NTSB and Skydiving

[danielcroft 2]

Also suggested that people not wearing their restraints may have caused the death of other occupants.

If they never actually got over 500ft why the hell weren't people wearing their belts?

[AggieDave 6]

Don't just think of the turbine DZs. Think about the hundreds of 182 and 206 DZs out there. A complete overhaul can cost $10k-40k depending on what is replaced, machined and what the A&P charges.

Now that plane is down for at least two weekends, unless the DZ has enough money to maintain a second aircraft and/or enough parts to rebuild while the old parts are sent to the factory for inspection.

For each hour on the hobbs you can assume 2-ish loads were flown in a 182 (yes I know that varies, but 2 is a good average). If the DZ maintains their aircraft, does their 100hr inspections and has an A&P that will ground a plane when needed, then it hasn't been a big deal to go past TBO. However, you have a DZ that runs a little loose due to the obvious money concerns, well then you have a motor that grenades on take off and gets "interesting" from there.

--"When I die, may I be surrounded by scattered chrome and burning gasoline."

[danielcroft 2]

I remember a while ago there someone posted a link to the actual study into restraint systems. Can someone please re-post that link?

[Fast 0]

Everything that I have seen of this so far doesn't bode well for the "cost" of operating a dropzone. For what it's worth, there must be people out there who follow TBO times and the like. I know that we are very diligent in following 100H inspections and general maintenance of our planes. Stuff costs a lot of money, but lawsuits cost more, not to even mention the part about how much it sucks to die/have your friends die.

I imagine we are going to start seeing a whole lot more ramp checks if the NTSB gets pushy with the FAA.

~D
Where troubles melt like lemon drops Away above the chimney tops That's where you'll find me.
Swooping is taking one last poke at the bear before escaping it's cave - davelepka

[AggieDave 6]

Quote

I imagine we are going to start seeing a whole lot more ramp checks if the NTSB gets pushy with the FAA.

That's seriously hit or miss as well, in terms of accountability and consistency of the inspections. We had one guy from the local FSIDO ramp check one of our 182s a few years ago and gave it the go ahead. About a year later he ramp checks the same plane and grounds it for a small dent on the horizontal stab that was there during the previous inspection.

The other times the guys have been out from the FSIDO, all they cared about was the paperwork, they didn't give a damn about the airplane at all! So yup, those ramp checks really help out!

--"When I die, may I be surrounded by scattered chrome and burning gasoline."

[billvon 2,396]

> About a year later he ramp checks the same plane and grounds it for a
> small dent on the horizontal stab that was there during the previous inspection.

That's true in many other areas, as well. Riggers will often miss stuff and find it later (wear on the inside of the reserve riser "ears" is a good place to miss, for example.) Doesn't mean that gear inspections during repacks are useless.

[AggieDave 6]

I wasn't implying that ramp checks were useless, I'm sorry if that's what my post sounded like. My point is that if the FAA is wanting to regulate us, they should regulate themselves and work out from there.

--"When I die, may I be surrounded by scattered chrome and burning gasoline."

[buzzer 0]

About TBO. The NTSB report only cited one accident of the 32 investigated where TBO was part of the cause yet they want to make everyone rebuild engines at a specified number of hours. This would be the greatest financial impact of all the recommendations they made. The fact is that engines can last much longer...or shorter. Putting a number down for TBO is like saying pilots are unsafe at a certain age. Not all pilots are equal...just like engines. I know what will happen if the FAA adopts the TBO rule. The airplane logs will not reflect the actual hours flown. The law is already in place for engines to get rebuilt/replaced/fixed when they need it. Some operators just choose to ignore the facts or fail to have the engines checked as directed. This is true in many other commercial operations as well. So, even though engine TBO is only a very small factor in parachute operation deaths, how can we make it better? Accountability for maintenance neglect. I have no idea of how to go about that but using the TBO number isn't the best answer IMHO. The NTSB shouldn't be concerned with cost so much in making a recommendation but they should have good data for recommending such a change.

[ZigZagMarquis 8]

Quote

Aviation Report - On July 29, 2006, a de Havilland DHC-6-100, N203E, operated by Skydive Quantum Leap as a parachute operations flight, crash after takeoff from Sullivan Regional Airport, near Sullivan, Missouri. The pilot and five parachutists were killed. Two parachutists were seriously injured. Media Contact: Terry Williams

So is the Final Report out yet on the 203E crash? Then NTSB website still only has the Factual.

Quote

Also suggested that people not wearing their restraints may have caused the death of other occupants.

This one is starting to irk me more and more... probably should have concerned me more in the past... folks not belting themselves in or not belting their helmets in if they choose not to wear them for takeoff AND getting pissy if someone on the load asks them to put their belt on and/or belt their helmet in if they're not wearing it because the thing could turn into a projectile in a crash, if not. Evidently the Perris Crash and the Sullivan Crash wasn't enough to teach us this?

[pilotdave 0]

Quote

Don't just think of the turbine DZs. Think about the hundreds of 182 and 206 DZs out there. A complete overhaul can cost $10k-40k depending on what is replaced, machined and what the A&P charges.

I'm a believer in condition-based maintenance... but that requires the operator to be on top of things. It makes it easy for an operator to skip required maintenance if they want to. I would be a lot less worried about going over TBO in a PT6 equipped plane than in a 50 year old 182. Skydiving is rough on a piston engine. I'm surprised most of them make it to TBO, let alone beyond.

Dave

[skybytch 259]

Just to muddy the waters a bit more, I found the following on a craigslist ad this morning (bold emphasis added by me) -

Quote

Tandem Skydiving: Is an easy, safe and enjoyable way to experience the excitement of skydiving without having to learn how.

Discover the thrill of freefalling and take the ultimate plunge! Skydiving is the most thrilling and breathtaking ride offered in the world today.

If the regular theme park rides are too boring for your daring soul, we'll get your adrenaline pumping!

If we're going to advertise skydiving as a "safe" thrill ride, is there not a duty to ensure that the elevator that takes these thrill seeking passengers to altitude is maintained according to a fairly high standard (ie what the manufacturer recommends)? Disneyland is required to maintain their thrill rides to a fairly high standard, aren't they?

The argument that skydiving involves only people who are aware of the risks they are taking and therefore the standards can be lower doesn't wash anymore, certainly not in the face of advertising that claims skydiving is safe and that it can be done without having to learn a thing about it.

In light of this type of advertising, I think we're very lucky that the NTSB didn't recommend that skydiving operations be moved wholesale to Part 135...

[jjrainyday 0]

Quote

So is the Final Report out yet on the 203E crash? Then NTSB website still only has the Factual.

According to the NTSB website, "Synopses of final reports and any related press releases are generally available immediately following the meetings; published reports are usually available 4-6 weeks later;

So, does anyone who saw the webcast have the unofficial findings yet?

[howardwhite 4]

http://www.faa.gov/library/reports/medical/oamtechreports/1990s/media/9811.pdf will download it as a PDF.

HW

[danielcroft 2]

Thanks Howard!

[jumpwally 0]

and don't forget the Hinckley crash,,,

smile, be nice, enjoy life
FB # - 1083

[SethInMI 145]

Quote

So, does anyone who saw the webcast have the unofficial findings yet?

I just missed the presentation about the crash, but I made notes from the summary. If I got stuff wrong or when the actual text is released I will edit it.

1. No way to tell why turbine blades fractured causing the engine to fail.
2. Pilot failed to maintain airspeed with one engine.
3. Autofeather system was broken for 5 years, and if operative this may have helped, although there was evidence the pilot feathered the failed engine. There was no MEL filed for the broken system, although it was placarded.
4. Pilot used only 1700 ft of runway, if he had taken off from one end, he may have been able to set the plane back down on the runway after the engine failed.
5. Greater FAA oversight may have prevented problem.
6. Fatal injuries for parachutists caused by restraints (not wearing?? single point??)
7. ??
8. Testing for dual point restraints are needed.

The chief reason for the crash: Pilot's failure to maintain airspeed after engine failure.

Safety recommendations from NTSB:
1. FAA should research with USPA for best dual point restraints.
2. Revise 105-C? for guidance about these systems.
3. USPA should work with FAA for dual point systems?
4. USPA should educate members and encourage members to use developed dual point systems.

This was me typing up what the chairman was reading, so I may have got something wrong.

It's flare not flair, brakes not breaks, bridle not bridal, "could NOT care less" not "could care less".

[buzzer 0]

Here are some details.

Conclusions
Findings
1. Although damage to the accident airplane’s right engine precluded determination of the initial event that precipitated the overload fracturing of the compressor turbine blades, and although the operator was not required to comply with the engine manufacturer’s service bulletins, it is possible that the initiating fracture event within the engine resulted from a condition that could have been detected and corrected during an engine overhaul performed within the manufacturer’s recommended time between overhauls.
2. Although engine wear would have likely prevented the accident airplane from obtaining its maximum published single engine climb performance, the pilot’s failure to maintain airspeed, according to the technique specified in the published emergency procedures following the loss of power in one engine, negated any possibility of continued, controlled flight that could have allowed for a return to the airport or other suitable landing area.
3. Although the airplane’s autofeather system, had it been operative, would have helped the pilot promptly feather the propeller of the inoperative engine, there is insufficient evidence to suggest that the inoperative autofeather system was a factor in the accident.
4. The pilot’s decision to use only 1,700 feet of the available runway diminished the margin of safety during takeoff and hindered his ability to safely respond to the airplane’s loss of engine power because it placed the airplane in closer lateral proximity to trees; this reduced the time available to the pilot to properly configure and effectively accelerate the airplane to achieve and maintain sufficient flying airspeed for takeoff, and it also eliminated the option of discontinuing the takeoff and performing a straight ahead, emergency landing on the runway.
5. Based on the results of the Civil Aerospace Medical Institute’s past testing and the serious and fatal injuries sustained by some of the restrained parachutists in this crash, a single point restraint system is not sufficient to provide adequate restraint for parachutists.
6. More parachutists may have survived, and injuries may have been reduced, if more effective restraints had been used.
7. Testing could identify the best method for dual point restraint for the accident airplane’s configuration and for the configurations of other airplanes commonly used in parachute operations.

Probable Cause
The National Transportation Safety Board determines that the probable cause of this accident was the pilot’s failure to maintain airspeed following a loss of power in the right engine due to the fracturing of compressor turbine blades for undetermined reasons. Contributing to the accident was the pilot’s decision to use only part of the available runway for the takeoff. Contributing to some parachutists’ injuries was the lack of a more effective restraint system on the airplane.


Recommendations
The National Transportation Safety Board recommends that the Federal Aviation Administration:
Conduct research, in conjunction with the United States Parachute Association, to determine the most effective dual point restraint systems for parachutists that reflects the various aircraft and seating configurations used in parachute operations.

Once the most effective dual point restraint systems for parachutists are determined, as requested in Safety Recommendation , revise Advisory Circular 105 2C, Sport Parachute Jumping, to include guidance information about these systems.

The National Transportation Safety Board recommends that the United States Parachute Association Work with the Federal Aviation Administration to conduct research to determine the most effective dual point restraint systems for parachutists that reflects the various aircraft and seating configurations used in parachute operations.

Once the most effective dual point restraint systems for parachutists are determined, as requested in Safety Recommendation, educate your members on the findings and encourage them to use the most effective dual point restraint systems.

[diablopilot 2]

Any instructor who believes that tripe, ought to have their rating pulled.

----------------------------------------------
You're not as good as you think you are. Seriously.

[diablopilot 2]

Quote

http://www.faa.gov/library/reports/medical/oamtechreports/1990s/media/9811.pdf will download it as a PDF.

HW

Ray Ferrell also did some similar testing at the OK facility with the FAA about 2001-2002. I'll see if anything was published.

----------------------------------------------
You're not as good as you think you are. Seriously.

[ZigZagMarquis 8]

Wow. I find it interesting that it was the compressor section that failed and not the turbine section.

Anyway...

Quote

2. Although engine wear would have likely prevented the accident airplane from obtaining its maximum published single engine climb performance, the pilot’s failure to maintain airspeed, according to the technique specified in the published emergency procedures following the loss of power in one engine...

Any Otter-smart pilots out there that can post the technique specified in the published emergency procedures? Currious to know.

[PhreeZone 15]

They were mentioning on the call that the Pilot should feather the dead engine and should have banked in the direction of the good engine but in this case the pilot was seen to have wings level in all the photos and videos. I don't know if this is the documented responce but this is what the NTSB was talking about on the call.

Yesterday is history
And tomorrow is a mystery

Parachutemanuals.com

[ZigZagMarquis 8]

Hmmm... interesting, I've always heard "never turn into a dead engine", so I guess that would be consistent with "bank in the direction of the good engine".

Are they saying that in the 203E crash the pilot failed to feather the dead engine or feathered the wrong engine? ... or am I miss-reading too much??

Around here and at the Drop Zone I've heard several differences of opinions from Otter pilots as to how much of a hand-full a Twin Otter is (or isn't) in an engine out situation. I suppose a lot of it falls into that big "it depends" category, but (personally) I still find the 203E crash "worrisome" (for lack of a better word) in that it was lightly loaded and wound up so badly balled up even after loosing an engine. I suppose there still a lot to the story?

[Gawain 0]

Here's a take on how the press is covering it. It's an AP article, linked from the El Paso Times:
http://www.elpasotimes.com/politics/ci_10478757

Quote

NTSB finds flaws in skydiver aircraft safety
By SAM HANANEL Associated Press Writer
Article Launched: 09/16/2008 12:22:24 PM MDT

WASHINGTON—Federal safety investigators called Tuesday for better government oversight of commercial skydiving operations because of too many recurring safety problems with the aircraft and pilots that fly skydivers to their jumps.

The National Transportation Safety Board reached its conclusion after conducting a special investigation into 32 airplane crashes that involved parachute jumpers since 1980, but were unrelated to the risks of skydiving.

Those accidents, which claimed the lives of 172 people, were caused by inadequate inspection and maintenance, pilot error or insufficient oversight by Federal Aviation Administration inspectors, the agency found.

While parachutists assume the risks associated with jumping out of airplanes, the NTSB said those risks should not include preventable hazards involved in flying and maintaining the aircraft itself.

"You expect to be gotten to your destination, whether it's jumping out of an airplane or landing at your destination," said NTSB member Steven Chealander. "The biggest safety problem that the jumper faces is getting in that airplane, it seems to me."

NTSB officials said they are concerned that parachute jump operators who advertise to the public are allowed to fly aircraft under FAA regulations that require little oversight and surveillance despite carrying millions of skydivers each year.

The agency is recommending that the FAA work with the United States Parachute Association—an
industry group—to develop guidelines for parachute jump operators to beef up maintenance and inspection programs and improve pilot training on the aircraft used in skydiving.

After the NTSB expressed similar concerns in 1994, the FAA decided to perform more ramp inspections of aircraft used in skydiving operations. But NTSB officials said they were disappointed to learn in several recent cases that FAA inspections often were not taking place.

NTSB member Deborah Hersman said she wants to make sure this time "we don't get the wool pulled over our eyes again."

"There were a number of accidents in the report that if adequate surveillance would have been performed, those maintenance discrepancies would have been detected," Hersman said.

Alison Duquette, an FAA spokeswoman, said the agency "would take a hard look at the recommendations and get back to the board as soon as possible."

The NTSB was prompted to launch the special investigation of aircraft safety in the skydiving industry after the July 29, 2006, crash of a skydiving plane in Sullivan, Mo., that killed the pilot and five passengers. Two other passengers were seriously injured.

A separate NTSB report on Tuesday said the probable cause of the Missouri crash was pilot failure to maintain air speed after losing power in the right engine of the DeHavilland DHC-6 Twin Otter airplane. A contributing factor was the lack of effective seat belt restraints for the passengers, which might have enabled more to survive the crash.

But the report also found such serious maintenance defects with the aircraft itself, that it decided to examine whether those problems were more widespread in the skydiving industry.

The engine, for example, may have failed because it had not been properly overhauled according to the manufacturer's requirements. Investigators also found that the pilot flew the plane with a propeller system that had been defective for more than two months.

So I try and I scream and I beg and I sigh
Just to prove I'm alive, and it's alright
'Cause tonight there's a way I'll make light of my treacherous life
Make light!

[NoShitThereIWas 0]

NTSB finds flaws in skydiver aircraft safety
9/16/2008, 2:19 p.m. EDT
By SAM HANANEL
The Associated Press

WASHINGTON (AP) — Federal safety investigators called Tuesday for better government oversight of commercial skydiving operations because of too many recurring safety problems with the aircraft and pilots that fly skydivers to their jumps.

The National Transportation Safety Board reached its conclusion after conducting a special investigation into 32 airplane crashes that involved parachute jumpers since 1980, but were unrelated to the risks of skydiving.

Those accidents, which claimed the lives of 172 people, were caused by inadequate inspection and maintenance, pilot error or insufficient oversight by Federal Aviation Administration inspectors, the agency found.

While parachutists assume the risks associated with jumping out of airplanes, the NTSB said those risks should not include preventable hazards involved in flying and maintaining the aircraft itself.

"You expect to be gotten to your destination, whether it's jumping out of an airplane or landing at your destination," said NTSB member Steven Chealander. "The biggest safety problem that the jumper faces is getting in that airplane, it seems to me."

NTSB officials said they are concerned that parachute jump operators who advertise to the public are allowed to fly aircraft under FAA regulations that require little oversight and surveillance despite carrying millions of skydivers each year.

The agency is recommending that the FAA work with the United States Parachute Association — an industry group — to develop guidelines for parachute jump operators to beef up maintenance and inspection programs and improve pilot training on the aircraft used in skydiving.

After the NTSB expressed similar concerns in 1994, the FAA decided to perform more ramp inspections of aircraft used in skydiving operations. But NTSB officials said they were disappointed to learn in several recent cases that FAA inspections often were not taking place.

NTSB member Deborah Hersman said she wants to make sure this time "we don't get the wool pulled over our eyes again."

"There were a number of accidents in the report that if adequate surveillance would have been performed, those maintenance discrepancies would have been detected," Hersman said.

Alison Duquette, an FAA spokeswoman, said the agency "would take a hard look at the recommendations and get back to the board as soon as possible."

The NTSB was prompted to launch the special investigation of aircraft safety in the skydiving industry after the July 29, 2006, crash of a skydiving plane in Sullivan, Mo., that killed the pilot and five passengers. Two other passengers were seriously injured.

A separate NTSB report on Tuesday said the probable cause of the Missouri crash was pilot failure to maintain air speed after losing power in the right engine of the DeHavilland DHC-6 Twin Otter airplane. A contributing factor was the lack of effective seat belt restraints for the passengers, which might have enabled more to survive the crash.

But the report also found such serious maintenance defects with the aircraft itself, that it decided to examine whether those problems were more widespread in the skydiving industry.

The engine, for example, may have failed because it had not been properly overhauled according to the manufacturer's requirements. Investigators also found that the pilot flew the plane with a propeller system that had been defective for more than two months.

© 2008 Associated Press. All Rights Reserved.
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Roy Bacon: "Elvises, light your fires."

Sting: "Be yourself no matter what they say."

[NoShitThereIWas 0]

My personal thoughts on this from being directly involved... I have gone from a completely liberal minded, easy going, laid back skydiver mentality to an uptight, ultra responsible and concerned staunch conservative skydiver. Can there really be such a thing?

Maybe not and maybe that is the main reason I don't skydive hardly anymore. It used to be when I signed my rights away on a waiver, I was nervous about owning my own responsibility for my actions and behavior to make a life threatening sport safe.

I saw it as signing my name to everything that I was in control of with the chance or potential for true risk or danger from unforseen circumstance or chance out of my control or the control of others.

When I sign a waiver now, I am not afraid of whether or not I will remember my Emergency procedures from a malfunction, or whether I will have a malfunction or whether I will be able to get that landing without injury or whether Joe Shmoe is going to take me out on exit. I worry about how the airplane is being maintained, who is flying that day... How much experience does that person have?
How much control as skydivers do we really have over really knowing the true ins and outs of the particular airplane engine we are using to get us to altitude or that particular pilot's history and/or training?

Call me scared, call me traumatized but after the first 9 years of skydiving with the occasional fatality usually caused by a snowball of bad happenings or error by the jumper, the following 3 years it seems the number of plane crashes and deaths due to pilot/maintenece error is astounding. We have had 2 here in Missouri just recently, one my home DZ and one our sister DZ. It seems like over the last couple of years the number of fatalities before people even left the airplane were considerable.

I used to think that skydiving should be "self regulated" so that we could enjoy our freedom in the sky. I like to regulate myself. I pack my main, I pack my reserve, I take responsibility for myself. But when I can't jump because I have an issue signing away my life to the potential negligence of a pilot or mechanic who I don't know from Adam and that fear outweighs my fear of skydiving, to me there is an issue.

Let's face it, skydiving is not a money making venture for the most part and most DZOs without other forms of income or start up capital struggle financially. If they are doing things right, they should definitely be poor. Airplanes aren't cheap to maintain or fly... Most pilots who fly jumpers are building time, are cheap or convenient. Don't get me wrong, there are a lot of talented and good jump pilots out there who know exactly how to effectively fly jumpers but there are a lot of pilots out there who don't.

My personal experience has jaded and changed my views to hoping that the FAA more strongly regulates A&P work, maintence logbooks, maintenence in general, pilot/mechanic credentials and flight ops for sport parachuting. I know there are many out there who disagree with me and that is OK. I used to feel the same way. I now believe when people get shafted due to negligence, money, laziness, maintenece issues or improper pilot training there needs to be regulation to prevent that. When I no longer fear skydiving itself but the ride to altitude so much that I don't skydive... that is different from signing my rights away on a waiver for taking responsibility for my own actions and not doing anything stupid or careless to injure or kill myself or anyone else.

Roy Bacon: "Elvises, light your fires."

Sting: "Be yourself no matter what they say."