Dr. Varanoa is going to receive the John J. Cahill Memorial Lecture Award. This prestigious lecture is given each year in honor of John Cahill, D.O., F-A-O-C-O-P-M, a founding member of the College and Division of Aerospace Medicine. Dr. Cahill was born in 1920 in Roxbury, Massachusetts, and died in 1995. Good morning, everyone. It's my pleasure. During the Korean War, Dr. Cahill became interested in aviation. After completing his Navy tour, Dr. Cahill attended the Kansas City College of Osteopathic Medicine. After graduation, he completed his residency in Nebraska, then moved to Arizona. In 1958, Dr. Cahill obtained his Arizona license. Next, he went into private practice. During the summer of 1969, the FAA beckoned and Dr. Cahill moved to Kansas City to begin his career in aerospace medicine. From Kansas City, he moved to Boston, where in 1971, he was named the first New England regional flight surgeon. Dr. Cahill served as president of the college in 1985 and was designated a fellow that same year. Dr. Cahill contributed greatly to the college, to osteopathic medicine, and to the field of aerospace medicine. Established in 1991, the John J. Cahill Memorial Lecture in Aerospace Medicine is presented to an individual, member or non-member, who has demonstrated a desire to see the field of aerospace medicine excel for the public good. This year, that honor goes to Dr. Stephen Barineau, who received his B.S. in 1979 and his M.D. in 1983 from the University of Manitoba, Winnipeg, Manitoba, Canada. He became board certified in aerospace medicine by the American Board of Preventive Medicine in 1990 and completed his aerospace medicine residency as well as receiving his M.S. from Wright State University. He is a teacher, mentor, and educator in aerospace medicine. As a manager of the Aerospace Medical Education Division at the Civil Aviation Institute, he has been involved with the education of both civilian and military residents in aerospace medicine. He's authored three textbook chapters, multiple presentations, and publications. He is qualified in federal court as an expert witness in aeromedical certification, aerospace medicine, and spatial disorientation in general aviation operations. He is a fellow of the Aerospace Medical Association, ASMA, and has received multiple awards, both national and international, including Greece and Africa. Dr. Barineau's topic will be spatial disorientation in aviation. Good morning, everyone. It's my pleasure to give you this morning the John J. Cahill lecture. The topic will be on spatial disorientation in aviation. And I'm very honored that I was asked to participate in your conference and pass on some information for you and hopefully answer your questions after the recorded presentation is made. I do not have any relevant financial disclosures to make. And I guess I would like to communicate to you that I hope to leave you with some usable, actionable information in your aviation aspects of your practices. I'm not here to be the fount of all knowledge, nor, as the dilution effect, is staffman to resident to intern to medical student. We'll try to avoid only an occasional insight. We will avoid the bucket of useless trivia, the sprinkler of dubious facts, and the puddle of misleading statistics, although there will be some statistics. Spatial disorientation is an extraordinarily interesting aspect of human existence. Aviation brought it to the forefront. However, as you'll see, the precursors to understanding human orientation, and therefore its effects in flight, precede the Wright brothers in heavier-than-air flight. This is a most interesting delve into an aspect of physiology that most people don't spend so much time on. And on my first slide, the road we're taking this morning is really the road less traveled. And while the two most important remaining, I think, medical issues that will never go away, since it's the Mark I human being still, are hypoxia and spatial disorientation. So there are many interesting presentations, and perhaps you'll have had them or will have them in the future. We'll go down the road a little less traveled with spatial disorientation and its physiology and understanding. So it's really a psychophysiology. Spatial disorientation is a component of the big picture. The big picture is what we refer to as situational awareness. And while we won't spend too much time on it, I wanted to place some context. There are several levels of situational awareness, understanding the mission, the big picture, all of the factors, and being a pilot, being oriented to their surrounding and to the attitude of the aircraft, you'll see is very important. So without being oriented, you cannot be situationally aware, but it is possible to be completely situationally. I mean, it's possible to be completely oriented, but not be situationally aware. So, you know, enough theory, perhaps an example is in order. Here's some situational awareness occupational medicine style. So, you know, where was I? Where am I? And where am I going? So you can see that there's the perception, the comprehension, and the projection of the future status here. Should the brakes not work well and should those be used port-a-potties? So situational awareness. A pilot needs to maintain a high level of situational awareness because they have a variety of tasks. I'm circling the graphic now. The instruments, the checklist, air traffic control, the airport, the weather conditions, the status of the aircraft, passengers on board. And so anytime the demands placed on the pilot exceed the pilot's capability, I'm kind of circling the danger area here, the red zone. That's where the propensity to have an accident really occurs. And to put it back into the aviation context, say, what's a mountain goat doing up here in a cloud bank? So just a reminder that to be able to be situationally aware, one needs to be properly oriented. And so spatial disorientation is essential to maintaining situational awareness. The textbooks that underlie, at least in the English language, there's only one textbook on the spatial disorientation in aviation from 2004 from the American Institute of Astronautics Aerospace. Fred Prevek and Bill Urkeline, colleagues of mine that edited it, I contributed a chapter to that. On the other side of the pond in the United Kingdom, Professor John Ernstine's textbooks on aviation and space medicine, widely renowned, physiology section superb. And of course, Alan Benson, who we'll talk about in a little bit, is also an author of a chapter in that book. I've contributed three chapters in three different editions, the third, fourth, and fifth editions of the Fundamentals of Aerospace Medicine on Accident Investigation. As I mentioned before, the fundamentals of understanding the theory of perception of movement predate aviation. So it was Ernst Mach, you know, you may know of the Mach number as well, those of you into aerodynamics, but Ernst Mach was particularly interested in balance. And while riding the train in corners, he noticed that the visual surround would tilt. So he embarked on a study of it, very fundamental study, some of the thresholds that he determined stand up extremely well to modern experimental standards. And his, this is the English version he published in Germany in 1875, so long before the Wright brothers in aviation, where of course it's going to be important as we discussed this morning. But his work was of great importance to Albert Einstein. And so whereas Ernst Mach's riding the train, Albert Einstein in Bern was riding the streetcar and looking at the tower clock, the Zeitlog, and wondering about subjective experience of time, Einstein was very interested in Ernst Mach's subjective and objective elements with respect to vestibular physiology. So you really had an influence there and the theory of relativity came out just a few years after Mach's work. And of course, Tom Cruise riding the train in risky business, perhaps his business acumen was contributed to by that motion experience. I'll leave it to your interpretation. There are other sources of information. Some of them you would have to purchase, such as the Handbook of Aviation and Space Medicine. However, there are many free resources, such as these two FAA publications I've listed here. And then the third, which is just a link in, if you go to the Airman Education section, the pilot safety brochures on spatial disorientation, all of these are freely available materials. So let's define it. If you're at a cocktail party and somebody asks you, what do you do? I recommend the short form version. Spatial disorientation occurs whenever the pilot incorrectly perceives the motion or position attitude of the aircraft relative to the ground or other significant objects. That's the one to do if you don't want to be just left alone in the corner as you ramble on. Of course, if you're standing next to the food and drink, perhaps it was a strategy all along. If you're a scientist, the long version is more important. And you'll see, I'll show you examples why. Alan Benson, probably from about 1975 on, I mentioned in that British textbook, spatial disorientation is a term used to describe a variety of incidents occurring in flight, in which the pilot fails to sense correctly the position, motion, or attitude of the aircraft or of themselves within the fixed coordinate system provided by the surface of the earth and the gravitational vertical. In addition, errors in perception by pilots of their position, motion, or attitude with respect to their aircraft or of their own aircraft relative to other aircraft may also be embraced within a broader definition of spatial disorientation in flight. Alan Benson from 1975-1976 era has stood the test of time. It's a better definition, some of you have already fallen asleep, perhaps. It doesn't include geographic disorientation, also known as being lost. So the precepts for pilots, aviate first and foremost, navigate, and communicate still stand in place. One of the doctors who's a flight surgeon at NASA, when he was in his residency training, Dr. Schuring, he was interested in spatial disorientation as well. And when I was doing research in accident investigation and spatial disorientation in particular, I noticed a trend in the NTSB database. I had a complete copy of the database, and we had linked it with two medical records and it was at one time the largest safety database in the world. He came along as a master's thesis student looking for a topic for dissertation. And you can see that in the late 1980s, there's a divergence in that the National Transportation Safety Board was calling a lot of accidents aircraft control not maintained. You can see that in red at the top. The green triangles, if it comes across as green to you, would be those that were fatal aircraft not maintained accidents. And you can see there's a big divergence there. If you then look at the bottom lines where they called it spatial disorientation and they were also fatal, as you'll see in another slide, they're practically one in the same. So aircraft control not maintained was hiding a variety of causes. You need to ask why to several levels in an accident investigation to try and pin down a root cause. So this is what he tried to do. He references my textbook chapter in 2004 and used the data that I provided him. And what he did was he was able to come up with a point estimation, you know, a count based methodology, you know, similar to what Napoleon wanted to know what's the probability of a soldier being kicked by a horse. And that's a rather infrequent event that, you know, uses count methodology. So he has calculated using the data in this green line, the estimated number of those aircraft control not maintained with a 95% confidence interval that could be reliably coded as spatial disorientation using a variety of subject matter experts and studying the inter-observer variation, you know, the kappa coefficient. So it was a very nice study. It's difficult to investigate accidents. It's expensive. And the National Transportation Safety Board doesn't spend a lot of time on general aviation accidents. They're primarily focused on the commercial accidents, but not exclusively so. But the resources they dedicate to these are somewhat limited. The timeframes are different. So this was a useful study to show that, you know, you that spatial disorientation is still a very important cause of fatal accidents in general aviation, in military aviation, and certainly as I'll show you in commercial aviation. So bottom line there, you know, let's ground the statistics a bit. It's probably fair to say that some estimates have 25% of military and civilian accidents involving spatial disorientation and 90% mortality is associated with those accidents, which is one of the highest fatality proportions associated with a type of accident. And there are three kinds of spatial disorientation accidents. The most common is a type one, unrecognized. The pilot never recognizes that they're in an unusual latitude or that death may be imminent. Type two is when the pilot recognizes that there is a problem. But now they have, you know, a pilot solution to figure out they need to fly out of that. And we'll talk a bit about that. The worst kind in one respect is a type three, an incapacitating spatial disorientation event. Atlas Air, the 767 coming in with cargo into Houston a few years ago, the first officer's reaction to the somatographic illusion, the panic and the startle was really an incapacitation. But many times the motions of the aircraft lead to vestibulo-ocular discoordination and an inability to see the instrument. So the worst kind really would be type three. But the most common is type one. It's unrecognized. And so the heart of the training issue has to go to that fact. If you want to get down into the weeds into how to model the human vestibular system, I have colleagues who do that. I'll show you some of the results of more basic modeling, but don't worry, that's not the purpose of this morning's lecture. Now Bob feathers one engine. He takes time to pour a glass of iced tea while flying. Upside down. That's an example. It's a very short snippet of Bob Hoover's zero energy performance routine and he used to do it on air shows. I met Bob Hoover. I've seen his performances. They're remarkable. The zero energy is really awe-inspiring. In this particular case, he had had some VIPs on board, some generals, and he was able to do a barrel roll without them even spilling a drink and some of them didn't even notice. And that's the point I wanted to make from it. You can see outside, you can see everything. So it's not difficult. Imagine if that was all no visual surround and the only information coming from the instruments. The aircraft is very happy to do a barrel roll under one G and all systems are normal according to the aircraft. But of course, according to the purpose of the mission, situational awareness, it may not be the appropriate action. So I wanted to show you how it is possible in the very dynamic arena of flight that that's why these illusions and spatial disorientation aspects become much more important. There's no way to design them out of human beings. So we need to, and I'll talk about countermeasures, we need countermeasures. So an example of a spatial disorientation accident, you know, the day the music died. This was Buddy Holly who had chartered the aircraft. He was tired of taking a bus with no heating system, you know, in the middle of the winter. And this was an accident near Clear Lake, Iowa in 1959. And he took a couple of other musicians with him. The young pilot who volunteered to fly them in this Bonanza V35. So it's a V-tailed Bonanza, which I've had the opportunity to fly. They didn't make it very far. As you'll see, they only a few miles from the airport impacted the ground. As I remember in a spiraling descent at great, great speed with a great deal of bank. I think it was a spiral to the right, but I don't remember right now. But if you look a little bit at the reconstruction of the, you know, the accident investigation at the time, it shows you the flight path here from the municipal airport. So they really only got a couple of miles to the accident scene. It was late at night. It was inclement weather. The pilot's instrument capabilities and training certainly were, although he'd been flying for four years and he was 21 years old, he did not have command of the aircraft that, you know, perhaps would have be fitted a, you know, a commercial type flight. As important, perhaps, is the fact that this aircraft was equipped with a Sperry F3 gyroscope, which used an alternate means of presenting the information than standard artificial horizons or main attitude indicators we call them. In the conventional, as you pitch the aircraft up to climb, the little aircraft will climb onto the top portion of the of the gyroscope display, but in the Sperry, the sky is the white part so actually it's the opposite manifestation for the for the same attitude of the aircraft and it was felt that this may have contributed to this young pilots, getting into a graveyard spiral and impacting the ground. So Don McLean immortalized this in 1971 with American pie, the day the music died. A more recent celebrity oriented spatial disorientation accident this time in a rotor craft was the Kobe Bryant crash, and you can see in the red circle, showing the helicopter this is the accident aircraft shortly before the pilot began a climbing turn, which ended into a descending left spiral. So, once again spatial disorientation at play. And if you look a little bit at the reconstruction, hopefully you can see this. The details aren't important but the trends that you have some information from from either a DSP or a flight data recorder maybe the cockpit voice recorder, you have sources of information ATC radar, all of these can be used to help reconstruct the accident. So the actual data from the flight can be converted into derived variable called the gravity inertial force. What's that, that's really the, the direction that the pilot will think is up and down. That's normal, but it could be in front of you, or behind you. And as the pilot climbed, there's a steeper portion of climb, which precipitated his succumbing to the illusion that the acceleration of the aircraft, combined with the gravity vector. Remember the complicated cocktail party definition you need this now, combined to give a vector, which is aiming behind the pilot, they then feel that they have over rotated that they're at a higher pitch degree than they should be for that phase of flight, it's illusory. Their flight engines will be reading correctly, but in response to it, they can allow the nose to lower. When they do so, the aircraft continues to accelerate now with gravity assisting instead of slowing. And so the illusion perpetuates itself. And that's one of the heart. The key points of the somatographic illusion, the dark night takeoff where the aircraft crashes on the runway extended line just a few miles later, with or without a turn, we'll explain that later. So you can see this quiver plot showed that all the time the pilot was descending towards the ground, he would have thought he was climbing. I think the cloud deck at the, at the, at the apogee here of climb, he was probably only one or 200 feet from coming into the visual surround again, very close, but the overwhelming sensation that he was pitching up too high, led to pushing the, you know, the collective forward to lower the nose 1999 john f kennedy and his wife and her sister were on a flight over the ocean, dark featureless night, and his training and experience really didn't let him overcome the fact that they fell prey to the graveyard spiral. And so the, the rapid descent, you know, without any mechanical cause or medical cause you might remember he had a boot on he was, he had just suffered a foot fractures I remember. So, you know, is it. We don't use the runners quite as often as you might think, but nevertheless, was that a good decision but the delays, meant that they got away at night, they were going to drop off his sister in law, Martha's published a book and I bought a couple of eight by 10s from him, where he rolled the precursor to the 707 in 1955 over Lake Washington here in the Seattle area where I'm broadcasting this from the British had problems with the de Havilland comment, there'd been a series of three accidents was very important there. Because of contributing to the accident analysis and those aircraft were found to have rectangular windows, and they discovered the concept of metal fatigue here we here we are in the United States trying to build competing aircraft and the British have the market and text decides to spontaneously demonstrate that, you know, one g barrel roll the aircraft never has any problems whatsoever. The other picture that I couldn't find it for this lecture was a picture of the wooden table that the engineer sat at, you know, behind the cockpit, which of course flight, I have that picture but I couldn't find it for you. So the idea is, it is possible to get into unusual attitudes without any sensation of anything being wrong at all here, visually startling, but if you didn't see you wouldn't be feeling very comfortable. The aircraft has six degrees of motion so it can accelerate or decelerate on the longitudinal axis, it can go up and down on the vertical axis. Turbulence can move you sideways, you rotate the aircraft about those same axes so there's linear acceleration and angular acceleration, all of which is picked up by the vestibular system. The size of a pea on each side in the in the Petrus Ridge and the deep in the bone protected these tiny little accelerometers, along with the cochlea for hearing are responsible for picking up all of these accelerations both the linear accelerations from the ventricle and the saccule and the angular accelerations from the semicircular canals, the, the, the, the organ the labyrinthine organ and the, the are oriented at about a 20 degree down so as we walk with our heads down a little bit, it's in a natural They're oriented with a 45 degree offset so that the anterior vertical semicircular canal on one side of the year is in alignment with the posterior vertical semicircular canal on the other ear so it's a push pull amplifier which allows for modulation of gain and a better of course the horizontals are also assisting each other so there's a push pull type amplifier effect that you incorporated in these amazing accelerometers. Now the, the balance organs communicate through nerves to the extraocular muscles and to other parts of the body, which is extremely important and understanding spatial disorientation. One of the primary purposes of the labyrinth organ is to provide stability to the retinal image so people who are born without these, you know, congenital absence of the labyrinth they can, they're oriented in the daytime, but not at night. So when you don't have vision to supply you your orientation cues, the vestibular apparatus does so it helps stabilize your vision as you do acquisition hunting seeking and in motion, such as a train, the fast motion followed by the slow, you know, allows you to see the scenery, you know, sitting on that train analogy again. The, the seat of the pants sensations are not so useful in flight, you know, aerobatic pilots use them it's not as though they're useless, but orientation is primarily a visual phenomenon in aviation, and I'll talk a little bit more about some of the details there. When you're in your commercial airliner, you flew to Tampa to be at the meeting, and you hold your beverage, the water is always staying flat but even though the aircraft is maneuvering perhaps in a hold maneuvering to approach to land, it never changes because you're in a coordinated flight situation that's what this picture of the helicopter shows it always feel straight and level, even when you're in turns, because the forces are balanced out in a coordinated turn and properly executed coordinated turn. So the water doesn't slosh to one side or the other, even though you may be in a 20 degree bank it's not going to be 20 degrees inclined in your cup. So that's one place to remember it. That, in a nutshell, 80% of your orientation information comes from the visual apparatus and their whole fields of study here so in one hour we're not covering them, but the visual dominance is particularly important because pilots use their training and experience, and they use their peripheral vision when there's a visual surround, and they use their foveal or central vision to read the instruments and make executive decisions on orientation, when they can't see outside. So, just like figure skaters who suppress the vestibular information, the vestibular system is always on, doesn't take a pause, but it's not useful in flight, it's frequently in, we're poorly adapted to the continuous accelerations of flight and our apparatus don't record it very well. So you suppress the orienting effects of the vestibular apparatus. However, when the visual surround degrades, when it's at night, when it's cloudy, when you haven't been paying attention to the instruments, the vestibular system is opportunistic and it will always try to tell you what's up and down, but many times in a dynamic flight environment in poor visibility, it's illusory. So, you must believe your instruments. The trainer has just stopped this subject in the Barani chair. They were rotating to their left, and when she brought it to a stop, the subjects are asked to indicate with their thumbs which way they're rotating. So he was rotating, this is my left, so he was rotating like this, and after about 20 seconds, despite still rotating, he puts his thumbs up in the air so he doesn't see it, but he'll get to see it in his colleagues who take the chair after him. When she brings it to a stop, he points in the other direction. And this is the simplest, easiest way. I highly recommend people take a ride in the Barani chair. We used it at the Civil Aerospace Medical Institute a lot. I suppose a dentist's chair doesn't swivel like this, but it's a very easy demo. You don't need to put eye occlusion and ear protectors on, but it makes it easier. And so this is kind of an example where the horizontal semicircular canal gets stimulated. So the subject says, I'm spinning left, the sign is wrong. And then as 20 seconds goes by, they all go vertical. I don't feel it, but they're still spinning. And then as you bring it to a stop, they point in the opposite direction. Another technique you can do is to put the head down and have them spin up for 20 seconds, and they've closed their eyes, or you could use this apparatus. Then he or she lifts their head, and one canal was engaged. Now another canal gets engaged. That's a Coriolis illusion, and it's startling. You'll see nystagmus. They often throw out their hands for balance. And so it's a bit overstimulatory, but there are many things you can show with the Barani chair. And of course, Dr. Barani earned a Nobel Prize for his distinctive discoveries using it. Another one that many have experienced in the Air Force would be the spatial disorientation devices, such as the Vertigon. But I personally found that this one, which is a Barani chair with instrumentation, looks like a cockpit that spins. It was quite stimulating. And if they make you reach down to change the transponder code or pick up a pencil you've dropped, if you drop your head down rapidly, you're going to have to clean up the mess, because sometimes it led to emesis. So I think that's counterproductive, because that's not exactly how it happens in flight. It happens like hypoxia. It's insidious. It's building to a dramatic conclusion, which might be a fatal accident, and it's not so overwhelming to draw your attention to the fact that this is happening. But this was a good one to experience what's known as the hand of God illusion, Coriolis, and a few others. But much better apparatus that we used to use when I ran the education division. We trained 1,000 doctors a year on how to do the pilot exam, and 5,000 in these sorts of threats. This is a virtual reality spatial disorientation simulator, but the gyro lab, too, in the bottom picture, very effective. And we even have one, CAMI has one for rotorcraft flight as well. So there's much better training that's available now. Some of it's going to be in flight with a flight instructor. It's a part of every practical test standards for airman certification. But there's ground-based training, something as simple as the Barani chair, highly recommend it. Visual illusions, which we're not going to spend much time on. But, you know, in this cube, is it projecting down and to what is my right or up and to the left? Is that a vase or two faces? Is it a young woman or an old woman? And, of course, in this one, our latest color vision test for the FAA, do you see predominantly green lines? Do you see red lines? Which lines are on top of which lines? Don't worry, I'm just showing you illusions. The only visual one I'd like to mention, because you've all experienced it on the subway or in your car, you come up to a stoplight and you're stopped. You may be a little distracted. The light changes. You're not the first to go, but the people around you start moving. How many of you have stomped on the brake, feeling you're moving backwards? That's the vection illusion. Very, very common. You can get it in car washes. When the apparatus is moving and you're not, you still feel like you're moving. It's your ambient peripheral vision information being processed in an illusory manner. There'll be one other I show you, but we're not going to go through these. It's a little easier to show you this. I'm flying this Piper Archer II. The late Dr. Stanley Moeller, my mentor and the residency director at the time, is in the right-hand seat taking the pictures. Those of you that are pilots, particularly those of you maybe instructor pilots, CFIs, it seems like I'm pretty high. This would be a pretty short turn to final with a lot of altitude to have to shed, except that this is a radio-controlled modeler's airport. It's not an airport for large aircraft. It just looks like it. You're a pilot at your home airport. Box A is really what you've experienced time and time again. In this case, they're saying it's 150 feet wide and 11,500 feet long, but that's not so important. What's important is compared to your home experience, A, B is a wider runway or maybe a shorter one, which makes you feel like you're really low, but you're not. You're in the identical location in each of these boxes, A, B, and C. In C, you think you're high because it's a narrow runway or a very long runway. You think you're steep. It's an illusion. It's the same in each one of these. Pilots learn this as they venture from their home airport. The two oldest illusions that came with aviation are the graveyard spiral and the graveyard spin. The two oldest illusions that were described in aviation experience with graveyard spiral and the graveyard spin, the graveyard spiral is much more common and is the vast nine out of 10. The graveyard spin is if you spin the aircraft in IMC, you're definitely going to experience the somatogyral illusion. When you stop the spin, it's going to feel improper and you will re-enter the original spin, feeling that it's not correct, having stopped the spin. That Barani chair where you stop the spin and you get a counter-rotation feeling, very much in effect here. The graveyard spiral, two illusions, the somatogyral, which we just mentioned, and the somatographic. If you look at vestibular illusions, which we're already talking about, they break down by angular or from the vestibule or from the otolith. The somatogyral and the oculogyral, it was Ernst Mach experiencing the oculogyral and the trains that led him to go down that research path. The somatogyral, it's an angular illusion. The Coriolis and the Barani chair where you bring two canals, one was currently spinning and you bring a new one in, the cross-coupling of those canals, that's called Coriolis, that's angular. The somatographic, as affects people, and I'll show you some cases, that's linear illusions where you think you're climbing too high and you're really not. We talked about that with the Kobe Bryant accident. The inversion illusion, the GXS illusion in formation flight, the oculographic effect upon the eyes, not the body. The leans is the most common in surveys. Pilots say, oh yeah, 80% of people said, I've experienced the leans. It's because it drew their attention. The most common is actually the somatogyral, but it goes type one undetected. It's actually somatogyral, but in surveys, the leans comes out on top. Notice it's a combination. It's an overpowering illusion that you're in a bank when you're not. I remember climbing out in instrument conditions and definitely having the leans, but you remember it because it draws your attention. The graveyard spiral is a combination of both the angular and the linear acceleration illusions. One reason why it's so convincing and deadly. An example of somatographic was an accident of a US Air DC-9, lightly loaded, a lot of extra thrust because of that, coming into Charlotte in a dark and stormy day. They encounter wind shear. The non-flying pilot, the captain, is looking for the runway environment. They begin to go around and the first officer sets the deck angle to 15. During that go around, in a wind shear situation, the non-flying pilot, the captain, tells the first officer, down, push it down. That's where the divergence begins right here. What you have, that I worked with Bill Erkeline, did this with the NTSB, was take the information from the flight data recorder and show the gravitational inertial force field. Their perception of what's up and down continues to be a climb. The actual pitch of the aircraft, as recorded by the flight data recorder, is a descent until they come out in the visual surround. They yank the nose up, but they still hit the ground. Half the passengers died in that accident. All the crew members lived, so we could interview them. Somatographic illusion, 1994. 2000, the NTSB was assisting the CIA in Bahrain, and I was working with the spreadsheet with the flight data information, did a similar calculation to show the somatographic illusion. And I'll show you the details later. Two of my colleagues working on that as well were Dr. Angus Rupert, and who's at Embry-Riddle currently, and Professor Brayden McGrath. And these are expert modelers. Dr. Rupert's well known in spatial disorientation research. He's a pilot himself. And they're trying on the tactile situation awareness system here, which is the another, I'll talk about it again later, but another way of presenting, orienting information using another channel, vibration through the torso. And they're just fitting this out. And I've tried it, and it's fascinating. It's very, very effective. So what should the aviator do? Well, realize the limits of the human sensory systems in flight. I'm trying to convince you, we need to convince aviators, and whatever means, show them that there are real limits, that the human orientation system on the ground is beautiful, remarkable. It's a little bit maladapted to the sustained accelerations of flight. So aviators should get some spatial disorientation training. They can get it in flight with a certified flight instructor. It's part of the practical test standards or airman certification. Ground-based, variety of means, like I showed you the Barani chair, or the ETC Gyro 2, or the FAA Airman Education Team, using various means to teach people about hypoxia, spatial disorientation, and global survival. When insufficient visuals surround to conduct your flight, you must believe your instruments. Your orientation can only come from that foveal vision, looking at the instruments, and the executive functions has to be trained. It's a perishable skill, and you're orienting yourself based on higher order understanding of what that aircraft is going through, because there's no horizon for your ambient vision to use to orient. So you're going to make the instruments read correctly. You were on a mission, you had some purpose, and the instruments will look like they're reading wrong, because you're under the effect of the illusion. So you need to believe your instruments and make them read correctly. That might mean pulling power, reducing bank, and gently pulling out of, you know, a graveyard spiral. But the specifics would depend on what your instruments are telling you. You don't need to categorize the illusion. You need to fix the aerodynamic problem. You need to maintain instrument proficiency, because it's a perishable skill. Not everybody can learn to do it. But if you're not rated for instrument meteorological conditions, you practice the 180 turn, which I'll talk about that study. One of the most important things is, aviators don't need to learn the names of the illusions. They need to learn that there's limits to our human functioning, that there are illusions. It's good to know some, or where they occur, dark, you know, dark night takeoff, and missed approach in inclement weather. But there's no point to learning all of the illusions. That won't help you deal with it, because they're very insidious, just like hypoxia. So you're not trying to decode them. You're just trying to acknowledge something's wrong. I got to fix my orientation. Back in 1954, AOPA commissioned a study done by the University of Illinois Institute of Aviation in Urbana, Illinois. And they found that on average, you had about 178 seconds to live. So they flew in an actual aircraft. They used ambient vision, suppressing information, and they weren't trained on instruments. So once they did that in the aircraft with a safety instructor pilot, 178 seconds on average, but as short as 20, as long as 480. But all of them lost control of the aircraft. 19 of the 20 subjects entered a graveyard spiral. One of them was the stall spin I told you about. So however, once they trained them, everybody could repeat that maneuver and recover successfully, which was the purpose of the study. But this is why you often hear about 178 seconds to live. And so that's just short of three minutes. So a standard rate turn is three degrees per second, which means in two minutes, you can do 360 degrees. You want to do a 180. You want to get out of the weather conditions where you lost your ambient vision, that horizon. So that's just a little piece of history there. You hear it referred to a lot. So compared to the aviators, you know, what should the AME, the flight surgeon, what should doctors do, the doctors in the audience be? You know, the same realization is important. The limits of the human sensory systems in flight, their maladaption to ideally suited to what we do on the ground, particularly with head and body motion, but the maladaption to the motions of flight where you're in a vehicle that's capable of sustained acceleration. It doesn't have to be F-16 type of sustained acceleration, just commercial airliner acceleration even. Get some training as I recommended for the aviators, you know, in flight with an instructor or ground-based, the Barani chair or any of the spatial disorientation demonstrators that are out there like the gyro too. The FAA Airman Education Team offers this free training at air shows like Air Venture and other places. And the addition is I would get some formal training in spatial disorientation, vestibular physiology, and learn the basics of the visual and vestibular illusions and the underlying psychophysiology. It's very useful and you're capable of understanding it. It's complicated for flight surgeons because it's not a part of regular clinical practice, but as I've given you some examples and there are others, be familiar with some accidents involving spatial disorientation. Whether or not they involve celebrities is not important, but people tend to remember hearing about those and it helps, you know, ground it a little bit more. Pilots don't care. They know that everybody can die from inattention or making mistakes. It's a very unforgiving environment aviation can be. If you're a pilot yourself, you're trying to maintain instrument proficiency. You're trying to use the foveal skills, the central vision, the high acuity vision to read the instruments and use your executive processing to make sense of your orientation. That takes training. It's a perishable skill. And so, foremost, if you're not rated in flying and instrument meteorological conditions, you know, avoid it and practice the 180 turn that we talked about. Same for the aviators, that 1954 study. So yes, the doctors should learn more about the illusions and be a fount of knowledge, if you will, in that first or second joke slide. So you might participate in accident reconstruction. With respect to that A320, you know, once again, reminding you that in flight, the combination of the aircraft acceleration, which is inertial, and the force of gravity, that results in a resultant vector. So that's the G field that the autoliths are going to be in. It's the combination of the two. We're back to Einstein, right? Acceleration and gravity are the same. So we don't need relativity theory or quantum mechanics here. I'm just saying those complicated processes that I don't think the pilots benefit from are captured in the flight performance. So it's a technique to use the flight performance, the aircraft reconstruction, and infer from that human performance elements. And so if you look at that A320, that gravito-inertial force vector shows them always in a climb, which would be expected since they were doing a go-around and they had hit the toga button for takeoff go-around thrust. But in reality, they had allowed the nose to precipitously drop and they were headed towards, you know, the Persian Gulf, which is where they went in without any surprise whatsoever on the cockpit voice recorder. And just the last portion of flight, zooming in on it, the same thing, this last two minutes of the flight, you can see that the perception was all the time climbing when in fact there was a descent compared to the initial climb stability until such time as they allowed the nose to come down, then the illusion gets stronger and they don't correct the fact that they're headed down until this is a small pullback on the stick. I have a graph where I put the control motion deflection and it was about half of the actual control authority available to those pilots in that aircraft. So they pulled back but they didn't do it with any great authority. The gear were up so they weren't going to get an enhanced ground proximity warning alert necessarily or, you know, as the gear were down. So they were trying to land and going around and therefore they didn't have anything but the sensation and their flight instruments. So it's a reconstruction element. The pilots don't need to know this. They don't need to be in the weeds on this. They need to know how to make their instruments feel right and when it can strike them. From the easiest to the most arcane, you know, the countermeasures training, ground-based or in flight, you can improve the technology. We talked about the Sperry gyroscope with that V35 accident with the day the music died where it was an opposite presentation mode. So you can use HUD, heads-up display, symbology. You can use auto recovery systems in the cockpit and that's part of the cognitive cockpit that you can use augmented reality, highway in the sky. So it's much simpler to fly based on some technology assist and there's a publication there I refer to you. It's a free one on the cognitive cost cockpit and safety net concept. You can screen your applicants. We're really only looking for, you know, more like clinical vertigo episodes, Meniere's or labyrinthitis or other, you know, acoustic neuromas or other things going on in the system that could cause problems. So there is an example of a naval aviator on their penultimate instrument training flight that they failed because there was turbulence. There hadn't been turbulence prior to that and it was found that they didn't have a vestibular ocular reflex. I briefly alluded to the eyeball, the vestibular apparatus and the nervous integration to the cerebellar processing that allows that all to work together. Well, some people are born without a vestibular ocular reflex. So they're not going to have that stabilization of the retinal image. And that young aviator had an absent vestibular ocular reflex. So unless you test for it, you're not necessarily going to know it. They otherwise, it was the aviation environment that brought it out. So you could screen for these things, but it lends itself to other problems. You can use, if you will, vestibular prosthetic devices. That's not physically the way it's done, but you can provide information through galvanic stimulation in the neural pathways to change the perception of the orientation. So sophisticated aircraft could do that. There's research there. And as I mentioned, you could provide orienting information through vibration to the torso. It's extremely effective. Another research project being looked at currently by the Air Force is the use of three-dimensional sound. So I'm saying we're going down to the more arcane. Now you can also intervene with aminoglycosides and take out the vestibular apparatus. So in 1954, Dr. von Beck, in a journal article, the Journal of Aviation Medicine, I would like to add that disorientation due to incorrect labyrinthine cues can be prevented by the toxic effect of streptomycin on the vestibular apparatus. I don't recommend that. You might have been presented with some test questions and you have here actually the question and answers. And it is correct that long before the Wright brothers, Ernst Mach in 1875, there's elucidation of the underlying mechanisms and limitations. So it didn't come after aviation. It preceded aviation. Vestibular and visual and proprioceptive sensations are equal in their contribution to orientation in aviation operations. It's obviously incorrect. I went over visual dominance, visual suppression, and vestibular opportunism, and the seat of the pants flying, and the references are here. And aviation accidents are very infrequently attributed to spatial disorientation since humans have no difficulty orienting during flight motions during periods of reduced visual surround visibility. And that's where 25% of accidents, civilian, military, with a 90% chance of mortality is associated. And I've listed the references there for all three. And that brings us to questions, which I'll be happy to answer, or I promise you an answer if we run out of time. And you can get a hold of me at the following email addresses, and I will endeavor to get you the information you need. And I hope you found this informative and better able to prepare you to talk about spatial disorientation. Thank you once again so much for the invitation to give this special lecture. Well, thank you so much, Dr. Verino. Appreciate the lecture. Are there any questions at all? I want to take just a... Good morning, everyone. It's my pleasure to give you this morning the John Jay... We almost watched your video again there, Dr. Verino. Dr. Verino, do you have any closing thoughts? I would have to unmute first. I've been waiting in the same suit the past three days so that no one would get a jarring experience. We had numerous power failures during the creation of that video. So thanks, Jeffrey and Rhonda, for taking care of things. The thing I forgot to mention, which I'm wearing again today, is I'm wearing the inverted Jenny tie. And so in attribute to SpatialD, but note or remember those stamps are worth about $1.5 million now if you have one in your attic. But it was published in 1918. So pandemic to pandemic and human susceptibility to spatial disorientation is still a very important threat in aviation, often under-recognized even by the investigating authorities. I hope some folks have some questions, but sometimes they're shy. Reach out and I can provide you with materials and point you in the right direction or just answer your question. Absolutely. Appreciate. I don't see that there's questions from our audience and I didn't... Oh, one question. Dr. Wriston will come up and pose it. Yes. In the example of the table that stayed placed, does that happen just at a certain temperature, a certain speed, a certain speed and a certain angle that you lose that if you're going faster or you lose that spatial orientation in which everything stays level? Okay, very good. If I understood the question correctly, if I didn't, please correct me. The thresholds for detection of acceleration, our sensors don't really detect once it becomes a constant velocity, have certain limits. So there is the possibility that you could stay underneath the ability to detect something that can happen. It's a bit complicated because it's not a speed or it's sort of the acceleration and the time of the acceleration. It's called Mulder's constant. It's a good board question in aerospace medicine. It's around two, but for accelerations under five seconds. The idea is that in a straightened level, unaccelerated flight, you take your eyes off the instruments. There's nothing to see. Nothing's going on. Maybe the autopilot's on. Nothing's going to happen. But in a dynamic environment, you can start to have an imperceptible bank that takes you a little bit off course. The bank, of course, is less lift in the vertical direction. So you start going down and the rate at which that occurs might not be sensed. So it's not really the speed with which you are going or things happen. If things happen, you know, at a high level, you feel it. The idea is that by checking your aircraft constantly, you detect it at the earliest possibility. I'm collecting more cases, but often GPS give us granular data. At what point does a pilot in a graveyard spiral really participate in the illusion, start pulling back on the stick because they see the altimeter unwinding? It's happening very gently initially. Well, it happens in about the first 10 to 11 seconds. That's based on a case of one where the natural radius of an aircraft in a spiral, the tightening of that past the aerodynamic component is due to the pilot input pulling back on the yoke. So your question's a good one. You're susceptible really in the environment when the vision isn't there. There will be speeds or accelerations that are detectable or not detectable. It's pretty common that things happen slowly enough that there's nothing to feel. And as it worsens, there's nothing to feel until dramatically at the end that, you know, the g-loading builds, the sound of the wind must be incredible. So initially it's really all taking place in a rather benign environment, which is why I call it insidious. So you'd have to watch out for it really any time, not a speed, but any time you're needing to maneuver with a complete understanding and belief in your instruments. And probably in other than straight and level unaccelerated flight, if you're in a dynamic environment and you take your eyes from the instruments to deal with whatever else, you might only need about six seconds, 10 seconds for your mental model to degrade. So I hope that helps answer that really any speed can result in a spatial disorientation, but the time element and the rate at which things are changing mean when you can't see out well and form your own view of the world picture and you're using instruments, it doesn't take very many seconds for the picture to degrade. Does that help? Yes and thank you so much for your presentation. Oh thank you. So for those of you on Zoom, usually right next to the green share button is the chat button. If you open up the chat and scroll up just a tad, you'll notice that we have a different Zoom room for our annual business meeting. So we're going to adjourn the mid-year meeting for the next hour or so and then we'll come right back into this room, but I wanted to create a separate environment so that the members that are not participating in the mid-year conference could join us for our annual membership business meeting. So Dr. Baranow, thank you so much. Allow us to applaud your efforts. Thank you. Thank you so much for the invitation and great success with your conference. Thank you everybody. Absolutely. God bless.

Stephen Barineau

John J. Cahill Memorial Lecture Award

aerospace medicine

spatial disorientation

aviation safety

vestibular illusions

heads-up displays

pilot training

aerospace professionals