Airshows, air races, flypasts, and air capability demonstrations; in fact, any event at which an aircraft is displayed or rehearses for an air event, in which the flow of the event is jeopardised. Des Barker



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DRAFT AIRSHOW ACCIDENT REVIEW 2012

The tenets expressed in this review are those of the author and addresses a sample of significant accidents and incidents at aerial events worldwide in 2012, both during actual events and during rehearsals and includes, airshows, air races, flypasts, and air capability demonstrations; in fact, any event at which an aircraft is displayed or rehearses for an air event, in which the flow of the event is jeopardised.



Des Barker

I have learned that carelessness and overconfidence are usually far more dangerous than deliberately accepted risks.” (Wilbur Wright 1900 in a letter to his father)



INTRODUCTION

If there was an international newspaper that covered airshows, the headlines at the end of the airshow calendar for 2012, would most probably have read: “An Historic Achievement - Year Ends With No Spectator or Public Deaths”. Why would this be so newsworthy? Well, since the inception of ‘air events’ in 1908, there have hardly been any years without death or injury to spectators or members of the public – such years are relatively rare. However, despite this achievement in reducing collateral losses, the death’s of thirteen display pilots in one year, remains unacceptable and emphasizes the requirement for ongoing ‘in your face’ safety education programmes for airshow participants from both the ground and air community. Every year, events on the periphery of airshows, in some way or the other, affect the community, positively, or negatively, and 2012 had its fair share.



AIRSHOW EVENTS


The 26 accidents in 2012 were only slightly below the 10 year average of 27.6 but was significantly less than the previous two years. Is the downward trend an indication that aggressive safety drives by ICAS, EAC and ASSA are paying dividends? Only time will tell.
FAA Public Hearing “Galloping Ghost”.

Most significantly in the USA, the display community anxiously watched the deliberations emanating from the FAA public hearing into the Reno Air Race accident 2011 in which Jimmy Leewards’ souped-up’ Mustang, “Galloping Ghost”, crashed in front of VIP boxes, killing Leeward and 10 spectators and injuring 70. The recommendations flowing from the FAA hearing could have had significantly adverse effects on the airshow community, not only air racing. However, the community were relieved, in January, when an FAA official stated: “it's unlikely there will be significant changes to airshow and air race safety rules”. If the FAA becomes aware "of a risk that exceeds the boundary of what we think is acceptable, we will make those changes. But not currently," he said.

The ‘good news’ of January was to turn in to rather bad news by the end of 2012 and could constitute a threat in future to the airshow community, particularly in terms of insurance costs. A ‘wrongful death’ lawsuit was filed in Texas on 31 October 2011 by the wife of a man killed in the crash. A $25 million lawsuit against the pilot and the Texas company that modified the Mustang, ‘Galloping Ghost’ was filed calling the crash a “predictable result of a reckless drive for speed by a risk-taking pilot and crew, coupled with an insatiable drive for profit by those who stood to profit from the show. The decisions arising from the court case, could set a precedent for litigation in future airshow accidents and incidents, the results of which are not yet evident.

At the time of the crash, the defendant in the case, was in fourth place and was rounding the last pylon when the plane pitched up, rolled inverted and then pitched down. The airplane crashed into the box section of the seats and exploded in front of the grandstands.

Craig Salerno, husband to Sezen Altug and father of two young children, was sitting in the box sitting area and was killed instantly. According to the lawsuit, the former military aircraft had undergone major modifications. The plaintiff argued that the P-51D airplane was never designed to operate at speeds approaching 550 mph. Defendant Richard Shanholtzer, an expert in aircraft modifications, changed the aerodynamics of the aircraft, such as shortening the wingspan over 10 feet from the plane’s original design, the suit states.

According to the lawsuit, the aircraft mechanics reported that the pilot’s team was having trouble with the electronically controlled trim-tab and that the aircraft lost the trim-tab, causing it to abruptly pitch up and as a result, the pilot lost consciousness and complete control of the aircraft. In an interesting legal twist on matters, defendant Reno Air Racing Association is accused of:



  • Negligence for failing to warn spectators of the risks associated with the air race.

  • Negligence for failing to test the plane’s modifications.

  • Failing to examine the parameters of the expected flight.

  • Failing to warn spectators that the plane was having issues.

  • Failing to warn spectators of the inherent risks with the race itself and spectator positioning.

The plaintiffs asked for an award of damages not to exceed $25 million in compensatory and punitive damages for loss of consortium, loss of society, loss of earning capacity, pain and suffering, mental anguish, interest and court costs.1

For 2012, organizers of the National Air Racing Championships secured $100 million in necessary insurance and changed the race course for the fastest planes to keep them farther from spectators by moving the largest pylon course for the 49th annual championships away from the crowd. The change would include the softening of some curves to ease the gravitational pull on pilots, including coming out of a stretch called the "Valley of Speed" where aircraft flying at speeds up to 500 mph gain momentum on the high Sierra plateau north of Reno. It will make the race course on the turn there, more consistent and probably less of a g-strain, for the less experienced race pilots. The announcements were made after a ‘blue ribbon panel’ of experts appointed by the association unveiled its list of safety recommendations, including formalizing plane inspection procedures.

The four-member panel, also advised further study of possible age limits for pilots. Jimmy Leeward was 74. The panel talked at length about whether age limits or other increased medical requirements should be imposed, but decided that they were not qualified to make "what are in effect medical recommendations." Instead, they urged the association to create a formal position of director of aerospace medicine to review areas such as pilot age and the medical impact of gravitational forces on pilots.

Other suggestions included creating an internal evaluation program modeled after the kind airlines use and formalizing inspection procedures to be sure "uncorrected discrepancies" regarding airplane modifications "do not slip through the system." The association continues to face financial challenges, having lost about $1 million last year and facing a $1.7 million increase in its insurance premium under the new deal with underwriters.2

International Council of Airshows

ICAS Board of Directors, in it’s ongoing drive to enhance safety, adopted a resolution that read, in part, that in 2017, ICAS will be an organization that…“is recognized as a leader in the general aviation and aerial entertainment arenas, and sets the world standard for airshow safety, performer proficiency and industry business practices, resulting in a stable foundation for the growth and development of the airshow industry.”

In that light, several Key Result Areas (KRA) with a “Board Champion”, were assigned to oversee several action plans. Ralph Royce’s Key Result Area assignment is Safety, and he was tasked with developing a set of draft goals which, if achieved, would pave the way for a successful achievement of the five-year ICAS vision.

At this point Royce has started with the general goals, with the how and why particulars to be fleshed out when the Safety goals will be matched with other 9 or 10 affected KRAs, a detailed analysis to refine the targeted items would commence and develop a specifically measurable, realistically achievable, and timely flight plan to achieve the objective. The first areas identified as possible KRAs include:



  • Analysis/Summary of safety issues to be sure we really know where and what the real safety issues are rather than what everybody thinks they are;

  • Continue to institutionalize the Safety Management Program, give it a prominent role in the industry and wide dissemination of its findings;

  • Flying Safety to include pilot selection and progression; maneuvers and maneuver packages; air boss industry endorsement; professionalizing the ACE program, role of the military, clear and consistent interpretation of ICAS and FAA rules etc;

  • Ground Safety to include all aspects of site build-up/teardown, the aerobatic box and its depiction; ingress/egress; etc;

  • Relationship of the industry to the other industry safety organizations and their programs and to the regulating organization and its policies.

Red Arrows

Across the Atlantic in the UK, demonstrating a stringently disciplined approach to safety, Britain’s first female Red Arrows pilot, Flt Lt Kirsty Stewart, Red 9, with one year of her tour remaining, was transferred from the tightly-knit aerobatic outfit to a ground role, suffering from stress after the deaths of two members of the team in 2011. Flt Lt Jon Egging, Red 4, died in August 2011 when he crashed near Bournemouth after a display and in November 2011, Flt Lt Sean Cunningham, Red 5, was killed when he was ejected from his Hawk T1 while it was on the runway at RAF Scampton.

The strain of the double tragedy left Stewart unable to be absolutely focused on flying for another demanding display season. Senior officers were concerned and ruled that she was not "in the right place" to fly and made the tough decision to reassign her.3

An MoD spokesman said: "The Red Arrows will conduct aerobatic displays with seven aircraft rather than the usual nine in 2012 due to the unavoidable posting of one of their pilots. "With safety paramount, the quality of the displays remain vitally important, it has been decided that seven aircraft presents the most visually-balanced and dynamic formation. The team will still carry out official flypasts with nine aircraft and will return to a full aerobatic formation of nine aircraft in 2013."



ICASs ‘OPS BULL’

ICASs monthly safety newsletter “Ops Bull” introduced ‘real and relevant’ safety article topics to provide continuous ‘in your face’ safety messages to focus the airshow community on the environmental risks that exist in airshows and display flying. Typical topics covered included "Safety is for sissies!" which highlighted the basics of surviving the airshow circuit thorough briefings and de-briefings, frequent practice and continual risk identification and mitigation.

Thoughtful consideration of energy management issues and how to respond to emergency situations at every point in the maneuver sequence, rigorous self-assessment before every flight, active elimination of pre-flight distractions, unemotional consideration of constructive criticism offered by fellow pilots, careful integration of new maneuvers into an established air show sequence, meticulously well-maintained equipment and an ongoing program to maintain physical conditioning were some of the pointers offered.

There is nothing any of us can do that will completely eliminate the risks inherent in low-level aerobatic flying, but approaching those risks as a professional is an airshow performer's surest path to predictable outcomes on every flight. It's not enough to simply aspire to being safe; it takes a commitment to professionalism.

In another article, “Pride Goeth Before a Fall”, the writer argued the timeless admonition that translates well in any language, including the language of airshows. In the event that a performer, event organizer or support service provider compromises the pride they take in doing their work, the results can be catastrophic. If a performer settles for less than his very best effort during a particular performance or on an individual maneuver, the fall will come. The margins for error are often so small that a tiny lapse, even by a veteran, can have tragic consequences. And, sadly, this lesson has been written in the blood of some of industry’s most talented and experienced pilots.

Similarly, even well-established shows can suffer problems and even tragedies, if key individuals become too confident or casual while working in the unforgiving airshow environment. Allowing activities that are unsafe, unplanned or against the established best practices and regulations, will eventually result in financial, publicity or safety problems.

In fact, the proverb could be even more appropriate for the airshow community with a little light editing: ‘professionalism goeth before the fall’. In other words, when we stop giving, demanding and expecting the very best of ourselves, those we work with and those we work for, the end result will always be failure. Thankfully, the inverse is also true; when we give, expect and execute in accordance with the highest standards of excellence, the end result will always be success.

The physiological aspects of display flying are not necessarily afforded the required attention and in this particular case, in the Midwest, drought adversely affected vast expanses of the country which experience record high temperatures and record low precipitation. ICAS made a call to take a collective step back and examine how the airshow industry should respond to environmental conditions. Such record-setting extremes can cause significant issues for both performers and event organizers alike, so the negative aspects of heat effects were revisited by considering the effect of heat on energy burn and fatigue, particularly critical during complex activities such as aerobatics.

The effect of sweating and fluid loss and the importance of replenishment to enable the body can still function at its peak performance levels, was emphasised. Decision making, G tolerance and even spectator health are directly impacted. Performers - drink more water. Event organizers - have more water available for performers and spectators. In two separate cases during the last twelve years, grass fires in parking areas at airshows resulted in immense fires causing millions of dollars in damage to the cars parked there. You’ll hear these incidents referred to as “Car-B-Ques.”.

Another article on Risk Mitigation addressed the topic from the perspective of the game of risk, ‘Black Jack’ from a point of view of small changes in risks, have big rewards. The airshow business needs simple tools that performers and producers can use to tip the odds and rake the table. The ICAS initiative to change the culture of airshow safety is about making rational decisions regarding the risks and searching for ways to reduce them. A simple methodology to start the process was propagated:



  • Step 1. Analyse and acknowledge the risks in our business. If we deny the risks, there is no chance we can manage them.

  • Step 2. Sit down, either alone or with a trusted peer and take a serious look at every part of your air show operation. For a performer, this includes maintenance, ferrying, practice, pre-show preparation, and the performance, as well as physical and psychological preparedness of the pilot. Any aspect of an airshow operation that adds risks to the overall equation is fair game and should be analyzed.

  • An example: Everyone knows that getting rushed before a performance is never a good thing, and yet this continues to happen, sometimes with tragic results. Make a list of things that you could do to prevent getting rushed and incorporate the procedures into your operation. Are these strategies always going to work? Maybe not, but if you can reduce the number of times you get rushed in a season, you have reduced the risks. It is all about tipping the odds in your favor, however minutely.

  • Step 3. Is tougher. In some cases, there is no way to mitigate risk for a certain aspect of our operation. For those activities, consider the risk and the reward and make a reasoned decision that the reward justifies the risk. If it does, accept that risk and carry on, carefully. If it doesn’t, then the tough question is, “Why do we do it?” And the follow up question: “What can we do that will accomplish the same thing with less risk?”

It really is that simple. analyzing airshow operations and developing methods to mitigate the risks that we can, and deliberately accepting the risks we can’t mitigate. Simple means uncomplicated, and while this is not a complicated formula, nobody said it was easy. We need some extra aces in the deck. What’s the difference between airshows and Black Jack? There are plenty of extra aces to find in the airshow business. We just need to have the discipline to look for them.

Farnborough 2012

In an unusual step, the Farnborough Management Team declined the participation of the Republic of Korea Air Force (ROKAF), 8-ship T-50 aerobatic team, the Black Eagles, which had been ‘wowing’ the crowds at the Royal International Air Tattoo the previous weekend, and in the process reeling in awards and accolades, instead, only allowed a solo performance by one of the Korean-built supersonic trainers.

Their dynamic routine included multiple splits and rejoins during a total of 22 maneuvers. Unique among jet aerobatic teams, the Black Eagles’ display includes a syncro pair plus two solos. After the first split, these aircraft perform various solo, two- and three-ship maneuvers, including a delightful tracing of the ROKAF roundel in blue-and-white smoke. Two of them temporarily rejoin the core four-ship before breaking away again during a downward bomb burst. “It looks dangerous, but we make repositioning calls by radio to keep each other informed,” team commander Lt. Col. Kim Young Hwa commented.

The Flying Control Committee turned down the Korean request for a Black Eagles appearane at Farnborough, according to their spokesperson: “Given our location, which is surrounded by built-up areas, there are very stringent rules in force,” the flying display director said. In recent years, only the Red Arrows have been allowed to fly here; the current rules were established when the UK Ministry of Defence was still running the airfield”, he continued. “Much as we wanted to invite the Black Eagles, we had already made a safety decision to expand incrementally,” he said. The Koreans had been informed of the decisions many months ago, he added.4



STATISTICAL OVERVIEW

2012 showed a continued decrease in airshow accidents and incidents from the ignominious 2010, which was most probably the worst year, safety wise, in the history of display flying. Trying to find some positives from the statistics, the question is: “Could the last two years decrease year on year indicate the start of a downward trend? It’s obviously too early to say, only time will tell. Could it be that the dynamic efforts being made by ICAS, EAC and FTSSA, particularly ICAS, to drive an ‘in your face’ safety campaign, is paying dividends? One can only trust that the efforts will provide a favourable return on investment.



ICAS’s aggressive drive to enhance display flying safety included initiatives such as their ICARUS system; a system to anonymously report safety hazards at airshows that would benefit the industry as a whole, not only the display pilots. ICARUS is one of the tools used to obtain the data needed to identify unsafe practices; in which not only accidents and major incidents would be available for review and lessons learned, but also to hear about the close calls and small mistakes. Their goal was to use this information, together with other data, to identify and mitigate risks before they result in accidents. ICARUS is not punitive, and completely anonymous with emphasis on the JUST culture and avoids ‘passing the buck’. The aim is for ALL potential hazards at an airshow to be identified and mitigation measures introduced.

Accidents by Country

26 accidents and incidents occurred in twelve different countries; a significant improvement on the 34 airshow accidents and incidents of 2011. The USA, by virtue of its significantly greater number of airshows annually, decreased from 14 in 2011 to 9 in 2012. Sadly, there are no accurate statistics regarding flying hours flown in practice and during air events against which to make more statistical sense of the accident figures.



Casualties


Airshow Accident and Incident Casualties 2012
The most important criteria in assessing the safety performance of the airshow community worldwide remains the actual loss rate, not only spectators and members of the public killed, but the entire airshow community losses, including all active airshow participants, ie pilots, wing walkers, parachutists, support crew, etc. In 2011, the 105 airshow accident casualties were 31 more than in 2010, most of course derived from the 67 spectators killed and injured at the Reno Air Races.


Airshow Accident Causal Factors 2012
In 2012, the loss rate was down to a total of 17 casualties, of which 14 were fatal. The most significant improvement to airshow safety during 2012, was that for the first time in many years, there were no casualties to any other person outside of the display performers, except for a passenger that was killed while flying along during a display. Sadly, a total of 13 pilots were killed. It must be pointed out that the two pilots that were injured, the Christen Eagle and the Bronco OV-10, were extremely fortunate to survive – a good case for ‘divine intervention’ perhaps?

Fatalities remain untenable and unsustainable if the airshow community is to continue to exist without additional regulatory and insurance interventions, both of which impose serious constraints on the ability to host air events.



Causal Factors

For the second year in succession, Mechanical causes (38%) were the most significant contribution to airshow accidents and incidents, not Flight Into Terrain (15%), Loss of Control (15%) or Midair collisions (8%). In a way, that is good news. What is of concern is the number of mechanical failures within the vintage aircraft category, mainly undercarriage related and then engine failures and engine fires. This contribution from MACHINE was thus inordinately high at 38% versus the historical average of 23%. Flight Into Terrain was down from the historical average of 28%, as in 2011 to 15% and Loss of Control, down from 21% to 15%.




Airshow Accident and Incident Causal Factors 2012.
The question is why the Mechanical contribution had increased so significantly? Not surprisingly, the primary contribution to Machine factors was closely tied into the increased number of vintage aircraft that were involved in airshow accidents; 54% of the vintage aircraft accidents were attributable to mechanical or structural failures. Conclusion, mechanical failures on vintage category aircraft contributed inordinately primary causal factor of accident statistics in 2012, a similar trend was evident in the previous year and is an indicator to monitor into the future.


Airshow Accident/ Incident Events 2012
Very reassuring was the swing away from human judgement error, down from 86% in 2010 to 53% in 2011 and 42% in 2012. Does this mean that the airshow community have become more sensitive to the threats and challenges? Does this imply that display pilots have improved their judgement and aircraft handling skills and that maintenance efforts have now regressed below standard?

Event Categorisation

The historical trend of 71% of accidents occurring during the actual events, not at rehearsals, remained unchanged. This phenomenon can best be explained by the fact that the pressure to perform during the actual event, watched by spectators, places additional stress on the pilot to push the display to the limit. There are often cases in which the conditions during rehearsal are less than ideal and pilots then elect to postpone rehearsals until conditions improve. The problem is that on show day, under less than ideal conditions, with the demands from the event organiser, and pilot’s wanting to meet their commitments, sometimes ‘press’ the performances under conditions for which they have not practiced. The military adage of “fight like you train” is especially relevant; display like you practice – anything else is pushing the error margin.



Aircraft Categories

Although trainer jets were involved in 25% of the accidents/incidents, what was of concern was the fact that vintage aircraft as a category, as was the case in 2011, made up 50% of the aircraft types involved in the accidents and incidents, this being 30% greater than the historical norm. The reason for this statistical event was the significant increase in vintage aircraft now found on airshow circuits worldwide. A further interrogation of these statistics points to mechanical failures which appear to be more prevalent on vintage types and then arguably, a shortcoming in flying skills by vintage aircraft owners being manifested primarily in Flight Into Terrain and Loss of Control accidents.




Airshow Accident / Incident Aircraft Categories 2012.





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