Special Investigation Report on the Safety of Parachute Jump Operations
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Special Investigation Report on the Safety of Parachute Jump Operations aviationSPECIAL INVESTIGATION REPORT NTSB/SIR-08/01 PB2009-917001 NTSB/SIR-08/01 PB2009-917001 Notation 8042A Adopted September 16, 2008 Special Investigation Report Special Investigation Report on the Safety of Parachute Jump Operations National Transportation Safety Board 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 National Transportation Safety Board. 2008. Special Investigation Report on the Safety of Parachute Jump Operations. Special Investigation Report NTSB/SIR-08/01. Washington, DC. Abstract: This special investigation report describes the results of a National Transportation Safety Board review of 32 accidents that involved parachute jump (“or skydiving”) operations and that occurred between 1980 and 2008. The report identifies the following recurring safety issues: inadequate aircraft inspection and maintenance; pilot performance deficiencies in basic airmanship tasks, such as preflight inspections, weight and balance calculations, and emergency and recovery procedures; and inadequate Federal Aviation Administration (FAA) oversight and direct surveillance of parachute operations. Parachute jump operators, many of which transport parachutists for revenue, maintain their aircraft under regulatory provisions that require little FAA oversight. Lack of operation-specific pilot training is also discussed. Safety recommendations to the FAA and to the United States Parachute Association are included. Appendix A details other current and past Safety Board recommendations related to parachute operations. The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also may be obtained from the website or by contacting: National Transportation Safety Board Records Management Division, CIO-40 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (800) 877-6799 or (202) 314-6551 Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB2009-917001 from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (800) 553-6847 or (703) 605-6000 The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. SPECIAL Investigation Report CONTENTS Figures .............................................................................................................................. v Tables ............................................................................................................................... vi Abbreviations ................................................................................................................vii Introduction ..................................................................................................................viii 1. Background ...................................................................................................................1 1.1 Parachute Jump Operators ............................................................................................................ 1 1.2 Parachute Jump Operations Accidents ........................................................................................ 1 2. Maintenance Issues .....................................................................................................7 3. Pilot Training and Proficiency Issues ....................................................................11 3.1 Inadequate Preflight Inspections ................................................................................................ 11 3.2 Noncompliance with Airplane Weight and Balance Limitations .......................................... 13 3.3 Failure to Maintain Airspeed During Powered Flight ............................................................ 14 3.4 Inadequate Performance of Emergency Procedures ............................................................... 15 4. Federal Aviation Administration Oversight and Surveillance Issues ............18 4.1 Accidents Preceding Increased Surveillance Action ............................................................... 18 4.2 Accidents Since Increased Surveillance Action ....................................................................... 19 5. Conclusions ................................................................................................................23 5.1 Findings .......................................................................................................................................... 23 6. Recommendations .....................................................................................................24 7. Appendixes A: Safety Recommendations Pertaining to Survivability Issues for Parachutists ...................... 25 B: Accident Synopses .......................................................................................................................... 30 National Transportation Safety Board iii SPECIAL Investigation Report FIGURES 1. Cracking (visibility enhanced during examination with a liquid penetrant) on the No. 4 piston skirt from the East Moriches, New York, accident airplane. ......................................................................9 2. Engine oil coating the underside of the horizontal stabilizer on the Grain Valley, Missouri, accident airplane. ..................................................12 3. Wreckage of the Homestead, Florida, accident airplane. ................................................14 4. Remains of the house impacted by the West Point, Virginia, accident airplane ....................................................................................21 National Transportation Safety Board v SPECIAL Investigation Report TABLES 1. Fatal parachute jump operations accidents since 1980 ......................................................3 2. Accident airplanes with engine hours that exceeded recommended time between overhaul (TBO) ............................................................................8 National Transportation Safety Board vi SPECIAL Investigation Report ABBREVIATIONS AC advisory circular AD airworthiness directive agl above ground level ATC air traffic control CAMI Civil Aerospace Medical Institute CFR Code of Federal Regulations cg center of gravity F Fahrenheit FAA Federal Aviation Administration FMS flight manual supplement FSDO flight standards district office lb pound MEL minimum equipment list msl mean sea level PMA parts manufacturer approval PTRS Program Tracking and Reporting Subsystem SB service bulletin SIL service information letter SPAS Safety Performance Analysis System TBO time between overhaul TCM Teledyne Continental Motors USPA United States Parachute Association National Transportation Safety Board vii SPECIAL Investigation Report INTRODU C TION Parachute jump (“or skydiving”) operations, which the Federal Aviation Administration (FAA) defines as the activities performed for the purpose of or in support of the descent parachutists (or “skydivers”) who jump from aircraft, represent a segment of U.S. general aviation operations, which, according to data compiled by the United States Parachute Association (USPA),1 transports parachutists on 2.16 to 3 million jumps annually.2 Most parachute operations flights3 are operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91 and are typically revenue operations; parachute jump operators provide the flights as part of their services to parachutists who pay to go skydiving,4 or parachutists pay dues for membership in parachuting clubs. The risks of parachuting are generally perceived to involve the acts of jumping from the aircraft, deploying the parachute, and landing; parachutists are aware of and manage these risks. However, a review of accident reports reveals that traveling on parachute operations flights can also present risks.5 Since 1980, 32 accidents involving parachute operations aircraft have killed 172 people;6 most of whom were parachutists. 1 The USPA is a voluntary organization made up of about 31,000 individual members and about 270 operator members, referred to as “group members” or “drop zone” members. The USPA’s mission is to support and promote safe skydiving through parachuting training, rating, and competition programs, and it distributes safety information through printed publications and its website. 2 According to a USPA membership survey, its members reported about 2.16 million jumps in 2007. In correspondence with a National Transportation Safety Board investigator dated February 5, 2008, the