Putting Accident/Incident Analysis to Work for our Air Show Family

In January of 2009, ICAS instituted a pair of programs designed to help bring safety back to top-of-mind awareness within the air show industry: the ICAS Confidential Reporting System (ICARUS) and the ICAS Safety Incident Response Procedures (SIRP). ICARUS was developed as an anonymous NASA Aviation Safety Reporting System-type reporting  program. SIRP, which is not anonymous, was built around a post-accident/incident investigation that seeks to draw useful lessons to be passed along to other air show professionals.

Together, these initiatives have generated interesting insight into the circumstances under which accidents, incidents and close calls occur.  And, as they have now been in place for more than three years, a triennial review is in order.

The written processes for both ICARUS and SIRP state that the ICAS Director of Operations will determine the most impactful way of communicating the lessons learned from each occurrence.  The most common mode of education and awareness is the ICAS Operations Bulletin or Ops Bull; however, information generated by the two programs has also prompted education sessions, as well as discussion topics for the Pilot Safety Debrief at the annual ICAS Convention.

In 2009, six incidents reported to the ICAS office prompted SIRP investigations. Each incident was handled in strict compliance with SIRP procedures, and the lessons learned from each were used in Ops Bull and other educational avenues.  Incidents and subsequent investigations occurring in 2009 were:

–          On practice day, a commercial airliner was cleared to land in the aerobatic box without the knowledge of a performer who was in the middle of a maneuver sequence.

–          Two warbirds had a near miss outside of the aerobatic box during an air show, as a result of an un-briefed action by one of the pilots.

–          An air boss did not hold a practice day briefing, which resulted in an aircraft being cleared to final approach while a performer practiced his routine, unaware that the other aircraft was landing.

–          A strong, on-crowd wind blew a performer well over the 500-foot line, but the performer could not be contacted over the frequency due to a cued microphone.

–          A jet-powered vehicle performed high-speed runs with passengers, despite a prohibition in the ICAS Jet Vehicle  Best Practices against such practices.

–          A pilot performed aerobatics without an active pilot’s license or Statement of Aerobatic Competency (SAC) card.  The pilot also operated the aircraft with more persons onboard than the number of required crew members.

ICAS determined that air boss-related issues were factors in four, perhaps even five, of the six incidents. To address these issues, ICAS developed the Air Boss Safety Debrief, introduced at the 2009 ICAS Convention, during which the incidents were reviewed. This debrief, which has been continued at each convention since (and will be again in 2012), provides a venue for air bosses and others to discuss incidents, accidents and near misses for the purpose of learning from and avoiding similar problems in the future.

In cooperation with air show veterans, ICAS also developed a checklist to provide air bosses with a detailed list of the issues that should be addressed in pre-show safety briefings. And ICAS then used its various communications vehicles to re-emphasize the importance of having an experienced, knowledgeable and competent air boss in charge of air show air operations. In addition, each of the incidents were used to produce Ops Bull news items throughout 2009.

Performer-related concerns were discussed during the annual Pilot Safety Debrief in 2009. In the case of the pilot who performed aerobatics without an active license or SAC card, ICAS leadership determined that, due to a pattern and attitude of non-compliance, the ICAS membership of this individual would be suspended for a period of not less than three years.

In 2010, SIRP was used in response to nine different incidents.  Subsequent investigations found the following:

–          An aerobatic team was reported as performing aerobatic maneuvers in non-waivered airspace.  The investigation found the claim against the team to be baseless, as all practices had been conducted in an opened practice box.

–          A Federal Aviation Administration (FAA) inspector in charge (IIC) disrupted performers by confronting them within minutes of their scheduled performances.  As a result of this investigation, ICAS staff worked with the FAA to incorporate the “sacred sixty minutes” policy into its regulatory guidance for air shows. The “sacred sixty minutes” has also been a frequent topic of conversation in multiple Ops Bull and Air Show Magazine articles. In addition and in cooperation with ICAS, the FAA is rewriting its guidance for inspectors on air show surveillance to ensure that inspectors are specifically advised not to disrupt a pilot’s pre-show preparation or have any confrontation in the time immediately preceding a performance.

–          An aerobatic performer did not understand the “knock it off” call that the performer received after repeatedly encroaching the 500-foot line. The performer was counseled by an ACE and ICAS ran an article about “knock it offs” in the September Ops Bull.

–          Following a performance in which he was observed flying several aerobatic maneuvers poorly and below his SAC-imposed altitude restriction, an aerobatic performer was instructed to fly above 250 feet until completion of ACE Committee-mandated aerobatic training. This episode also triggered a holistic analysis of the current ACE/SAC system by the ICAS ACE Committee to ensure that applicants begin the SAC application process with sufficient training and/or experience in aerobatics.

–          After a performer had successfully landed on a vehicle, he got out to hand start the engine.  After the engine started, a headset knocked the throttle into full power, causing the aircraft to knock the performer off the vehicle and damaging the aircraft and the landing vehicle. The incident resulted in an article on keeping the aircraft organized and avoiding deviations from established practices, which ran in a September issue of Ops Bull.

–          An aerobatic performer lost situational awareness and crossed the crowd line. The ACE Committee spoke with the pilot and determined that the pilot was aware of the need for corrective action and had taken appropriate steps to assure the mistake would not be replicated. The incident was documented and filed with the performer’s record.

–          Three separate incidents involving near misses were investigated. These were discussed at both the Pilot Safety Debrief and the Air Boss Safety Debrief at the ICAS Convention. The solutions were discussed in an issue of Ops Bull published on March 17, 2011.

Unfortunately, it is not just the close calls and non-fatal accidents that generate “lessons learned;” during the 2011 air show season, the industry suffered five fatal accidents. Among the lessons learned were:

–          An aerobatic performer was reported as flying lower than briefed at an international air show. Upon investigation, this report was found to be baseless, as the performer had flown the briefed sequence and held a current surface-level SAC card. To help other performers avoid similar problems, ICAS published an article in Ops Bull discussing the differences and potential challenges encountered when flying outside of North America.

–          A wing walker’s aircraft experienced a loss of power and was forced to land in an area of brush. The post-impact fire that ensued was fed by the smoke oil pump, which continued to eject smoke oil after the aircraft had crashed. The tethering harness that the wing walker was wearing made it difficult to successfully exit the burning aircraft. Following this accident, ICAS worked with industry professionals to develop several different kinds of smoke oil shut-off switches which automatically disable the smoke oil pump in the event of a loss of power and/or accident. ICAS also discussed fire retardant gear in Ops Bull and at the Pilot Safety Debrief.

–          A member of an aerobatic team experienced a loss of consciousness at the top of a loop and entered a fatal spin. Because initial reports suggested that the pilot may not have built up his G tolerance before this early season show, ICAS published two different articles related to developing and re-establishing G tolerance, as well as the potential danger of assuming that G tolerance is available when it is not.

–          A non-member aerobatic performer was performing an eight-point roll, lost situational awareness, dished out of the roll, and, fortunately, survived the subsequent crash. ICAS ran an Ops Bull article in July that discussed situational awareness.

–          An aerobatic performer improperly recovered from a tumble and the induced spin caused by incorrect recovery, and fatally crashed. The investigation found that the performer was rushed to his aircraft following a weather delay. The accident was discussed at the Pilot Safety Debrief during the 2011 ICAS Convention, and a pair of Ops Bull articles were published to discuss the need for performers to take 30 minutes prior to flying to clear their minds of all distractions. Because response time by emergency personnel was also thought to be an issue in this accident (and because similar concerns had been expressed at previous accidents), ICAS launched an initiative to encourage event organizers to have a “fast attack” type vehicle available at their events, in addition to traditional fire engine-type pumper trucks, to ensure the fastest possible response following a small aircraft accident.

–          A stuntman fatally fell from an aircraft while performing an aerial transfer. The investigation determined that the stuntman attempted to complete the transfer earlier than had been briefed. There were also reports that the stuntman had spent time prior to the flight trying to secure extra parking passes and trying to figure out the most effective departure method for his friends and family. With this additional evidence about the importance of human factors-related issues and the critical need to eliminate pre-performance distractions, ICAS republished articles related to “The 60 Sacred Minutes.”

–          A warbird team pilot lost consciousness during a low level roll and fatally crashed. The investigation determined that, despite initial incorrect reports that an unsecured parachute in the back seat had locked the controls, the pilot had a heart attack during the roll and could not effectively control the aircraft. This accident was discussed at the Pilot Safety Debrief and, since the pilot had not recently flown with the team, an article discussing identifying personal hazards was published in Ops Bull.

–          Several performers reported concerns over the quality and thoroughness of a particular briefing given by an air boss.  When, as part of the SIRP investigation, the event organizer learned about this hole in the show’s safety net, the show subsequently hired a consultant to supplement the air boss’s knowledge. Also in response to this incident, ICAS used time during the Air Boss Safety Debrief at the 2011 ICAS Convention to reemphasize the importance of using the Pre-Show Safety Briefing Checklist to ensure that all important issues are de-conflicted prior to every air show.

Even after three full years, this part of our Safety Management System is still a work in progress. But a couple of things are already clear:

First, conducting the investigation and analysis is often more important than reaching any specific determination about an accident or incident.  Whatever the precise cause of an accident, our research and analysis have made it clear that there are recurring contributing factors. Often, the trend that is identified as a contributing factor is more important than the principal cause. As an example, pre-performance distractions have been the principal cause of a small number of accidents, but a contributing factor in several others.  Identifying these common themes has helped shape our safety-related education, information and communication programs.

Secondly, for our information gathering purposes, an incident or near miss is just as important — and perhaps even more useful – than an actual accident. The number of accidents and incidents has varied widely from one year to the next since we first began these programs. And the frequency of fatalities has been inconsistent from one year to the next. So far during the 2012 season, several different performers have come within a very thin margin of becoming fatality statistics. Fortunately, in addition to avoiding the tragedy of a death in our air show family, their near-death experiences have provided us with invaluable insight. And if that seems like an exaggeration, be sure to seek out Buck Roetman, Greg Koontz or Kent Pietsch at this year’s ICAS Convention and ask them what they learned from their non-fatal accidents earlier this year.

What are the tangible results of these ICAS safety programs?  Quite a lot, actually:

–          The ICAS Air Boss Academy;

–          Over 30 articles for the ICAS Operations Bulletin;

–          The ICAS Air Boss Briefing Checklist;

–          The development of relationships between ICAS and the Air Traffic Organization of the FAA and the subsequent access to TFRs for air shows and frequency request forms;

–          Education sessions at the ICAS Convention geared to respond to hazards identified through the SIRPs;

–          Development of inexpensive smoke oil shut-off switches that are usable in any aircraft with a smoke oil pump; and

–          Regulatory guidance for FAA IICs that restricts any contact with performers within an hour of their performance.

It would be folly to ever declare victory in the field of safety, especially in an environment as relentlessly unforgiving as ours.  While the industry has not had a fatal accident in 2012, the incidents that have thus far been investigated by SIRP suggest that the industry is a couple inches, a few degrees and less than a couple Gs away from, relative to recent years, an awful year.  Conversely, I am a strong believer in the saying that “fortune favors the well prepared,” and a very strong case can be made to state that the differences between a bad year and a safe year lie in the increasing knowledge, preparedness and situational awareness of ICAS members.

It’s impossible to quantify how many mishaps DID NOT happen because of the initiative to change the culture of air show safety that was launched five years ago by ICAS, but what we can say for sure is this: for the first time, our industry is making a deliberate, organized effort to learn from those incidents that did happen, and we are constantly communicating those lessons throughout the air show community. We will never stop making mistakes, but it is encouraging to see some evidence that, as an industry, we are doing more to learn from those mistakes than ever before. Our success and our failures are entirely reliant upon our willingness to be open to the constant flow of knowledge produced through lessons learned.