aviation

Crash of Skydive Quantum Leap 

de Havilland DHC-6-100, N203E

Sullivan, Missouri

July 29, 2006

AIRCRAFT ACCIDENT SUMMARY REPORT

NTSB/AAR-08/03/SUM

PB2008-910403

National

Transportation

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

Aircraft Accident Summary Report

Crash of Skydive Quantum Leap 

de Havilland DHC-6-100, N203E

Sullivan, Missouri

July 29, 2006

NTSB/AAR-08/03/SUM

PB2008-910403

Notation 8040

Adopted September 16, 2008
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National Transportation Safety Board. 2008. Crash of Skydive Quantum Leap, de Havilland DHC-6-100, 

N203E, Sullivan, Missouri, July 29, 2006. Aircraft Accident Summary Report NTSB/AAR-08/03/SUM. 

Washington, DC.

Abstract: This report explains the July 29, 2006, accident involving a de Havilland DHC-6-100, N203E, 

registered to Adventure Aviation, LLC, and operated by Skydive Quantum Leap as a local parachute 

operation flight. The aircraft crashed into trees and terrain after takeoff from Sullivan Regional Airport, 

near Sullivan, Missouri. The safety issues discussed in this report relate to the inadequate protection 

provided by single-point restraints for parachutists. Included are safety recommendations addressed to 

the Federal Aviation Administration and the United States Parachute Association regarding this issue.
National Transportation Safety Board

Aircraft Accident

Summary Report

iii

Contents

Figures ............................................................................................................................... v

Abbreviations .................................................................................................................vi

Executive Summary ......................................................................................................vii

1. The Accident.................................................................................................................1

2. Investigation and Analysis........................................................................................3

2.1 Loss of Power in One Engine........................................................................................................ 3

2.2 Pilot Performance of Emergency Procedures ............................................................................ 5

2.3 Intersection Takeoff Considerations ............................................................................................ 8

2.4 Operator Information..................................................................................................................... 8

2.4.1 General..................................................................................................................................... 8

2.4.2 Maintenance Program for the Airplane ............................................................................. 9

3. Safety Issues ...............................................................................................................12

3.1 Accident Survivability ................................................................................................................. 12

3.1.1 Single‐Point Restraints in the Accident Airplane ............................................................ 13

3.1.2 Parachutists’ Seating Locations, Restraint Use, and Injuries ......................................... 13

3.1.2.1 Tandem pair seated on the right................................................................................... 14

3.1.2.2 Tandem pair seated on the left ..................................................................................... 15

3.1.2.3 Three solo parachutists .................................................................................................. 15

3.2 Restraint Performance ................................................................................................................ 16

4. Conclusions ................................................................................................................19

4.1 Findings.......................................................................................................................................... 19

4.2 Probable Cause.............................................................................................................................. 20

5. Recommendations.....................................................................................................21

National Transportation Safety Board v

Aircraft Accident

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Figures

1. Witness’ photograph showing accident airplane above 

the end of runway 24 with smoke and flames visible from 

right engine. (Inset shows an enlarged view.)...........................................................................1

2. Aerial map of UUV showing runway 24, the intersecting 

taxiway, and the accident site. .....................................................................................................2

3. Preaccident photograph of accident airplane interior 

showing both foam block benches and some left-side 

restraints (view from left‐side cargo door, looking 

forward); photograph provided by a relative of the pilot. ....................................................10

4. Photograph of the crush damage on the fuselage 

(right wing removed from wreckage).......................................................................................12

5. Seating diagram showing the approximate preaccident 

locations of the parachutists and the pilot with respect to 

the crush-intrusion line. ..............................................................................................................14
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Abbreviations

AC advisory circular

CAMI Civil Aerospace Medical Institute

CFR Code of Federal Regulations 

EMMA equalized maintenance for maximum availability

FAA Federal Aviation Administration

FSDO flight standards district office

IAS indicated airspeed

MEL minimum equipment list

MMEL master minimum equipment list

PMA parts manufacturer approval

SB service bulletin

TBO time between overhaul

USPA United States Parachute Association

UUV Sullivan Regional Airport 
National Transportation Safety Board vii

Aircraft Accident

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Executive Summary

On July 29, 2006, about 1345 central daylight time, a de Havilland DHC-6-100, 

N203E, registered to Adventure Aviation, LLC, and operated by Skydive Quantum Leap 

as a local parachute operation flight, crashed into trees and terrain after takeoff from 

Sullivan Regional Airport, near Sullivan, Missouri. The pilot and five parachutists were 

killed, and two parachutists were seriously injured. The flight was operated under 14 Code 

of Federal Regulations Part 91 with no flight plan filed. Visual meteorological conditions 

prevailed. Witnesses at the airport reported (and photographic evidence showed) that, 

shortly after the airplane lifted off from the runway, flames emitted from the airplane’s 

right engine. Witnesses reported that the airplane continued to fly low above the treetops 

before turning right and diving nose first into the ground. 

The safety issues discussed in this report relate to the inadequate protection 

provided by single-point restraints for parachutists. Two safety recommendations to the 

Federal Aviation Administration and two to the United States Parachute Association are 

included.

National Transportation Safety Board 1

Aircraft Accident

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1. The Accident

On July 29, 2006, about 1345 central daylight time, a de Havilland DHC-6-100,1

N203E, registered to Adventure Aviation, LLC, and operated by Skydive Quantum Leap 

as a local parachute operations flight, crashed into trees and terrain after takeoff from 

Sullivan Regional Airport (UUV), near Sullivan, Missouri. The pilot and five parachutists 

were killed, and two parachutists were seriously injured. The flight was operated under 

14 Code of Federal Regulations (CFR) Part 91 with no flight plan filed. Visual meteorological 

conditions prevailed. 

According to photographic evidence provided by a witness, the pilot taxied the 

airplane onto runway 24 from the intersecting taxiway, which is about 1,700 feet from the 

runway’s west end, and began a takeoff roll to the west from that location, rather than 

using the runway’s entire 4,500-foot length. Photographic evidence depicting the airport 

windsock shows that the airplane departed into a moderate headwind. Witnesses at the 

airport reported seeing the airplane take off and climb to about treetop height.2

 Several 

witnesses reported hearing a “poof” or “bang” noise and seeing flames and smoke coming 

from the right engine. One witness reported that, after the noise and the emergence of flames, 

the right propeller was “just barely turning.” Photographic evidence shows that, at one point 

after the flames occurred, the airplane was about one wingspan (about 65 feet) above the 

runway. (See figure 1.) One witness estimated that the airplane climbed to about 150 feet.

1 The DHC‐6‐100 was originally manufactured by de Havilland, but the type certificate is currently held 

by Viking Air Limited of Sidney, British Columbia, Canada. 

2 According to estimates from witnesses and other sources, the tree height ranged from 30 to 100 

feet.

Figure 1. Witness’ photograph showing accident airplane above the end of runway 24 with smoke 

and flames visible from right engine. (Inset shows an enlarged view.)
The Accident

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Summary Report

Witnesses reported that the airplane lost some altitude, regained it, and then 

continued to fly low above the treetops before turning to the right and disappearing from 

their view behind the treeline. Another witness in the backyard of a residence northwest 

of the airport reported that she saw the airplane flying straight and level but very low 

over the trees before it dived nose first to the ground. She and her father called 911, and 

she said that local emergency medical service personnel arrived within minutes. The 

airplane impacted trees and terrain and came to rest vertically, nose down against a tree 

behind a residence about 1/2 mile northwest of the end of runway 24. (An aerial map of 

the runway and accident site is shown in figure 2.) 

Figure 2. Aerial map of UUV showing runway 24, the intersecting taxiway, and the accident site.
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2. Investigation and Analysis

The airplane was powered by two Pratt & Whitney Canada PT6A-20, 

550-horsepower engines equipped with three-bladed, single-acting, hydraulically 

operated, constant-speed, reversible Hartzell propellers with feathering3 capabilities. 

Examination of the wreckage, including both engines and propellers, revealed that the 

right engine’s compressor turbine disk was intact but that its attached blades4 were 

fractured; the damage observed within the engine resulted in the loss of engine power. No 

evidence of any other preimpact conditions that would interfere with normal operations 

was found during examinations of the airplane, engines, propellers, and components.

2.1 Loss of Power in One Engine

Microscopic examination of the right engine’s fractured compressor turbine blades 

revealed features consistent with overload. Additional damage was observed in engine 

sections beyond the compressor turbine section along the engine’s gas path. Also, several 

of the right engine’s compressor turbine blade tips were missing. The overload fractures 

on the blades in the compressor turbine section and the damage beyond that section were 

consistent with mechanical damage caused by separated compressor turbine blade tips 

migrating within the engine. Because no preimpact anomalies were observed in engine 

areas forward of the damaged compressor turbine along the engine’s gas path, there is no 

evidence that an ingested object, such as a bird or debris, initiated the overload events in 

the compressor turbine section.5

 Therefore, the initial blade separation originated within 

the compressor turbine section. However, because several separated compressor turbine 

blade tips were not located for examination, the source of the initial event or condition 

that precipitated the overload events could not be determined. 

The airplane’s maintenance records indicate that the left and right engines had 

accumulated 5,829 hours and 6,493 hours since overhaul, respectively (15,155 hours and 

17,264 hours since new, respectively), which far exceeded the manufacturer’s recommended 

time between overhaul (TBO) period of 3,600 hours, as stated in Pratt & Whitney Canada 

Service Bulletin (SB) 1803R1, “Turboprop Engine Operating [TBOs] and Hot Section 

Inspection Frequency.”6

 However, Federal regulations do not require operators of aircraft 

3 Feathering means to rotate the propeller blades so that the blades are parallel to the line of flight 

(streamlined to the airflow) to reduce the drag caused by the blades and prevent further damage to an engine 

that has stopped operating.

4 The compressor turbine blades were Federal Aviation Administration (FAA) PMA (parts manufacturer 

approval) blades manufactured by Doncasters, Inc., Turbo Products Division. 

5 In addition, the engine’s intake port is at the rear of the engine and is designed with a mesh‐screen 

cover, further reducing the likelihood of an ingestion of objects or birds during flight.

6 Further, SB 1803R1 specifically excludes engines that have been used in parachute jump operations 

from eligibility for the manufacturer’s program for extending TBOs. Pratt & Whitney Canada reported that it 

had no documentation indicating that the operator requested to participate in the TBO extension program. 
Investigation and Analysis

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Aircraft Accident

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operated under 14 CFR Part 91 to comply with manufacturers’ recommended TBOs 

specified in SBs or service information letters. 

In developing TBOs, manufacturers analyze the cumulative effects of various 

stresses placed on different components over time. Based on this analysis, manufacturers 

determine a schedule of maintenance and inspection that they believe will provide an 

acceptable level of safety. Overhauling an engine within the manufacturers’ recommended 

TBO increases the likelihood that potentially catastrophic conditions that may otherwise 

be undetectable will be discovered and corrected. Therefore, the Safety Board concludes 

that, although damage to the accident airplane’s right engine precluded determination of 

the initial event that precipitated the overload fracturing of the compressor turbine blades, 

and although the operator was not required to comply with the engine manufacturer’s SBs, 

it is possible that the initiating fracture event within the engine resulted from a condition 

that could have been detected and corrected during an engine overhaul performed within 

the manufacturer’s recommended TBO.

Because most parachute jump operators function under Part 91 and thus, are not 

required to comply with TBOs, the Safety Board in its 2008 Special Investigation Report 

on the Safety of Parachute Jump Operations,

7

 issued Safety Recommendation A-08-63 on 

September 16, 2008, that asked the Federal Aviation Administration (FAA) to do the 

following: 

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.[8]

In addition, to help operators implement effective maintenance and inspection 

quality assurance programs, on September 16, 2008, the Safety Board issued Safety 

Recommendation A-08-64 that asked the FAA to do the following: 

Develop and distribute guidance materials, in conjunction with the United 

States Parachute Association [(USPA9

)], for parachute jump operators to 

7 National Transportation Safety Board, Special Investigation Report on the Safety of Parachute Jump 

Operations, Special Investigation Report NTSB/SIR‐08/01 (Washington, DC: NTSB 2008).

8 Safety Recommendation A‐08‐63 is classified “Open—Await Response.”

9 The USPA is a voluntary organization made up of about 31,000 individual members and about 

270 operator members, also called “group members” or “drop zones.” USPA supports and promotes safe 

skydiving through parachuting training, rating, and competition programs and distributes safety information 

through printed publications and its website.
Investigation and Analysis

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Aircraft Accident

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assist those operators in implementing effective aircraft inspection and 

maintenance quality assurance programs.[10]

2.2 Pilot Performance of Emergency Procedures 

According to section 3.1 of the emergency procedures of the airplane’s flight 

manual, which was found in the wreckage, the emergency procedures for an engine 

failure during takeoff include, in part:

If engine failure occurs above Vmc [minimum control speed11] and a decision 

is made to continue the take-off, proceed as follows: ... Maintain heading 

by applying rudder and lowering wing against the live engine as necessary 

and lower nose to hold desired airspeed. ... Advance power levers. ... 

Power lever of failed engine - IDLE. ... Propeller lever of failed engine -

FEATHER. ... Hold 71 knots IAS[12]

 if flaps at 30°; ... 83 knots IAS if flaps at 

0°. ... When clear of obstacles, the flaps should be retracted in increments 

and the airspeed increased appropriately per the above schedule in order 

not to lose altitude during retraction. Best single engine rate of climb is 

achieved with flaps 0° at 83 knots IAS.

The emergency procedures to configure a multiengine airplane for climb following 

a loss of engine power during takeoff are generally considered “memory items,” which 

are procedures that a pilot must execute immediately from memory rather than first using 

a checklist. However, evidence showed that the accident pilot failed to effectively perform 

most of those procedures. For example, as the photograph in figure 1 illustrates, the 

airplane’s rudder was not deflected and its wings were not banked toward the operating 

engine. Witnesses’ descriptions of the flight indicated that the pilot instead allowed the 

airplane to drift to the right (toward the inoperative engine)13 before it nose-dived into the 

ground. 

10 On September 16, 2008, the Safety Board also issued Safety Recommendation A‐08‐69 that asked 

the USPA to do the following: “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.” Safety Recommendations A‐08‐64 and A‐08‐69 are each classified 

“Open—Await Response.”

11 According to FAA definitions, Vmc is the minimum airspeed at which the airplane could remain 

controllable with its critical engine inoperative; for twin‐engine airplanes, the critical engine is the engine in 

which a failure would have the most adverse effect on directional control. On the DHC‐6‐100 airplane, which 

has engines that both rotate in conventional, clockwise rotation as viewed from the pilot’s seat, the left engine 

is the critical engine.

12 Knots IAS stands for knots indicated airspeed, which is the speed of the airplane as shown on the 

airspeed indicator on the cockpit control panel.

13 A turn toward an inoperative engine can degrade climb performance. See National Transportation 

Safety Board report AAR‐79‐10 for information about a similar accident involving a DHC‐6‐300 airplane. This 

report stated, in part, “expected climb performance can be degraded by ... turns into the failed engine, by 

failure to minimize drag by inducing a sideslip or not maintaining correct speeds, and by turns away from the 

headwind.”
Investigation and Analysis

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Aircraft Accident

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The information provided by witnesses, the nose-down attitude of the wreckage, 

and the crush damage to the forward fuselage of the airplane are consistent with an 

uncontrolled descent due to an aerodynamic stall. Further, the filaments of the stall 

warning light, recovered from the wreckage, were found stretched, which is consistent 

with the light having been illuminated at impact. 

According to a performance assessment provided by the airplane’s current 

type‐certificate holder, given the weather conditions at the time of the accident, airport 

altitude, and calculated weight for the accident airplane, the airplane should have been 

capable of a positive single-engine climb rate of about 300 feet per minute if the pilot had 

configured the airplane properly according to the published procedures by feathering the 

propeller on the failed engine and attaining the recommended airspeed.

However, according to the Airplane Flying Handbook, published by the FAA, factors such 

as “engine and propeller wear, or poor technique in airspeed, bank angle, and rudder control,” 

among others, can reduce actual rate-of-climb performance.14 Several performance-reducing 

factors were present during the accident flight: the accident airplane’s engines were thousands 

of hours beyond the manufacturer’s recommended TBO, and photographic evidence indicates 

that the pilot used poor technique by not banking the airplane or using rudder control to 

maintain airspeed as prescribed in the airplane’s emergency procedures. Therefore, the 

Safety Board concludes that, although engine wear would likely have prevented the accident 

airplane from obtaining its maximum published single-engine climb performance, the pilot’s 

failure to maintain airspeed, according to the technique specified in the published emergency 

procedures following the loss of power in one engine, negated any possibility of continued, 

controlled flight that could have allowed for a return to the airport or other suitable landing 

area. Because the pilot did not effectively configure the airplane for continued single‐engine 

flight, the airplane could not sustain a climb; therefore, the pilot’s only other available option 

would be to maintain a controllable airspeed and perform a controlled descent. However, the 

airplane’s descent was not controlled; the pilot allowed the airplane’s airspeed to decay to the 

point of aerodynamic stall. 

In the Safety Board’s 2008 special investigation report on parachute operations,15

the Board identified several parachute operations accidents in which the pilots were 

deficient in maintaining airspeed and properly executing emergency procedures. As a 

result, the Safety Board issued Safety Recommendation A-08-65 on September 16, 2008, 

that asked the FAA to do the following: 

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, 

14 See U.S. Department of Transportation, Federal Aviation Administration, Airplane Flying Handbook,

FAA‐H‐8083‐3A (Washington, DC: FAA, 2004): Ch. 12, p. 12‐10.

15 See NTSB/SIR‐08/01.
Investigation and Analysis

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Summary Report

emergency and recovery procedures, and parachutist egress procedures 

for each type of aircraft flown.[16]

In addition, the Safety Board issued Safety Recommendation A-08-66 on 

September 16, 2008, that asked the FAA to do the following:

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 the pilots’ 

competence in practical skills and techniques in each type of aircraft.[17]

As noted in the emergency procedures, the propeller configuration is also a 

factor in the accident airplane’s single‐engine climb performance; the propeller of the 

inoperative engine should be feathered. Although the accident airplane was equipped 

with a propeller autofeathering system designed to automatically feather the propeller 

of an underpowered engine, the system was deactivated.18 With the system deactivated, 

the pilot would need to manually position the propeller-control lever of the failed 

engine to the “feather” position to feather the propeller blades. Because of the impact 

damage to the cockpit propeller-lever controls, it was not possible to determine their 

preimpact positions. However, postaccident examination of the right propeller assembly 

revealed that the blades were at high angles at impact, which is consistent with a feather 

or near-feather condition. Also, the autofeather system had been inoperative since the 

operator acquired the airplane in 2001, and its deactivated status was placarded in the 

cockpit; therefore, the pilot (who also operated Skydive Quantum Leap) was likely aware 

of the discrepancy. Further, the airplane was originally certificated without an autofeather 

system, and the airplane’s published emergency procedures, which were available to the 

pilot in the cockpit, correctly indicated the procedure for feathering the propeller without 

the autofeather system. Therefore, the Safety Board concludes that, although the airplane’s 

autofeather system, had it been operative, would have helped the pilot promptly feather 

16 In addition, to help operators implement effective pilot training programs, on September 16, 2008, 

the Safety Board issued Safety Recommendation A‐08‐67 that asked the FAA to “[r]evise 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.” Also, on September 16, 2008, the Safety Board 

issued Safety Recommendation A‐08‐70 that asked that the USPA do the following: “Once Advisory Circular 

(AC) 105‐2C 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.” 

Safety Recommendations A‐08‐65, A‐08‐67, and A‐08‐70 are each classified “Open—Await Response.”

17 Safety Recommendation A‐08‐66 is classified “Open—Await Response.”

18 The accident airplane was modified with a propeller autofeather system, which, according to the 

airplane’s flight manual, is designed to “automatically feather the propeller of an underpowered engine when 

a decrease in torque to 13 [to] 11 [pounds per square inch] is detected ... .” Examination of the airplane at the 

accident site, however, revealed that the autofeather system switch was placarded “DEACTIVATED.”
Investigation and Analysis

National Transportation Safety Board 8

Aircraft Accident

Summary Report

the propeller of the inoperative engine, there is insufficient evidence to suggest that the 

inoperative autofeather system was a factor in the accident. 

2.3 Intersection Takeoff Considerations

The pilot elected to perform the departure from an intersection location that left 

only 1,700 feet of the 4,500‐foot runway available; photographic evidence shows that the 

airplane, at one point, was above the runway and near the departure end with flames 

and smoke visible on the right engine. Because the airplane had already achieved a speed 

above Vmc when the engine lost power, the pilot’s decision to continue the flight was 

appropriate, according to the published emergency procedures for the airplane, regardless 

of available runway. However, page 12-18 of the FAA’s Airplane Flying Handbook points 

out that a loss of engine power during takeoff is a critical emergency because altitude and 

time are minimal and that “it is paramount [for the pilot] to maintain airplane control 

and comply with the manufacturer’s recommended emergency procedures.” According 

to the airplane flight manual, the emergency procedures for configuring the airplane are 

to be performed if “a decision is made to continue the takeoff.” A decision to discontinue 

a takeoff and land the airplane following a loss of engine power at an airspeed above 

Vmc would be up to the discretion of the pilot based, in part, on the pilot’s assessment of 

available runway. 

Because the accident airplane’s airspeed and altitude at the time that the engine 

problem could have first been detected is not known, precise estimates of runway 

requirements to land the accident airplane following the loss of power cannot be 

determined. However, available witness and photographic information and performance 

information provided by the airplane’s current type-certificate holder indicate that had the 

entire 4,500-foot runway been used, the airplane could have been landed straight ahead on 

the remaining runway following the loss of engine power but it might have overrun the 

end of the runway before coming to a stop within the airport boundary. The Safety Board 

concludes that the pilot’s decision to use only 1,700 feet of the available runway diminished 

the margin of safety during takeoff because it eliminated the option of discontinuing the 

takeoff and performing a straight-ahead, emergency landing on the runway. 

2.4 Operator Information

2.4.1 General

Skydive Quantum Leap was corporately owned and operated by the accident 

pilot since November 1993 and carried an estimated 10,000 to 12,000 parachutists per year, 

with a maximum of about 15,000 parachutists carried in 1 year. The accident airplane, 

which was owned by a limited liability company controlled by the accident pilot, was the 

operator’s only airplane. Although the accident flight carried revenue parachutists, it was 

operated under Part 91 because 14 CFR 119.1(e) (6) exempts nonstop parachute operations 
Investigation and Analysis

National Transportation Safety Board 9

Aircraft Accident

Summary Report

flights conducted within a 25‐mile radius of the departure airport from the rules that 

govern air carriers and other commercial operators. 

The accident pilot, age 42, held an airline transport pilot certificate with a rating 

for multiengine land airplanes and commercial privileges for single-engine land airplanes. 

He held a first‐class airman medical certificate, issued June 8, 2006, with no restrictions. 

On his application for the medical certificate, the pilot reported that he had accumulated 

6,000 total civilian flight hours, with 400 hours accumulated in the previous 6 months. 

The pilot was properly certificated and qualified to perform the parachute operations 

flight, and there was no evidence that any physiological or other impairment affected his 

performance. 

2.4.2 Maintenance Program for the Airplane 

The operator used an independent maintenance facility to perform maintenance 

and inspections on the airplane, which was maintained under an equalized maintenance 

for maximum availability (EMMA) controlled inspection program.19 According to the 

airplane’s maintenance logbooks, its most recent inspection was an EMMA check number 

1620 completed on May 21, 2006, at an airframe total time of 37,434 hours.

Although evidence indicates that the operator followed the EMMA program for 

inspecting the airplane at the prescribed intervals, the operator did not repair all the 

discrepancies observed during the inspections. For example, the mechanic who performed 

the most recent EMMA inspection recalled that the operator had not wanted him to repair 

the airplane’s inoperative autofeather system, so the mechanic ensured that the system 

was deactivated and that a “DEACTIVATED” placard was placed in the cockpit near 

the autofeather switch. Because the operator did not have an FAA-approved minimum 

equipment list (MEL) for the airplane, the operator was not authorized to dispatch 

the airplane with any inoperative equipment.21 Further, an FAA-approved MEL, if the 

19 The EMMA inspection program was designed to use work cards to inspect airplanes in 5 delineated 

areas during 48 checks that take place every 125 flight hours. Special cards are included to address routine 

inspections, airworthiness directives, corrosion inspections, and items affected by calendar rather than flying 

hours.

20 According to the EMMA inspection record, the number 16 inspection work cards specify a detailed 

grouping of tasks designed to inspect a wide variety of listed items on the airplane, such as specific airframe 

and powerplant items; electrical, hydraulic, and fuel system items; and communication and navigation system 

items, among others. The tasks include inspecting the specified items for security, condition, freedom of 

movement, cleanliness, corrosion, function, and operability, and the cards specify the removal, reinstallation, 

and/or replacement of items, as indicated.

21 According to 14 CFR 91.213, no person may take off in a turbine‐powered airplane with inoperative 

instruments or equipment installed unless an FAA‐approved MEL exists for that airplane and the airplane has 

within it a letter of authorization from the local flight standards district office (FSDO) authorizing its operation 

under the MEL. A review of records on file at the St. Louis, Missouri, FSDO revealed that the operator had no 

letter of authorization or MEL on file for the accident airplane.
Investigation and Analysis

National Transportation Safety Board 10

Aircraft Accident

Summary Report

operator had obtained one for 

the airplane, would have limited 

operation of the airplane to a 

maximum of 10 consecutive 

calendar days with an inoperative 

autofeather system.22

The airplane had been 

modified from its original 

configuration to accommodate 

parachute operations; these 

modifications included the 

removal of the original cabin seats 

and installation of parachutists’ 

restraints attached to the sidewalls 

of the cabin. Examination of the 

wreckage revealed that the accident 

airplane’s cabin configuration 

differed from that which was 

specified in the FAA’s records 

for the airplane. For example, 

according to an FAA Form 337,23

dated October 5, 2000, the airplane 

was modified with two straddle 

benches, which, according to 

the information provided by the 

designer, are structural, metal 

benches that attach to the seat 

attachment points. However, the 

straddle benches described in the 

Form 337 were not observed in the 

wreckage; instead, two solid foam blocks, each measuring about 5 to 6 feet long and 15 to 

18 inches tall and wide, were in the airplane. Each solid foam block served as a seating 

bench that extended aft from the forward cabin, parallel to each exterior cabin wall. The 

position of the two foam block benches allowed space for a center aisle and space between 

each bench and sidewall. (See figure 3 above.) 

22 For FAA approval, a MEL must be no less restrictive than the FAA’s master minimum equipment 

list (MMEL) for that aircraft. According to the MMEL for DHC‐6‐series airplanes, the autofeather system is 

considered a “Category C” item, which means that it must be repaired within 10 consecutive calendar days, 

excluding the day the malfunction was recorded in the aircraft maintenance record or logbook.

23 An FAA Form 337 is used as part of the field approval process for approving a major repair or alteration 

of an aircraft. An applicant wishing to perform a major repair or alteration must submit to the local FSDO a 

completed FAA Form 337 that identifies the aircraft by serial number, describes the intended modification, 

and includes any applicable engineering drawings and/or other data, such as a flight manual supplement, 

pertinent to the change. FSDO inspectors review the submitted information, and, depending on the scope and 

complexity of the proposed modification, the FSDO may approve the proposed modifications as presented, 

request more data and support from the applicant, or forward the data to the aircraft certification office for 

further review.

Figure 3. Preaccident photograph of accident airplane 

interior showing both foam block benches and some 

left‐side restraints (view from left‐side cargo door, looking 

forward); photograph provided by a relative of the pilot.
Investigation and Analysis

National Transportation Safety Board 11

Aircraft Accident

Summary Report

A review of the airplane’s maintenance records revealed that the removal of the 

straddle benches was not documented. Although there is no evidence this undocumented 

configuration or the inoperative autofeather system contributed to the accident, such 

discrepancies are not consistent with FAA airworthiness requirements; therefore, the 

operator should not have dispatched the accident airplane until the discrepancies were 

resolved. 

One method by which the FAA can detect and require an operator to correct 

aircraft airworthiness discrepancies is through direct surveillance visits to the operator. 

However, a review of FAA Program Tracking and Reporting Subsystem data and Safety 

Performance Analysis System data showed no record of FAA inspectors conducting 

any maintenance or operations surveillance visits to the operator.24 The Safety Board 

notes that, in the absence of surveillance, the operator was able to repeatedly dispatch 

the airplane in an unairworthy condition and that, had an FAA inspector observed the 

discrepancies, the airplane likely would have been grounded until the repairs were made. 

Therefore, the Safety Board concludes that greater FAA surveillance of the operator 

would have discouraged improper aircraft maintenance procedures, such as dispatching 

the airplane with an inoperative autofeather system and an undocumented cabin seating 

configuration. 

In fact, the Safety Board’s 2008 special investigation25 identified a number of 

parachute operations airplanes that had open maintenance discrepancies at the time that 

they crashed. As a result, the Safety Board issued Safety Recommendation A-08-68 on 

September 16, 2008, that asked the FAA to do the following: 

Require direct surveillance of parachute jump operators to include, at a 

minimum, maintenance and operations inspections.26

24 The records did show three FAA contacts with the operator related to the operator’s airspace waiver 

requests.

25 See NTSB/SIR‐08/01.

26 Safety Recommendation A‐08‐68 is classified “Open—Await Response.”
National Transportation Safety Board 12

Aircraft Accident

Summary Report

3. Safety Issues

3.1 Accident Survivability

Only two of the seven parachutists survived the accident even though the airplane 

was equipped with parachutists’ restraints and the cabin area in which all the parachutists 

were seated showed little crush 

intrusion. In fact, the crush damage 

observed on the wreckage showed 

that only the space where the 

pilot was seated was subjected to 

nonsurvivable crush intrusion. 

The airplane’s nose,27 cockpit, and 

cabin were crushed aft to an area 

immediately forward of the second 

window in the cabin passenger 

compartment. (See figure 4.) 

The survival of the two 

parachutists indicates that the 

forces generated during the crash 

sequence were survivable. Several 

sources of information, such as 

witness estimates of the airplane’s 

height above the ground (ranging 

from 50 to 150 feet) at the onset of 

the dive, estimates of vertical speed 

derived from the airplane’s vertical 

speed indicator at the accident site, 

the extent of crush damage observed 

on the wreckage, and the depth of 

the ground impact crater, were 

used when performing various 

load analyses. These analyses 

showed that the peak deceleration 

was between 6.6 G28 and 19.7 G 

and that final velocity was between 

40.1 and 69.5 feet per second; these 

ranges fall within survivable limits 

outlined in the Safety Board’s 1985 

General Aviation Crashworthiness 

27 The airplane’s nose is not structural; it is constructed of balsawood and composite materials.

28 One G is equivalent to the acceleration caused by the earth’s gravity (32.174 feet/second2

).

Figure 4. Photograph of the crush damage on the 

fuselage (right wing removed from wreckage).
Safety Issues

National Transportation Safety Board 13

Aircraft Accident

Summary Report

Project report.29 In addition, the cabin area in which all of the parachutists were seated was 

aft of the area of direct crush intrusion observed on the airplane. 

Because of the near-vertical orientation of the airplane at impact, most of the 

crash load forces were directed along the longitudinal axis of the airplane. As a result, 

the parachutists traveled primarily forward—toward the front of the cabin—during the 

crash sequence, and some of the parachutists entered the area of intrusion. The level of 

injury for each parachutist was affected by restraint use, surfaces impacted, and impacts 

received from other restrained and unrestrained parachutists in the cabin.

3.1.1 Single-Point Restraints in the Accident Airplane

According to preaccident photographs of the airplane’s interior and to information 

recovered from two onboard video cameras worn on the helmets of two of the parachutists, 

the airplane’s cabin was equipped with 20 sets of sidewall-mounted webbing restraint 

systems for parachutists (10 sets on the left sidewall and 10 on the right).30 This type of 

single-point restraint is designed to pass through the parachute harness, anchoring the 

parachutist to a single point on the airplane’s sidewall using the sidewall-mounted seat 

tracks. 

3.1.2 Parachutists’ Seating Locations, Restraint Use, and Injuries

The parachutists—three solo parachutists and two tandem pairs (one 

parachutist‐in‐command and one passenger parachutist per pair)—all sat facing aft at 

the time of the crash.31 The three solo parachutists sat on the floor, and each tandem 

pair straddled one of the foam block benches in the forward cabin. (See figure 5 on the 

following page.) According to company practice, this seating arrangement was typical. 

The foam block benches allow easier harnessing for the tandem pairs by enabling a more 

upright seated position than provided by the airplane’s floor. According to company 

practice, tandem pairs usually harness together about 2 to 5 minutes before jumping from 

the airplane. 

All of the parachutists had restraints accessible from their seated locations. 

According to company practice, all parachutists are restrained before the airplane moves; 

however, no specific instructions are provided to parachutists regarding which restraint 

to use or how tightly to fasten it. Parachutists typically route the restraints through the 

vertical (main lift) webbing or the leg webbing of their parachute harnesses.

29 For more information, see National Transportation Safety Board, General Aviation Crashworthiness 

Project Phase III: Acceleration Loads and Velocity Changes of Survivable General Aviation Accidents, Safety 

Report NTSB/SR‐85/02 (Washington, DC: NTSB, 1985).

30 An FAA Form 337 dated April 17, 2000, indicated that 22 sets of seatbelt restraints for parachutists 

were installed. Only 20 sets were identified in the videos, the preaccident photographs, and the postaccident 

photographs. It is unknown if these additional restraints were present at some time. The characteristics of the 

identified restraints appeared consistent with the descriptions provided on the Form 337.

31 Video evidence indicated that two of the parachutists in the aft cabin initially faced forward during 

takeoff but later repositioned and sat on the floor facing aft.
Safety Issues

National Transportation Safety Board 14

Aircraft Accident

Summary Report

3.1.2.1 Tandem pair seated on 

the right

One tandem pair sat 

straddling the foam block 

bench on the right side. The 

parachutist-in-command wore 

a tandem parachute, and his 

seating position was the most 

forward (closest to the front of the 

cabin) of the parachutists seated 

on the right side of the airplane. 

His passenger-parachutist sat in 

close proximity and immediately 

aft of his position; she wore 

a tandem passenger harness 

with no parachute. Analysis of 

postaccident restraint damage 

evidence, including a break in the 

attachment track at the normally 

installed location of one restraint 

and the pulled appearance of 

the attachment pin of a second 

restraint that was also missing one 

side, suggests that each member 

of this pair likely used a restraint. 

Also, the close proximity of this 

pair while seated on the foam block 

bench, as observed from an onboard 

video, suggests that they may have 

harnessed together before takeoff, 

although this would be inconsistent 

with company practice. 

The parachutist‐in‐command did not survive the accident. His injuries included a 

cervical fracture, bilateral rib fractures, and blunt chest trauma, suggesting that the loose, 

single-point restraint enabled considerable forward motion of his upper body and head, 

exposing him to large forces and allowing him to enter the intrusion area and impact 

surfaces there. Further, he was impacted by his tandem partner. His tandem partner, 

however, survived the accident. Her injuries, which were serious, included a cervical 

fracture, multiple minor lumbar spinal fractures, and a right clavicle fracture. She likely 

benefited from her restraint and from the impact attenuation achieved by having another 

person coupled to her back acting as a barrier between her and the cabin crush intrusion. 

She was also likely not impacted by parachutists seated aft of her location because the 

parachutist seated on the floor directly aft of her location was restrained. 

Figure 5. Seating diagram showing the approximate 

preaccident locations of the parachutists and the pilot with 

respect to the crush‐intrusion line.
Safety Issues

National Transportation Safety Board 15

Aircraft Accident

Summary Report

3.1.2.2 Tandem pair seated on the left

Like the tandem pair just described, the pair on the left side of the airplane sat 

straddling a foam block bench. The parachutist-in-command wore a tandem parachute, 

and his seating position was the most forward of the parachutists seated on the left side 

of the airplane. His passenger-parachutist sat in close proximity and immediately aft 

of his position; she wore a tandem passenger harness with no parachute. Analysis of 

postaccident restraint damage, including elongation deformation of the attachment ring 

on one restraint, suggests that at least one member of this pair likely used a restraint. 

Although a second restraint showed damage, that damage did not clearly indicate use. As 

with the other tandem pair, the seated proximity of the members of this pair suggests that 

they may have harnessed together before takeoff. 

Neither member of this pair survived. Although the parachutist-in-command 

was likely restrained (either independently or through his attached tandem partner) his 

injuries, which included blunt pelvic trauma, suggest that the loose restraint allowed him 

to be exposed to large forces and to impact the surfaces in the intrusion area. He was also 

impacted by his tandem partner. Although the partner, too, was likely restrained (likely 

to the sidewall) and likely benefited from the impact attenuation achieved by having 

another person coupled to her back, she was likely impacted by at least one of two likely 

unrestrained parachutists seated in the aft cabin. Her injuries, which included bilateral 

pelvic fractures, kidney and liver lacerations, multiple lower extremity fractures, and 

multiple fractures of the lumbar spine, may have resulted from an impact from at least 

one other parachutist and from the failure of the loose, single-point restraint to adequately 

restrain her.

3.1.2.3 Three solo parachutists

One parachutist sat on the floor on the right side of the airplane just aft of the 

foam block bench on which a tandem pair was seated. She was in a semi-reclined position 

with her parachute leaning against the end of the foam block bench. According to video 

evidence, she appeared to have restraint webbing routed through the left-leg portion of 

her parachute harness. Although she was restrained, she did not survive the accident. Her 

injuries, which included a fracture at the base of the skull and a thoracic spine fracture, 

likely resulted from the failure of the loose, single-point restraint to adequately restrain 

her and from the impact received from the likely unrestrained parachutist seated on the 

right side of the airplane aft of her position.

Another parachutist, according to video evidence, initially looked out the left side 

cargo door but, after the engine noise changed (which was audible on the video), sat on the 

floor on the left side of the airplane and appeared to lean backward against his parachute 

in a semi-reclined position. There was no evidence that he used a restraint, and he did not 

survive the accident. His injuries, which included closed head trauma, blunt chest trauma, 

and blunt abdominal trauma, suggest that, because he was seated a distance aft of the 

passenger-parachutist seated forward of his position on the left, he likely traveled a large 

distance before impacting her and/or a surface, resulting in high impact forces. Despite 

the attenuation of these forces through impacts with the other parachutist, he also likely 
Safety Issues

National Transportation Safety Board 16

Aircraft Accident

Summary Report

traveled into the area of intrusion. Therefore, his lack of restraint use, along with a lack of 

support forward of his seating position, contributed to his fatal injuries.

Another parachutist, according to video evidence, initially leaned toward the left 

cargo door but, after the engine noise changed, eventually sat on the floor in the aft cabin on 

the right side of the airplane (aft of the restrained solo parachutist). There was no evidence 

that he used a restraint; however, he survived the accident. His injuries, which were serious 

and included a concussion, multiple thoracic and lumbar spinal fractures, complete spinal 

cord injury, and blunt chest trauma, suggest that he impacted the restrained parachutist 

forward of his position on the right and possibly also the passenger-parachutist on the 

left. Colliding with other parachutists may have absorbed some of his impact energy, 

thus, reducing the forces experienced by his body during the crash. Also, he was not 

impacted by other parachutists because none were seated aft of his position. 

3.2 Restraint Performance 

Only one of the five parachutists who were likely restrained survived the accident. 

Historically, parachutists have fared poorly during parachute operations airplane crashes 

because they do not have the crash protection provided by typical aircraft passenger 

seat structures and passenger seatbelts. As a result of the Safety Board’s investigation 

of several parachute operations accidents, the Board issued safety recommendations in 

1994 regarding parachutists’ seating and restraints.32 In response to the recommendations, 

the FAA’s Civil Aerospace Medical Institute (CAMI), in conjunction with the Parachute 

Industries Association and the USPA,33 performed a series of dynamic sled tests to evaluate 

various types of restraint systems for parachutists and published a report on its findings.34

The restraint systems evaluated included both single-point systems and dual-point 

systems intended for aft‐facing, floor‐seated occupants. All of the systems tested were 

designed to pass through the parachute harness and attach to the aircraft floor.

Tests involving single-point restraint systems, such as those installed on the 

accident airplane, showed poor kinematics of the test dummies. The results of the sled 

32 On February 17, 1994, the Safety Board issued Safety Recommendation A‐94‐16, which asked 

the FAA to do the following: “In conjunction with industry, the United States Parachute Association, and the 

Civil Aerospace Medical Institute, develop and test universal restraint systems capable of providing adequate 

protection to parachutists similar to that provided for seated passengers.” The FAA responded on March 26, 

1999, that testing identified possible improvements in restraining parachutists and that it is not possible to 

provide the same level of protection afforded to occupants in seats. Because the FAA’s actions met the intent 

of Safety Recommendation AS-94-16, the Safety Board classified it “Closed—Acceptable Action” on January 

4, 2000. The full text of the safety recommendation letter (which references several accidents), is available on 

the Board’s website at <http://www.ntsb.gov/Recs/letters/1994/A94_16_19.pdf>.

33 On February 17, 1994, the Safety Board also issued Safety Recommendation A‐94‐22, which asked 

the USPA to do the following: “Participate in the design, development, and testing of a universal restraint system 

that would provide adequate protection for parachutists seated on an aircraft floor.” The USPA participated, 

as requested, in CAMI’s restraint testing. Therefore, the Board classified Safety Recommendation A‐94‐22 

“Closed—Acceptable Action” on June 5, 2001.

34 See U.S. Department of Transportation, Federal Aviation Administration, Civil Aerospace Medical 

Institute, Evaluation of Improved Restraint Systems for Sport Parachutists, DOT/FAA/AM‐98/11 (Washington, 

DC: DOT/FAA, 1998).
Safety Issues

National Transportation Safety Board 17

Aircraft Accident

Summary Report

test for one single-point restraint design,35 which attached around the near side of the 

parachutist’s back strap, noted the following:

During the impact, the [dummy] slid forward significantly, then violently 

rotated counterclockwise about the center of the pelvis. The upper torso 

rotated forward to 40 degrees from vertical and the legs flailed about the 

vertical axis to a position 90 degrees from initial.

Like the test sled configuration, the accident airplane’s configuration provided no 

support for the upper body, enabling each restrained parachutist’s upper body to rotate 

toward the front of the airplane during the impact sequence. As in the test findings, some of 

the parachutists in the accident airplane who used the single-point restraints experienced 

harmful movement, such as large translational and rotational motion. Lack of support for 

the upper body and head, slack in the restraints, and any restraint and/or harness stretch 

during the accident sequence enabled forward motion of each restrained parachutist into 

the region of intrusion and/or into other parachutists. These types of issues contributed to 

the severity of the injuries sustained by the five parachutists who were likely restrained.

Load calculations indicate that this accident was survivable for some parachutists; 

yet only two parachutists survived the crash. As stated previously, had the parachutists 

been securely restrained in their seating positions, all of the parachutists would have been 

away from the areas of major crush and intrusion. Based on the results of CAMI’s past 

testing and the serious and fatal injuries sustained by some of the restrained parachutists 

in this crash, the Safety Board concludes that a single‐point restraint system is not sufficient 

to provide adequate restraint for parachutists. The Board further concludes that more 

parachutists may have survived, and injuries may have been reduced, if more effective 

restraints had been used.

The results of the CAMI tests revealed that dual-point restraint systems were 

superior to single-point restraints.36 However, the CAMI tests for the dual-point restraints 

were conducted with the restraints mounted to the floor and attached symmetrically to 

the parachute harness system. The accident airplane, which had sidewall attachment 

tracks, was not configured for a symmetrical, dual‐point system; other common seating 

arrangements on parachute operations aircraft likely also have attachment configurations 

that differ from the symmetrical dual-point design tested by CAMI. Although the absence 

of test data specific to the accident airplane’s configuration precludes a determination of 

the optimal dual-point restraint design for that airplane, the Safety Board concludes that 

testing could identify the best method for dual-point restraint for the accident airplane’s 

configuration and for the configurations of other airplanes commonly used in parachute 

operations. Therefore, the Safety Board believes that the FAA should conduct research, in 

conjunction with the USPA, to determine the most effective dual‐point restraint systems 

for parachutists that reflects the various aircraft and seating configurations used in 

parachute operations. The Safety Board also believes that the USPA should work with the 

35 The tested design anchored the parachutist tautly to the floor, whereas the accident airplane’s 

restraints anchored the parachutists loosely to the sidewall.

36 The results also concluded that survival may be improved by providing head support, by anchoring 

the restraint at a specific point, and by bracing in a specific manner for impact.
Safety Issues

National Transportation Safety Board 18

Aircraft Accident

Summary Report

FAA to conduct research to determine the most effective dual-point restraint systems for 

parachutists that reflects the various aircraft and seating configurations used in parachute 

operations. In addition, the Board notes that FAA Advisory Circular (AC) 105‐2C, Sport 

Parachute Jumping, is an established source of guidance containing suggestions for 

improving the safety of parachute jump operations, including information for operators 

about modifying aircraft for parachute operations. However, AC 105-2C contains little 

information about restraint systems beyond the statement that “seatbelts must be provided 

to each person, and their installation must be approved.” Therefore, the Safety Board 

believes that, once the most effective dual-point restraint systems for parachutists are 

determined, the FAA should revise AC 105-2C to include guidance information about 

these systems. Further, the Safety Board believes that, once the most effective dual-point 

restraint systems for parachutists are determined, the USPA should educate its members on 

the findings and encourage them to use the most effective dual‐point restraint systems. 
National Transportation Safety Board 19

Aircraft Accident

Summary Report

4. Conclusions

4.1 Findings

1. Although damage to the accident airplane’s right engine precludeded termination of 

the initial event that precipitated the overload fracturing of the compressor turbine 

blades, and although the operator was not required to comply with the engine 

manufacturer’s service bulletins, it is possible that the initiating fracture event within 

the engine resulted from a condition that could have been detected and corrected 

during an engine overhaul performed within the manufacturer’s recommended time 

between overhauls.

2. Although engine wear would have likely prevented the accident airplane from 

obtaining its maximum published single-engine climb performance, the pilot’s failure 

to maintain airspeed, according to the technique specified in the published emergency 

procedures following the loss of power in one engine, negated any possibility of 

continued, controlled flight that could have allowed for a return to the airport or other 

suitable landing area.

3. Although the airplane’s autofeather system, had it been operative, would have helped 

the pilot promptly feather the propeller of the inoperative engine, there is insufficient 

evidence to suggest that the inoperative autofeather system was a factor in the 

accident. 

4. The pilot’s decision to use only 1,700 feet of the available runway diminished the 

margin of safety during takeoff because it eliminated the option of discontinuing the 

takeoff and performing a straight-ahead, emergency landing on the runway. 

5. Greater Federal Aviation Administration surveillance of the operator would have 

discouraged improper aircraft maintenance procedures, such as dispatching the 

airplane with an inoperative autofeather system and an undocumented cabin seating 

configuration.

6. Based on the results of the Civil Aerospace Medical Institute’s past testing and the 

serious and fatal injuries sustained by some of the restrained parachutists in this 

crash, a single‐point restraint system is not sufficient to provide adequate restraint for 

parachutists. 

7. More parachutists may have survived, and injuries may have been reduced, if more 

effective restraints had been used.

8. Testing could identify the best method for dual-point restraint for the accident 

airplane’s configuration and for the configurations of other airplanes commonly used 

in parachute operations.
Conclusions

National Transportation Safety Board 20

Aircraft Accident

Summary Report

4.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of 

this accident was the pilot’s failure to maintain airspeed following a loss of power in the 

right engine due to the fracturing of compressor turbine blades for undetermined reasons. 

Contributing to some parachutists’ injuries was the lack of a more effective restraint 

system on the airplane.
National Transportation Safety Board 21

Aircraft Accident

Summary Report

5. Recommendations

The National Transportation Safety Board recommends that the Federal Aviation 

Administration:

Conduct research, in conjunction with the United States Parachute 

Association, to determine the most effective dual-point restraint 

systems for parachutists that reflects the various aircraft and seating 

configurations used in parachute operations. (A‐08‐71)

Once the most effective dual-point restraint systems for parachutists 

are determined, as requested in Safety Recommendation A-08-71, 

revise Advisory Circular 105-2C, Sport Parachute Jumping, to include 

guidance information about these systems. (A‐08‐72)

The National Transportation Safety Board recommends that the United States 

Parachute Association:

Work with the Federal Aviation Administration to conduct research 

to determine the most effective dual-point restraint systems for 

parachutists that reflects the various aircraft and seating configurations 

used in parachute operations. (A‐08‐73)

Once the most effective dual-point restraint systems for parachutists 

are determined, as requested in Safety Recommendation A-08-71, 

educate your members on the findings and encourage them to use the 

most effective dual‐point restraint systems. (A‐08‐74)
National Transportation Safety Board 22

Aircraft Accident

Summary Report

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

MARK V. ROSENKER ROBERT L. SUMWALT

Acting Chairman Member

DEBORAH A. P. HERSMAN STEVEN R. CHEALANDER

Member Member

KATHRYN O’LEARY HIGGINS

Member

Adopted: September 16, 2008

Recommendations