NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of September 16, 2008
(Information subject to editing)

Special Investigation Report
on the Safety of Parachute Jump Operations
NTSB/SIR-08/01 

This is a synopsis from the Safety Board’s report and does not include the Board’s rationale for the conclusions and safety recommendations.  Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted.  The attached information is subject to further review and editing. 

EXECUTIVE SUMMARY

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 2.2 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.
  
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:

• Inadequate aircraft inspection and maintenance;
• Pilot performance deficiencies in basic airmanship tasks, such as preflight inspections, weight and balance calculations, and emergency and recovery procedures; and
• Inadequate FAA oversight and direct surveillance of parachute operations.

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 operation‑specific 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.

CONCLUSIONS

1. Because parachute jump operations are particularly conducive to engine wear, the lack of requirements for parachute jump operators to comply with manufacturer‑recommended maintenance instructions for their aircraft, including service bulletins and service information letters for time between overhauls and component life limits, increases the potential for the persistence of conditions that could lead to engine failure.
2. The current flight review requirements for pilots contained in 14 Code of Federal Regulations Part 91 are insufficient for parachute operations because they do not ensure that parachute jump operations pilots are proficient in the specific aircraft in which they fly passengers, and they do not adequately address the unique considerations for performing parachute operations flights, including frequent takeoffs, slow‑speed maneuvering while the parachutists exit, and subsequent high‑speed, low‑power descents.
3. Training and examinations can help ensure that pilots are familiar with the skills needed to perform parachute operations and with the specific characteristics of the aircraft that they fly; recurrent training and examinations would refresh these skills and serve as a reminder to pilots of their duty to operate in a safe manner.
4. The Federal Aviation Administration’s oversight and surveillance of parachute jump operators have been inadequate to ensure that operators are properly maintaining their aircraft and safely conducting operations.

SAFETY RECOMMENDATIONS

As a result of this special report, the National Transportation Safety Board makes the following recommendations:

To the Federal Aviation Administration:

1. 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‑XX)
2. 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‑XX)
3. 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‑XX)
4. 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 competency in practical skills and techniques in each type of aircraft. (A‑08‑XX)
5. 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.
6. Require direct surveillance of parachute jump operators to include, at a minimum, maintenance and operations inspections. (A‑08‑XX)

To the United States Parachute Association:

7. 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‑XX)

8. 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‑XX)