Tag Archives: aviation defense

Scott Brooksby is co-planning the 2016 ABA Aviation Litigation National Institute

Scott Brooksby will be involved in planning the American Bar Association’s 2016 22nd Annual National Institute on Aviation Litigation in New York, New York.

This prominent, annual conference features seasoned aviation lawyers who present and educate on a variety of aviation litigation topics.  Scott is on the aviation subcommittee of the American Bar Association’s Mass Torts section.

Scott Brooksby has experience representing airlines, aviation insurers, aviation product manufacturers, and airplane owners.  Scott has handled a broad variety of aviation law matters, including personal injury defense; product liability defense litigation; contract and lease drafting; contract negotiation and disputes; and general aviation commercial litigation.

Much of Scott’s practice is devoted to aviation law, and Olson Brooksby is one of the few firms in Oregon with aviation trial experience.  Scott Brooksby leads the firm’s aviation practice, devoting a substantial amount of his time and practice to aviation-related matters.

Scott served as local counsel for one of the largest aviation manufacturers in the world in a nine-week trial in Oregon state court.  The trial involved product liability issues and concerned a helicopter crash that resulted in burns, permanent injuries, and multiple deaths.

While Olson Brooksby’s specialized aviation practice is headquartered in Portland, Oregon, the nature of the firm’s practice often takes its attorneys to various other geographical locations, particularly for investigations, witness interviews, and depositions.

Scott is experienced with a broad range of aviation law topics, and is familiar with allegations concerning: mechanical malfunctions due to airframe or component defects; improper repair or maintenance; improper weight and balance; weather; piloting and human factors; instruments and avionics; air traffic control; and even issues relating to bird strikes and lasers.

Scott Brooksby featured as moderator regarding helicopter accidents


Scott Brooksby recently moderated a panel at a prominent aviation conference concerning helicopter accidents.  Scott’s panel was featured at the American Bar Association’s Aviation Litigation National Institute in New York regarding “Helicopter Accidents: A Review of Recent Cases of Interest”.

At this prominent aviation conference, Scott was part of a distinguished faculty, which highlighted current developments in aviation law and insurance topics including:

• Safety in the cockpit issues and precedents that developed from the 9/11 litigation and how they relate to the Germanwings tragedy

• The unique challenges involved in emergency medical helicopter services both from a legal and safety perspective

• Choice of forum and other legal issues and precedents arising from several high profile international disasters

• London market claims leaders’ perspectives on handling aviation disasters spanning the globe

• Flying special missions for government and industry from explosives to ebola

• New developments in the law of aircraft financier liability in connection with the tortious actions of lessees and operators

• Common themes and issues faced by the trial teams in domestic cases such as the Colgan Air 3407 and Comair 5191

• Ethical considerations when selecting and preparing experts in aviation accident litigation

• The future of aviation, aerospace law, and litigation in connection with drones and commercial space/sub-orbital travel

 Scott Brooksby is an aviation lawyer in Portland, Oregon, with experience in a broad variety of aviation topics, including helicopter litigation and crashes.

Aviation Fatalities: Most are Caused by Human Error

Developing and Following Good Standard Operating Procedures (“SOPs”) and Crew Resource Management (“CRM”) Procedures Are the Keys to Avoiding Aviation Fatalities

The National Transportation Safety Board (“NTSB”) recently released its statistical data calculating transportation fatalities across all modes of transportation in 2011.  There were 494 fatalities in aviation.  The breakdown was as follows: general aviation, 444; air taxi, 41; foreign/unregistered, 9; airlines, 0; commuter, 0.[1]

In comparing the 2011 data against the prior decade or so, there are certainly positive signs.  But, like all raw statistics, the numbers are most useful when integrated into a longitudinal data comparison from which conclusions are drawn.  The NTSB fatality statistics draw a conclusion that might not be obvious from the 2011 data alone: Human error absolutely dominates as the leading cause of aviation fatalities (and injuries).

There are two keys to avoiding aviation fatalities: developing and following good SOPs and CRM procedures.  This article will examine some of the persistent human causes of aviation accidents, many of which are merely outgrowths of the failure of aviation organizations to develop, adhere to, and not willfully disregard SOPs.  The second cause of aviation fatalities examined in this article is the failure of flight deck crews to follow CRM procedures.  Complications that lead to failure to follow CRM procedures include factors such as cockpit chaos; multi-lingual cockpits; failure to maintain cockpit discipline; surprise; and failure, during emergencies, to rely on the crew member with the most flight time, if appropriate given the constitution of the crew as a whole.

Accidents Can Be Avoided Through Proper Cockpit Procedures and Compliance With SOPs

On September 16, 2013, NTSB Member Robert Sumwalt (“Member Sumwalt”) gave a presentation to the Southern California Aviation Association[2] on the importance of SOPs.  Member Sumwalt, quoting from an NTSB accident report, noted that, “[w]ell-designed cockpit procedures are an effective countermeasure against operational errors, and disciplined compliance with SOPs, including strict cockpit discipline, provides the basis for effective crew coordination and performance.”[3]

Member Sumwalt then presented facts about what the accident data show regarding crew-caused accidents.  In an NTSB study of 37 crew-caused air carrier accidents between 1978 and 1990, procedural errors, such as not making required callouts or failing to use appropriate checklists, were found in 29 of the 37 (78%) reviewed accidents.  The accident data also show that, with respect to turbine-powered operations (2001-2010), the NTSB identified at least 86 accidents involving lack of adequate procedures, policies, or checklists, or lack of flight crew adherence to procedures, policies, or checklists.  These accidents resulted in 149 fatalities.[4]

Developing Effective SOPs

The development of SOPs in various industries has been accomplished through a variety of regulatory bodies, industry groups, and volunteerism.  One of the first groups to establish such guidelines was the International Conference on Harmonisation (ICH), which defines SOPs as “detailed written instructions to achieve uniformity of the performance of a specific function.”  The international quality standard (“ISO”) 9001 essentially requires the establishment of SOPs for any manufacturing process that could affect the quality of the product.  Although ICH’s implementation of the ISO 9001 SOPs was in the context of clinical drug trials, a substantially similar system has been expanded to other industries.[5]

In the context of aviation, the SOP provides a flight crew with a step-by-step guide to effectively and safely carry out operations.  A particular SOP must not only achieve the task at hand but also be understood by a crew of various backgrounds and experiences within the organization.  SOPs can also be developed over time to incorporate improvements based on experience, accidents, near misses, or innovations from other manufacturers or operators to suit the needs of a particular organization.  SOPs can also provide employees with a reference to common business practices, activities, or tasks.[6]  New employees use SOPs to answer questions without having to interrupt supervisors to ask how an operation is performed.[7]

Although reference is made to ISO 9001 in the context of clinical trials, the ISO 9000 family of standards is related to quality management systems and designed to help organizations follow consistent procedures to meet the needs of customers and other stakeholders.[8]  “AS 9000” is the Aerospace Basic Quality System Standard–an interpretation developed and adopted by virtually all the major aerospace manufacturers.  The current version is AS 9100C.  A new version of the standard will be published in September 2015 if the ISO members vote favorably in March 2015.[9]

The Failure of Flight Crews to Comply With SOPs and the Consequences

During his remarks on flight crew error, Member Sumwalt cited a Boeing study of accident prevention strategies where the data suggested that the single most important factor in prevention of hull loss accidents over a ten-year period was pilot flying (PF) adherence to SOPs.  Member Sumwalt noted that SOPs are typically not followed for three specific reasons.  He discussed each reason, and then used data from an NTSB investigation, or preliminary cause report, as support or illustration for each of the three reasons.

The reasons SOPs are typically not followed are:

(1) the organization lacks adequate SOPs;

(2) the organization doesn’t adhere to their SOPs; and

(3) flight crews intentionally disregard SOPs.

SOPs should be clear, comprehensive, and readily available in the manuals used by flight deck crew members.[10]  Member Sumwalt provided three real-life corollary examples:

  • The Organization Lacks Adequate SOPs – Crash of East Coast Jets, Hawker Beechcraft BAe 800, on July 31, 2008, Owatonna, Minnesota (8 fatalities)

The NTSB found that, although as a charter operator, East Coast Jets was not required to incorporate SOPs into its operations manual, if it had done so, it may have supported the accident pilots in establishing cockpit discipline and, therefore, a safer cockpit environment.  An example was provided where the SOP identifies the triggering event, designates which crewmember performs the action or callout, what the callout is, and what the action is.

  • The Organization Fails to Adhere to Its Established SOPs – Crash of Cessna 310, N501N, July 10, 2007, Sanford, Florida (5 fatalities)

In this case the organization did not adhere to SOPs.  The aviation director could not locate the SOP manual, which was viewed as merely a training tool.  The aircraft was to be used only for company business, but the accident flight was a personal flight.  The Pilot in Command (“PIC”) must possess an Airline Transport Pilot (“ATP”) Certificate/Rating, but the PIC did not possess the necessary ATP.  The last three maintenance discrepancies had not been addressed.  The NTSB noted that these lapses were contrary to industry guidelines directing that procedures should be written in accordance with the organization’s operating methods, and once the procedures are in place, the organization should make every effort to follow those procedures.  Having a strong commitment to standardization and discipline were among the key elements of safe operations observed in a Boeing study.  Cockpit procedural language is tightly controlled to maintain consistency and to avoid confusion from non-standard callouts.  Callouts and responses should be done verbatim.[11]

  • Flight Crews Intentionally Disregard Established SOPs – Hard Landing of US Airways Express, January 19, 2010, Charleston, West Virginia

The NTSB probable cause determination was “the flight crewmembers’ unprofessional behavior, including their non-adherence to sterile cockpit procedures by engaging in non-pertinent conversation, which distracted them from their primary flight-related duties and led to their failure to correctly set and verify the flaps.”  Intentional crew non-compliance was a factor in 40% of the worldwide accidents reviewed.[12]

NTSB Member Sumwalt concluded by noting that well-designed SOPs are essential for safety.  Making a strong commitment to procedural compliance should be a core value of the organization.  The SOPs must not merely exist, but they must be religiously followed as a way of doing business.

Well-Coordinated CRM is a Crucial Part of Accident Prevention

CRM[13] is a set of training procedures for use in environments where human error can have devastating effects.  Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit.

CRM grew out of an NTSB analysis of the crash of United Airlines flight 173 where the plane, a DC-8, ran out of fuel while troubleshooting a landing gear problem over Portland Oregon.[14]  The NTSB issued its landmark recommendation on June 7, 1979, to require CRM training for airline crews.  A few weeks later, NASA held a workshop on the topic, endorsing this innovative training.[15]  United Airlines was the first airline to provide CRM training for its cockpit crews in 1981.[16]

Since that time, CRM training concepts have been modified for application to a wide range of activities where people must make dangerous time-critical decisions.  These arenas include air traffic control, ship handling, firefighting, and medical operating rooms.[17]

The Difficulty of Precisely Executing CRM Procedures In a Multicultural Cockpit

Multiculturalism in the cockpit is a largely recent phenomenon.  Globalization and shrinking militaries around the world have led to a decrease in the availability of trained pilots, a lack of homogenous flight crews, and the emergence of multicultural cockpits.  In 2005, a Helios Airways Boeing 737-300, with its pilots incapacitated by hypoxia after they failed to recognize a cabin pressurization system malfunction, provides a good example of what can happen when communication and crew resource management break down in the multicultural cockpit.[18]  All 121 people on the airplane were killed when the 737 depressurized and ran out of fuel, the engines flamed out, and the airplane crashed, after what was to have been a flight from Larnaca, Cyprus, to Prague, Czech Republic, with a stop in Athens.

In its final report on the accident, the Hellenic Air Accident Investigation and Aviation Safety Board said the crew had failed to recognize that the cabin pressurization mode selector was in the wrong position.  The Helios crew exhibited poor CRM before takeoff and during climb, and the difference in their nationalities and primary languages–the captain was German, the first officer was Cyprian–contributed to poor communication during the event.  A blaring cabin altitude warning horn and the illumination of master caution lights degraded the crew’s cognitive abilities and processes.  Inter-cockpit communications were reduced, perhaps in part because English was a second or third language for the crew.[19]

The CRM Lessons Learned From Air France 447–“Crew Coordination Vanished”

On March 27, 1977, two Boeing 747s crashed on the single runway on the Spanish island of Tenerife, killing 583 people.  More than 35 years later, it is still measured by the number of casualties, and is by far the worst aviation disaster in history.  One aspect of the accident, unlike many tragic and significant disasters, is that the non-aviation community was fixated on the Tenerife crash, the individuals involved, and exactly what the sequence of events was.  Arguably the next time both the aviation community and the non-aviation community became as fixated on an aviation disaster was the 2009 crash of Air France 447.[20]

Within four and a half minutes in the early hours of June 1, 2009, an Airbus A330-200 operating as Air France Flight 447 from Rio de Janeiro to Paris, departed from cruise flight at 35,000 feet and descended into the Atlantic Ocean, killing all 216 passengers and 12 crewmembers.  Glimpses of what may have gone wrong emerged from the several interim reports issued by the French Bureau d’Enquetes et d’Analyses (BEA) during the long investigation.  In July, 2012, the BEA issues a nearly 300-page final report.

According to the report, the trouble began when the A330’s pitot tubes were obstructed by ice crystals, causing the various air data sources to produce unreliable airspeed information.  Reacting as designed, the autopilot and autothrottle disengaged, and reverted to a lower control law that provides fewer protections against flight-envelope deviations.  Startled, the pilot flying (“PF”) inadvertently commanded a steep nose-up pitch change while leveling the airplane’s wings.  The flight crew–a copilot and a relief pilot filling in for the resting captain–recognized the loss of reliable airspeed data but did not conduct the associated checklist procedure.  As a result, “[c]onfusion reigned on the flight deck, and crew coordination vanished.” [21]  Without automatic angle-of-attack protection, the airplane entered a stall.  The crew either believed that the stall warnings were spurious or mistook the airframe buffeting as a sign of an overspeed condition.  When the resting captain was called to return to the flight deck, he continued to apply nose-up flight inputs, when, at such a low altitude, the only possible chance to get the plane back into the flight envelope would have been nose-down inputs.  In addition, the PF almost immediately took back priority without any callout and continued piloting.  The priority takeover by the PF contributed to the de-structuring of the task-sharing between the pilots.  No recovery action was taken, and the A330 remained in a stall as it descended into the sea.

Additional sections of the BEA final report comment on the fragmented nature of the augmented crew, and the fact that some junior officers had far more flight hours in type than some of the more senior crew members, further eroding the opportunity for effective CRM in a surprise situation.

SOPs and CRM Must be Properly Implemented and Adhered To

Disciplined implementation of, and adherence to, SOPs is inseparable from the disciplined implementation of, and adherence to, CRM.  Although this article only scratches the surface on data supporting this conclusion, it is an irrebuttable presumption that if flight crews fully embrace SOPs and CRM, flying will be safer.

[1] Data and Statistics-NTSB-National Transportation Safety Board http://www.ntsb.gov/data/index.html (last visited, October 18, 2013).

[2] Member Robert L. Sumwalt, Standard Operating Procedures:  The Backbone of Professional Flight Operations,  http://www.ntsb.gov/news/speeches_sumwalt.html  September 16, 2013 (last visited October 18, 2013) (unpaginated).

[3] Id. (citing from National Transportation Safety Board Accident Report NTSB/AAR-11/01, PB2011-910401, Crash During Attempted Go-Around After Landing, East Coast Jets Flight 81, Hawker Beechcraft Corporation, 125-800A, N818MV, Owatonna, Minnesota, July 31, 2008).

[4] Id.

[5] ICH Harmonized Tripartite Guidelines For Good Clinical Practice. (1.55.)  May 1, 1996.

[6] Green, R. G., Muir, H., James, M., Gradwell, D., & Green, R. L. (1996) Human Factors for Pilots (2nd ed). Ashgate Publishing Ltd (Hants, England), 1996.

[7] Anderson, Chris.  How to Write Standard Operating Procedures.  Bizmanualz, June 4, 2012.

[8] Poksinska, Bozena; Dahlgaard, Jens Jörn; Antoni, Marc (2002). The State of ISO 9000 Certification: A Study of Swedish Organizations. The TQM Magazine 14 (5): 297.

[9] Nigel H. Croft (2012). ISO 9001:2015 and Beyond – Preparing for the Next 25 Years of Quality Management Standards“. ISO.

[10] FAA Advisory Circular AC 120-71.

[11] Reference to Lautman-Gallimore Study.  Member Robert L. Sumwalt, Standard Operating Procedures:  The Backbone of Professional Flight Operations  http://www.ntsb.gov/news/speeches_sumwalt.html  September 16, 2013 (last visited October 18, 2013) (unpaginated).

[12] R. Khatwa & R. Helmreich, cited in Member Robert L. Sumwalt, Standard Operating Procedures:  The Backbone of Professional Flight Operations  http://www.ntsb.gov/news/speeches_sumwalt.html  September 16, 2013 (last visited October 18, 2013) (unpaginated).

[13] Diehl, Alan (2013) “Air Safety Investigators: Using Science to Save Lives-One Crash at a Time.” Xlibris Corporation. ISBN 9781479728930. http://www.prweb.com/releases/DrAlanDiehl/AirSafetyInvestigators/prweb10735591.htm.

[14] UNITED AIR LINES, INC. “McDONNELL-DOUGLAS DC-8-61, N8082U PORTLAND, OREGON : DECEMBER 28, 1978.” National Transportation Safety Board. December 28, 1978. 9 (15/64).

[15] Cooper, G.E., White, M.D., & Lauber, J.K. (Eds.) 1980. “Resource Management on the Flight Deck,” Proceedings of a NASA/Industry Workshop (NASA CP-2120).

[16] Helmreich, R. L.; Merritt, A. C.; Wilhelm, J. A. (1999).  “The Evolution of Crew Resource Management Training in Commercial Aviation.”  International Journal of Aviation Psychology.  9 (1): 19–32.

[17] Diehl, Alan (June, 1994). “Crew Resource Management… It’s Not Just for Fliers Anymore.” Flying Safety, USAF Safety Agency.

[18] Hellenic Air Accident Investigation and Aviation Safety Board.  Aircraft Accident Report 11/2006, Helios Airways Flight HCY522, Boeing 737-315, at Grammatiko, Hellas, 14 August 2005.

[19] Id.

[20] The following summary of the facts and conclusions associated with AF 447 is based on the English translation of the BEA’s “Final Report on the Accident on 1st June 2009 to the Airbus A330-203, Registered F-CZCP, operated by Air France, Flight AF 447, Rio de Janeiro-Paris”.  The report is available in English and the original French at www.bea.aero.

[21] Mark Lacagnina, Sustained Stall: Blocked Pitot Tubes, Excessive Control Inputs and Cockpit Confusion Doomed Air France 447, http://flightsafety.org/aerosafety-world-magazine/august-2012/sustained-stall (accessed October 22, 2013).

Oregon Law Does Not Permit Experts to Testify in the Form of Legal Conclusions in Product Liability or Negligence Cases

Under Oregon law, witnesses are not allowed to testify as to legal conclusions.  See, e.g., Olson v. Coats, 78 Or App 368, 370 (1986) (excluding testimony by witness that certain road signs complied with statutory requirements).  “Each courtroom comes equipped with a ‘legal expert,’ called a judge, and it is his or her province alone to instruct the jury on the relevant legal standards.” Burkhart v. Washington Metro. Area Transit Auth., 112 F3d 1207 (D.C. Cir. 1997).  Examples of inappropriate testimony in the form of legal conclusions include, but are not limited, to:

  • Defendants were clearly reckless, acted in a reckless manner, or acted in a grossly reckless manner;
  • Plaintiff was negligent; and
  • The helicopter/engine had a known and recognized defect.

Neither plaintiff nor defendant should be permitted to elicit such legal conclusions at trial.  An increasing number of products liability cases have excluded similar expert testimony.  A district court was held to have correctly excluded expert testimony that “the lack of adequate warnings and instructions constituted defects which made the products unreasonably dangerous.”  Strong v. E.I. DuPont de Nemours Co., 667 F2d 682, 685-86 (8th Cir. 1981).  Similarly, in Harris v. Pacific Floor Machine Mfg. Co., 856 F2d 64, 67 (8th Cir. 1988), a district court was held to have properly refused to permit the plaintiff’s expert to opine as to the adequacy of the particular warning on the product.

Likewise, expert testimony that a party was “willful” was excluded in United States v. Baskes, 649 F2d 471, 478 (7th Cir. 1980).  On similar grounds, a federal district court excluded expert testimony that the plaintiff was “negligent.”  The court’s ruling also encompassed “any testimony . . . that contains a variation of the term ‘negligent,’” or any opinions that certain conduct was the “direct, proximate and efficient cause” of an accident.  Hermitage Industries v. Schwerman Trucking Co., 814 F Supp 484, 487-88 (D. S.C. 1993).

Defending the Pediatric Burn Case: How Knowing the Medical Literature and New Treatment Modalities Can Help Control Damages

Surgeons discussing computed tomography (CT) scans in operating theatre


Most seasoned defense attorneys are well aware of the three subjects that often tend to cause far higher-than-expected verdicts: burns, kids, and cancer.  In this article we will address the danger of situations where there is not only a child, but the child is severely burned.

In prior posts we addressed burn classification, conventional treatment modalities, and aspects of expected outcomes.  We will not repeat that information here but instead address some general mortality statistics and where children, specifically those age six and younger, fit in.  We will also address experimental and new therapies for children, as described in the recent literature, including the use of virtual reality, albuterol inhalants, and aerosolized Heparin/Acetylcystine therapies.  All of these therapies have been shown to lower mortality rates in children.

Regardless of the burn mechanism, defending a pediatric burn case, especially if it was fatal, can be extremely difficult.  Juries tend to be very sensitive to burn injuries, especially in cases involving children.  Therefore, the product liability or aviation defense lawyer must have an in-depth understanding of the mechanics of burn injuries and available treatment options, particularly in those cases where inhalation injury is a component.  Both an aircraft cabin and a home are confined spaces that can be filled with fatal levels of smoke, sometimes within seconds.  Given these considerations, it is essential that the defense attorney be thoroughly prepared, armed with both knowledge and empathy.

Statistical Overview of Burn Injuries

According to the National Burn Repository,[1] which gathers and analyzes statistical data from burn centers throughout the United States and Canada, there were 126,000 hospital admissions for burns from 1995 – 2005.  The mean burn size was 13.4 percent total body surface area (TBSA) with sixty-two percent of the full thickness burns covering less than ten percent TBSA.  Sixty-one percent of patients were transferred to another hospital for a higher level of care.  Six and one-half percent of admissions had inhalation injuries.  The data also show that the patients were seventy percent male with a mean age of 33 years.  Flame and scald burns accounted for seventy-eight percent of all burn injuries.

The prognostic burn index, a sum of the patient’s age and percentage of TBSA burn, was used as a gauge for patient mortality for many years.  This index suggested that by taking into consideration the patient’s age and the size of their full thickness TBSA burn, and adding twenty percent for inhalation, the patient’s mortality probability could be predicted.[2]  Advances in early excision of burn eschar,[3] skin grafting, early enteral feeding,[4] and wound closure with advanced techniques (skin substitutes) have altered the simple mathematical calculation.[5]  Patients with a prognostic burn index of 90 – 100 now have a mortality rate in the 50 – 70% range with poorer outcomes at both extremes of age.[6]

The Importance of Pediatric Treatment in Cases Involving Inhalation Burns 

As noted above, mortality rates are higher in pediatric patients.  Smoke inhalation injury continues to be implicated as the leading cause of death in persons with burn injuries.  Smoke inhalation injury has a reported mortality of 20 – 80%.[7]  This is also supported by the addition of 20% traditionally added to the prognostic burn index.

In smoke inhalation injury, there is a destruction of the ciliated epithelium[8] that lines the tracheobronchial tree.  Casts[9] from these cells cause upper-airway destruction, and this leads to obstruction, causing pulmonary failure.  In one recent study, the reduction in mortality in pediatric patients with inhalation injuries placed on a regimen of aerosolized heparin[10] and acetylcystine[11] was tested.[12]  Forty-seven children, acting against forty-three controls, received 5000 units of heparin and 3 ml of a 20% solution of acetylcystine aerosolized every four hours for the first seven days of injury.  All patients were extubated when they were able to maintain spontaneous oxygen levels.  The number of patients requiring re-intubation for successive pulmonary failure was recorded, as was mortality.

The results indicate a significant decrease in re-intubation rates, incidence of atelectasis,[13] and mortality for patients treated with the regimen of heparin and acetylcystine when compared with the controls.  Heparin/acetylcystine nebulization in children with massive burn and smoke inhalation injuries results in a significant decrease in incidence of re-intubation for progressive pulmonary failure and a reduction in mortality.

The Use of Virtual Reality For Acute Pain Management in Pediatric Burn Patients

In one experimental case, virtual reality was tested for pain management.[14]  Managing high pain levels associated with pediatric burns can result in a decreased reliance on opioid medications and can potentially minimize future risk of developing psychiatric problems.  During the study, hospitalized patients over the age of six and without facial burns were selected.  A lightweight helmet with binocular display provided patients with a Virtual Reality (VR) experience during acute pain procedures such as wound care or therapy.  Pain levels were assessed using the Faces Pain Scale (FPS).[15] Constitutional signs and symptoms, opioid medication usage, as well as nursing and family member assessments of pain were also recorded.  VR provided a three-dimensional computer-simulated environment where patients could see, hear, and interact with objects displayed in the virtual world.

Preliminary results suggested at least a 20% decrease on FPS during VR intervention.  Pediatric patients report an increased tolerance to exposed dressing sites during VR.  It remains unknown which patient factors (age, sex, characteristics of the burn, background pain level, etc.) are predictive of effective pain management with VR.


Olson Brooksby has defended many product liability and aviation cases where the resulting injury was a serious, sometimes fatal, burn.  From a defense perspective, such cases pose difficulties if defense counsel is not prepared to skillfully handle the cross examination of the treating burn physician.  The best way to do so is to be familiar with the prevailing treatment methods and the relevant literature.  Conversance with the literature will provide a working understanding of the techniques that were available to the treatment team to minimize the pediatric burn patient’s pain and increase the likelihood of survival.


[1] Miller, S.F.M., et al., National Burn Repository, 2005, American Burn Association: Chicago, IL. P. 1-51.

[2] Grunwald, T.B. and Garner, W.L. Acute Burns. University of Southern California; Los Angeles County + USC Burn Center, Los Angeles, California.

[3] Dead matter cast off the surface of the skin after a burn.

[4] Tubal feeding through the intestine.

[5] Rose, D.D. and E.B. Jordan, Perioperative management of burn patients.  Aorn J, 1999. 69(6): p. 1211-22; quiz 1223-30.

[6] N., K. Aoki, and M. Yamazaki, Recent advances in the management of severely burned patients.  Nippon Geka Gakkai Zasshi, 1999. 100(7): p. 424-9.

[7] Thompson PB, Herndon DN, Taber DL, et al.  Effects of mortality of inhalation injury. J. Trauma 1986; 26:163-5.

[8] Threadlike projections from the free surface of epithelial cells such as those lining the trachea, or bronchi.  The propel or sweep materials, such as mucus or dust across a surface such as the respiratory tract.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[9] Pliable or fibrous material shed in various  pathological conditions, the product of effusion.  It is molded to the shape of the part in which it has been accumulated, i.e., bronchial or tracheal casts.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[10] Heparin is an aparenteral anticoagulant drug with a faster effect than warfarin or its derivatives.  It is composed of polysaccharides that inhibit coagulation by forming an antithrombin. An antithrombin is anything that prevents action on the thrombin.  The Thrombin is an enzyme formed in coagulating blood which reacts with soluble fibrinogen to form a blood clot.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[11] Acetylcystine is a chemical substance that, when nebulized and inhaled, liquefies mucus and pus.  Taber’s Cyclopedic Medical Dictionary, 19th Ed.. 2001. Venes. D., Ed., F.A. Davis Co., Philadelphia.

[12] M.H. Desai, MD, R. Micak, RRT, RCP, J. Richardson, RCP, RRT, R. Nichols, MD, and D.N. Herndon, MD.  Reduction in Mortality in Pediatric Patients with Inhalation Injury with Aerosolized Heparin/Acetylcystiine Therapy.  University of Texas Medical Branch and Shriners Burns Institute, Galveston.  American Burn Association, 1998.

[13] Collapse of part (or, less commonly, all) of a lung.

[14] Minassian, A PhD; Kotay, A MS; Perry, W PhD; Tenenhaus, M MD, FACS; Potenza, B M. MD, FACS.  The Use of Virtual Reality for Acute Pain Management in Pediatric Burn Patients.  University of California San Diego, The American Burn Association, 2006.

[15] The Faces Pain Scale, also known as the Wong-Baker FACES Pain Rating Scale, is intended for children over three years of age.  It provides a series of six drawn facial expressions with an associated numerical value from zero through 5 representing the associated pain.  Hockenberry MJ, Wilson D:  Wong’s Essentials of Pediatric Nursing, 8th Edition. St. Louis:  2009: Mosby.


NTSB Factual Reports and the Hearsay Rule in Oregon Aviation Cases

Oregon books

Oregon Evidence Code Rule 803(8) Provides the Necessary Exception to the Hearsay Rule for NTSB Fact Reports

Although the statements made in the Group Chairman’s reports (“the fact reports”) are arguably hearsay, the reports fall within an exception to the hearsay rule provided under the Oregon Evidence Code (“OEC”).  First, the fact reports are admissible as hearsay exceptions under OEC 803(8)(b).  That rule provides, in part, that reports “of public offices or agencies” that set forth “[m]atters observed pursuant to duty imposed by law as to which matters there was a duty to report” are admissible as exceptions to the hearsay rule.

Second, fact reports are admissible as hearsay exceptions under OEC Rule 803(8)(c), which provides, in part, that reports in civil actions “of public offices or agencies” that contain “factual findings resulting from an investigation made pursuant to authority granted by law” are admissible as exceptions to the hearsay rule “unless the sources of information or other circumstances indicate lack of trustworthiness[.]”

A factual NTSB report falls within the exception for hearsay provided by 803(8)(b)-(c) because it contains “factual findings” resulting from an investigation made by the NTSB, a government agency, pursuant to the authority granted to the NTSB investigators by law.  The NTSB “shall investigate…each accident involving civil aircraft:”  49 USC § 1132(a)(1)(A).  Moreover, by law, the investigation is required to result in a report.  49 USC § 1131(e) (“The Board shall report on the facts and circumstances of each accident investigated by it under subsection (a) or (b) of this section.  The Board shall make each report available to the public * * *.”).  The report and its attachments thus satisfy the foundational elements of OEC 803(8)(b)-(c).

The Admissibility of NTSB Fact Reports at Trial

Businesswoman standing in airplane engine


The admissibility of NTSB fact reports at trial is a key issue for aviation lawyers.  The aviation accident defense lawyer must know how the NTSB works and what the relevant authorities are related to the admissibility of the various reports that the NTSB creates.  Aviation defense lawyers must also know what arguments plaintiffs are likely to make in a case where the factual reports prepared by the NTSB under the party system it employs, are unfavorable.  The aviation defense lawyer must be properly schooled on NTSB agency procedure, the party system, the enabling legislation, and the federal statutes that outline the NTSB mandate and system.

Finally, the aviation defense lawyer must know the local rules of evidence typically implicated in what is usually a hard fought battle to admit one or more of what may be the many NTSB group fact reports. This is extremely important for the aviation defense lawyer to understand in jurisdiction like Portland, Oregon, where state court is generally very plaintiff-friendly. Most state court judges do not have experience presiding over cases where a federal agency, let alone a federal agency as unique and specialized such as the NTSB, plays such a central role.

The NTSB Mandate

The NTSB s a unique federal agency.  It is not a federal executive branch agency, but rather is a congressionally chartered, completely independent agency.  The NTSB has a single aviation mandate: to investigate every aviation (and other forms of transportation such as rail, ferry, bus, subway) accident in the Unites States; to determine the probable cause of the accident; and to make recommendations to help protect against future accidents.  49 U.S.C. §§ 1131, 1132, 1135.  See also Chiron Corp. v. NTSB, 198 F.3d 935, 938 (D.C. Cir. 1999).   An NTSB investigation is “not conducted for the purpose of determining the rights or liabilities of any person.  Board regulations and policies are explicit in providing that parties participating in an investigation are involved in NTSB processes only to assist the safety mission and not to prepare for litigation.”  Id. (quotation marks and alterations omitted).

Under the NTSB investigative system discussed below, the operational and investigative methods of the NTSB result in the production of numerous so-called group chairman’s reports, which are intended to be factual in nature.  These are typically referred to as the NTSB “fact reports”.  At the end of the investigation, the NTSB board members may conduct a hearing during which the NTSB group chairs who lead the groups who authored the factual reports may testify.

When the investigation is complete, the Investigator In Charge (“IIC”) of the investigation issues a final report that contains conclusions and a finding of probable cause, which is then released to the public after adoption by the NTSB board members.  Although discussed in further detail below, 49 U.S.C. § 1154(b) prohibits the use of the final probable cause report prepared by the Board itself, as distinguished from it staff’s factual accident reports.

The NTSB Party System and Factual Report Process

For major aviation accidents, the NTSB typically sends a “Go Team”, one of several that the NTSB maintains in readiness so that they can typically leave within hours to go to the site of an accident and immediately begin investigating.  Rachel G. Clingman, LITIGTING THE AVIATION CASE FROM PRE-TRIAL TO CLOSIING ARUMENT 385 (Andrew J. Harakas ed., 3rd ed. 2008).  The NTSB then designates an IIC to oversee the full investigation.  Id. The NTSB and the IIC then nominate parties to participate in the investigation, and organizes themselves and the participating parties into different investigatory groups.  Id.

Each group investigates specific factors related to the accident, including operations, survival factors, meteorology, airworthiness, and aircraft performance.  Id.  Each group is headed by a chairperson who drafts a factual accident report regarding his or her subject matter that is submitted to the IIC.  Id.  The IIC submits the various chairperson factual accident reports to the NTSB, which then uses these reports to prepare the final Board accident report  Id. at 385-86.  Typically, but not always, the Board issues its final report very shortly after the final public hearing, if one is held.

Since aviation crashes can lead to incredibly complicated investigations and require countless individuals with extremely deep experience in sometimes unusual and unique skills including sound spectrum, meteorology, survival factors, CVR and FDR data recovery, aviation operations, metallurgy, airworthiness, crashworthiness, and a host of other factors, the NTSB investigation and reporting process is essential for the aviation defense lawyer to understand.  As noted above, the depth of this investigatory process is typically something most state court judges are not very familiar with.  The parties who are nominated to participate by the NTSB sign declarations attesting that they will not use or shape the information obtained during the investigation as advocates for their employers, who are often stakeholders in the investigation.  The parties agree to use their skill and knowledge and bring what they contribute to the party system investigation only for the purpose of finding the cause of the accident and making recommendations to improve safety.

The investigations conducted by some groups are incredibly broad.  For example, often the operations group will interview pilots and witnesses; travel to the scene, however remote; obtain records; travel to pilot bases; obtain and review pilot records; interview co-workers; and obtain records associated with the maintenance and flight house of the helicopter.

Method For Determining Admissibility

A motion in limine is “any motion, whether made before or during trial, to exclude anticipated prejudicial evidence before the evidence is actually offered”.  Luce v. United States, 469 U.S. 38, 40 n.2 (1984).  The court has inherent authority to decide such motions in order to manage the course of trials. Id at 41.  The court also has broad discretion to decide preliminary questions concerning the qualifications of a witness or the admissibility of evidence.  O.E.C. 104.  In State v. Busby, 315 Or. 292, 844 P.2d 897 (1993), the Oregon Supreme Court noted that it had “expressly approved the use of a pretrial motion in limine to obtain a ruling on evidence before the evidence is sought to be introduced.”  315 Or. n.16 at 305.

Other courts have permitted motions in limine to be filed by a party seeking pretrial rulings that NTSB group chairman’s factual reports were admissible, In re Air Crash at Charlotte, N.C. on July 2, 1994, 982 F. Supp. 1071, 1075 (D. S.C. 1996), or inadmissible, Brown v. Teledyne Continental Motors, Inc., No. 1:06-CV-00026 (N.D. Ohio March 15, 2007).

It is particularly appropriate to file a motion in limine well before the start of any aviation trial.  The NTSB investigation will likely be extensive, and by statute and regulation the NTSB is the only authorized investigatior into the facts and circumstances of the subject accident.  By the time the final report is released in a major NTSB investigation, thousands of hours may have been spent to produce an extensive body of evidence, all of which would be contained on the NTSB’s own public docketing system, and which would be virtually impossible to reproduce absent significant additional time and at incredible cost.


Aviation defense counsel should begin studying the NTSB fact reports, as well as what is virtually always a massive amount of attachments (exhibits) to the reports, as soon as possible.  The reports are virtually always primarily new information since during the pendancy of the NTSB investigation, the NTSB will use its powers as the exclusive investigating agency to voluntarily obtain or subpoena documents related to the investigation which, pursuant to the regulations, are not discoverable until released by the NTSB.  In many cases this is not until after the factual group chairman’s reports are posted to the NTSB docket, or even until after the Board’s report is due, although, as noted above, the report containing the Board’s causal conclusions and safety recommendations is inadmissible pursuant to statute.  The skilled aviation defense attorney will assess the judge’s familiarity with the NTSB and the NTSB process, if any, as soon as possible and begin educating the judge appropriately so that the proper rulings are obtained.


Key Changes to the DSM-5 for the Product Liability, Personal Injury, and Aviation Defense Lawyer

DSM-5 book

The creation of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was a massive undertaking that involved hundreds of psychiatrists, psychologists, physicians, and other medical professionals working together over a 12-year period.  The DSM-5, which replaced the 2000 DSM-IV (TR), is the foundation for reliable diagnosis and treatment of psychological and mental disorders.  As with prior DSM publications, which now date back decades, it is not intended to be a substitute for sound, objective clinical judgment, training, and skill.

Reflecting and prompted by the many new longitudinal studies, research papers, and experimental treatment modalities that have appeared since 2000, this new DSM edition contains significant changes in the classification of some disorders, and the removal or addition of other disorders.  This discussion will provide a brief overview of some of the key changes to the DSM-V and will touch on issues of interest to legal professionals working in the areas of product liability, personal injury, and aviation defense.

In a trial setting, familiarity with the DSM-5 and the underlying literature will be critical to an effective cross-examination of plaintiff’s expert.  Often, with forensic psychologists, the defense can make significant inroads on the basis that plaintiff’s expert is not sufficiently familiar with the DSM or associated literature.  For example, a significant new body of literature related to “resiliency and benefit realization” after a traumatic experience is largely unknown to most plaintiffs’ forensic psychologists.

A substantial percentage of high exposure cases in those categories involve a diagnosis of PTSD by plaintiff’s expert and a Global Assessment of Functioning (GAF) score based on the five-level multiaxial system, with Axis 5 providing the GAF score.  This brief post will focus on the changes to ­– or more accurately, the elimination of – the multiaxial system, as well as the changes to the criteria, symptoms, and diagnosis of PTSD.

A subsequent post will deal specifically with the criteria for PTSD and will include suggestions for cross-examination of plaintiff’s diagnosing mental health professional.

Changes to the Multiaxial System in DSM-5

Despite its widespread use, particularly among some insurance agencies and the government, the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis.  DSM-5 has moved to a nonaxial diagnostic model (formerly AXES I, II, and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).  The approach of distinguishing diagnosis from psychosocial and contextual factors is also consistent with established WHO and ICD guidelines, which consider the individual’s functional status separately from his or her diagnosis or symptom status.

DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, representing the clinician’s judgment of the individual’s overall level of “functioning on a hypothetical continuum of mental health-illness.”  It was recommended that the GAF be dropped from DSM-5 for a number of reasons, including its conceptual lack of clarity (e.g., including symptoms, suicide risk, and disabilities in the descriptors) and questionable psychometrics in routine practice.  In order to provide a global measure of disability, the WHO Disability Assessment Schedule (WHODAS) is included in DSM-5 for further study.

Changes to PTSD in DSM-5

Post-Traumatic Stress Disorder (“PTSD”) is a Trauma- and Stressor-Related Disorder.  DSM-5 criteria for PTSD differ significantly from the DSM-IV.  The stressor criterion (Criterion A) is more explicit with regard to events that qualify as “traumatic” experiences.  Also, DSM-IV Criterion A2 (subjective reaction) has been eliminated.

Whereas there were three major symptom clusters in DSM-IV – re-experiencing, avoidance/numbing, and arousal – there are now four symptom clusters in DSM-5 because the avoidance/numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood.  The latter category, which retains most of the DSM-IV numbing symptoms, also includes new or re-conceptualized symptoms such as persistent negative emotional states.  The final cluster – alterations in arousal and reactivity – retains most of the DSM-IV arousal symptoms.  It also includes angry outbursts and reckless or self-destructive behavior.

PTSD is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents.  Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.

The DSM-IV childhood diagnosis of reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited.  In DSM-5, these subtypes are defined as distinct disorders: “reactive attachment disorder” and “disinhibited social engagement disorder.”

Olson Brooksby is a product liability, personal injury, and aviation defense firm.