which includes filing of FAA flight plans and compliance
with FAA ARTC throughout. Exceptions, such as operating at higher
speed under 10,000 feet, are well coordinated with FAA.


NASA has a similar regulation, of course. We do not, however, file
flight plans or comply with ARTCC instructions when the Orbiter is
reentering the atmosphere. The Orbiter also don't pay much attention
to that airspeed limit below 10,000 ft. Something about L/D. We do
tell the FAA we're coming, though. We don't like to surprise them too
much, after all.

Seriously, Dryden, like the USAF, uses the restricted areas around
Edwards, which are controlled by the FAA RAPCON (SPORT) there on base,
for most of its flying. The FAA isn't very involved in the actual
operations, except to issue traffic calls and warn of possible
boundary violations. They track the aircraft on radar, obviously, and
help do vectors when new chases join up or we're looking for the
tanker. It's a nice, friendly relationship, with all three agencies
occasionally conspiring against LA Center over the Daggett Shelf, a
little piece of airspace.

When Dryden aircraft leave the restricted areas, particularly to go
cross-country, the only thing special is that we've been allocated the
call sign "NASA". Otherwise, we're just like any other civil jet
fighter or 747 carrying an Orbiter in the airspace. We even give our
aircraft N numbers, from a block of numbers reserved to us.

It's always seemed fair to me that the FAA should allocate special
airspace for special purposes, like research flying or Oil
Burner/Olive Branch routes. After all, they create special restricted
airspace for borate bombing forest fires, too. Someone has to have
the final word on how the airspace is used, after all. They just
can't tell us (or the military) what airplanes to fly or exactly how
to fly them once we get the airspace, unless it's airspace used for
regular operations.

Mary

--
Mary Shafer Retired aerospace research engineer

  #76  
Old August 19th 03, 06:17 AM
Larry Dighera
external usenet poster
 
Posts: n/a
Default

On Mon, 18 Aug 2003 21:48:11 GMT, Ed Rasimus
wrote in Message-Id: :

Larry Dighera wrote:

On Mon, 18 Aug 2003 16:54:21 GMT, Ed Rasimus
wrote in Message-Id: :

Exceptions, such as operating at higher
speed under 10,000 feet, are well coordinated with FAA


Some times they are, and some times they're not.

Well, the statement I made was with regard to exceptions to FAA
regulations made in the regulations themselves.


Umm Hmmm...

We shouldn't reasonably expect realistic training operations in tactical jet
aircraft to be conducted below 250 KIAS and above FL 180,


Today, Military Training Routes are typically very low-leval and
high-speed in the USA.

nor should we expect tactical training to require detailed route of flight
clearances from FAA controllers.


Your reasoning behind that statement is not obvious to me. Care to
elaborate?

Deconfliction takes place through air space management


What is your definition of 'airspace management'? Who participates in
this 'airspace management'?

and when operating under Visual Flight Rules, through the time-honored
practice of "see-and-avoid"


Actually, see-and-avoid is MANDATORY AT ALL TIMES when operating in
Visual Meteorological Conditions, under VFR and IFR; see-and-avoid is
not limited solely VFR operation.

(Center/Approach radar is seldom useful close to the surface where
military pilots rocket through joint-use airspace on MTRs.)

The issue with attempting to visually deconflict when closing speeds
are in the 500+ knot range is, that the traffic the pilot is
attempting to see appears stationary in the windscreen, presenting its
smallest profile (frontal). And because the aircraft the military
flies on MTRs are incapable of displaying a landing light, it makes
them virtually impossible for the civil pilot to spot in time to take
evasive action.

On the other hand, the military aircraft operating at high-speed need
only deconflict a much smaller region of his windscreen than the pilot
of an aircraft obeying the 250 knot limit below 10,000'. But from the
accounts of the two military-civil MACs that I've read, it appears
that the military pilot is on top of the civil aircraft before he
knows of its being in his path.

A rational assessment of the issue with an eye toward increasing
flight safety immediately presents several facts:

1. At speeds above the 250 knot limit below 10,000', reliance
on see-and-avoid FAILS to separate aircraft. Highly trained,
experienced, military pilots readily admit this publicly.

2. The inconspicuous, high-speed, low-level military aircraft
creating the public safety hazard unjustly SHARES aircraft
separation RESPONSIBILITY with the slow civil pilot when
operating in Visual Meteorological Conditions.

3. Because most military aircraft operating on MTRs are not
TCAS equipped, there is little chance to avoid a MAC.

4. Because MTRs do not lie within Special Use Airspace,
more military/civil MACs are likely.

5. ...


That being said, I've snipped the dross of your accident report and
we'll now jump to the portions that provide an example of the type of
"exceptions" in the FAR's that I refer to:


Yes. I've read it.

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."


I'm happy you brought Part 91.113 up. The NTSB didn't, in 1988, when
the A-7 on a MTR hit the glider.
The pilot's stories are he
http://groups.google.com/groups?as_e...ting&lr=&hl=en
NTSB report:
http://www.ntsb.gov/ntsb/brief.asp?e...13X33340&key=1

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."


Flight lead, Parker, Failed to comply with that required communication
to enter Class C airspace. He also violated the requirement to
receive ATC clearance into Miami Class B!

Now, having read the "exceptions" coordinated between military and FAA
with regard to the operation of tactical aircraft in a training
environment, please return to your original comments--(I've taken the
liberty to paste them here at the end of this lengthy post for easy
access:

Sometimes a renegade military fighter pilot just ignores FAA
Regulations, enters Class B airspace at ~500 knots without a
clearance, leads his wingman into a midair collision, and scatters the
remains of a Cessna 172 ATP rated pilot over 4 acres of golf course,
and retains his pension and rank without being criminally charged for
the death he caused:


How can you characterize this military pilot as "renegade"? The
accident report says nowhere that the intrusion was intentional or
even knowing action.


The flight lead, Parker, was still above Miami Class B when he became
unable to contact Approach Control for further clearance. Instead of
aborting the MTR practice flight, he canceled his IFR flight plan,
rejected Radar Traffic Advisory Service, and went blazing into the
congested terminal areas of Miami and Tampa which resulted in the
grizzly death of an ATP rated flight instructor and president of the
local business association. That's why.

What "criminal charge" would you bring?


A charge of Third Degree Murder would be appropriate in Florida.

Certainly not "murder" which requires intent and pre-meditation. Now
for certain that no military pilot plans to intentionally have a
mid-air either for himself or his wingman. Maybe manslaughter?
Reckless endangerment?

Do you really see a case of "just ignore" FARs?


In the F-16 v Cessna 172 MAC, I see a flight lead military pilot who
violated several military and civil regulations, made many piloting
mistakes, lacked any regard for the safety of the civil aircraft
operating in congested Terminal airspace, which resulted in Jacques
Olivier's death. His Commanding Officer, John Rosa, felt a verbal
reprimand was appropriate in this fatal mishap. Parker continued with
his planned retirement with full pension and rank. An example of fine
military (in)justice. :-(

Or, have you got some kind of anti-military axe to grind?


Prior to reading of these two civil/military MACs, I always thought
highly of the US military (and the NTSB).

Certainly the accident report that you posted shows nothing in the
conclusions to support any portion of your paragraph.


Below is the military AIB's report. See if you can tell me how many
days elapsed between the date of the accident and the date of the
medical reports.

Incidently, this accident has been discussed at length in this forum.
These two links contain ~600 articles on the subject of the
F-16/Cessna 172 midair:
http://groups.google.com/groups?hl=e...sota%26hl%3Den
http://groups.google.com/groups?hl=e...sota%26hl%3Den
There you will find a lot of other analytical information.



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

Irrational beliefs ultimately lead to irrational acts.
-- Larry Dighera,
  #77  
Old August 19th 03, 11:38 AM
Cub Driver
external usenet poster
 
Posts: n/a
Default


I once did a story about the Missing Man Formation, and had a
wonderful exchange of emails with a navy pilot who'd recently flown
one at Arlington Natl Cemetery.

Probably the thing that amazed me most about the whole thing was that
he was under the control of ATC for the overflight.

He did get a "discrete", however--a radio frequency all to his own.

And he did bust the speed limit for low altitude work.

all the best -- Dan Ford
email: www.danford.net/letters.htm#9

see the Warbird's Forum at www.warbirdforum.com
and the Piper Cub Forum at www.pipercubforum.com
  #78  
Old August 19th 03, 03:45 PM
Ed Rasimus
external usenet poster
 
Posts: n/a
Default

"Tarver Engineering" wrote:

In that case, Ed, you certainly should be able to disearn what entities are
in the Constitution and which is not. Take for example the department of
Education, which is alternatively praised and then threatened with
disbandment. Limiting Federal powers to those entities that are
Constitutional in nature is at the heart of libertarian thought. Wheras
through republican thinking, one might come to the conclusion that Federal
power should be limited to those things the States are unable to deal with;
under a civil free society. Then there is the democratic idea that Federal
power should be unlimited and seek to satisfy the desires of the masses. I
don't see how you can convey the meaning of this experiment in democracy
without understanding the differences in the basic ideas of our Republic.

Please educate us, educated one.


In discerning "what entities are in the Constitution" you will find
upon searching for the Cabinet--and all of the agencies included--that
not a single one of them is mentioned. Not only do you not find NASA
or DOT or DOE which you mention, you also don't find State, Defense,
the AG, SG, Interior, et. al. Not a one. You also don't find NSA--and
didn't until Eisenhower; or CIA, not till Truman, or SEC or FDA or any
mention of the Executive Office of the President. All you find listed
for the Executive branch is a Prez and VP. They are charged with a
number of functions and given the authority to organize as they see
fit to accomplish them.

Your initial description of NASA as an "extra-Constitutional entity"
is probably linquistically correct in that it is an agency not
described in the document, but legally incorrect in that agencies
would be described as "Constitutional" or un-Constitutional.

Libertarian thought, while enlightening in some instances it certainly
would create a workload for the President if it disbanded those
entities which are not described in the Constitution. Wonder how long
it would take George Dubya to deliver the mail to the entire country
with just him and Cheney doing the job?

Your description of (R)epublican "thinking" as the Feds only doing
what the States can't is really the "Anti-Federalist" thinking of
Thomas Jefferson--father of the Democratic Party. And your description
of the (D)emocratic idea that Federal power should be unlimited and
seek to satisfy the masses is really the great shift instituted by FDR
in response to the political process. The people in the depths of the
Great Depression demanded that the great White Father in Washington
rescue them--and, of course he responded. Today, both Republicans and
Democrats routinely beg Washington to solve every problem that society
encounters.

We are indeed "an experiment in Democracy", but if you examine the
Constitution (which you so freely refer to) you'll see that the
Founding Fathers weren't all that confident in the ability of the
"great unwashed" to govern themselves. Until the 17th Amendment,
ratified in 1913, the Senate was "appointed" by the various state
legislatures--not popularly elected. For the first 126 years of the
Republic, only the House was popularly elected. The Senate, the Prez,
the Judiciary, all were selected by a process that was isolated from
"we the people"--insuring the control of the elites, the Founders
themselves.


Ed Rasimus
Fighter Pilot (ret)
***"When Thunder Rolled:
*** An F-105 Pilot Over N. Vietnam"
*** from Smithsonian Books
ISBN: 1588341038
  #79  
Old August 19th 03, 07:38 PM
Billy Beck
external usenet poster
 
Posts: n/a
Default


Cub Driver wrote:

I once did a story about the Missing Man Formation, and had a
wonderful exchange of emails with a navy pilot who'd recently flown
one at Arlington Natl Cemetery.

Probably the thing that amazed me most about the whole thing was that
he was under the control of ATC for the overflight.


I don't understand at all why that should surprise you. Have you
ever looked at Arlington and where it lays in the D.C. Terminal Area?


Billy

http://www.two--four.net/weblog.php
  #80  
Old August 19th 03, 10:33 PM
Ed Rasimus
external usenet poster
 
Posts: n/a
Default

(Jake McGuire) wrote:

Ed Rasimus wrote in message . ..
We are indeed "an experiment in Democracy", but if you examine the
Constitution (which you so freely refer to) you'll see that the
Founding Fathers weren't all that confident in the ability of the
"great unwashed" to govern themselves. Until the 17th Amendment,
ratified in 1913, the Senate was "appointed" by the various state
legislatures--not popularly elected. For the first 126 years of the
Republic, only the House was popularly elected. The Senate, the Prez,
the Judiciary, all were selected by a process that was isolated from
"we the people"--insuring the control of the elites, the Founders
themselves.


While deferring to your expertise in this matter, isn't the opposite
spin of "The founders thought that it was wise to add some inertia
between the sometimes erratic and fickle vote of the populace and the
actual mechanism of power, while still leaving the people in ultimate
control" just as valid?

I think that there's a lot to be said for "Give someone the
responsibility and the authority to do the job, give them time to do
it, and then review their performance at appropriate intervals"
instead of "micromanage every aspect of everything." I don't trust
myself to make an informed decision on everything that comes down the
pike, and I sure as hell don't trust my fellow citizens. Especially
since I live in California.

-jake


I couldn't agree more. Just as in California, we in Colorado are
plagued by "initiatives" (what you in CA refer to as
"propositions")--the "take-it-or-leave-it" simple majority, populist
vote without regard to budget cost, priority, long-term consequence or
even Constitutionality. No debate, no amendment, no compromise, no
consensus-building required--a simple up or down vote on something
that everyone wants and no one wants to pay for. Yeahh, this democracy
is sure great!!!


Ed Rasimus
Fighter Pilot (ret)
***"When Thunder Rolled:
*** An F-105 Pilot Over N. Vietnam"
*** from Smithsonian Books
ISBN: 1588341038
 




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