FlarePath
Cases › CEN23MA034 · Major investigation · Class 1

BOEING B17Commemorative Air Force

Dallas, TX, USA · 2022-11-12·N7227C

6
fatal
0
serious
Fatal
highest injury
Destroyed
damage

What happened

NTSB summary, verbatim

On November 12, 2022, about 1322 central standard time, a Boeing B-17G airplane, N7227C, and a Bell P-63F airplane, N6763, collided in flight during a performance at the Commemorative Air Force’s (CAF) Wings Over Dallas air show at Dallas Executive Airport (KRBD) in Dallas, Texas. The pilot, copilot, flight engineer, and two scanners on board the Boeing B 17G and the pilot of the Bell P-63F were fatally injured, and both airplanes were destroyed. No injuries to persons on the ground were reported. Both accident airplanes (and six other historic, former military airplanes that were airborne as part of the same performance) were operated by the CAF under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 and a certificate of waiver for the air show. The Boeing B 17G and the Bell P-63F departed from KRBD about 1310 and 1315, respectively, for the local flights.

Probable cause

the Board's determination
the air boss’s and air show event organizer’s lack of an adequate, prebriefed aircraft separation plan for the air show performance, relying instead on the air boss’s real-time deconfliction directives and the see-and-avoid strategy for collision avoidance, which allowed for the loss of separation between the Boeing B-17G and the Bell P-63F airplanes. Also causal was the diminished ability of the accident pilots to see and avoid the other aircraft due to flight path geometry, out-the-window view obscuration by aircraft structures, attention demands associated with the air show performance, and the inherent limitations of human performance that can make it difficult to see another aircraft. Contributing to the accident were the lack of FAA guidance for air bosses and air show event organizers on developing plans and performing risk assessments that ensure the separation of aircraft that are not part of an approved maneuvers package and the lack of FAA requirements and guidance for recurrent evaluations of air bosses and direct surveillance of their performance.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Maneuvering-low-alt flying
    Midair collision
    defining event
  2. 1 · Maneuvering-low-alt flying
    Midair collision
    defining event

Findings

12 causal · 0 contributing
  • CAUSE
    Organizational issues › Management › Policy/procedure › Adequacy of policy/proc — Other institution/organization
  • CAUSE
    Organizational issues › Management › Policy/procedure › Adequacy of policy/proc — Other institution/organization
  • CAUSE
    Personnel issues › Psychological › Perception/orientation/illusion › Perception — Pilot
  • CAUSE
    Environmental issues › Task environment › Pressures/demands › Other pressure/demand — Effect on personnel
  • CAUSE
    Environmental issues › Task environment › Pressures/demands › Other pressure/demand — Effect on personnel
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — FAA/Regulator
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — FAA/Regulator
  • CAUSE
    Personnel issues › Psychological › Perception/orientation/illusion › Perception — Pilot
  • CAUSE
    Personnel issues › Physical › Sensory ability/limitation — Pilot
  • CAUSE
    Personnel issues › Physical › Sensory ability/limitation — Pilot
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Oversight › Oversight of operation — FAA/Regulator

Safety recommendations

7 issuedwhat changed because of this accident
  • A-24-031Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Work with the International Council of Air Shows Inc. (ICAS) and the warbird community to establish standard operating procedures for air show event organizers and air bosses that include: 1) applying administrative controls to ensure that multiple, dissimilar aircraft not operated as part of an approved maneuvers package remain deconflicted; 2) performing a safety risk assessment for each performance to determine hazards and apply effective mitigations, including consideration for any revenue ride flights conducted during air show operations; and 3) completing a daily debriefing that includes continuous feedback to the Federal Aviation Administration and the ICAS to address any identified deficiencies.

  • A-24-032Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require recurrent air boss evaluations as part of the letter of authorization renewal process.

  • A-24-033Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Work with the International Council of Air Shows Inc. and other air show industry stakeholders to develop standardized, unambiguous terms to help ensure that the directives that air bosses provide performers, such as those related to show lines, are clear and brief.

  • A-24-034Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Revise Federal Aviation Administration (FAA) Order 8900.1 to provide guidance and a job aid for FAA inspectors who evaluate an air boss’s performance and require the FAA inspector-in-charge of an air show to observe an air boss’s performance visually and on the air boss radio frequency and provide appropriate feedback during the air show debriefing.

  • A-24-035Open - Acceptable ResponseCLASS IIletter ↗

    TO THE INTERNATIONAL COUNCIL OF AIR SHOWS, INC.: In collaboration with the Federal Aviation Administration and other air show industry stakeholders develop standardized, unambiguous terms to help ensure that the directives that air bosses provide performers, such as those related to show lines, are clear and brief.

  • A-24-036Open - Acceptable ResponseCLASS IIletter ↗

    TO THE INTERNATIONAL COUNCIL OF AIR SHOWS, INC.: In collaboration with the Federal Aviation Administration (FAA) and the warbird community establish standard operating procedures for air show event organizers and air bosses that include: 1) applying administrative controls to ensure that multiple, dissimilar aircraft not operated as part of an approved maneuvers package remain deconflicted; 2) performing a safety risk assessment for each performance to determine hazards and apply effective mitigations, including consideration for any revenue ride flights conducted during air show operations; and 3) completing a daily debriefing that includes continuous feedback to the FAA and the International Council of Air Shows to address any identified deficiencies.

  • A-24-037Open - Acceptable ResponseCLASS IIletter ↗

    TO COMMEMORATIVE AIR FORCE: Using the guidance provided in Advisory Circular 120-92D, “Safety Management Systems for Aviation Service Providers,” revise your safety risk assessment process for identifying and mitigating risks, tracking safety hazards, and routinely assessing trend data to include policies and procedures that specifically address the unique aspects of air show operations, such as considerations for serving as event organizer; participating in air boss–directed performances involving multiple, dissimilar aircraft; and ensuring the safety of revenue passenger rides.

NTSB analysis

from the final report

On November 12, 2022, about 1322 central standard time, a Boeing B-17G airplane, N7227C, and a Bell P-63F airplane, N6763, collided in flight during a performance at the Commemorative Air Force’s (CAF) Wings Over Dallas air show at Dallas Executive Airport (KRBD) in Dallas, Texas. The pilot, copilot, flight engineer, and two scanners on board the Boeing B 17G and the pilot of the Bell P-63F were fatally injured, and both airplanes were destroyed. No injuries to persons on the ground were reported. Both accident airplanes (and six other historic, former military airplanes that were airborne as part of the same performance) were operated by the CAF under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 and a certificate of waiver for the air show. The Boeing B 17G and the Bell P-63F departed from KRBD about 1310 and 1315, respectively, for the local flights.