The NTSB's Final Narrative...
Last Thursday the NTSB released the final report on
the crash of John F. Kennedy Jr.'s Saratoga II on the evening of July 16, 1999. The Piper
PA-32R-301, registered N9253N, was owned and piloted by Kennedy when it crashed into the
Atlantic Ocean seven miles southwest of Martha's Vineyard, Mass., killing its three
occupants. The NTSB listed the probable cause as spatial disorientation. Of all the things
covered by the report, perhaps the most all-inclusive lesson to be learned is that things
can go wrong very quickly. The duration of the flight was approximately one hour and two
minutes. There is no indication from radar records or the post-crash wreckage analysis
that there were any problems at all for a full hour of the total trip time. In fact, the
report indicates that the span of time between the last radar returns, which indicated a
subtle climb (to 2,600 feet) and the final radar contact at 1,100 feet, was approximately
35 seconds. If the estimated descent rate for that final return (more than 4,700 fpm)
remained constant, final impact with the ocean occurred less than 14 seconds later. It has
taken the NTSB a year to investigate all the questions of this case. Keep this in mind: It
is quite likely that the amount of time which elapsed during the last segment of the
accident -- from subtle climb to impact -- was less than the time it took you to read this
paragraph.
…Details The Evidence…
The NTSB investigators sifted through wreckage,
records, and interviews, but with a probable cause of spatial disorientation, pilot
reports of what it was like to fly through the thick haze that night bear most of the
load. Observations on the night of the crash at airports along the route listed visibility
as high as ten miles, but the departure point of Caldwell, N.J., reported visibility at
four miles in haze. Martha's Vineyard airport (MVY) reported visibility at six miles just
prior to the aircraft's departure and Point Judith, R.I., (approximately 30 miles west of
the crash site) reported three miles in haze at 8 p.m., reducing to two miles by 11p.m.
Kennedy, or someone using his user code, made two weather requests from Weather Service
International's PILOTbrief Web site on July 16, 1999. The first request was for a radar
image and the second was for a route briefing from Teterboro. N.J., to Hyannis, Mass.,
with Martha's Vinyard, Mass., as an alternate. Kennedy's last contact with ATC was made
within the first minute of the trip.
According to NTSB computer simulation, approximately 34 miles
from MVY the aircraft began a descent from 5,500 feet, which appears consistent and
controlled until the aircraft began a turn toward the south. The aircraft turned with a
near-constant roll angle of 13 degrees for approximately half a minute and stopped its
descent at 2,200 feet. As the aircraft continued turning, it began to climb at a shallow
angle for thirty seconds and rolled wings level heading to the southeast before leveling
at 2,500 feet and attaining 160 knots. Less than one minute later, the aircraft entered a
left turn with a subtle climb to 2,600 feet. The time was now approximately 9:40 p.m.
local. As the aircraft continued to roll to the left, it began to descend at close to 900
fpm achieving a bank angle of 28 degrees, but within ten seconds, the wings were again
level and the aircraft was heading east. The descent continued at 900 fpm, but the
aircraft began to bank right at nearly a constant rate. Ten seconds later, the bank angle
had exceeded 45 degrees and the airspeed had increased to 180 knots. The bank, dive
angles, acceleration and turn rate increased until impact at approximately 9:41p.m. about
17 miles southwest of MVY.
...That Lead To The Tragic Conclusion
The aircraft had an automatic flight control system
which incorporated a flight director, and was capable of interfacing with a GPS receiver
that was found with the switch in the ON position. The autopilot appears to have been
powered up, but not engaged. Nonvolatile memory extracted from the two transceivers showed
that the radios were tuned for MVY tower, the Bridgeport VOR, Teterboro ATIS and New Haven
VOR. Two frequencies on standby differed from Caldwell ATIS and MVY ATIS by one digit
each. The pictorial display of the flight command indicator indicated a bank angle of
about 125 degrees and a 30 degree nose-down pitch, and the right flight surfaces were
found with more substantial damage than those on the left side. No evidence of upward
bending was found on the wing spar. The airspeed indicator needle had made a mark on the
face of the instrument at the position of maximum travel. The fuel selector valve was
found in the off position, but the selector valve linkage was deformed and engine
instrument needles were stuck at 2750 rpm and 27 inches Hg with fuel flow indicated near
22 gallons per hour. The position of the flaps was not determined in the report, but
landing gear actuators were found in the fully retracted position. The alternate air
control was closed.
Kennedy's most recent logbook was not found, but it has been estimated that his total
flight time was 310 hours (with 55 hours night time) at the time of his death. Time in the
accident aircraft was near 36 hours with almost ten at night. He had flown routes similar
to the accident route roughly 35 times over a span of 15 months prior to the accident. It
has been established that, within the four months leading up to the crash, he had
accumulated at least 30 hours of instrument instruction from Flight Safety International,
plus more than eight hours of instruction in actual IMC and had passed his written for the
instrument exam with a score of 78. He had also flown the same route, in the same
airplane, with an instructor, at night, to a landing in IMC at MVY 15 days prior to his
last flight.
Of all the questions left unanswered, we'll pose just one: If it had been you, would
you have gone?
NOTE: AVweb's NewsWire coverage includes the complete narrative of the
NTSB final report on the John F. Kennedy Jr. accident.
But This Time You Can Opt Out
It seems that the FAA has begun a mail campaign as part of
Section 715 of the Aviation and Investment Reform Act for the 21st Century to
make airmen's addresses available to the public -- again. The letter, from L. Nicholas
Lacey, Director, Flight Standards Service, indicates that the FAA will offer every
airman's name, address, and ratings to anyone who goes looking for them "120 days
following its enactment (August 4)." Now, the FAA is perfectly willing to withhold
your information from those who might seek it for the price of a letter indicating the
degree of your paranoia and the price of a stamp. However, you should consider that for
all the Nigerian-based-bank-account scams you might avoid by being taken off the list, you
might also miss out on any or all new mailings from aviation associations and industry
organizations intent on disseminating information about: new products, flying techniques,
legislative and regulatory issues (which might pose negative consequences to you),
aviation-related special events -- oh, and mailings addressing key safety concerns. For
those of you who enjoy receiving that sort of stuff, rest assured that to do so the effort
involved is minimal -- just don't do anything and the FAA will take care of it for you.
And to everyone who is concerned that the FAA isn't really on top of this, rest assured
that " your name, address, and ratings held are the only information that will be
made available no matter what you choose to do" -- well, you know what they mean.
Also, if you're particular about where you get what mail, the FAA has added the option of
listing a mailing address for you which is different than your home address as maintained
by the FAA.
NOTE: AVweb has been a strong advocate of this more reasonable approach to
the release of pilot data, as evidenced by the articles "Throwing Out The Baby With The Bath Water"
and "Martha King Speaks Out".
United Pilots Are Just That...
United
Airlines, the nation's largest carrier, confirmed last week that it has cancelled nearly
5,000 scheduled flights between May and September as a result of being unable to convince
its pilots to work overtime. While the number seems huge, so is the carrier, and
ultimately the cancellations reflect only about 2% of the carrier's scheduled operations,
which can see as many as 2,500 flights per day. Still, the economic impact of shutting
down flights when United is seeing its aircraft operating at near 90% capacity is not one
that goes unnoticed, and the carrier's 11,000 ALPA member pilots still stand a chance of
being heard as contract negotiations continue. Because of the airline's distribution of
pilots, the "strike" -- it was never formally announced -- initially stood to
impact the carrier's west-coast operations the most, but management has acted to spread
the cancellations across the entire route system covered by the airline. Still,
union-induced management angina is far from over for United. The pilots are using United's
recent proposal to buy US Airways to leverage their position -- they have formally come
out against the merger ... but are open to a change of position if their labor concerns
are attended to favorably. And what would "favorably" mean exactly? Well, it
seems at least part of a favorable outcome would include the hiring of some new pilots, as
United's are claiming that their ranks have grown too thin. How's that day job treating
you?
...But Air Canada Pilots May Be A Step Ahead
They're back at the tables and talking again in Canada, but that doesn't mean
that there will be an end to the threat of an Air Canada pilots' strike anytime soon.
Still, there has been no fresh talk of setting a strike date, and voices on both sides of
the talks seem optimistic that the key issues of wages, pensions and seniority swirling
around Air Canada's takeover of Canadian Airlines and the company's allocation of the two
route networks may yet be resolved. The pilots voted almost unanimously in favor of a
strike just last month, but cannot legally take action without giving Air Canada at least
72 hours notice. Complicating matters are Air Canada's plans to start new services
including a discount airline, cargo carrier and charter. The company's pilots have been
working without a contract since April 1 of this year, and while that's no big deal by
U.S. standards, that's nothing to brag about.
Safety On The Ground: NTSB Ups The Ante
The NTSB recommended last week that the FAA "require, at all airports with
scheduled passenger service, a ground movement safety system that will prevent runway
incursions," but they didn't stop there. The recommendation includes changes that
would require all runway crossings to be authorized by runway-specific clearances, which
means (among other things) that when multiple runways will be traversed, explicit
instructions must be issued for each successive crossing after the previous runway has
been forged. But wait, there's more. Under the recommendation, no aircraft would be
allowed to take position and hold on an active runway at night or any time when conditions
might prevent arriving aircraft from identifying traffic on the runway in time to safely
initiate a go-around. Further, the pace and phraseology used for ATC parlance would be
getting some more attention -- specifically in the form of training which would reinforce
the use of standard ICAO phraseology, with special attention to the rate of speech
controllers use when dealing with foreign flight crews.
NOTE: AVweb's NewsWire coverage includes the
NTSB recommendation letter on improved ground movement safety in Adobe's Portable
Document Format, free readers for which are available at www.adobe.com.
Big Black Hole Down Under
Last Thursday evening a power blackout turned the Sydney,
Australia, airport into a non-tower field for more than ten minutes, about 20 commercial
aircraft approaching the airport to ad-lib-it while personnel scrambled to reboot systems
-- what did you think we were talking about? The blackout occurred just after 6 p.m. local
time during a period of peak evening traffic at the airport. As a result, while more than
1,000 passengers aboard aircraft that were maneuvering within 45 nautical miles of the
airport were preparing for landing, their pilots were busy trying to figure out why no one
was talking to them. While Australian officials were quick to suggest that the pilots
avoided multiple potential disasters by choosing to enter holding patterns, one has to
wonder if their choreography suffered from all those pilots coming to that decision
independently and at different times. In fact, some pilots simply chose to head back out
to sea while the airport personnel scrambled around in the dark. The cause of the blackout
was unknown and at the time of this writing it was not known why backup systems also
failed -- or whether controllers will be keeping candles in the tower from now on. Don't
forget the matches.
Cheap Seats, Cheap Grub
It's not easy making money in the airline business and it seems
that the airlines have found some unique ways to try to keep more of it. The Wall Street
Journal reported last week that in 1999, America West created a meal plan that matched the
quality of food dispensed with the revenue earned by the flight. This basically translates
to travelers flying higher-revenue business routes getting fancy meals with salads and hot
entrees while flights taking coachloads of vacationers to WallyWorld get the leftovers --
so to speak. If they're lucky, that means a sandwich in a bag. Though the phenomenon isn't
restricted to America West (Continental cuts back on the croutons too), the airline did
come off a $2.5 million civil penalty in 1998 -- but the food formula probably has more to
do with stiff competition from low-fare Southwest Airlines. At the other end of the
market, some airlines are expanding their cuisine choices, such as Northwest's plans to
expand its food service to the tune of an extra $23.7 million annually.
The Great Plane Robbery
Last Thursday at the international airport in Brasilia, Brazil, 15 men removed
$500,000 worth of gold from a Vasp airliner with some 70 passengers on board as it
prepared to depart. The men, who were described as heavily armed, entered the airport in
three cars through a cargo hangar, made their way directly to the aircraft and forced open
a cargo hold. They quickly removed 132 pounds of gold, which had just been delivered to
the airport by helicopter, and fled, exchanging gunfire with airport security. Though one
bullet found its way into the wing of the airliner, the fuel tank was not ruptured and no
injuries were reported in the drama. As startling as this heist seems, airport robberies
are not unheard of in Brazil, and Sao Paulo and Rio de Janeiro airports in particular have
suffered from rather high crime rates in recent years. Something to keep in mind when you
plan your next vacation...
Air France Jumbo Gets Fighter Escort
No, not because they were under the threat of attack, but because they had a complete
communications failure. The French air force said officials at Paris Charles de Gaulle
airport requested help last Tuesday after losing contact with an Air France Boeing 747
traveling from Miami with 275 passengers. The air force sent a Mirage 2000 fighter up to
find and then escort the 747 to a safe landing. Early reports are the jumbo lost
communications after being struck by lightning. Makes you wonder why airlines don't equip
their cockpits with inexpensive handheld com radios for just such scenarios.
Good Ways To Use Your Radio
A Cessna 170 pilot flying two passengers from Washington state to Williams Lake, B.C.,
last Wednesday radioed that he had become disoriented in bad weather, was low on fuel and
was contemplating using a local highway to land. Alerted to the situation, police cleared
one of the only straight lengths of highway and hoped for the best as the disoriented
pilot circled somewhere in the cloud-shrouded mountains between Squamish and the town of
Whistler. Luckily, the 170 was intercepted by a private helicopter and a B.C. Air
Ambulance helicopter which had been dispatched to clean up whatever mess might have been
created if the aircraft had an abrupt encounter with the local countryside. Both
helicopters established visual and radio contact with the aircraft and guided it through a
mountain pass to a small airport where the 170 terminated its flight much less eventfully.
Priority Pet Program?
Just in case there was anyone out there who wasn't convinced the
economy was going gangbusters, we'd like to mention that Northwest will be adding 18
positions for " Priority Pet" program staffers to cater to the needs of VIPs
(very important pets) and a toll-free number for pet owner assistance. The positions will
be added at three of the airline's hubs, which will also receive their very own, brand
new, air-conditioned vans to transport the animals and their new support teams. The phone
service will be handled by personnel with special skills in handling policy questions and
describing documentation requirements for traveling pets. The new program comes with a new
pricing structure for pet travel in North America, which will apply fees based on weight
and size for all pets carefully thrown into the checked luggage compartment while holding
reservations made after July 18. For pampered pets fortunate enough to weigh in under 15
pounds -- and be considered "carry-on luggage" -- fees will remain the same. We
don't know what exactly prompted Northwest's special pet PR campaign, but then we don't
know which carrier's jet crushed the bunny on the center runway at DFW the other week
either...
American Airlines dropped all legal motions related to a recent court ruling
allowing long-haul service from Love Field in Dallas, Texas...
Under AIR-21, Washington National opened airport to eight new carriers which
currently have no service to the field...
Flight attendants held a day of action last Thursday to raise awareness of the
safety threat imposed by unruly passengers and air rage...
The results of Alaska Air's internal safety review were released Thursday and
agreed with the FAA's findings that the carrier needs to improve safety and maintenance
procedures...
Syrian hijacker was seeking asylum in Germany according to reports about last
week's violent highjack attempt of a Royal Jordanian Airlines Airbus A320...
Crash of the Avro Lancastrian "Star Dust" of Aug. 2, 1947, blamed on
pilot disorientation due to "ignorance" of the jetstream.
From our "Eye of the beholder" file...
The student pilot was too high on his approach so he decided to use a slip to lose some
extra altitude. But, being not very experienced, the maneuver lacked somewhat in
effectiveness. The instructor, a bit surprised seeing such execution, asked his student,
"What was that?!"
The student, a bit embarrassed by the tone in the instructor's voice, responded,
"Well, it was a slip...."
The instructor, unconvinced, responded, "No, that wasn't a slip, it was an
intentional loss of control."
Contributions to Short Final are welcomed at sf@avweb.com.
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