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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