September 16, 2008
NTSB Number: SIR-08/01
NTIS Number: PB2009-917001
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),transports parachutists on 2.16 to 3 million jumps annually.Most parachute operations flights 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, 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. Since 1980, 32 accidents involving parachute operations aircraft have killed 172 people; most of whom were parachutists.
The National Transportation Safety Board's interest in performing this special investigation stemmed from its investigation of the July 29, 2006, accident involving a de Havilland DHC-6-100 that crashed after the right engine lost power during a 14 CFR Part 91 revenue parachute operation flight in Sullivan, Missouri. The pilot and five parachutists were killed, and two parachutists were seriously injured. The investigation identified maintenance discrepancies on the airplane and deficiencies with the pilot's performance of emergency procedures; these issues prompted the Safety Board to examine accident reports for parachute operations to determine if such safety issues may be widespread. The results, discussed in this investigation report, show that these issues were present in many accidents. The investigation of the Sullivan, Missouri, accident also addressed accident survivability and restraints for parachutists; the resulting recommendations are detailed in appendix A of this report.
This special investigation report is not intended to represent a comprehensive statistical analysis of parachute jump operations accidents. Because most parachute operators are not required to maintain flight activity data, such an analysis is not possible. The purpose of this report is to discuss the safety issues identified during the Safety Board's investigation and to provide recommendations for addressing those issues.
The Safety Board's review of parachute operations accidents since 1980 identified the following recurring safety issues:
Although parachutists, in general, may accept risks associated with their sport, these risks should not include exposure to the types of highly preventable hazards that were identified in these accidents and that the parachutists can do little or nothing to control. Passengers on parachute operations aircraft should be able to expect a reasonable level of safety that includes, at a minimum, an airworthy airplane, an adequately trained pilot, and adequate Federal oversight and surveillance to ensure the safety of the operation.
The Safety Board is concerned that parachute jump operators, many of which advertise to the public and transport parachutists for revenue, are allowed to maintain and service their aircraft under 14 CFR Part 91 regulatory provisions that require little FAA oversight and surveillance, despite passenger loads of millions of parachutists per year. The Board is also concerned that parachute operations pilots are not required to undergo operationspecific initial and recurrent training, including preflight, weight and balance, and emergency procedures training, or recurrent FAA examinations in the types of aircraft that they fly. As a result of this special investigation, the Board has issued six safety recommendations to the FAA and two to the USPA.
The National Transportation Safety Board recommends that the Federal Aviation Administration:
Require parachute jump operators to develop and implement Federal Aviation Administration-approved aircraft maintenance and inspection programs that include, at a minimum, requirements for compliance with engine manufacturers' recommended maintenance instructions, such as service bulletins and service information letters for time between overhauls and component life limits. (A-08-63)
Develop and distribute guidance materials, in conjunction with the United States Parachute Association, for parachute jump operators to assist operators in implementing effective aircraft inspection and maintenance quality assurance programs. (A-08-64)
Require parachute jump operators to develop initial and recurrent pilot training programs that address, at a minimum, operation - and aircraft-specific weight and balance calculations, preflight inspections, emergency and recovery procedures, and parachutist egress procedures for each type of aircraft flown. (A-08-65)
Require initial and recurrent pilot testing programs for parachute jump operations pilots that address, at a minimum, operation - and aircraft-specific weight and balance calculations, preflight inspections, emergency and recovery procedures, and parachutist egress procedures for each type of aircraft flown, as well as competency flight checks to determine pilot competence in practical skills and techniques in each type of aircraft. (A-08-66)
Revise the guidance materials contained in Advisory Circular 105-2C, "Sport Parachute Jumping," to include guidance for parachute jump operators in implementing effective initial and recurrent pilot training and examination programs that address, at a minimum, operation - and aircraft-specific weight and balance calculations, preflight inspections, emergency procedures, and parachutist egress procedures. (A-08-67)
Require direct surveillance of parachute jump operators to include, at a minimum, maintenance and operations inspections. (A-08-68)
The National Transportation Safety Board recommends that the United States Parachute Association:
Work with the Federal Aviation Administration to develop and distribute guidance materials for parachute jump operators to assist operators in implementing effective aircraft inspection and maintenance quality assurance programs. (A-08-69)
Once Advisory Circular (AC) 105-2C, "Sport Parachute Jumping," has been revised to include guidance for parachute jump operators in implementing effective initial and recurrent pilot training and examination programs that address, at a minimum, operation - and aircraft-specific weight and balance calculations, preflight inspections, emergency procedures, and parachutist egress procedures, distribute this revised AC to your members and encourage adherence to its guidance. (A-08-70)
Issues for Parachutists
Open Safety Recommendations
Following the Safety Board's investigation of the July 29, 2006, accident in Sullivan, Missouri, the Board issued four safety recommendations related to more effective restraints for parachutists. The recommendations were issued on September 16, 2008.
The following recommendations were issued to the Federal Aviation Administration (FAA):
Conduct research, in conjunction with the United States Parachute Association [USPA], 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 A-08-71, revise Advisory Circular 105-2C, Sport Parachute Jumping, to include guidance information about these systems.
The following recommendations were issued to the USPA:
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 A-08-71, educate your members on the findings and encourage them to use the most effective dual-point restraint systems.
Safety Recommendations A-08-71 through -74 are classified "Open-Await Response."
Closed Safety Recommendations
Previously, following the Safety Board's investigation of the April 22, 1992, accident in Perris, California, the Board issued seven safety recommendations (three to the FAA and four to the USPA) regarding parachutists' seating and restraints. These recommendations were issued on February 17, 1994.
The following recommendations were issued to the FAA:
In conjunction with industry, USPA, and CAMI [Civil Aerospace Medical Institute], develop and test universal restraint systems capable of providing adequate protection to parachutists similar to that provided for seated passengers. (Class II, Priority Action)
In response to this safety recommendation, CAMI, in conjunction with the Parachute Industries Association and the USPA, performed a series of dynamic sled tests to evaluate various types of restraint systems and occupant orientations for parachutists and produced a report on its findings. Although none of the restraint methods tested were capable of providing protection to parachutists "similar to that provided for seated passengers," as requested, the FAA responded to the Safety Board on March 26, 1999, that the testing identified possible improvements in restraining parachutists and that it is not possible to provide the same level of protection for floor-seated parachutists that is afforded to occupants in seats. As a result, because the FAA's testing identified possible improvements in restraining parachutists, the Board determined that the FAA's actions met the intent of Safety Recommendation A-94-16 and classified it "Closed-Acceptable Action" on January 4, 2000.
In conjunction with industry, USPA, and CAMI, provide for the seating of parachutists to assure an adequate level of crash energy absorption in the event of a survivable aircraft accident. (Class II, Priority Action)
In a November 2, 2000, letter to the Safety Board, the FAA reported that, because of the typically small size of the aircraft used in parachute operations, the installation of an energy-absorbing structure, such as crushable seating or modified flooring, would impact the flight mission by substantially reducing payload and adequacy of cabin emergency evacuation. The FAA further reported that such modifications would also significantly alter the performance and handling qualities of the aircraft and significantly change the airplane design and that any requirements for such a design change for existing airplanes "would constitute a ban on sport parachuting as it is known today. Consequently, the FAA does not intend to continue efforts to address the attenuation of vertical energy." As a result of the FAA's response, Safety Recommendation A-94-17 was classified "Closed-Unacceptable Action" on March 9, 2001.
Amend 14 CFR [Code of Federal Regulations] 91.30 to require each parachutist or other passenger who is seated on an aircraft cabin floor to use restraint systems. The restraint system must be designed, tested, and approved to provide a level of occupant protection similar to that provided for passengers in forward and aft facing seats that have a safety belt and shoulder harness. (Class II, Priority Action) In response to this recommendation, the FAA reported that 14 CFR 91.107 already requires parachutists seated on an aircraft cabin floor to use restraint systems and that, although no restraint system for floor-seated parachutists could provide a level of protection similar to that provided to seated passengers, if an improved restraint system were developed and installed, the parachutists would automatically be required to use it. In a January 4, 2000, response letter to the FAA, the Safety Board acknowledged that regulations require parachutists to use restraints and that FAA guidance materials and actions since the recommendation was issued have resulted in improved operator adherence to the requirements. The Board also acknowledged that, despite CAMI's testing, no restraint system could be found that would meet the intent of the safety recommendation. As a result, Safety Recommendation A-94-18 was classified "Closed-Acceptable Alternate Action" on January 4, 2000.
The following recommendations were issued to the USPA:
Revise the USPA operations manual to require restraint system use during takeoffs and landings. (Class II, Priority Action)
Publish and distribute the content of this recommendation letter to all USPA members. (Class II, Priority Action)
In response to Safety Recommendations A-94-20 and -21, the USPA developed the USPA Skydiving Aircraft Operations Manual and distributed it to its group member facilities, completed its manual revisions, and published multiple magazine articles (including at least one that referenced the Safety Board's letter in its entirety) emphasizing seatbelt use. As a result, Safety Recommendations A-94-20 and -21 were each classified "Closed-Acceptable Action" on August 11, 1997.
Participate in the design, development, and testing of a universal restraint system that would provide adequate protection for parachutists seated on an aircraft floor. (Class II, Priority Action) The USPA participated, as requested, in the previously referenced CAMI testing of seating for parachutists; therefore, Safety Recommendation A-94-22 was classified "Closed-Acceptable Action" on June 5, 2001.
Participate in the design, development, and testing of seating for parachutists that would provide an adequate level of crash energy absorption in the event of a survivable aircraft accident. (Class II, Priority Action)
On June 2, 1997, the USPA informed the Safety Board that it had obtained samples of energy-absorbing material that could potentially be used as floor seating material in parachute operations airplanes but that it had not developed a plan, or been informed by the FAA of a plan, to test the material. After the USPA did not respond to follow-up correspondence from the Board in 1997 and 2000 requesting updates on USPA's progress, Safety Recommendation A-94-23 was classified "Closed-Unacceptable Action" on June 5, 2001.
Previous Safety Recommendation Pertaining to Federal Aviation Administration Surveillance of Parachute Operations
The Safety Board's investigation of the April 22, 1992, accident in Perris, California, also resulted in a recommendation regarding FAA surveillance of parachute operations. The following safety recommendation was issued to the FAA on February 17, 1994:
Direct flight standards district offices to increase their surveillance of sport parachute operations and comply with their associated operations bulletins regarding parachute operations. (Class II, Priority Action)
Safety Recommendation A-94-19 was classified "Closed-Acceptable Action" on May 31, 1995, after the FAA responded on November 21, 1994, that "the FAA agrees with this recommendation" and that the FAA had published Notice 1800.134, Required National Flight Standards Program Work Functions, on July 8, 1994, to provide guidance to flight standards field offices on the development and execution of annual national work program guidelines. The FAA stated that the notice directed principal operations inspectors to perform increased interior and exterior ramp inspections of parachute operations aircraft, paying particular attention to inadequate aircraft maintenance and contaminated fuel, the use of restraint systems by parachutists during flight, the use of unapproved crewmembers' seatbelts, inadequate training of pilots, pilot inattention to weight and balance, and aircraft operating limitations issued for parachute operations.