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#1
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Hi all,
While I was on my way home this evening from Flying Traffic survey. I was nearly run over by a Baron driver coming out of Stafford Airport (RMN) on his way to Frederick (FDK). He called Potomac approach saying level 3200. I was cruising at 3000 between Stafford, Virginia near Quantico (NYG) and Culpeper (CJR). I needed to go around the Quantico Restricted areas (R-6608ABC). They were all hot, one to 10,000. This is one of my usual routes to/from work. I have flown it 50 maybe 100 times without any problems. He came up at my 7 o'clock and departed at the 1 o'clock. He said he never saw me. He passed directly over my head by about 200 feet. He was so non-chalant about the whole thing. I immediately reported a near mid-air. Once on the ground I called the supervisor and they called me back. They are sending me the forms. A NASA form is being filled out tonight. To compound the problem the controller was having trouble getting the Baron radar identified. His transponder did not start working until he "recycled it" (turned it from standby to Mode C, I suspect). By now it was too late he had passed me. All the controller could tell me was I had another airplane in the area. I live to fly another day. TCAS anyone? ok so it would not have helped since he did not have his transponder on. Michelle |
#2
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Hi all,
While I was on my way home this evening from Flying Traffic survey. I was nearly run over by a Baron driver coming out of Stafford Airport (RMN) on his way to Frederick (FDK). Unfortunately, that's flying. Somebody on the interstate almost changed lanes into me yesterday, nearly causing an accident at 70mph that probably would have killed me. After I honked, he waved as though to say sorry, I didn't see you. That's driving. Just gotta do your best to be careful. |
#3
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Damn scary when someone proves that they don't have a grasp of the
basics... He didn't see you because he had his head in the panel playing with the transponder.. I'm surprised that ATC didn't insist that he move up to 3500 on his altimeter, per the rules, until he could get his Mode C going,especially knowing you were squawking 3000... .. denny |
#4
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![]() "Michelle P" wrote in message ink.net... Hi all, While I was on my way home this evening from Flying Traffic survey. I was nearly run over by a Baron driver coming out of Stafford Airport (RMN) on his way to Frederick (FDK). He called Potomac approach saying level 3200. I was cruising at 3000 between Stafford, Virginia near Quantico (NYG) and Culpeper (CJR). I needed to go around the Quantico Restricted areas (R-6608ABC). They were all hot, one to 10,000. This is one of my usual routes to/from work. I have flown it 50 maybe 100 times without any problems. He came up at my 7 o'clock and departed at the 1 o'clock. He said he never saw me. He passed directly over my head by about 200 feet. He was so non-chalant about the whole thing. I immediately reported a near mid-air. Once on the ground I called the supervisor and they called me back. They are sending me the forms. A NASA form is being filled out tonight. To compound the problem the controller was having trouble getting the Baron radar identified. His transponder did not start working until he "recycled it" (turned it from standby to Mode C, I suspect). By now it was too late he had passed me. All the controller could tell me was I had another airplane in the area. I live to fly another day. TCAS anyone? ok so it would not have helped since he did not have his transponder on. Michelle Glad you made it. This is a tough call, and roughly involves something I've been screaming about for many years in safety meetings. Don't know what you were flying, but the general design of a lot of our airplanes isn't all that conducive to visual checks behind the 3-9 line. Taking a hit through your 7-1 line would be right there in your blind spot. Even low wing is hard to check visually at 7-1. There really isn't a solid safety data point on this from your side. There is of course something for the Baron to chew. It brings home quite clearly that in the three dimensional world we enter when we fly, even though we do everything right and by the book, even exceeding the book in many cases, we're STILL dependent on OTHERS doing the right thing to complete the safety picture for us. It's a sobering thought, but something we have to live with every day both in aviation and in our normal lives on the ground as well. I know how you must have felt coming out of this one because I've had close ones as well. We're all defensive ahead of our wing line, at least those of us who fly defensively as we should........but strapped into the seat with a fuselage behind us leaves a blind spot that has to be filled by whoever it is overtaking us back there. If there's a safety data point that can be made by your experience, it would be to remind EVERYBODY (in this case the Baron pilot) that as they are scanning ahead, as well as protecting their nose, they are as well responsible for our tail!!! Impact has no right of way. It's too late at that point. Everybody dies!! Dudley Henriques |
#5
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On Fri, 02 Sep 2005 13:31:35 GMT, "Dudley Henriques"
dhenriques@noware .net wrote in . net:: Impact has no right of way. It's too late at that point. Everybody dies!! Not all the time. Sometimes only those who are in compliance with FAA regulations are splattered over four acres of golf course and those causing the fatality is erroneously exonerated less than impartial investigators. Below are the NTSB and USAF reports of a MAC in which only the innocent died: MIA01FA028A HISTORY OF FLIGHT On November 16, 2000, at 1548 eastern standard time, a U.S. Air Force F-16CG, operated by the 347th Wing, Air Combat Command, collided in mid air with a Cessna 172, N73829, near Bradenton, Florida. The F-16, based at Moody Air Force Base (AFB), Valdosta, Georgia, was on a low-altitude training mission. The Cessna 172, registered to Crystal Aero Group, was operating as a 14 CFR Part 91 personal flight. The airline transport (ATP)-rated Cessna pilot was killed. The F-16 pilot, who held a commercial pilot's certificate, ejected from the airplane and sustained minor injuries. Visual meteorological conditions prevailed at the time of the accident. The accident F-16 was part of a flight of two F-16s. A composite military instrument flight rules (IFR)/visual flight rules (VFR) flight plan was filed. The two F-16s departed Moody AFB at 1513. The Cessna 172 departed Sarasota Bradenton International Airport (SRQ) Sarasota, Florida, about 1541. No flight plan was filed. The accident F-16 pilot, who was using call sign Ninja 2, stated that he was maintaining visual formation with his flight lead, call sign Ninja 1, when he saw a blur "like a sheet of white" appear in front of him. He stated that the airplane shuddered violently, and part of the canopy on the left side was broken away. The accident pilot stated that wind, smoke, and a strong electrical smell filled the cockpit. He stated that he called his flight lead several times, but could not hear a reply. Because the airplane was still controllable, he decided to try to reach MacDill AFB, and he began a right turn in that direction. He stated that his primary flight instruments were shattered and that he could not see them. He stated that the engine began to spool down and that he realized that he would not be able to make the airport. He stated that he turned the airplane left toward a wooded area away from a residential area and attempted an engine restart, which was not successful. When the airplane cleared the residential area, it started an uncommanded left roll. When the airplane went past a 90-degree bank angle, the pilot stated that he decided to eject. During his parachute descent, he observed the airplane "pancake" into the ground inverted and explode. The flight lead stated that the two F-16s were assigned a block altitude of between 25,000 feet and 26,000 feet en route to the entry point of visual military training route (MRT) VR-1098. As the flight approached the SRQ area, Miami Air Route Traffic Control Center (ARTCC) cleared the F-16s to descend to 13,000 feet. At 1543:39, the Miami ARTCC controller instructed the flight lead to contact Tampa Terminal Radar Approach Control (TRACON) controllers. The flight lead was not successful (because he was given an incorrect frequency), and he reestablished contact with Miami ARTCC and canceled IFR. Miami ARTCC advised him of traffic at 10,000 feet, which was acquired on radar. The controller accepted the cancellation and asked the pilot if he wished to continue receiving radar traffic advisory services. The flight lead declined. According to the air traffic control (ATC) transcripts, the controller then stated, "radar service terminated, squawk VFR [transponder code 1200], frequency change approved, but before you go you have traffic ten o'clock about 15 miles northwest bound, a Beech 1900 at ten thousand [feet]." The flight then began a VFR descent to enter VR-1098. (For additional information see Air Traffic Control Group Chairman's Factual Report attachment to this report.) The flight lead informed Ninja2 that they were going to perform a "G" check (G awareness maneuver). They accelerated to 400 knots, made a right 90-degree turn, followed by a left 90-degree turn back on course, and continued their descent below 10,000 feet. The flight lead then instructed the accident pilot to assume the "fighting wing" formation (with the wingman at the 7 o'clock position behind the flight lead). They continued to descend through 5,000 feet about 6 miles north of the entry point to VR-1098. The flight lead attempted to obtain a visual reference to the entry point. The flight lead also looked at his low-altitude en route chart to reference the class B airspace at Tampa and the class C airspace at Sarasota. About 1547, the F-16 flight was heading south and descending through 4,300 feet on a converging course with N73829. Radar data indicated that the flight had overshot its intended entry point to VR-1098 and was several miles southwest of the MTR. The flight had also inadvertently passed through Tampa class B airspace without the required ATC clearance and was about to enter the Sarasota class C airspace without establishing communications with ATC, which is required by Federal regulations. After continuing to descend, the flight lead looked back to the left and observed the accident F-16 slightly below him at the 7 o' clock position and about 4,000 feet to 5,000 feet behind him. The flight lead also observed a white, high-wing white airplane (the Cessna) in a 30 to 45-degree right turn. The Cessna and the accident F-16 collided in a left-to-left impact at the flight lead's 10 o' clock position, he stated. After the collision, the flight lead observed vaporizing fuel on the F-16's right side. The flight lead did not see the Cessna. The flight lead called the accident pilot and stated, "it appears you have had a mid air and are streaming fuel." There was no response. The flight lead began a left turn to keep the accident F-16 in sight. The flight lead saw the accident pilot bail out and the airplane collide with the ground. At 15:48:55, the flight lead stated, "mayday mayday." At 15:49:11, the flight leader stated, "mayday mayday mayday F sixteen down." At 15:50:00, the flight lead stated, "yes this is Ninja one we have an F sixteen down there is a light aircraft may have also gone down sir I am not sure." The collision occurred about 2,000 feet msl, about 6 miles southwest of the entry point for VR-1098. A review of ATC transcripts of communications between N73829 and Tampa TRACON and communication between Miami ARTCC and Tampa TRACON indicated that N73829 contacted Tampa TRACON at 15:45:19 stating he was off Sarasota-Bradenton at 1,600 feet. At 15:45:23, Tampa TRACON told N73829 to maintain 1,600 feet. N73829 acknowledged the transmission at 15:45:30. At 15:46:59, Tampa TRACON informed N73829 to turn left to heading 320 and to follow the shoreline northbound. At 15:47:10, Tampa TRACON instructed N73829 to climb and maintain 3,500 feet, which was acknowledged by N73829 at 15:47:15. The Miami ARTCC controller contacted Tampa TRACON at 15:47:55 and asked Tampa TRACON for the flight lead's altitude because he had lost radar contact with the lead F-16 (only the flight lead had his transponder activated because formation flights are handled as a single aircraft by ATC). Tampa TRACON replied at 20:48:00, stating "ahh hang on I see him down at two thousand." At 15:48:09, Tampa TRACON informed N73829 that he had traffic off his left side at 2,000 feet. N73829 did not respond. (For additional information see the ATC transcript attachment to this report.) A review of altitude data and ground track data (and airspace boundaries) determined that Tampa TRACON's intruder conflict detection software noted a conflict between the flight lead and the Cessna, and generated an aural conflict alert in the TRACON facility at 1547:39 that continued until 1548:03. The controller receiving instruction at the time of the accident told Safety Board investigators that he heard an alarm (conflict alert), but that he could not recall where it was. The controller providing instruction at the time of the accident stated that he didn't remember whether he saw an alert on his radar display or if he heard an aural conflict alert. He added that conflict alerts occur frequently, and that many were false. The conflict detection system did not account for the accident F-16, or a possible conflict, because it's transponder was in the standby mode. (For additional information see the NTSB Recorded Radar Study and the Air Traffic Control Group Chairman's Factual Report attached to this report.) Witnesses stated that they heard the sound of approaching jets. They observed the first jet flying south, followed by the second jet located to the left and slightly lower than the first. They also observed a small civilian airplane flying from west to east, perpendicular to the military jets. The second jet collided with the civilian airplane and initially continued southbound, according to witness statements. The second jet was observed to make a right turn, followed by a left turn. A parachute was observed, and the airplane was observed to enter a flat spin to the left before it disappeared from view below the trees. An explosion was heard, followed by heavy dark smoke rising above the terrain. (For additional information see NTSB Group Chairman's Field Report, Ninja 1 and Ninja 2 pilot statements, and witness statements.) PERSONNEL INFORMATION Air Force training, flight evaluations and flight records indicated that the accident F-16 pilot, age 31, completed undergraduate pilot training on September 27, 1996. He was qualified in the F-16 on March 3, 1997, and graduated from the F-16 basic course on July 22, 1997. His most recent instrument/qualification examination was completed on October 22, 1999. His most recent mission examination was completed on June 21, 2000. He was qualified as a 2-airplane flight lead on March 19, 1999, and as a 4-airplane flight lead on January 11, 2000. He held a current military flight physical completed on May 30, 2000, with the restriction, "required to wear vision correction devices while performing flying or special operational duty." The pilot indicated on AF Form 1042 that he wore contact lenses while performing flying or special operational duty. A review of FAA records indicated that the accident pilot held a commercial pilot certificate issued on September 9, 1999, with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. In addition, he held a flight instructor certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The pilot's FAA second-class medical certificate was issued on December 21, 1998, with no restrictions. He had accumulated a total of 1,279 flying hours. Air Force training, flight evaluations and flight records indicated that the flight lead completed undergraduate pilot training on May 16, 1980. He was qualified in the F-16 on December 20, 1988, and graduated from the F-16 basic course in March 1989. Following a non-flying tour he completed the F-16 re-qualification course on June 8, 1998. His most recent instrument/qualification examination was completed on September 29, 2000. His most recent mission examination was completed on December 29, 1999. He was qualified as a 4-airplane flight lead on February 10, 2000. He held a current military flight physical completed on August 30, 2000, with the restriction "required to wear vision correction devices while performing flying or special operational duty." The pilot indicated on Air Force form 1042 that he did not wear contact lenses while performing flying or special operational duty. A review of FAA records indicated that the flight lead held an ATP certificate issued on May 18, 2000, with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The flight lead held a first-class medical certificate issued on October 30, 2000, with the restriction "must wear corrective lenses." The Cessna 172 pilot, age 57, held an ATP certificate issued on December 15, 1999, with ratings for airplane single-engine land, multi-engine land, and instrument airplane. In addition, he held a flight instructor certificate with ratings for airplane single-engine and multi-engine land, instrument airplane, and a ground instructor certificate for basic and advanced instruments. His first-class medical certificate was issued on September 14, 2000, with the restriction "must wear corrective lenses and possess glasses for near and distant vision." The pilot's logbook was destroyed in the crash. The pilot indicated on his last medical certificate application that he had accumulated 2,020 flight hours. AIRCRAFT INFORMATION The accident F-16 was equipped with a General Electric turbofan F110-GE-100 engine. The engine was overhauled by Tinker AFB Oklahoma, Air Logistics Center, on December 17, 1998. The engine operating time was 2,537.5 hours, with 5,610 engine total accumulated cycles (TACs). The engine had accumulated 640 operating hours since overhaul. The airframe had accumulated 3,243.7 total flight hours. All time compliance technical orders pertaining to the airframe and engine assembly had been accomplished. A Safety Board review of N73829's airplane logbooks indicated that the last recorded altimeter, static, and transponder system checks were completed on November 11, 1999. The last annual inspection was conducted on April 7, 2000. The last 100-hour inspection was conducted on November 13, 2000. METEOROLOGICAL INFORMATION The nearest weather reporting facility at the time of the accident was Sarasota-Bradenton Airport. The 1553 surface weather observation indicated the following: clear, visibility 10 miles, temperature 80 degrees Fahrenheit, dew point 64 degrees Fahrenheit, wind 210 degrees at 11 knots, altimeter 29.97 Hg. WRECKAGE AND IMPACT INFORMATION The F-16's wreckage was located in a wooded area near Sarasota. The wreckage was about 4 miles southwest of the Cessna 172 crash site on a bearing of 187 degrees magnetic. Examination of the F-16 crash site revealed that the airplane collided with the ground in a left flat spin on a heading of 170 degrees. The right wing was found inverted and had evidence of an impact 81 inches inboard of the wing tip in the vicinity of the SUU-20 (bomb and rocket training dispenser). A aluminum fuel line from the Cessna 172 was found wedged between the lower wing surface and the SUU-20 attachment point. The Air Combat Maneuvering Instrumentation (ACMI) pod, with the associated missile rail launcher (MRL), was separated from the right wing tip at station 9. A faint transfer of red paint was present on the upper aft surface of the MRL. The ACMI pod exhibited scarring discoloration on the upper aft surface. A segment of one of the Cessna 172's flight control cables was found wedged in the F-16's right wing leading edge. The wing's leading edge was deformed upward and aft. Scratches were observed on the upper wing surface between the SUU-20 mount point area and the wing tip. The scratches extended from the wing's leading edge to the trailing edge. The canopy was located about 640 feet northwest of the main wreckage. The canopy was shattered on the left side extending from the 11 o'clock position rearward to the 7 o'clock position. Gouging from the Cessna was present on the canopy rail's leading edge. The gouging extended aft and over the transparency portion of the canopy, ending at the 11 o'clock position. A faint paint transfer was present on the right forward canopy rail. The SUU-20 was found imbedded tail first in the ground adjacent to the entrance of Rosedale Golf and Country Club Community. Part of the Cessna's main landing gear trunnion was found imbedded in the upper leading structure of the SUU-20. Visual examination of the airframe revealed no evidence of a precrash mechanical failure or malfunction. Flight control continuity was confirmed through data retrieved from the crash survivable memory unit (CSMU). The engine assembly was not examined because the pilot reported that he did not experience any engine-related problems before the collision. The Cessna wreckage was located in numerous pieces in the southwest quadrant of the Rosedale Golf and Country Club community on the east side of Bradenton. Numerous small pieces of F-16 structure and canopy material were located within the Cessna debris field. Because of airframe disintegration, verification of flight control continuity was not possible. No preimpact discrepancies were observed during the on-site wreckage inspection. The engine, propeller and forward cabin section were found in one piece at the edge of the main north-south entry road on the southwest side of the complex. The propeller was attached to the engine with the No.2 blade buried in the ground vertically to the hub. Propeller blade No.1's outer 4 1/2 inches was missing. Gray/white paint transfer was observed spanwise at the mid span on the forward side of the No.1 blade. Minor scrapes were observed chordwise on the No. 2 blade, which was imbedded in the dirt. The engine was attached to the engine mounts and firewall, and came to rest in about a 20-degree, right-side-low attitude. The cabin section was separated just forward of the rear seat location. The front and rear seats were not found in the aircraft cabin section. Parts of the seats were found in the debris field. The left front seat belt was found buckled and its length was consistent with normal use. The inboard attach point was found separated from the floor structure. The right wing, including the lift strut, was recovered from a pond. A portion of the cabin roof (rear seat area) was attached to the right wing root. The right wing's flap surface was fully retracted. The left wing was located in the back yard of a nearby residence. The left wing had impacted the roof of the residence, coming to rest in the back yard. The left wing fuel tank had evidence of hydraulic deformation "ballooning," which was more pronounced at the root. The left wing root structure had evidence of span-wise compression damage. A leading edge deformation, semicircular five to six inches in diameter, started at the broken upper wing strut attachment and was oriented forward and outward through the leading edge at a 45-degree angle. An empennage section (baggage area to rear flight surfaces) was removed from the pond about 100 feet south of the right wing location. The bottom side of the empennage section had impact marks, which were oriented approximately 38 degrees from the empennage centerline. The impact marks originated from the right front of the empennage and progressed to the left rear. MEDICAL AND PATHOLOGICAL INFORMATION Toxicology samples from the F-16 accident pilot and flight lead were forwarded to the Armed Forces Institute of Pathology, Washington, DC, for analysis. The results were negative for carbon monoxide, major drugs of abuse and prescription and over-the-counter medications. An autopsy determined that the Cessna pilot was killed by blunt force trauma. The FAA's Forensic Toxicology Research Section in Oklahoma City performed a postmortem toxicology analysis of tissue and fluid specimens from the pilot. The results were negative for major drugs of abuse and prescription and over-the-counter medications. Traces of ethanol were detected, but the toxicology reported noted that "ethanol found in this case may be potentially be from postmortem ethanol formation and not from the ingestion of ethanol." FLIGHT RECORDERS The accident F-16 was equipped with a General Dynamics seat data recorder (SDR). The unit was forwarded to Lockheed-Martin, Fort Worth, Texas, for examination. The flight lead F-16's SDR was downloaded at Moody AFB. The data were forwarded to Lockheed-Martin for further analysis. However, due to a recoding anomaly with the flight lead F-16's SDR, no useful data was recovered. (For additional information see the NTSB F-16 Recorded Data Study attached to this report.) The CSMUs (crash survivable memory units) were forwarded to the U. S. Air Force Safety Center in Albuquerque, New Mexico, for readout and evaluation. The data were forwarded to the Safety Board for further analysis. (For additional information see the NTSB F-16 Recorded Data Study attached to this report.) In addition, the F-16s were equipped with 8mm audio airborne video tape recorders (AVTRs). The tapes were also forwarded to the Air Force Safety Center for analysis. Examination determined that accident airplane's tapes were destroyed by fire. The tapes from the flight lead F-16 were found to have good quality voice and video. The recorded data of the accident sortie covered about 25 minutes, and began about two minutes before the midair collision. Lockheed Martin examined the download data from the crash survivable flight data recorder (CSFDR), the SDR, data printouts from the general avionics computer (GAC), the global positioning system (GPS), the inertia navigation system (INS) and the AVTR tapes from the flight lead's airplane. Lockheed Martin's examination report stated that M Aero stated that GPS "was removed from the navigation solution at some time prior to the midair. It cannot be determined from the data why the GPS was removed from the navigation solution." The report added: "A position error of approximately 9-11 nm was entered into the navigation system at some time on the mishap flight prior to the video recording. It can not be determined from the data what caused this position error." (For additional information see the Lockheed Martin Aeronautics Company Report of F-16C 89-2104 Mishap Investigation and the NTSB F-16 Recorded Data Study attached to this report.) The flight lead stated during an interview conducted by the Air Force Accident Investigation Board that he did not perform an INS update before the accident flight. He stated that navigation along their planned route was conducted in the NAV mode and that they were steering off INS steer points. He added that no INS en route updates were accomplished. The flight lead stated that he not detect any NAV problems on the return flight to Moody Air Force Base after the accident. He stated that he thought the navigation system was functioning correctly and giving him accurate information. He stated, "I had no suspicion at all that there was a navigation system problem." TEST AND RESEARCH Radar data from the FAA's Sarasota-Bradenton ASR7 facility and radar data from the Air Force's 84th Radar Evaluation Squadron (84th RADES) were used to determine the airplane flight paths, speeds and altitudes. (The radar tracks for the three aircraft are shown in the plots included in the recorded radar study.) The F-16 flight entered the top of the class B airspace about 380 knots airspeed and left the airspace at 6,000 feet about a minute later at 360 knots. Speeds of up to 450 knots were noted during the descent. The airspace between Tampa class B airspace and Sarasota class C airspace is Class E airspace, with a lower floor at 700 feet. About 30 seconds after leaving the Tampa class B airspace, the flight entered the Sarasota class C airspace at 380 knots. The flight remained in the Sarasota class C airspace where the midair collision took place. The flight lead's speed remained above 300 knots until the accident F-16's collision with the Cessna. OTHER INFORMATION The Department of Defense's (DoD's) Flight Information Publication General Planning GP, Section E-Supplementary Information, Para 5-35, "Aircraft Speed Below 10,000 Feet Mean Sea Level" states: "(Exemption to Federal Air Regulations 91.177 issued to DOD, May 18, 1978)-Operations below 10,000 feet Mean Sea Level at Indicated Air Speed in excess of 250 knots, in noncompliance with Federal Air Regulations 91.117 (a), are authorized for military aircraft, including Reserve and Air National Guard components, only under the following conditions:... "g. If the airspeed required or recommended in the airplane flight manual to maintain safe maneuverability is greater than the maximum speed described in Federal Air regulations 91.117, the airplane may be operated at that speed." The F-16C/D flight manual, in Section VI, "Flight Characteristics," recommends "a minimum of 300 knots during normal cruise operation below 10,000 MSL." The Air Force Instruction 11-2f-16, F-16 Operations Procedures states in Chapter 5, "Air to Air Weapons Employment," Para 5.3.2, that the "minimum airspeed during low altitude offensive or defensive maneuvering is 350 KIAS." The DoD's Flight Information Publication Area Planning AP/1B, Military Training Routes, North and South America states (in Chapter 2, "VFR Military Training Routes (VR)," Para I, General) that "VRs are developed by DoD to provide for military operational and training requirements that cannot be met under terms of FAR 91.117 (Aircraft Speed). Accordingly, the FAA has issued a waiver to DoD to permit operation of an aircraft below 10,000 feet MSL in excess of 250 knots indicated airspeed along DOD developed and published VFR routes." It further states (in Para IV, Flight Plans) that "operations to and from VRs should be conducted on an IFR flight plan. Pilots operating on an IFR flight plan to a VR shall file to the fix/radial/distance (FRD) of their entry/alternate entry point." The DoD's Flight Information Publication Area Planning AP/1, North and South America notes (in Chapter 3, "Flight Planning 3 f. Class B Airspace") that "generally that airspace from the surface to 10,000' surrounding the nation's busiest airports in terms of IFR operations or passenger enplanements. The configuration of each Class B Airspace area is individually tailored and consists of a surface area and two or more layers and is designed to contain all published instrument procedures once an aircraft enters the airspace. An ATC clearance is required for all aircraft to operate in the area and all aircraft that are so cleared receive separation services within the airspace." CFR Part 91.113, Right-of-way rules (Paragraph (b), General), states: "When weather conditions permit, regardless of weather an operation is conducted instrument flight rules or visual flight rules, vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft. When a rule of this section gives another aircraft the right-of-way, the pilot shall give way to that aircraft and may not pass over, under, or ahead of it unless well clear. (f) Overtaking. Each aircraft that is being overtaken has the right-of-way and each pilot of an overtaking aircraft shall alter course to the right to pass well clear. (g) Landing. Aircraft while on final approach to land or while landing, have the right-of-way over other aircraft in flight operating on the surface, except that they shall not take advantage of this rule to force an aircraft off the runway surface which has already landing is attempting to make way for an aircraft on final approach. When two or more aircraft are approaching an airport for the purpose of landing, the aircraft at the lower altitude has the right-of-way, but it shall not take advantage of this rule to cut in front of another which is on final approach to land or to overtake that aircraft." The FAA's Aeronautical Information Manual, Section 3-2-4, Class C Airspace, states that "two-way radio communication must be established with the ATC facility providing ATC services prior to entry" and that pilots must "thereafter maintain those communications while in Class C airspace." The manual adds that "radio contact should be initiated far enough from the Class C airspace boundary to preclude entering Class C airspace before two-way communications are established." The wreckage of the accident F-16 was released to the Air Force Safety Investigation Board. The Cessna 172 wreckage was released to the owner's agent. ==================== USAF Report begins ============================= 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 |
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Although some mid airs are survivable, and incidents can be easily found and
quoted, the standard for dealing with the avoidance of mid air collisions from the instructor's standpoint as well as the flight safety position is to consider ALL mid airs as potential fatals. To consider a mid air collision as a survivable event is something I have never come across in fifty years of dealing with flight safety issues. I need go no further than June 5th 1971 at the Cape May National Air Races at Cape May New Jersey where in one incident, I witnessed two friends die among the five pilots who died instantly in two mid air collisions there. Mid-air collisions should NEVER be considered as survivable when being discussed in a flight safety context. Citing incidents where pilots survived after mid airs in no way changes or alters in any respect how the subject of mid air collisions is viewed by the safety community; at least this has been my experience anyway. Dudley Henriques "Larry Dighera" wrote in message ...[i] On Fri, 02 Sep 2005 13:31:35 GMT, "Dudley Henriques" dhenriques@noware .net wrote in . net:: Impact has no right of way. It's too late at that point. Everybody dies!! Not all the time. Sometimes only those who are in compliance with FAA regulations are splattered over four acres of golf course and those causing the fatality is erroneously exonerated less than impartial investigators. Below are the NTSB and USAF reports of a MAC in which only the innocent died: MIA01FA028A HISTORY OF FLIGHT On November 16, 2000, at 1548 eastern standard time, a U.S. Air Force F-16CG, operated by the 347th Wing, Air Combat Command, collided in mid air with a Cessna 172, N73829, near Bradenton, Florida. The F-16, based at Moody Air Force Base (AFB), Valdosta, Georgia, was on a low-altitude training mission. The Cessna 172, registered to Crystal Aero Group, was operating as a 14 CFR Part 91 personal flight. The airline transport (ATP)-rated Cessna pilot was killed. The F-16 pilot, who held a commercial pilot's certificate, ejected from the airplane and sustained minor injuries. Visual meteorological conditions prevailed at the time of the accident. The accident F-16 was part of a flight of two F-16s. A composite military instrument flight rules (IFR)/visual flight rules (VFR) flight plan was filed. The two F-16s departed Moody AFB at 1513. The Cessna 172 departed Sarasota Bradenton International Airport (SRQ) Sarasota, Florida, about 1541. No flight plan was filed. The accident F-16 pilot, who was using call sign Ninja 2, stated that he was maintaining visual formation with his flight lead, call sign Ninja 1, when he saw a blur "like a sheet of white" appear in front of him. He stated that the airplane shuddered violently, and part of the canopy on the left side was broken away. The accident pilot stated that wind, smoke, and a strong electrical smell filled the cockpit. He stated that he called his flight lead several times, but could not hear a reply. Because the airplane was still controllable, he decided to try to reach MacDill AFB, and he began a right turn in that direction. He stated that his primary flight instruments were shattered and that he could not see them. He stated that the engine began to spool down and that he realized that he would not be able to make the airport. He stated that he turned the airplane left toward a wooded area away from a residential area and attempted an engine restart, which was not successful. When the airplane cleared the residential area, it started an uncommanded left roll. When the airplane went past a 90-degree bank angle, the pilot stated that he decided to eject. During his parachute descent, he observed the airplane "pancake" into the ground inverted and explode. The flight lead stated that the two F-16s were assigned a block altitude of between 25,000 feet and 26,000 feet en route to the entry point of visual military training route (MRT) VR-1098. As the flight approached the SRQ area, Miami Air Route Traffic Control Center (ARTCC) cleared the F-16s to descend to 13,000 feet. At 1543:39, the Miami ARTCC controller instructed the flight lead to contact Tampa Terminal Radar Approach Control (TRACON) controllers. The flight lead was not successful (because he was given an incorrect frequency), and he reestablished contact with Miami ARTCC and canceled IFR. Miami ARTCC advised him of traffic at 10,000 feet, which was acquired on radar. The controller accepted the cancellation and asked the pilot if he wished to continue receiving radar traffic advisory services. The flight lead declined. According to the air traffic control (ATC) transcripts, the controller then stated, "radar service terminated, squawk VFR [transponder code 1200], frequency change approved, but before you go you have traffic ten o'clock about 15 miles northwest bound, a Beech 1900 at ten thousand [feet]." The flight then began a VFR descent to enter VR-1098. (For additional information see Air Traffic Control Group Chairman's Factual Report attachment to this report.) The flight lead informed Ninja2 that they were going to perform a "G" check (G awareness maneuver). They accelerated to 400 knots, made a right 90-degree turn, followed by a left 90-degree turn back on course, and continued their descent below 10,000 feet. The flight lead then instructed the accident pilot to assume the "fighting wing" formation (with the wingman at the 7 o'clock position behind the flight lead). They continued to descend through 5,000 feet about 6 miles north of the entry point to VR-1098. The flight lead attempted to obtain a visual reference to the entry point. The flight lead also looked at his low-altitude en route chart to reference the class B airspace at Tampa and the class C airspace at Sarasota. About 1547, the F-16 flight was heading south and descending through 4,300 feet on a converging course with N73829. Radar data indicated that the flight had overshot its intended entry point to VR-1098 and was several miles southwest of the MTR. The flight had also inadvertently passed through Tampa class B airspace without the required ATC clearance and was about to enter the Sarasota class C airspace without establishing communications with ATC, which is required by Federal regulations. After continuing to descend, the flight lead looked back to the left and observed the accident F-16 slightly below him at the 7 o' clock position and about 4,000 feet to 5,000 feet behind him. The flight lead also observed a white, high-wing white airplane (the Cessna) in a 30 to 45-degree right turn. The Cessna and the accident F-16 collided in a left-to-left impact at the flight lead's 10 o' clock position, he stated. After the collision, the flight lead observed vaporizing fuel on the F-16's right side. The flight lead did not see the Cessna. The flight lead called the accident pilot and stated, "it appears you have had a mid air and are streaming fuel." There was no response. The flight lead began a left turn to keep the accident F-16 in sight. The flight lead saw the accident pilot bail out and the airplane collide with the ground. At 15:48:55, the flight lead stated, "mayday mayday." At 15:49:11, the flight leader stated, "mayday mayday mayday F sixteen down." At 15:50:00, the flight lead stated, "yes this is Ninja one we have an F sixteen down there is a light aircraft may have also gone down sir I am not sure." The collision occurred about 2,000 feet msl, about 6 miles southwest of the entry point for VR-1098. A review of ATC transcripts of communications between N73829 and Tampa TRACON and communication between Miami ARTCC and Tampa TRACON indicated that N73829 contacted Tampa TRACON at 15:45:19 stating he was off Sarasota-Bradenton at 1,600 feet. At 15:45:23, Tampa TRACON told N73829 to maintain 1,600 feet. N73829 acknowledged the transmission at 15:45:30. At 15:46:59, Tampa TRACON informed N73829 to turn left to heading 320 and to follow the shoreline northbound. At 15:47:10, Tampa TRACON instructed N73829 to climb and maintain 3,500 feet, which was acknowledged by N73829 at 15:47:15. The Miami ARTCC controller contacted Tampa TRACON at 15:47:55 and asked Tampa TRACON for the flight lead's altitude because he had lost radar contact with the lead F-16 (only the flight lead had his transponder activated because formation flights are handled as a single aircraft by ATC). Tampa TRACON replied at 20:48:00, stating "ahh hang on I see him down at two thousand." At 15:48:09, Tampa TRACON informed N73829 that he had traffic off his left side at 2,000 feet. N73829 did not respond. (For additional information see the ATC transcript attachment to this report.) A review of altitude data and ground track data (and airspace boundaries) determined that Tampa TRACON's intruder conflict detection software noted a conflict between the flight lead and the Cessna, and generated an aural conflict alert in the TRACON facility at 1547:39 that continued until 1548:03. The controller receiving instruction at the time of the accident told Safety Board investigators that he heard an alarm (conflict alert), but that he could not recall where it was. The controller providing instruction at the time of the accident stated that he didn't remember whether he saw an alert on his radar display or if he heard an aural conflict alert. He added that conflict alerts occur frequently, and that many were false. The conflict detection system did not account for the accident F-16, or a possible conflict, because it's transponder was in the standby mode. (For additional information see the NTSB Recorded Radar Study and the Air Traffic Control Group Chairman's Factual Report attached to this report.) Witnesses stated that they heard the sound of approaching jets. They observed the first jet flying south, followed by the second jet located to the left and slightly lower than the first. They also observed a small civilian airplane flying from west to east, perpendicular to the military jets. The second jet collided with the civilian airplane and initially continued southbound, according to witness statements. The second jet was observed to make a right turn, followed by a left turn. A parachute was observed, and the airplane was observed to enter a flat spin to the left before it disappeared from view below the trees. An explosion was heard, followed by heavy dark smoke rising above the terrain. (For additional information see NTSB Group Chairman's Field Report, Ninja 1 and Ninja 2 pilot statements, and witness statements.) PERSONNEL INFORMATION Air Force training, flight evaluations and flight records indicated that the accident F-16 pilot, age 31, completed undergraduate pilot training on September 27, 1996. He was qualified in the F-16 on March 3, 1997, and graduated from the F-16 basic course on July 22, 1997. His most recent instrument/qualification examination was completed on October 22, 1999. His most recent mission examination was completed on June 21, 2000. He was qualified as a 2-airplane flight lead on March 19, 1999, and as a 4-airplane flight lead on January 11, 2000. He held a current military flight physical completed on May 30, 2000, with the restriction, "required to wear vision correction devices while performing flying or special operational duty." The pilot indicated on AF Form 1042 that he wore contact lenses while performing flying or special operational duty. A review of FAA records indicated that the accident pilot held a commercial pilot certificate issued on September 9, 1999, with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. In addition, he held a flight instructor certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The pilot's FAA second-class medical certificate was issued on December 21, 1998, with no restrictions. He had accumulated a total of 1,279 flying hours. Air Force training, flight evaluations and flight records indicated that the flight lead completed undergraduate pilot training on May 16, 1980. He was qualified in the F-16 on December 20, 1988, and graduated from the F-16 basic course in March 1989. Following a non-flying tour he completed the F-16 re-qualification course on June 8, 1998. His most recent instrument/qualification examination was completed on September 29, 2000. His most recent mission examination was completed on December 29, 1999. He was qualified as a 4-airplane flight lead on February 10, 2000. He held a current military flight physical completed on August 30, 2000, with the restriction "required to wear vision correction devices while performing flying or special operational duty." The pilot indicated on Air Force form 1042 that he did not wear contact lenses while performing flying or special operational duty. A review of FAA records indicated that the flight lead held an ATP certificate issued on May 18, 2000, with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The flight lead held a first-class medical certificate issued on October 30, 2000, with the restriction "must wear corrective lenses." The Cessna 172 pilot, age 57, held an ATP certificate issued on December 15, 1999, with ratings for airplane single-engine land, multi-engine land, and instrument airplane. In addition, he held a flight instructor certificate with ratings for airplane single-engine and multi-engine land, instrument airplane, and a ground instructor certificate for basic and advanced instruments. His first-class medical certificate was issued on September 14, 2000, with the restriction "must wear corrective lenses and possess glasses for near and distant vision." The pilot's logbook was destroyed in the crash. The pilot indicated on his last medical certificate application that he had accumulated 2,020 flight hours. AIRCRAFT INFORMATION The accident F-16 was equipped with a General Electric turbofan F110-GE-100 engine. The engine was overhauled by Tinker AFB Oklahoma, Air Logistics Center, on December 17, 1998. The engine operating time was 2,537.5 hours, with 5,610 engine total accumulated cycles (TACs). The engine had accumulated 640 operating hours since overhaul. The airframe had accumulated 3,243.7 total flight hours. All time compliance technical orders pertaining to the airframe and engine assembly had been accomplished. A Safety Board review of N73829's airplane logbooks indicated that the last recorded altimeter, static, and transponder system checks were completed on November 11, 1999. The last annual inspection was conducted on April 7, 2000. The last 100-hour inspection was conducted on November 13, 2000. METEOROLOGICAL INFORMATION The nearest weather reporting facility at the time of the accident was Sarasota-Bradenton Airport. The 1553 surface weather observation indicated the following: clear, visibility 10 miles, temperature 80 degrees Fahrenheit, dew point 64 degrees Fahrenheit, wind 210 degrees at 11 knots, altimeter 29.97 Hg. WRECKAGE AND IMPACT INFORMATION The F-16's wreckage was located in a wooded area near Sarasota. The wreckage was about 4 miles southwest of the Cessna 172 crash site on a bearing of 187 degrees magnetic. Examination of the F-16 crash site revealed that the airplane collided with the ground in a left flat spin on a heading of 170 degrees. The right wing was found inverted and had evidence of an impact 81 inches inboard of the wing tip in the vicinity of the SUU-20 (bomb and rocket training dispenser). A aluminum fuel line from the Cessna 172 was found wedged between the lower wing surface and the SUU-20 attachment point. The Air Combat Maneuvering Instrumentation (ACMI) pod, with the associated missile rail launcher (MRL), was separated from the right wing tip at station 9. A faint transfer of red paint was present on the upper aft surface of the MRL. The ACMI pod exhibited scarring discoloration on the upper aft surface. A segment of one of the Cessna 172's flight control cables was found wedged in the F-16's right wing leading edge. The wing's leading edge was deformed upward and aft. Scratches were observed on the upper wing surface between the SUU-20 mount point area and the wing tip. The scratches extended from the wing's leading edge to the trailing edge. The canopy was located about 640 feet northwest of the main wreckage. The canopy was shattered on the left side extending from the 11 o'clock position rearward to the 7 o'clock position. Gouging from the Cessna was present on the canopy rail's leading edge. The gouging extended aft and over the transparency portion of the canopy, ending at the 11 o'clock position. A faint paint transfer was present on the right forward canopy rail. The SUU-20 was found imbedded tail first in the ground adjacent to the entrance of Rosedale Golf and Country Club Community. Part of the Cessna's main landing gear trunnion was found imbedded in the upper leading structure of the SUU-20. Visual examination of the airframe revealed no evidence of a precrash mechanical failure or malfunction. Flight control continuity was confirmed through data retrieved from the crash survivable memory unit (CSMU). The engine assembly was not examined because the pilot reported that he did not experience any engine-related problems before the collision. The Cessna wreckage was located in numerous pieces in the southwest quadrant of the Rosedale Golf and Country Club community on the east side of Bradenton. Numerous small pieces of F-16 structure and canopy material were located within the Cessna debris field. Because of airframe disintegration, verification of flight control continuity was not possible. No preimpact discrepancies were observed during the on-site wreckage inspection. The engine, propeller and forward cabin section were found in one piece at the edge of the main north-south entry road on the southwest side of the complex. The propeller was attached to the engine with the No.2 blade buried in the ground vertically to the hub. Propeller blade No.1's outer 4 1/2 inches was missing. Gray/white paint transfer was observed spanwise at the mid span on the forward side of the No.1 blade. Minor scrapes were observed chordwise on the No. 2 blade, which was imbedded in the dirt. The engine was attached to the engine mounts and firewall, and came to rest in about a 20-degree, right-side-low attitude. The cabin section was separated just forward of the rear seat location. The front and rear seats were not found in the aircraft cabin section. Parts of the seats were found in the debris field. The left front seat belt was found buckled and its length was consistent with normal use. The inboard attach point was found separated from the floor structure. The right wing, including the lift strut, was recovered from a pond. A portion of the cabin roof (rear seat area) was attached to the right wing root. The right wing's flap surface was fully retracted. The left wing was located in the back yard of a nearby residence. The left wing had impacted the roof of the residence, coming to rest in the back yard. The left wing fuel tank had evidence of hydraulic deformation "ballooning," which was more pronounced at the root. The left wing root structure had evidence of span-wise compression damage. A leading edge deformation, semicircular five to six inches in diameter, started at the broken upper wing strut attachment and was oriented forward and outward through the leading edge at a 45-degree angle. An empennage section (baggage area to rear flight surfaces) was removed from the pond about 100 feet south of the right wing location. The bottom side of the empennage section had impact marks, which were oriented approximately 38 degrees from the empennage centerline. The impact marks originated from the right front of the empennage and progressed to the left rear. MEDICAL AND PATHOLOGICAL INFORMATION Toxicology samples from the F-16 accident pilot and flight lead were forwarded to the Armed Forces Institute of Pathology, Washington, DC, for analysis. The results were negative for carbon monoxide, major drugs of abuse and prescription and over-the-counter medications. An autopsy determined that the Cessna pilot was killed by blunt force trauma. The FAA's Forensic Toxicology Research Section in Oklahoma City performed a postmortem toxicology analysis of tissue and fluid specimens from the pilot. The results were negative for major drugs of abuse and prescription and over-the-counter medications. Traces of ethanol were detected, but the toxicology reported noted that "ethanol found in this case may be potentially be from postmortem ethanol formation and not from the ingestion of ethanol." FLIGHT RECORDERS The accident F-16 was equipped with a General Dynamics seat data recorder (SDR). The unit was forwarded to Lockheed-Martin, Fort Worth, Texas, for examination. The flight lead F-16's SDR was downloaded at Moody AFB. The data were forwarded to Lockheed-Martin for further analysis. However, due to a recoding anomaly with the flight lead F-16's SDR, no useful data was recovered. (For additional information see the NTSB F-16 Recorded Data Study attached to this report.) The CSMUs (crash survivable memory units) were forwarded to the U. S. Air Force Safety Center in Albuquerque, New Mexico, for readout and evaluation. The data were forwarded to the Safety Board for further analysis. (For additional information see the NTSB F-16 Recorded Data Study attached to this report.) In addition, the F-16s were equipped with 8mm audio airborne video tape recorders (AVTRs). The tapes were also forwarded to the Air Force Safety Center for analysis. Examination determined that accident airplane's tapes were destroyed by fire. The tapes from the flight lead F-16 were found to have good quality voice and video. The recorded data of the accident sortie covered about 25 minutes, and began about two minutes before the midair collision. Lockheed Martin examined the download data from the crash survivable flight data recorder (CSFDR), the SDR, data printouts from the general avionics computer (GAC), the global positioning system (GPS), the inertia navigation system (INS) and the AVTR tapes from the flight lead's airplane. Lockheed Martin's examination report stated that M Aero stated that GPS "was removed from the navigation solution at some time prior to the midair. It cannot be determined from the data why the GPS was removed from the navigation solution." The report added: "A position error of approximately 9-11 nm was entered into the navigation system at some time on the mishap flight prior to the video recording. It can not be determined from the data what caused this position error." (For additional information see the Lockheed Martin Aeronautics Company Report of F-16C 89-2104 Mishap Investigation and the NTSB F-16 Recorded Data Study attached to this report.) The flight lead stated during an interview conducted by the Air Force Accident Investigation Board that he did not perform an INS update before the accident flight. He stated that navigation along their planned route was conducted in the NAV mode and that they were steering off INS steer points. He added that no INS en route updates were accomplished. The flight lead stated that he not detect any NAV problems on the return flight to Moody Air Force Base after the accident. He stated that he thought the navigation system was functioning correctly and giving him accurate information. He stated, "I had no suspicion at all that there was a navigation system problem." TEST AND RESEARCH Radar data from the FAA's Sarasota-Bradenton ASR7 facility and radar data from the Air Force's 84th Radar Evaluation Squadron (84th RADES) were used to determine the airplane flight paths, speeds and altitudes. (The radar tracks for the three aircraft are shown in the plots included in the recorded radar study.) The F-16 flight entered the top of the class B airspace about 380 knots airspeed and left the airspace at 6,000 feet about a minute later at 360 knots. Speeds of up to 450 knots were noted during the descent. The airspace between Tampa class B airspace and Sarasota class C airspace is Class E airspace, with a lower floor at 700 feet. About 30 seconds after leaving the Tampa class B airspace, the flight entered the Sarasota class C airspace at 380 knots. The flight remained in the Sarasota class C airspace where the midair collision took place. The flight lead's speed remained above 300 knots until the accident F-16's collision with the Cessna. OTHER INFORMATION The Department of Defense's (DoD's) Flight Information Publication General Planning GP, Section E-Supplementary Information, Para 5-35, "Aircraft Speed Below 10,000 Feet Mean Sea Level" states: "(Exemption to Federal Air Regulations 91.177 issued to DOD, May 18, 1978)-Operations below 10,000 feet Mean Sea Level at Indicated Air Speed in excess of 250 knots, in noncompliance with Federal Air Regulations 91.117 (a), are authorized for military aircraft, including Reserve and Air National Guard components, only under the following conditions:... "g. If the airspeed required or recommended in the airplane flight manual to maintain safe maneuverability is greater than the maximum speed described in Federal Air regulations 91.117, the airplane may be operated at that speed." The F-16C/D flight manual, in Section VI, "Flight Characteristics," recommends "a minimum of 300 knots during normal cruise operation below 10,000 MSL." The Air Force Instruction 11-2f-16, F-16 Operations Procedures states in Chapter 5, "Air to Air Weapons Employment," Para 5.3.2, that the "minimum airspeed during low altitude offensive or defensive maneuvering is 350 KIAS." The DoD's Flight Information Publication Area Planning AP/1B, Military Training Routes, North and South America states (in Chapter 2, "VFR Military Training Routes (VR)," Para I, General) that "VRs are developed by DoD to provide for military operational and training requirements that cannot be met under terms of FAR 91.117 (Aircraft Speed). Accordingly, the FAA has issued a waiver to DoD to permit operation of an aircraft below 10,000 feet MSL in excess of 250 knots indicated airspeed along DOD developed and published VFR routes." It further states (in Para IV, Flight Plans) that "operations to and from VRs should be conducted on an IFR flight plan. Pilots operating on an IFR flight plan to a VR shall file to the fix/radial/distance (FRD) of their entry/alternate entry point." The DoD's Flight Information Publication Area Planning AP/1, North and South America notes (in Chapter 3, "Flight Planning 3 f. Class B Airspace") that "generally that airspace from the surface to 10,000' surrounding the nation's busiest airports in terms of IFR operations or passenger enplanements. The configuration of each Class B Airspace area is individually tailored and consists of a surface area and two or more layers and is designed to contain all published instrument procedures once an aircraft enters the airspace. An ATC clearance is required for all aircraft to operate in the area and all aircraft that are so cleared receive separation services within the airspace." CFR Part 91.113, Right-of-way rules (Paragraph (b), General), states: "When weather conditions permit, regardless of weather an operation is conducted instrument flight rules or visual flight rules, vigilance shall be maintained by each person operating an aircraft so as to see and avoid other aircraft. When a rule of this section gives another aircraft the right-of-way, the pilot shall give way to that aircraft and may not pass over, under, or ahead of it unless well clear. (f) Overtaking. Each aircraft that is being overtaken has the right-of-way and each pilot of an overtaking aircraft shall alter course to the right to pass well clear. (g) Landing. Aircraft while on final approach to land or while landing, have the right-of-way over other aircraft in flight operating on the surface, except that they shall not take advantage of this rule to force an aircraft off the runway surface which has already landing is attempting to make way for an aircraft on final approach. When two or more aircraft are approaching an airport for the purpose of landing, the aircraft at the lower altitude has the right-of-way, but it shall not take advantage of this rule to cut in front of another which is on final approach to land or to overtake that aircraft." The FAA's Aeronautical Information Manual, Section 3-2-4, Class C Airspace, states that "two-way radio communication must be established with the ATC facility providing ATC services prior to entry" and that pilots must "thereafter maintain those communications while in Class C airspace." The manual adds that "radio contact should be initiated far enough from the Class C airspace boundary to preclude entering Class C airspace before two-way communications are established." The wreckage of the accident F-16 was released to the Air Force Safety Investigation Board. The Cessna 172 wreckage was released to the owner's agent. ==================== USAF Report begins ============================= 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 "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 |
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On Fri, 02 Sep 2005 22:57:52 GMT, "Dudley Henriques"
dhenriques@noware .net wrote in . net:: Although some mid airs are survivable, and incidents can be easily found and quoted, ... Yep. Here are a couple of mo http://www.ntsb.gov/ntsb/brief.asp?e...13X33340&key=1 http://www.ntsb.gov/ntsb/brief.asp?e...26X00109&key=2 Did you notice that all three I cited are civil/military? In each case the military pilot survived, and in one case the civil pilot did too. |
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![]() "Larry Dighera" wrote in message ... On Fri, 02 Sep 2005 22:57:52 GMT, "Dudley Henriques" dhenriques@noware .net wrote in . net:: Although some mid airs are survivable, and incidents can be easily found and quoted, ... Yep. Here are a couple of mo http://www.ntsb.gov/ntsb/brief.asp?e...13X33340&key=1 http://www.ntsb.gov/ntsb/brief.asp?e...26X00109&key=2 Did you notice that all three I cited are civil/military? In each case the military pilot survived, and in one case the civil pilot did too. I've been reading these reports for years. There's nothing new in them. There is no doubt an ejection seat will improve a mid air situation, and some pilots do survive, but in the safety community we don't treat a mid air as a survivable situation when discussing them in the flight safety context. What is so difficult to understand about this? If you wish to quote mid airs where pilots have survived, by all means be my guest. I'm aware that pilots have survived mid airs. That wasn't my point. DH |
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Dudley Henriques wrote:
This is a tough call, and roughly involves something I've been screaming about for many years in safety meetings. Don't know what you were flying, but the general design of a lot of our airplanes isn't all that conducive to visual checks behind the 3-9 line. Taking a hit through your 7-1 line would be right there in your blind spot. Even low wing is hard to check visually at 7-1. Sure there is Dudely! The submariners call it a "Crazy Ivan"! ;-)) |
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