Superior Formation Accident Revisited

The filing cabinet had barely clicked shut on the National Transportation Safety Board’s investigation of the spectacular mid-air collision of two aircraft flying in formation at Skydive Superior in late 2013, when far worse occurred: In August, two L-410 turboprops hauling skydivers for a formation load collided over Slovakia, killing four crew and three skydivers. Thirty-one skydivers exited and survived.

That accident—and the Skydive Superior mid-air collision we’ll discuss in this article—should serve as harsh reminders that aircraft formation flight requires significant skill and training and even then the risks are substantial. As the NTSB investigation and conclusions revealed, formation flying can be intolerant of cursory training before the fact and of a moment’s inattention during it.

Miracle Eleven
Viewers of NBC’s “Today” show on the morning of November 5, 2013, had the dubious privilege of seeing a routine skydive go horribly wrong (and thanks to the ubiquitous presence of GoPro cameras, they saw it from no fewer than five angles). The two airplanes collided just before the jumpers were to exit, and despite the fiery breakup of one of the airplanes and serious damage to the other, everyone survived. Viewing the footage, one could understand why the group became known as the Miracle Eleven. But the footage showed something else, too. Even before the NTSB’s investigation began, a discerning pilot—even one without formation experience—could have gained a working understanding of what happened.

The accident occurred on November 2, 2013, at Skydive Superior, a long-established drop zone located on the Minnesota-Wisconsin border at the far western tip of Lake Superior. Skydive Superior was then (and remains) a Cessna drop zone, operating a Cessna 182 and a 185 at the time of the accident. According to the NTSB’s narrative, the accident flight was the last load of the day and was to be a formation load with four jumpers in the 182 and five in the 185. Irrespective of aircraft type, formation loads are anything but routine, but pilots generally plan them carefully, since flying aircraft in close proximity to others leaves little margin for error.

FEATURE201510-11 The NTSB’s investigation revealed that the two pilots had briefed the flight, including determining that the 185 would fly trail due to its better performance. The 182 pilot would lead, handling local calls on the Unicom frequency, while the 185, which had two radios, would coordinate with air-traffic control.

The aircraft ascent proceeded normally, climbing in a box pattern to the 12,700-foot MSL exit altitude. As the video footage showed, the skydive began to unravel as the jumpers positioned on the steps and struts for the exit. One clip clearly shows that rather than being aft of or below the lead 182, the trail 185 was well above and almost abeam of the lead aircraft. The 185 pilot said after the accident, “When it was time for the skydivers to climb out, the two planes began to drift together, and in seemingly no time at all, the two were colliding. The bottom of the 185 and the top of the 182 met.”

The results were catastrophic. One of the 185’s wheels penetrated the 182’s windshield, and the overall impact compromised the right wing, eventually causing it to depart the aircraft. A fuel plume from the damaged wing tank ignited into a bright ball of fire. Two jumpers became temporarily wedged between the 185’s strut and the cabin roof of the 182, but all of the skydivers escaped (although one received serious injuries and four received minor injuries, according to the NTSB report).

The pilot of the 182, which was uncontrollable after the loss of a wing, exited on his pilot emergency rig and landed safely. The 185 pilot recovered the airplane and landed safely despite the plane’s serious damage. The final part of the miracle NBC failed to make note of: The 185 pilot forgot his pilot rig, which the Federal Aviation Administration required the pilot to wear as a condition of the jump-door modification. Had the airplane been more significantly damaged, the Eleven might have been 10.

Aftermath
As NTSB investigations go, the Skydive Superior accident wasn’t especially complicated. All the participants lived to be interviewed, and the investigator had an exceptional volume of video footage to review. The agency’s probable cause minced no words: “The failure of the pilot who was flying the trail airplane to maintain separation from the lead airplane. Contributing to the accident was the inadequate pilot training for formation skydiving operations.”

Frequent readers of NTSB reports will find this conclusion neither unusual nor surprising. Pilot error that may or may not be a consequence of lack of training causes nearly 80 percent of general aviation accidents. For its part, Skydive Superior accepts the NTSB’s finding but rejects its claim of inadequate training. More on that in a moment.

That the trail pilot lost sight of the lead aircraft is inarguable; the video and fact pattern confirm this. As for training, the NTSB investigator found that while the trail pilot had flown some formation work, it had been mainly as the lead. In formation flying, the lead’s job is simply to smoothly hold heading and altitude, handle the communication (usually) and fly the desired course. The trail pilot has but two jobs: keep the lead in sight and maintain separation. All things being equal—if they ever can be—the least experienced pilot flies the lead, the more experienced pilot the trail.

Drop zones vary in how they train and what they expect of formation pilots. It’s likely that drop zones flying turbine twin-engine aircraft do more than Cessna DZs simply because the stakes are higher. The NTSB learned that Skydive Superior did not specifically provide pilots with formation training; instead, it expected a pilot to accumulate about 100 hours at the DZ before flying formation loads. As a result, the first time a pilot flew formation, skydivers would be aboard. Moreover, the NTSB said that the DZ didn’t maintain training records, so it was unclear what training and experience the pilots actually had. Both were relatively low-time commercial pilots; the trail pilot had 535 hours, the lead pilot 428 hours. This is not particularly unusual for Cessna DZs, nor should it be a disqualification for formation flying.

The accident pilots and the DZ’s chief pilot told the investigator that they had briefed the formation before the flight, including the run-in course and the breakoff, loss-of-contact and lost-wingman procedures. Significantly, all three had a different definition of what constitutes the correct trail position. The lead pilot thought trail should be 20 to 30 feet behind and lower than the lead, on a 45-degree angle. The trail pilot said he actually tried to fly the trail position one to two aircraft lengths behind the lead but at the same altitude. The italics are mine for a reason. USPA’s guidelines on formation flight (available at snipurl.com/2a5xyqa) suggest that the best way to reliably separate airplanes is vertically. On-level formations invite loss of visual contact because the lead can momentarily descend, the trail can climb just a few feet or the trail can overrun the lead. Any of these combinations can cause the trail pilot to lose sight of the lead if the aircraft’s nose, door or other structure blocks the view at a moment when the closure rate may be high. And judging by the video, that’s exactly what happened.

Experienced formation pilots sometimes say they want “a windshield full of airplane” when closing on a lead from the trail position. An on-level formation complicates the ability to judge closure rate and provides no safety valve against a slight overshoot that 30 feet of vertical separation will guarantee.

When Skydive Superior provided its views on the NTSB’s report, DZO Gary Androsky said that the organization wanted to put the accident behind it, something that has proven difficult. “We accept the findings, but we don’t agree that there wasn’t sufficient training. We thought there was,” Androsky said. “It was a teachable moment. We’re happy where we are now, and we’re moving on,” he added.

Mike Robinson, the DZ’s Safety and Training Advisor, was on the load in the lead 182 and agrees. “Both pilots were experienced flying formations. This was his first time in the trail, but he had gone through an orientation with the chief pilot prior to takeoff. So I don’t think it was lack of training. I think it was just a failure to execute,” Robinson said. The chief pilot, by the way, was in the 185, but the accident occurred when he was on the step preparing to exit.

Final Thoughts
With the accident’s star turn on the “Today” show and numerous other media outlets, the teachable moment of the Skydive Superior accident risks being obscured by the sheer sensationalism of the footage. The workaday press likes fires, rended metal and tearful survivors. Those of us who wish to survive in a sport intolerant of mistakes don’t have the pleasure.

When things unravel in any high-risk activity, the rush of adrenaline will assure that survival depends on reverting to the lowest level of training: muscle memory in the face of panic. In reading the NTSB report and talking to the investigator, I couldn’t help but feel that training across the board in skydiving has gaps we fail to see until an accident reveals them.

And that’s where I part company with the DZ on how this pilot might have been trained. Somewhere in the process, the pilot’s understanding of what constitutes a lowest-risk trail approach should have been discussed and agreed upon. While an on-level trail position is not specifically wrong, it offers less margin for error for no particular gain in the quality of the skydive. For a pilot new to the trail slot, more rather than less margin makes the most sense. The trail pilot never explained why he neglected to wear his pilot rig, but it’s not a trivial oversight given the outcome. Another inch or two fore or aft could have rendered the 185 unflyable, necessitating a pilot bailout … if he had a rig.

In the end, one word describes the Superior accident: avoidable. It turns out to be a cheap lesson for all of us who may be leaving risk assessment and the means to mitigate it to chance. We only benefit from it by listening.

About the Author
FEATURE201510-10Paul Bertorelli, D-24222, is editorial director of avweb.com and is an experienced flight instructor with more than 4,000 hours. He’s also an active skydiver with 2,500 jumps.

 

 

 

 

 

GoPros Told the Tale

In an idle moment on the climb to altitude a few weeks ago, I counted the helmet-mounted cameras. On a 20-person load, there were nine. That’s about the same ratio for those aboard the two aircraft in the Skydive Superior accident, and their footage proved valuable to the NTSB. It may not be the most photographed aircraft accident, but it may be the first with both inside and outside views.

“It kind of presented an interesting situation,” said Jim Silliman, the NTSB investigator in charge of the accident. “Here we had views from inside the airplane, and under NTSB rules, we’re restricted. We can’t show videos from inside the aircraft because that’s like a cockpit voice recorder. We have strict rules.” As a result, even though the footage is all over NBC and YouTube, only select stills from the footage appear in the official NTSB docket.

Silliman added that seeing all of the footage, which showed the lower lead aircraft and the closure rate, was very helpful. But even without video, “the conclusion wouldn’t have been in doubt,” Silliman said, because the lack of separation was obvious. However, the cameras allowed a much more accurate reconstruction of the timeline. “Perhaps with interviews you could have established that, but with the video, it was much more clear and more graphic,” Silliman said.

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