31 December 2015

Ben Davis

111 Tulane Dr. SE

Albuquerque, NM 87106

Draft Consulting Expert Report

Professional Background

My name is Don Lewis and I am a professional pilot for a major United States airline. I have been

actively engaged in private, corporate, and commercial aviation for over 25 years and in that time

accumulated over 12,000 hours of flight time in aircraft ranging from two-seater light planes to large

transport category airliners. During this time I have served:

in both Captain and First Officer capacities in aircraft type certificated for two or more pilots,

and

as a Standards Captain for an FAR 135 domestic and international on-demand passenger jet

transport operator (charter),

assistant manager in an FAR 91 corporate flight department engaged in domestic and

international passenger jet operations,

manager of a Fixed Base Operator engaged in private, light-aircraft rental and maintenance,

a Flight Controller ensuring FAR 135 operational control and compliance for each aircraft and

crew member operating under the certificate holder.

I graduated with honors from Embry-Riddle Aeronautical University with a Bachelor of Science degree

in Professional Aeronautics and a minor in Aviation Security and Intelligence. My professional

certifications include a Multi-Engine Land Airline Transport Pilot certificate with type specific ratings

in five different turbojet aircraft and a Single-Engine Land Commercial Pilot certificate.

While I have not specifically flown the incident aircraft (Raytheon Aircraft Company Bonanza G36) I

have flown other Beechcraft1 Bonanzas including the A36, F33, and the V35 and am familiar with its

flight characteristics.

Documents Reviewed

Analysis for my opinions are based on review of the following:

Maintenance records subpoenaed from Cutter Aviation,

The post-crash incident videos produced by the New Mexico Department of Public Safety,

The surviving pilot logbooks not destroyed in the incident crash,

Transcript of the Steve Blake deposition,

Complaint for Wrongful Death & Other Damages,

Def Hochla Answer to Pltfs' Complaint for Wrongful Death & Other Damages,

Hochla Production re Plane,

State of New Mexico Incident Report,

FAA Aerospace Medical Files,

Witness Statements from

◦ Philip Ormand

◦ Matt Ormand

◦ Thomas Beddow, and

Factual Report from the National Transportation Safety Board investigation.

Summary of Preliminary Opinions

The Raytheon Aircraft Company Bonanza G36 is an advanced light airplane intended for the

experienced pilot. It offers speed and comfort at the expense of docility and forgiveness.

The incident pilot did not execute a stabilized approach into Whiskey Creek Airport which was

exacerbated by the meteorological conditions existing at the time.

1 Beechcraft was purchased by Raytheon Company on 8 February 1980. In 1994, Raytheon merged Beechcraft with the Hawker product line it had acquired in 1993 from British Aerospace, forming Raytheon Aircraft Company.

The incident pilot failed to execute a go-around in a timely manner while it was still safe to do

so.

The incident flight was not one of his routine flights, but a special flight which exerted a

pressure on him to complete the mission as promised.

Preliminary Opinions

I have been asked to evaluate the reasonableness of the incident flight, offer explanation and

elaboration relating to the NTSB investigation, and offer my opinion on how this incident should have

been avoided.

The incident aircraft (N536G) is a modern variant of the Beechcraft A36 Bonanza first built in 1970,

itself based on an airframe that was first introduced in 1947. N536G had a 300 horsepower engine with

retractable landing gear and considered a complex, high-performance aircraft by the Federal Aviation

Administration. The incident pilot first flew N536G on 8 Jan 2011.

In general the Bonanza line of aircraft are considered “slippery”, meaning that they are among the

fastest single-engined piston aircraft available to the general aviation consumer. The Bonanza's

characteristics make it significantly different than the type of aircraft used in pilot training or beyond.

Aircraft used in pilot training are by design more docile and forgiving in pilot inexperience or

inattention. The Bonanza is not at all like these training aircraft. The Bonanza has faster approach and

landing speeds in addition to its sleek airframe which offers very little drag opportunity compared to

other aircraft.

While Its range of speed, from 61 knots at the low end to 205 knots at the high end affords the pilot a

rather large envelope of performance, it is rare in the sense that the Bonanza is very well capable of

cruising towards the top end of its speed envelope, whereas most aircraft are only capable of reaching

their top speed in a dive.

A good overview of industry opinion comes from the Aircraft Owner's and Pilot's Association where

they describe the G36 Bonanza in the following way2.

Over the years, the Bonanza has grown in size, engine power, and model designations, always

preserving its well-earned niche. Bigger than competing Mooneys, faster than competing

Pipers, with great fit and finish and plush, tasteful interiors, it seems that the Bonanza's

designers have simply gotten it right from day one.

This is not to say that the Bonanza has been trouble free. The same slipperiness and light control

forces that give Bonanzas their famed speed and handling characteristics also could lead to

high-speed, loss-of-control accidents if a pilot was inattentive or not proficient. And there have

been many such accidents over the years.

From my personal experience flying the Bonanzas a landing begins many many miles from the airport.

Due to this “slippery” airframe (and high-powered engine shock-cooling3) there are times you must

begin managing the speed sometimes up to 30 miles from the airport. Certainly by the time you arrive

in the traffic pattern your speed has to be slow enough to begin extending the landing gear and flaps.

The incident aircraft is considered an advanced aircraft requiring a higher degree of pilot experience

and skill as well as an advanced level of judgment to stay ahead of the aircraft. Regardless of the

weather conditions, the level of skill and judgment exhibited by the incident pilot during this incident

was below that required to safely fly the aircraft.

While the weather that day was not perfect, I would not consider the weather on its own to possess any

danger to flight, but it was unquestionably a threat to be mitigated. Depicted in the pictures produced

from the incident flight, Virga (a type of rain which does not reach the ground) indicated the probability

of gusty winds up to and including windshear and should have been at the forefront of the pilot's mind

as he approached the Whiskey Creek airport that day.

2 Horne, Thomas A. (2006, October 1). Gimme a G. Retrieved from HTTP://www.aopa.org/News-and-Video/All-News/2006/October/1/G36-Bonanza

3 A “high-powered” air-cooled piston engine cannot simply be reduced from cruise power to idle power without causing dramatic cylinder-head temperature changes. Which, over time, will damage the engine. Therefore, these higher-performance engines need to be cooled slowly by incremental power reductions during the descent and require attentive management during the approach and landing phase of flight.

I do not necessarily believe that the pilot was negligent in approaching the airport and attempting the

landing but I believe that continuing the approach as it became obvious that it was not progressing

normally (for example: excessive bank angle attempting to line up with the runway and excessive

speed carried on the approach) was negligent.

By definition flight takes place in an atmosphere that is fluid and constantly changing. Clear, calm

days are enjoyable but rare; so it is to be expected that at some point, either by choice or happenstance,

that a pilot will find him or herself in less than ideal weather conditions. As student pilots we are

trained to avoid the danger. As our experience grows we are trained to expand our skills to a greater

envelope and given the tools to do so. However, as most endeavors of time, all training is based on the

foundation of the training that came before.

I believe that the plane crashed due to an unstabilized approach that was continued to its destruction.

There were several indicators that a go-around was necessary. Indicators so prominent that even

witnesses on the ground could see the imminent crash unfolding.

One of the skills obtained through study and honed during flight training is recognizing one's limits and

the limits of the aircraft. Regardless of the thoroughness of preflight planning and preparation it is

completely reasonable to expect that any of a myriad of conditions could change during the course of a

flight. Recognition of these threats requires constant analysis and evaluation to keep the flight either

progressing safely or utilizing an “out”; for example diverting. These skills are called tools, tools that

we use to counter the threats that arise during a flight. One of the most fundamental tools is the balked

landing or go-around.

As an experienced major airline pilot I can attest to the very normal and routine procedure of what we

call “going around”. Every pilot has been doing them since basic training. In fact, it is introduced

early in a student pilot's flight instruction and a procedure that must be mastered before an instructor

will endorse a student pilot for the right of passage known as the first solo flight.

While in the beginning many of the go-arounds are self-induced ( from unstabilized approaches ) go-

arounds continue to be an ever required technique that every pilot will be performing routinely for the

rest of their careers. Even the crusty 60-something airline captain will be called upon to execute a go-

around from time-to-time. Less likely the result of a mistake that they have made but more likely from

external influences such as the weather or Air Traffic Control.

One fact that the general public does not know, is that the go-around rate is one of the metrics used in

pacing airport arrivals. In an effort for efficient runway utilization at busy airports Air Traffic Control

exercises aircraft spacing such that the landing aircraft is pulling off of the runway as the next aircraft

is touching down. This tight spacing necessitates that at some point, under changing conditions, this

spacing will be too tight and a go-around will be necessary. You may have heard this yourself when a

captain announced over the PA that “an aircraft was on the runway” while climbing away from the

ground after you were about to land. Therefore, I hope this explains that go-arounds are so normal that

they are actually considered routine and utilized for normal operations.

Why the incident pilot did not choose to go around is unknown. The National Transportation Safety

Board (NTSB) proposed that the existing weather conditions (lightning in the vicinity and high winds)

may have affected the pilot's judgment. Meaning that the incident pilot may have felt an urgency to

return for landing. However, Grant County Airport, whose runway was more closely aligned with the

existing wind, was less than 15 air miles south of Whiskey Creek. Which, were the weather conditions

at Whiskey Creek truly beyond the capabilities of the aircraft, the pilot could have elected to divert to

Grant County. From Grant County Airport the pilot could have simply waited for weather conditions

to improve at Whiskey Creek or had the school pick up the children at Grant County Airport; a Google

Maps drive time of 23 minutes.

The incident pilot did not declare an emergency, nor did any witnesses on the ground see or hear

anything abnormal emanating from the incident aircraft prior to the landing attempt, there is no reason

to believe that the incident flight was operating under any duress with an immediate requirement to

land as soon as possible.

Considering the extreme maneuvers executed by the pilot on the approach, the chain of events was set

regardless of the weather conditions. The NTSB also posited that windshear or gusty winds could have

contributed to the final roll and crash of the airplane. It is important to note that the NTSB is tasked

with considering every factor relating to a crash; regardless of how minimal its influence. However, as

I will outline below, the aircraft was already in an extremely dangerous condition before reaching the

runway and while any possible weather events certainly did not help, the outcome would have been the

same under mild weather conditions.

The concept of a stabilized approach is taught early during a pilot's training, shortly after basic flying is

introduced. While the layman focuses on the intensity of the subtle kiss of the wheels onto the runway

at touchdown, the reality is that the landing began several miles from the runway. To expedite the

understanding of this concept I will start at the end and work backwards.

The landing is not truly over until the airplane is moving at a walking pace, what we call “taxi” speed.

At this point the air is no longer able to influence the aircraft to any great extent other than perhaps

buffeting the wings and tail if the winds were strong enough. In order to get to this walking pace the

plane must have sufficient distance along the ground with its wheels in contact with the surface.

Through a combination of air resistance, rolling resistance, and braking the airplane reaches this

walking pace.

In order to have sufficient distance to transition from flight to taxi the pilot is compelled to touchdown

in the Touchdown Zone of the runway. The touchdown zone is considered to begin 1,000' feet from the

arrival end of the runway in use. While one might consider that touching down at the very beginning

of the runway pavement may seem desirable, it is actually not considered the safest area for touchdown

as it removes any layer of safety for last second changes to airspeed or sink rate. In simple terms you

want runway beneath you the last few seconds before touchdown.

The next section, while tedious, is necessary to understand the complexity of the actual touchdown and

highlight the purpose of a stabilized approach, and further highlight the necessity and normalcy of

going-around. I will try not to get any more technical than necessary to highlight the concepts

involved.

The actual point of touchdown is a very delicate ballet between airspeed, sink rate (rate of descent),

power setting, wind correction (crosswind, headwind, tailwind) and runway conditions (for example a

wet or icy runway). The variable of runway conditions is somewhat self explanatory and had no affect

on the outcome of this flight. With this understanding I will move to the other variables, the first of

these to consider is airspeed.

Airspeed is mathematically linked to the angle-of-attack of the wing. For a successful landing airspeed

must be managed within very tight constraints. Since too low of an airspeed is just as dangerous as too

high of an airspeed at landing; the latter of which led to the devastating outcome of this flight.

On the low side a pilot needs an airspeed slow enough that the plane can be enticed to stop flying.

Additionally, considering that you need to touch down on the rear wheels4, the nose of the aircraft also

needs to be angled up at the point of touchdown. Favorably, a low airspeed gives us these two things:

1. insufficient energy for the aircraft to “zoom” away from the ground, and

2. a speed slow enough that the aircraft can touchdown in a nose-high attitude.

Of course, too-low an airspeed means an angle-of-attack5 where the wing is no longer able to keep the

aircraft aloft, and is a very dangerous condition considering the proximity to terrain during a landing.

However, too high of an airspeed is actually considered an equally dangerous condition.

When an aircraft approaches landing with too high of an airspeed we have several problems that exhibit

themselves. In addition to the excess energy which must be dissipated to reach taxi speed, any attempt

to raise the nose for touchdown will cause the aircraft to climb away from the runway (zoom). This

airplane, now with its nose pointed up and climbing, is still being pulled by gravity and this condition

along with an engine at idle (for landing) creates decaying airspeed and a condition rapidly

approaching the danger of too low of an airspeed.

The second and third considerations for touchdown are power setting and sink-rate, which are also

mathematically linked. You can be perfectly on speed but have too high of a descent rate and bounce

away from the ground at landing or even worse structurally damage the aircraft. The appropriate

technique for controlling the rate of descent is power setting.

4 The nose-wheel of an airplane with tricycle-type landing gear is not considered a landing wheel. Dangerous consequences arise from allowing the nose-wheel to touchdown first; an out-of-control condition called “wheelbarrowing”.

5 Angle-of-Attack: The angle between the wing and the relative wind approaching the wing. This angle is purely a product of the aircraft's movement through the atmosphere and is independent of the actual horizon.

The power is modulated during the approach in order to keep a stabilized descent rate and only pulled

to idle for the actual touchdown. One of the skills learned during flight instruction, which helps with

mastery of the power setting, is reaching the touchdown zone of the runway - on speed - and gently

modulating power to keep the plane from neither landing nor taking off again. A skill exhibited by

maintaining a constant height, usually a few inches, off the runway until the instructor says to actually

land or go-around.

The fourth consideration to touchdown is wind correction. While operating into a perfect headwind is

always desirable for takeoff and landing it is very seldom possible. Simply because the runway is

literally set in concrete and the atmosphere is not. So it is a regular, everyday, and expected occurrence

that a pilot will need to compensate for some degree of wind variation with respect to the runway. It is

important to note here that while having a headwind or a crosswind with at least some headwind

component is the preferred default value for takeoff and landing, it is not actually required. Sometimes

tailwind operations are necessary; be it for terrain at the end of the runway, airport flow, or any other

variable precluding operations “into the wind”. In fact, while not necessarily published as a

“limitation”, most aircraft, including the Bonanza, have performance calculations for up to 10 knots of

tailwind.

Regarding crosswinds there are two generally acceptable techniques for countering a crosswind on

landing. Each technique would require a lengthy explanation and would add little to the substance of

the report. Suffice it to say that each technique has the same goal, to have the aircraft pointed down the

runway centerline with zero side-drift. Regardless of the differences between the two techniques,

setting up for a crosswind does take time in order recognize and establish an effective correction that

the pilot will take to the runway.

Following this primer on the different variables effecting the actual touchdown of an aircraft to the

runway it is apparent that you need several variables to be within tight tolerances in order to achieve

the actual touchdown. This is where the concept of the “stabilized approach” is introduced.

AvWeb columnist Thomas P. Turner describes the stabilized approach concept in the following way6:

Predicting aircraft performance by using the same technique every time;

Increasing situational awareness by allowing the pilot to focus on instrument or outside

references, as appropriate to conditions, instead of diverting attention to changing trim,

power and configuration settings during final approach;

More easily detecting and correcting for glidepath deviations;

Increased ability to establish crosswind corrections; and

Landing in the touchdown zone at the proper speed to ensure landing performance.

One of the tenets of the stabilized approach concept is that of “gates”. Gates are predefined points

along the approach path where an evaluation is made regarding the condition of the aircraft and the

feasibility of a successful landing. Each successive gate has tighter tolerances for acceptable variance

to a normal approach. The overlying concept here is that an aircraft not within certain parameters

should not pass through the gate and the inverse in that an aircraft within acceptable parameters could

be reasonably expected to pass through the next gate and so forth all the way to touchdown.

For commercial airliners our gates begin at 1,500 feet above the ground with tolerances for airspeed,

sink-rate, power-setting and wind corrections that get progressively tighter until the final gate at 500

feet where any variable out of tolerance is an immediate go-around. While these gates are effectively

considered regulations by virtue of each airline or charter operator's operating certificate, it is not “set

in stone” in this manner for private aircraft.

While the concept is clearly outlined by the FAA and codified in numerous documents and publications

it is left to the individual pilot to establish these gates in recognition of each pilot's differing abilities

with relation to the flight characteristics of each aircraft. Regardless, it is a concept introduced to the

student pilot and whose mastery is required before the first solo flight and must be exhibited during a

checkride and any subsequent Flight-Reviews.

6 Turner, Thomas P. (2008, November 3rd). Leading Edge #23: Stabilized Approaches in Light Airplanes. Retrieved from HTTP://www.avweb.com/news/leadingedge/leading_edge_23_stabilized_approaches-199047-1.html

The first indication for the pilot of an unstabilized approach would have become apparent on the base7

to final turn. Shortly after initiating the turn to final the pilot would have noticed that the aircraft was

overshooting the extended centerline of the runway. The FAA considers a 30 degrees bank to meet

stabilized approach criteria; the incident flight reached 60 degrees of bank in an attempt to align with

the extended centerline of the runway. Once a bank angle exceeding 30 degrees was necessary to

return to the extended centerline, then a go-around should have been initiated. Followed by a full

pattern around the airport to observe the existing wind patterns (viewing the wind socks at the field).

Assuming that the winds were still favorable for a landing to the north then the pilot could have begun

his next base to final turn sooner in order to compensate for the wind effects on his ground track. In

addition to the shorter base leg, in recognition of the gusty crosswind the pilot could have extended the

downwind leg by a few more miles to provide for a longer final approach segment affording more time

to setup the necessary corrections.

The next opportunity for a successful go-around would have been on the final approach. On a

stabilized approach, the rapidly approaching runway would have offered further evidence of a non-

normal landing condition as the aircraft was consistently too high in addition to the excessive airspeed

required to keep the aircraft pointed down at the touchdown zone. Either of these factors on their own (

high groundspeed, high sink-rate, excessive airspeed ) demanded at go-around at this point; the incident

aircraft had all three.

The last opportunity for a go-around was actually a long opportunity in that between the point that the

aircraft flew over the touchdown zone too high and too fast to land and the actual point of touchdown

(a distance of several thousand feet), a successful go-around could have been conducted from any point

along this span. A go around from this span with the aircraft airborne at a safe flying speed would have

been successful.

Ultimately, reading between the lines of the events immediately preceding the crash, there was a pilot-

induced time compression. No landing should ever be conducted at a break-neck pace. In other words,

a normal landing should be a long, methodical, and slow process affording every opportunity to

7 The base leg of an airport traffic pattern is the ground path perpendicular to the final approach course.

recognize developing anomalies. Countering those anomalies with techniques and going-around when

those techniques are insufficient.

At the point that the pilot initiated the go-around, the safest course of action would have been to try to

slow the aircraft as much as possible and roll off of the end of the runway at a relatively slow speed.

Analysis of the NTSB report, including eye witness statements, describes an aircraft that did not match

stabilized approach criteria. The excessive bank angle and excessive speed, either of which would have

called for a go-around, were ignored by the incident pilot. The aircraft was forced into a position

where it could not possibly land. Evidenced by the plane floating almost two-thirds of the length of the

runway before actually touching down. Even still at touchdown the speed was too high to allow the

aircraft to stop within the remaining runway.

Referencing the data from the hand-held portable GPS system presented in the NTSB report the last 44

seconds of the flight:

... the airplane's position returned at 1552:42 as the airplane was over the runway. At that

time, the airplane was about 770 feet down the runway and 175 feet above ground level.

At 1552:53, the airplane touched down with a groundspeed of 120 knots, skipped, and

touched down 3 seconds later at 100 knots groundspeed with about 1,810 feet remaining

on the runway. The airplane slowed to 87 knots and with 1,060 feet remaining on the

runway the airplane's groundspeed began to increase...

It was at this point, without adequate runway remaining, that the pilot chose to initiate the go-around.

However, as the aircraft did slow somewhat during its short time on the ground its airspeed was too

slow to accelerate back to a safe flying speed (under the conditions) on the remaining runway. The

pilot made a last second decision to force the airplane into the air to avoid running off of the end of the

runway. As has happened many times before during this scenario, the aircraft may have enough energy

to zoom off of the runway but does not have enough airspeed to fly.

The aircraft struggled to stay airborne in spite of the low speed and high power; but as the energy of the

zoom dissipated and the wing began taking over its gravity-fighting role the insufficient lift caused an

aerodynamic stall. Typically in this scenario, either due to the high torque of the engine, propwash

effects along the airframe, or even the effects of the gusty wind conditions or a combination of all of

these, one wing will stall before the other – causing a roll. Which is what is described in the NTSB

report.

The aircraft striking the power line did not help the situation but nor did it create it; by that point the

aircraft was already in the process of crashing.

In trying to understand how this pilot got into this situation, how he could commit such a pre-solo

student pilot mistake I considered several alternatives. After reviewing the pilot's logbooks and

specifically noting the amount of flight time in complex and high-performance aircraft I believe that

the best explanation would hinge on a fundamental weakness in his flying background combined with

an unfamiliar pressure to complete the mission as promised.

On 25 February 2004 there is a note about having a propeller strike8 during a crosswind landing. After

this event the incident pilot seemed very diligent to highlight flights that included crosswind landings

or strong winds in the remarks section of his logbook. In 2006 on 15 March and 9 May the pilot

commented on diverting to alternate airports due to high crosswinds at the airport of intended landing.

There were also mentions of go-arounds both during training and non-training flights. All examples of

good aeronautical decision-making and judgment.

On 5 February 2010 the pilot mentioned blowing a tire on landing at Whiskey Creek Airport. While

this could have been an defect with that particular tire it was more likely not. This is representative of a

landing that was too fast or too long requiring heavy braking to stop the airplane on the remaining

runway. I have personally witnessed a Bonanza pilot blow a tire while trying to stop after landing too

fast and too far down the runway. In addition I have witnessed several pilots scuff and blow tires under

the same conditions of landing too fast or landing too long in aircraft other than the Bonanza.

Flying is such a multi-faceted and complex endeavor that it is not uncommon to have a weakness in

8 Having a propeller strike on landing is the result of approaching the runway at excessive speed and trying to force the aircraft onto the runway. See “wheel barreling” in footnote 4.

one area. I believe that the incident pilot's weakness was landing the airplane in gusty conditions. I

believe that under any other circumstance the pilot would likely have gone around or even diverted to

another airport, he had exhibited this decision making in the past. However there is also a decision

making phenomena called “normalization of deviance”. Which put simply means that it worked out in

the past so it will work out again, in spite of being incorrect. Unfortunately once a pilot starts operating

outside of normal boundaries then there remains no guidepost whereby to recognize boundaries.

I believe that he had become comfortable with the Bonanza and was accustomed to it stopping when he

finally touched down. But the problem is, if the landing zone is not the goal then what is? The last

time it stopped after landing half-way down the runway. Surely it will stop if I go a little beyond that,

or a little beyond that; and so on and so forth. Eventually such a normalization of deviance leads to an

incident unless it is recognized and stopped.

Recognition of these tendencies forms the basis of the Safety Management Systems (SMS) that are

codified in the operating certificates of airlines and 135 charter operators. Unfortunately there is no

compulsory SMS system for private pilots. However, the FAA, various private organizations (i.e.

Aircraft Owners and Pilots Association), and even various manufacturers have instituted SMS

programs; but they are strictly voluntary. I found no evidence that the incident pilot participated in any

of these, nor was there a requirement to.

Normalization of deviance was likely one of the factors in his decision to continue the landing in spite

of the growing evidence that it wasn't progressing normally. The next factor is a well known human

factor in aviation accidents and that is “mission completion bias”.

The only difference that I can ascertain between this flight and any other flights was his passengers and

the mission profile. This was not a routine flight for him, this was a special flight; a sightseeing flight

for children. It is my opinion that he felt pressure to conclude the mission as promised to the the

concerned parents and teachers waiting back on the ground. This concept is not at all rare, and is in

fact one of the many external pressures that pilots are cautioned against.

Regardless of the reasons why the incident pilot chose to complete the approach and landing I do know

that the manner in which he conducted it would have initiated a response from the FAA had an FAA

Inspector witnessed it; even if the landing had turned out successful. The FAA likely would have

initiated a certificate action to suspend his certificate until such time that he was deemed capable of

exercising the privileges of that certificate. A process that is called a 7099 ride. 709 actions have

happened for less.

A 709 ride is the FAA's way of reevaluating an airman's proficiency in exercising the privileges of his

or her certificate. Outcomes of 709 rides range from a simple letter in the airman's file to downgrade or

even suspension of the airman's certificate.

Unfortunately we do not get the benefit of a 709 ride. We do not get to learn exactly why he chose to

conduct the flight in that manner. But I do know that it should not have happened.

The FAA has a process whereby the school could have given the students the experience that they

desired in a safe manner; this process is codified in FAR 135. FAR 135 is the FAA's approach to

providing the unsuspecting public safe access to small planes. Both the pilot and the company must be

certificated. The pilot, with a commercial pilot certificate, and the company, with an operating

certificate. FAR 135 provides the framework for a safe operation which includes rigorous maintenance

requirements, training standards, proficiency requirements, a mandatory drug testing program, and

safety management systems. Were the incident pilot employed by an FAR 135 operator he would

either be trained to proficiency or released from employment.

The proper choice for the school would have been to charter the flight whereby the children would

have been afforded the protections offered under an FAR 135 operator. Unfortunately by putting the

children in an aircraft with a private pilot the school bypassed every layer of safety provided to protect

the general public in air transportation.

In closing, ultimately it was not the weather that killed them, nor the airport, nor the airplane. It was

the pilot allowing the situation to develop to one that was unrecoverable. The situation was not rare

nor, at least initially, irrecoverable; it was an everyday occurrence during routine aircraft operations.

9 49 U.S. Code 44709 – Amendments, modifications, suspensions, and revocations of certificates