aviation

Special Investigation Report on the Safety of 

Parachute Jump Operations

SPECIAL INVESTIGATION REPORT

NTSB/SIR-08/01

PB2009-917001

National

Transportation

Safety Board

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

Special Investigation Report

Special Investigation Report on the Safety of 

Parachute Jump Operations

NTSB/SIR-08/01

PB2009-917001

Notation 8042A

Adopted September 16, 2008
The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, 

highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through 

the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, 

issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies 

involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, 

special investigation reports, safety recommendations, and statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available 

publications also may be obtained from the website or by contacting:

National Transportation Safety Board

Records Management Division, CIO-40

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information 

Service. To purchase this publication, order report number PB2009-917001 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of 

Board reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

National Transportation Safety Board. 2008. Special Investigation Report on the Safety of Parachute 

Jump Operations. Special Investigation Report NTSB/SIR-08/01. Washington, DC.

Abstract: This special investigation report describes the results of a National Transportation Safety 

Board review of 32 accidents that involved parachute jump (“or skydiving”) operations and that occurred 

between 1980 and 2008. The report identifies 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 

Federal Aviation Administration (FAA) oversight and direct surveillance of parachute operations. 

Parachute jump operators, many of which transport parachutists for revenue, maintain their aircraft 

under regulatory provisions that require little FAA oversight. Lack of operation-specific pilot training is 

also discussed. Safety recommendations to the FAA and to the United States Parachute Association are 

included. Appendix A details other current and past Safety Board recommendations related to parachute 

operations.
National Transportation Safety Board iii

SPECIAL

Investigation Report

Contents

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

Tables ............................................................................................................................... vi

Abbreviations ................................................................................................................vii

Introduction ..................................................................................................................viii

1. Background...................................................................................................................1

1.1 Parachute Jump Operators ............................................................................................................ 1

1.2 Parachute Jump Operations Accidents........................................................................................ 1

2. Maintenance Issues.....................................................................................................7

3. Pilot Training and Proficiency Issues....................................................................11

3.1 Inadequate Preflight Inspections................................................................................................ 11

3.2 Noncompliance with Airplane Weight and Balance Limitations.......................................... 13

3.3 Failure to Maintain Airspeed During Powered Flight............................................................ 14

3.4 Inadequate Performance of Emergency Procedures ............................................................... 15

4. Federal Aviation Administration Oversight and Surveillance Issues............18

4.1 Accidents Preceding Increased Surveillance Action ............................................................... 18

4.2 Accidents Since Increased Surveillance Action ....................................................................... 19

5. Conclusions ................................................................................................................23

5.1 Findings.......................................................................................................................................... 23

6. Recommendations.....................................................................................................24

7. Appendixes

A: Safety Recommendations Pertaining to Survivability Issues for Parachutists...................... 25 

B: Accident Synopses .......................................................................................................................... 30

National Transportation Safety Board v

SPECIAL

Investigation Report

Figures

1. Cracking (visibility enhanced during examination 

with a liquid penetrant) on the No. 4 piston skirt from 

the East Moriches, New York, accident airplane.......................................................................9

2. Engine oil coating the underside of the horizontal 

stabilizer on the Grain Valley, Missouri, accident airplane...................................................12

3. Wreckage of the Homestead, Florida, accident airplane.................................................14

4. Remains of the house impacted by the 

West Point, Virginia, accident airplane ....................................................................................21
National Transportation Safety Board vi

SPECIAL

Investigation Report

Tables

1. Fatal parachute jump operations accidents since 1980 ......................................................3

2. Accident airplanes with engine hours that exceeded 

recommended time between overhaul (TBO)............................................................................8
National Transportation Safety Board vii

SPECIAL

Investigation Report

Abbreviations

AC advisory circular

AD airworthiness directive

agl above ground level

ATC air traffic control

CAMI Civil Aerospace Medical Institute

CFR Code of Federal Regulations 

cg center of gravity

F Fahrenheit

FAA Federal Aviation Administration

FMS flight manual supplement

FSDO flight standards district office

lb pound

MEL minimum equipment list

msl mean sea level

PMA parts manufacturer approval

PTRS Program Tracking and Reporting Subsystem

SB service bulletin

SIL service information letter

SPAS Safety Performance Analysis System

TBO time between overhaul

TCM Teledyne Continental Motors

USPA United States Parachute Association
National Transportation Safety Board viii

SPECIAL

Investigation Report

Introduction

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),1

 transports 

parachutists on 2.16 to 3 million jumps annually.2

 Most parachute operations flights3

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,4

 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.5 Since 1980, 32 accidents involving parachute operations aircraft 

have killed 172 people;6

 most of whom were parachutists. 

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

270 operator members, referred to as “group members” or “drop zone” members. The USPA’s mission is to 

support and promote safe skydiving through parachuting training, rating, and competition programs, and it 

distributes safety information through printed publications and its website. 

2 According to a USPA membership survey, its members reported about 2.16 million jumps in 2007. In 

correspondence with a National Transportation Safety Board investigator dated February 5, 2008, the USPA 

director of safety and training noted that, because that number does not include jumps by students, and 

because skydiving activity has increased in the past few years, the current total number of parachutists’ jumps 

per year is likely closer to 2.5 to 3 million. 

3 According to 14 Code of Federal Regulations 105.3, parachute operations include both parachute 

jumps (the descent of parachutists from aircraft) and parachute drops (the descent of objects). The parachute 

operations discussed in this report involve parachute jumps.

4 Types of paying passengers include licensed skydivers who pay only for a “lift ticket” on the aircraft 

and members of the public who, with little training, can be paired with an instructor parachutist‐in‐command to 

experience a tandem jump as a passenger‐parachutist.

5 According to USPA safety records, from 1992 through 2007, about 30 parachutists per year were 

killed in jumping mishaps. Safety Board accident data show that, for the same time frame, about five parachutist 

fatalities per year resulted from accidents involving parachute operations aircraft. Direct comparisons of 

associated risk are difficult to calculate due to the likelihood of multiple parachutists being carried on each 

flight and a lack of departure data for parachute jump operations. The Safety Board notes that the FAA does 

not have data on the number of parachute jump operators or the number and type of aircraft used in parachute 

jump operations in the U.S. The absence of these data precludes any calculations of safety statistics for 

parachute jump operations, including accidents rates.

6 Fatal accidents excluded from this review were ground accidents in which persons walked into 

propellers, accidents related to the accidental deployment of parachutes and/or entanglement with aircraft, 

and one unauthorized parachute operation flight. 
Introduction

National Transportation Safety Board ix

SPECIAL

Investigation Report

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.7

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; the resulting recommendations are 

detailed in appendix A of this report. 

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. 

7 Summary information about this accident is in appendix A of this report. For more information, see 

National Transportation Safety Board, 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 (Washington, DC: 

NTSB, 2008). 
Introduction

National Transportation Safety Board x

SPECIAL

Investigation Report

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. 
National Transportation Safety Board

SPECIAL

Investigation Report

1

1. Background

1.1 Parachute Jump Operators

According to 14 CFR 119.1(e)(6), parachute operations conducted as nonstop flights 

within a 25-mile radius of the departure airport are exempt from the rules pertaining 

to commercial operators and are allowed to operate under 14 CFR Part 91. Additional 

parachute operations regulations pertaining specifically to aircraft radio and equipment, 

parachute equipment, flight visibility and cloud clearance, and operations over certain 

areas and within certain airspace are contained in 14 CFR Part 105. 

The Safety Board reviewed 32 fatal parachute operations accidents that occurred 

since 1980. All involved 14 CFR Part 91 flights that met the definition of parachute jump 

operations, but the Board notes that the regulation does not specifically define what 

constitutes a parachute jump operator. Title 14 CFR 1.1 defines “operational control” as 

“the exercise of authority over initiating, conducting, or terminating a flight.” Based on 

this definition, the Board considers a parachute jump operator to be any entity that has 

operational control over a parachute jump flight. 

In its review of the 32 accidents, the Safety Board observed that the characteristics 

of the accident operators varied widely. Some operators provided services to thousands 

of paying passengers annually by using relatively large, turbine-powered, multiengine 

airplanes capable of carrying more than 20 parachutists per flight, whereas other operators 

used single-engine, piston-powered airplanes capable of carrying 3 or 4 parachutists 

per flight. Although most of the accident flights were flown by commercial and airline 

transport pilots, six of the accident flights were flown by private pilots. Private pilots are 

not authorized to fly aircraft for compensation or hire; however, some arrangements such 

as private parachuting clubs in which parachutists pay dues for membership or for part 

ownership of an aircraft used for parachute jump operations could be permitted to use 

private pilots, depending on the FAA’s interpretation of the arrangement.1

1.2 Parachute Jump Operations Accidents

In spite of the differences among operators, several of the 32 fatal accidents 

reviewed shared common deficiencies in maintenance, pilot training and proficiency, and 

FAA oversight and surveillance. For example, 85 people were killed in 11 accidents in 

which the airplanes crashed following a loss of engine power shortly after takeoff. Most 

of these accident airplanes had maintenance or fuel quality deficiencies, and nearly all 

of the accident pilots failed to maintain adequate airspeed, or they made other critical 

procedural mistakes while responding to the engine emergencies. Ten accidents, which 

1 The nature of the operation for each of the six flights flown by private pilots was not detailed in the 

accident reports.
Background

National Transportation Safety Board 2

SPECIAL

Investigation Report

killed 65 people, involved the aerodynamic stalling and/or loss of control of the airplanes 

during powered flight, and one accident, which killed 6 people, involved a pilot who 

aerodynamically stalled the airplane after a loss of engine power at 3,700 feet above mean 

sea level (msl). Further, 12 of the 32 accident airplanes were loaded beyond their maximum 

gross weight. 

Information from some of the accidents is specifically referenced, where applicable, 

in this report’s discussion of each safety issue. Brief synopses of all the accidents, including 

flight histories, probable cause statements, and other pertinent information, are provided 

in appendix B, and summary information for each accident is provided in table 1.

Table 1. Fatal parachute jump operations accidents since 1980

NTSB 

identification, 

location, 

accident date

Airplane

Power 

loss?

Maintenance 

or 

mechanical 

issues?

Weight/

balance

exceeded?

Inadequate

airspeed/

stall?

Comments Fatalities

ATL80FA051

Salisbury, 

North Carolina

June 8, 1980

Cessna 172 yes inadequate 

maintenance, 

overdue 

inspections

no yes, causal private pilot failed 

to abort takeoff 

following partial loss 

of engine power, 

stalled airplane 

2

DCA81AA015

Loveland, Colorado

April 17, 1981

Cessna

TU206A

no none detected no no midair collision with 

commuter flight, 

no transponder, 

parachute 

operations allowed 

near airway

2 (plus 13 

on other 

airplane)

FTW81FA079

Beaumont, Texas

April 25, 1981

Cessna

TU206B

no none detected yes, factor no private pilot 

exceeded design 

stress limits of 

airplane, door 

separated, 

horizontal stabilizer 

obstructed

1

LAX82FA024

Honolulu, Hawaii

Dec. 5, 1981

Beech

C‐45H

no none detected yes, factor yes, causal private pilot 

unqualified for flight, 

exceeded center of 

gravity (cg) aft limit

11

LAX83FA012

Taft, California

Oct. 17, 1982

Beech 

C‐45H

no none detected yes, causal yes, but 

prevention or

recovery likely 

not possible

maximum gross 

weight exceeded 

by several hundred 

pounds, cg beyond 

aft limit 

14

CHI83FA365

Marseilles, Illinois

Aug. 6, 1983

Cessna 182 no none detected no no airplane crashed in 

airport pattern in a 

steep, descending 

left turn; reason 

for occurrence 

undetermined

1

DCA83AA036

Silvana, Washington

Aug. 21, 1983

Lockheed 

L‐18‐56

no airplane 

unairworthy due 

to unapproved 

modifications

yes, causal yes, causal cg beyond aft limit, 

pilot stalled airplane 

during parachutists’ 

egress, improper 

operator supervision

11

ATL85FA072

Dublin, Virginia

Dec. 30, 1984

Cessna 182A no none detected no no private pilot 

deliberately buzzed 

a parked van, struck 

van with airplane’s 

landing gear

1
Background

National Transportation Safety Board 3

SPECIAL

Investigation Report

NTSB 

identification, 

location, 

accident date

Airplane

Power 

loss?

Maintenance 

or 

mechanical 

issues?

Weight/

balance

exceeded?

Inadequate

airspeed/

stall?

Comments Fatalities

ATL85MA286

Jenkinsburg, 

Georgia

Sept. 29, 1985

Cessna 

208

yes known 

deficiencies 

in equipment, 

warning system 

disabled

yes yes, causal pilot stalled 

airplane following 

loss of engine 

power, operator’s 

fuel source 

contaminated 

(recurrent problem), 

inadequate FAA 

surveillance of 

operator, seatbelts 

not used

17

LAX88FA241

Perris, California

June 30, 1988

Helio 

HST 550A

no failure of electrical 

stabilizer trim 

control

no no uncommanded full 

nose‐down trim 

during return to 

airport

1

SEA91FA038

Estacada, Oregon

Dec. 31, 1990

Cessna 182B yes muffler cones 

missing, 

carburetor heat 

inoperative, 

inspections 

inadequate

no yes, causal carburetor ice, 

private pilot stalled 

airplane following 

loss of engine 

power during takeoff

2

CHI91FA088B

Osceola, Wisconsin

Feb. 3, 1991

Cessna 182 no none detected no no midair collision, 

failure of private 

pilot and pilot of 

other airplane to 

see and avoid each 

other

5 (plus 2

on other 

airplane) 

LAX92MA183

Perris, California

April 22, 1992

de Havilland 

DHC‐6‐200

yes none detected yes, factor no loss of engine power 

during takeoff due to 

fuel contamination, 

pilot did not sump 

fuel tanks, pilot 

feathered wrong 

propeller, operator 

did not provide 

adequate pilot 

training

16

DCA92MA048

Hinckley, Illinois

Sept. 7, 1992

Beech C‐45H yes inadequate 

maintenance 

and inspection 

by operator, 

engine sat 

18 years without 

preservation 

before being 

installed by 

noncertificated 

personnel

no yes, but 

propeller 

possibly not 

controllable 

loss of engine 

power during 

takeoff, propeller 

not feathered but 

possibly could not 

be feathered to 

maintain airspeed, 

seatbelts not used 

12

NYC93FA154

East Moriches, 

New York

Aug, 14, 1993

Cessna 182A yes Manufacturing 

defect of pistons, 

engine beyond 

time between 

overhaul (TBO), 

which is allowed 

under Part 91

yes, factor yes, causal following loss of 

engine power during 

takeoff, pilot stalled 

airplane attempting 

to return to runway 

rather than land 

adjacent to runway

1

NYC94FA128

Tremont City, Ohio

July 16, 1994

Cessna

R172K

no none detected yes yes, causal 

(report cites 

control loss, 

describes 

stall‐like 

descent)

pilot failed to 

maintain control 

of airplane during 

takeoff, factor 

was pilot’s lack 

of experience 

in operation 

(first parachute 

operations flight)

4
Background

National Transportation Safety Board 4

SPECIAL

Investigation Report

NTSB 

identification, 

location, 

accident date

Airplane

Power 

loss?

Maintenance 

or 

mechanical 

issues?

Weight/

balance

exceeded?

Inadequate

airspeed/

stall?

Comments Fatalities

NYC95MA220

West Point, Virginia

Sept. 10, 1995

Beech 65 yes, reason 

unknown

airplane not 

airworthy due 

to unapproved 

modifications, 

fueling from jugs 

questionable

yes, causal yes, causal stalled during 

takeoff following 

loss of engine 

power 

11 (plus 1 

person in a 

home)

MIA97FA173

Homestead, Florida

May 25, 1997

Cessna 205 no none detected, 

however, operator 

could not locate 

maintenance 

records

no yes, causal stalled during 

parachutists’ egress, 

pilot did not recover 

airplane from spin

6

SEA97FA201

Bremerton, 

Washington

Sept. 1, 1997

Cessna 182C no none detected yes, factor yes, causal stalled during 

takeoff

5

IAD97FA117

Smithfield, Rhode 

Island

Sept. 6, 1997

Cessna 182E yes, reason 

unknown

none detected yes yes, causal 

(report cites 

control loss, 

describes 

stall‐like 

descent)

airplane lost engine 

power during 

takeoff, then pitched 

nose‐high, rolled 

left, and descended 

to the ground

5

CHI98FA106

Grain Valley, 

Missouri

March 21, 1998

Cessna 

U206G

yes, related 

to oil loss 

none detected no yes, factor pilot performed 

inadequate preflight 

check (airplane’s oil 

filler tube and other 

parts loose), pilot 

failed to maintain 

airspeed following 

loss of engine 

power at 3,700 feet

6

IAD99FA043

Celina, Ohio

May 9, 1999

Cessna 205 yes, related 

to fuel 

quantity

none detected possibly yes, causal

(report cites 

control loss, 

describes 

stall‐like 

descent)

pilot failed to fuel 

airplane, failed to 

maintain control 

of airplane after 

power loss; operator 

lacked published 

operational or safety 

procedures, failed to 

verify pilot’s medical 

qualifications

6

LAX99LA190

Mokuleia, Hawaii

May 22, 1999

Beech B90 no none detected no no pilot failed to 

use oxygen as 

required, became 

incapacitated due to 

hypoxia

1

CHI99MA269

Marine City, 

Michigan

July 31, 1999

Beech

65‐A90

no airplane 

unairworthy 

(incomplete 

records and no 

compliance with 

five airworthiness 

directives [ADs])

no yes, causal pilot stalled airplane, 

had history of 

alcohol‐related 

driving offenses 

(alcohol not 

determined to be 

related to accident 

but operator 

unaware of total 

arrests/convictions) 

10

FTW99FA261

Bryan, Texas

September 18, 1999

Cessna 182A yes fatigue cracking 

and separation 

of No. 6 cylinder 

head

no yes, causal pilot stalled airplane 

following power loss 

during takeoff

5
Background

National Transportation Safety Board 5

SPECIAL

Investigation Report

NTSB 

identification, 

location, 

accident date

Airplane

Power 

loss?

Maintenance 

or 

mechanical 

issues?

Weight/

balance

exceeded?

Inadequate

airspeed/

stall?

Comments Fatalities

FTW01LA132

Fentress, Texas

May 27, 2001

de Havilland 

DHC‐6

no none detected no no pilots of two 

airplanes performed 

formation parachute 

operations flight, 

one airplane struck 

airborne parachutist, 

pilots not 

experienced in that 

type of operation

1

FTW03FA174

Cushing, Oklahoma

June 21, 2003

Cessna 182H no engine beyond 

TBO, which is 

allowed under 

Part 91 

no yes, causal pilot failed to 

maintain airspeed 

during powered 

flight, radioed that 

he did not know how 

to recover airplane 

from spin

1

MIA05FA017

Jacksonville, Florida

Oct. 30, 2004

Cessna P206 no engine beyond 

TBO, which is 

allowed under 

Part 91 

no yes, causal pilot stalled airplane 

during powered 

flight, failed to follow 

checklist for elevator 

trim

1

MIA05LA096

Deland, Florida

April 23, 2005

de Havilland 

DHC‐6

no none detected no no pilot had inadequate 

visual lookout, 

struck airborne 

parachutist with 

airplane

1

CHI06FA210

Sullivan, Missouri

July 29, 2006

de Havilland 

DHC‐6‐100

yes compressor 

turbine blade 

fractures in 

right engine for 

undetermined 

reasons, engines 

beyond TBO, 

which is allowed 

under Part 

91, airplane 

unairworthy due 

to inoperative 

equipment, other 

discrepancies

no yes, causal pilot failed to 

perform emergency 

procedures following 

loss of power 

6

SEA07FA119

Marion, Montana

May 12, 2007

Cessna 182C no, but 

possibly 

imminent 

due to oil 

loss

none detected yes, factor yes, causal

(report cites 

control loss, 

describes 

stall‐like 

descent)

pilot performed 

inadequate preflight 

check (oil filler cap 

not secure), pilot 

failed to maintain 

control of airplane 

5

DEN08FA078

Mount Vernon, 

Missouri

April 19, 2008

Cessna P206 not yet 

determ‐

ined, but 

none 

reported

not yet 

determined

not yet 

determined

not yet 

determined, 

but preliminary 

report 

describes 

stall‐like 

descent

preliminary 

information: 

survivors reported 

that pilot stalled or 

spun airplane during 

powered flight 

2
National Transportation Safety Board

SPECIAL

Investigation Report

6

2. Maintenance Issues

Maintenance is critical for parachute operations aircraft because jump operations 

typically involve a high ratio of cycles to flight hours and periods of climb power followed 

by sudden reductions in power (to descend), which can be particularly conducive to engine 

wear. Aircraft used in parachute operations are subject to the inspections required under 

14 CFR 91.409; these include annual aircraft inspections, 100-hour inspections for aircraft 

that carry persons for hire, and additional requirements for turbopropeller-powered 

multiengine airplanes and certain other aircraft. 

However, 14 CFR Part 91 requirements are not as extensive as the requirements 

for most other revenue, passenger-carrying operators, such as air carriers or on-demand 

Part 135 air-taxi and air-tour operators; these operators, unlike Part 91 operators, are 

required to incorporate their maintenance programs into an FAA‐approved maintenance 

manual that specifies policies and procedures for ensuring that each aircraft is airworthy 

before it is released to service. Part 91 (excluding some provisions of Part 91, Subpart K, 

which apply to certain fractionally owned aircraft) does not contain the same mechanism 

for ensuring aircraft airworthiness before dispatch, but 14 CFR 91.403 does state that the 

owner or operator is responsible for maintaining aircraft in an airworthy condition, and 

14 CFR 91.407(a) states that, following maintenance, an aircraft cannot be operated unless 

it has been approved for return to service by authorized maintenance personnel. Review 

of the 32 accidents showed that 8 of the accident airplanes were not airworthy at the 

time they were dispatched. Allowing such maintenance discrepancies not only indicates 

poor aircraft maintenance and inspection quality assurance practices, but also represents 

noncompliance with regulations.2

In addition to not being required to have FAA‐approved maintenance programs, 

parachute jump operators, because they operate under Part 91, are not subject to 

the Federal regulations that require compliance with manufacturers’ recommended 

maintenance instructions, such as service bulletins (SBs) and service information letters 

(SILs). Manufacturers often publish SBs or SILs that contain recommended time between 

overhauls (TBOs) and/or component service life limits3

 for their engines. Some of these 

publications indicate that parachute operations may induce more engine wear than most 

operations. For example, Teledyne Continental Motors (TCM) Aircraft Engine SIL98‐9A, 

“[TBO] Periods,” applicable to the reciprocating engines on airplanes involved in some 

of the accidents reviewed, states that “aircraft used in parachute jumping ... may require 

more frequent engine overhauls than listed for the specific engine.” Also, Pratt & Whitney 

SB 1803R1, “Turboprop Engine Operating [TBOs] and Hot Section Inspection Frequency,” 

2 Because of the regulatory noncompliance issues, these accidents are discussed in the “FAA Oversight 

and Surveillance Issues” section of this report.

3 TBOs are typically based on hours, and life limits are typically based on cycles. According to an engine 

cycle formula published in Pratt & Whitney Canada SB 1002R24, “Turboprop Engine Rotor Components ‐ 

Service Life,” a full cycle consists of an engine start, one flight, and an engine shutdown. The Safety Board 

notes that many parachute operations pilots do not shut down the aircraft engines completely between flights. 

However, the SB also defines an abbreviated cycle as consisting of idle, takeoff, flight, landing, and idle, and 

it provides a formula for use in accounting for abbreviated cycles in an engine’s accumulated total cycles. 
Maintenance Issues

National Transportation Safety Board 7

SPECIAL

Investigation Report

applicable to the turboprop engines on an airplane involved in an accident in Sullivan, 

Missouri,4 specifically excludes engines that have been used in parachute jump operations 

from eligibility for the manufacturer’s program for extending TBOs. 

In the 32 parachute operations accidents reviewed, at least 4 of the accident airplanes 

were powered by engines that were operated beyond their manufacturers’ recommended 

TBOs. (See table 2.) Because these airplanes were operated under Part 91, the operators 

were not required to comply with the recommended TBOs. 

Table 2. Accident airplanes with engine hours that exceeded recommended time between 

overhaul (TBO)

NTSB 

Identification, location, 

accident date

Airplane engine Engine hours

since 

overhaul

Recommended TBO

CHI06FA210

Sullivan, Missouri

July 29, 2006

de Havilland DHC‐6‐100/

Pratt & Whitney Canada PT6A‐20

Left: 5,829

Right: 6,493

3,600 hours

MIA05FA017

Jacksonville, Florida

Oct. 30, 2004

Cessna P206/

Teledyne Continental 

Motors IO‐550‐F

1,774 1,700 hours or 

12 years

FTW03FA174

Cushing, Oklahoma

June 21, 2003

Cessna 182H/

Continental O‐470‐R

2,652 1,500 hours or 

12 years

NYC93FA154

East Moriches, New York

Aug. 14, 1993

Cessna 182A/

Continental O‐470‐L

N/A; more 

than 12 years 

since overhaul

1,500 hours or 

12 years

Two of these airplanes crashed following a loss of engine power. On August 14, 

1993, a Cessna 182A lost engine power during takeoff and crashed in East Moriches, New 

York. The investigation found that inadequate piston manufacturing (all were of the same 

design and part number and were not manufactured by the original engine manufacturer5) 

resulted in fatigue cracking in the skirts of all six pistons. (See figure 1 on page 8.) 

Although TCM SIL98‐9A notes that “TCM cannot provide a TBO for engines 

that have been assembled with non‐TCM‐approved parts,” it is possible that, had an 

overhaul been performed within the TCM‐recommended TBO or sooner, the inadequately 

manufactured pistons and/or cracking could have been detected and corrected before 

engine failure occurred. Similarly, although the Sullivan, Missouri, accident airplane’s 

right engine (which lost power) sustained damage that precluded determination of the 

4 For more information, see National Transportation Safety Board, 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 (Washington, DC: NTSB, 2008)

5 The engine was equipped with Superior Air Parts pistons. The factual report for the accident noted 

that Superior Air Parts had ceased selling the accident piston part number, SA626992, in 1981 because it had 

been superseded by a new TCM design. The report also noted two service difficulty reports that documented 

other instances of cracking discovered on SA626992 pistons.
Maintenance Issues

National Transportation Safety Board 8

SPECIAL

Investigation Report

initial event that precipitated the overload fracturing observed on the compressor turbine 

blades,6 it is possible that the initiating factor resulted from a condition that could have been 

detected and corrected during an engine overhaul performed within the manufacturer’s 

recommended TBO. 

The purpose of TBO and life-limit SBs and SILs is to establish periodic inspections 

of the engines to ensure their serviceability. The analysis involved in developing such 

SBs and SILs considers the cumulative effects of various stresses placed on the engine 

components over time and establishes a threshold that the manufacturer has determined 

will provide an acceptable level of safety. Federal regulations require that commercial 

operators, such as air carrier, air taxi, and Part 135 air tour operators, maintain and inspect 

their aircraft engines in accordance with these instructions, which provides an increased 

level of safety by increasing the likelihood that potentially problematic conditions could 

be detected and corrected, thus preventing more serious problems from developing. 

Although some manufacturers indicate in their SBs and SILs that aircraft used 

in parachute operations may require increased engine maintenance and inspections, 

no mechanism is in place to ensure that the operators of these aircraft perform the 

recommended maintenance and inspections. The Safety Board concludes that, because 

parachute jump operations are particularly conducive to engine wear, the lack of 

6 The compressor turbine blades were FAA PMA (parts manufacturer approval) blades manufactured 

by Doncasters, Inc., Turbo Products Division, part number T-023401J.

Figure 1. Cracking (visibility enhanced during examination with a liquid penetrant) on the No. 4 

piston skirt from the East Moriches, New York, accident airplane.
Maintenance Issues

National Transportation Safety Board 9

SPECIAL

Investigation Report

requirements for parachute jump operators to comply with manufacturer‐recommended 

maintenance instructions for their aircraft, including SBs and SILs for TBO and component 

life limits, increases the potential for the persistence of conditions that could lead to engine 

failure. Therefore, the Safety Board believes that the FAA should require parachute jump 

operators to develop and implement FAA-approved aircraft maintenance and inspection 

programs that include, at a minimum, requirements for compliance with engine 

manufacturers’ recommended maintenance instructions, such as SBs and SILs for TBO 

and component life limits. 

The Safety Board recognizes that parachute jump operations include a wide 

variety of aircraft and operators, including some that operate for revenue and others that 

may involve some other type of business and/or nonbusiness arrangements. Although 

the Board intends that additional maintenance and inspection program requirements 

should be universally implemented by all operators, the Board acknowledges that the 

diversity of the parachute operations industry may require flexibility in determining the 

best mechanisms by which to implement maintenance program requirements. In addition, 

guidance materials could assist operators in developing effective aircraft inspection and 

maintenance quality assurance programs. Because the USPA is knowledgeable about 

skydiving operations and distributes safety information to its member operators through 

printed publications and its website (much of which is also accessible to nonmember 

operators and the public), the USPA can be a valuable resource with which the FAA can 

work to develop and distribute safety information for operators. Therefore, the Safety Board 

believes that the FAA should develop and distribute guidance materials, in conjunction 

with the USPA, for parachute jump operators to assist operators in implementing effective 

aircraft inspection and maintenance quality assurance programs. The Safety Board further 

believes that the USPA should work with the FAA to develop and distribute guidance 

materials for parachute jump operators to assist operators in implementing effective 

aircraft inspection and maintenance quality assurance programs.
National Transportation Safety Board

SPECIAL

Investigation Report

10

3. Pilot Training and Proficiency Issues

A disturbing common denominator in nearly all of the accidents reviewed is that 

the pilots, most of whom were commercial or airline transport pilots,7 were deficient in 

basic airmanship tasks, such as performing adequate preflight inspections of airplanes, 

complying with airplane weight and balance limitations, maintaining airspeed during 

powered flight, and executing emergency procedures. These deficiencies or combinations 

of these deficiencies were noted in nearly all the accidents with few exceptions.8

The Safety Board is concerned that these pilots, whose experience levels in parachute 

operations ranged from one flight to hundreds of flights, were unprepared to provide the 

parachutists with the basic level of safety that passengers should have been able to expect 

from professional, for‐hire, or parachuting club flight operations.

3.1 Inadequate Preflight Inspections

Preflight inspection of an aircraft represents one mechanism by which a pilot 

can mitigate potential flight risks before the aircraft leaves the ground. Such inspections, 

according to each aircraft’s preflight procedures and checklists, typically include checking 

the airframe for discrepancies, checking flight control trim settings, and ensuring adequate 

fuel (quantity and quality) and engine oil. Twelve of the accidents reviewed involved a 

loss of aircraft engine power. Although a loss of engine power represents a challenging 

emergency requiring immediate and appropriate pilot responses, at least four of these 

engine-related emergencies could have been prevented if the pilots had adhered to basic 

preflight practices. 

For example, the Cessna U206G that crashed on March 21, 1998, near Grain Valley, 

Missouri, lost engine power after losing engine oil because the pilot did not adequately 

check the security of the oil‐filler tube and other components before the flight. (See 

figure 2 on page 11.) 

Similarly, the pilot of a Cessna 182C that crashed in Marion, Montana, on May 12, 

2007, failed to ensure that its oil‐filler cap was secure before the flight, allowing engine 

oil to escape. Although that engine did not lose power, the escaping oil likely coated the 

windscreen and obstructed the pilot’s view as he attempted to return the airplane to the 

airport for a precautionary landing. 

7 Six of the accident pilots were private pilots. Five of the accident airplanes flown by private pilots were 

piston‐powered, single‐engine Cessnas, and one was the Beech C‐45H that crashed in Honolulu, Hawaii, on 

December 5, 1981.

8 The report for the Beech C‐45H accident that occurred on September 7, 1992, in Hinckley, Illinois, 

did not rule out the possibility that the pilot may have been unable to attain a full‐feather position on the left 

engine propeller. An inability to feather the propeller on the inoperative engine would make it very difficult for 

the pilot to maintain a controllable airspeed. Also, the airline transport pilot of a Helio HST‐550A that crashed 

June 30, 1988, in Perris, California, due to an uncommanded nose‐down elevator trim condition likely could 

not control the airplane because of the malfunction. One accident, which involved a commercial pilot of a 

Cessna 182 that crashed in Marseilles, Illinois, on August 6, 1983, crashed for undetermined reasons.
Pilot Training and Proficiency Issues

National Transportation Safety Board 11

SPECIAL

Investigation Report

In addition, the May 9, 1999, accident in Celina, Ohio, involved a commercial pilot 

of a Cessna 205 who failed to ensure that the airplane had a sufficient amount of fuel on 

board. The airplane lost engine power during takeoff due to fuel exhaustion. Further, the 

two pilots of the de Havilland DHC-6-200 that crashed in Perris, California, on April 22, 

1992, did not sump the airplane’s fuel tanks after the airplane was fueled before the 

accident flight. That airplane lost engine power because of fuel contamination, which 

likely could have been detected if the pilots had performed routine preflight sumping of 

the airplanes’ tanks.9

Also, one accident involving a functional, powered airplane could also have been 

prevented with appropriate preflight action. The commercial pilot of the Cessna P206 that 

crashed on October 30, 2004, in Jacksonville, Florida, failed to follow the before-takeoff 

checklist procedures and did not properly set the airplane’s elevator trim for takeoff. 

A passenger who survived the accident reported that, during the takeoff, the airplane 

pitched up after becoming airborne and that the pilot responded by “frantically” moving 

the elevator trim wheel four or five times toward the nose‐down direction. The pilot’s 

remedial actions were not successful, and the airplane stalled and crashed about 400 feet 

from the edge of the runway.

9 Although the report for this accident did not publish excerpts from the airplane’s preflight procedures 

checklist, routine preflight procedures for aircraft include using a sampler cup to drain a small quantity of fuel 

from the airplane’s fuel tanks to visually check it for water, sediment, and proper fuel grade before the first flight 

of the day and after each refueling.

Figure 2. Engine oil coating the underside of the horizontal stabilizer on the Grain Valley, Missouri, 

accident airplane.
Pilot Training and Proficiency Issues

National Transportation Safety Board 12

SPECIAL

Investigation Report

3.2 Noncompliance with Airplane Weight and Balance 

Limitations

Aircraft weight and balance computations represent another mechanism by 

which a pilot can mitigate potential flight risks before the aircraft leaves the ground. 

All pilots must ensure that an aircraft is loaded within its maximum allowable gross 

weight limitation before takeoff because excessive weight loading can adversely affect 

an aircraft’s performance and controllability to the extent that, in some circumstances, 

the aircraft may be unable to obtain or sustain flight. In addition, parachute operations 

present unique challenges for pilots because the aircraft’s load changes and shifts in flight 

as parachutists egress, and aircraft drag forces change as parachutists open and close 

aircraft doors and/or position themselves outside of the aircraft. Parachute operations 

pilots must consider these weight changes and perform multiple calculations before each 

flight to ensure that the airplane will remain within its cg limits for the duration of the 

flight. Failure to ensure that the loading remains within the cg limits can adversely affect 

an airplane’s stall and spin characteristics and controllability and, thus, the pilot’s ability 

to prevent a stall or to recover the airplane from an inadvertent stall or spin. In 9 of the 12 

accidents involving airplanes that were loaded beyond their maximum allowable gross 

weights or outside their cg limits, the weight and balance issue was found to be a cause 

or factor. 

In the September 1, 1997, accident involving the Cessna 182C that crashed in 

Bremerton, Washington, witnesses observed that, during takeoff, the airplane climbed to 

about 300 to 500 feet and began a left turn back toward the runway. The airplane’s left bank 

increased, its nose dropped vertically, and it entered a spin and crashed about 900 feet 

from the end of the runway. The investigation found that the airplane’s loading exceeded 

its maximum allowable gross weight and that there was no evidence of mechanical 

malfunction or engine power loss. 

Similarly, in the October 17, 1982, accident involving the Beech C-45H that crashed 

shortly after takeoff in Taft, California, the airplane departed and climbed to about 150 feet, 

then its nose pitched up, and it rolled to the left and crashed. The investigation revealed 

that the airplane’s loading exceeded its maximum gross weight by several hundred 

pounds, making it likely impossible for the pilot to maintain airspeed and control of the 

airplane.

In the accident involving the Lockheed L-18-56 that crashed on August 21, 1983, 

in Silvana, Washington, the airplane was at 12,500 feet when parachutists began to egress. 

The first parachutists who exited the airplane reported that they were unaware of any 

problem, but, after exiting the airplane, they saw it bank steeply and spiral down. The 

investigation found that the airplane’s cg was behind its aft limit. Similarly, the Beech 

C-45H that crashed on December 5, 1981, near Honolulu, Hawaii, was loaded to about 

10 inches behind its aft cg limit. That airplane entered a spin during a turn toward the 

jump area and descended into the water. 
Pilot Training and Proficiency Issues

National Transportation Safety Board 13

SPECIAL

Investigation Report

3.3 Failure to Maintain Airspeed During Powered Flight

Although several of the powered‐flight accidents involved weight and balance or 

trim issues that could have adversely affected the pilots’ ability to control the airplanes, 

at least three accidents, and possibly a fourth that remains under investigation, involved 

pilots who failed to maintain airspeed during powered flight in functional airplanes that 

were not reported to have been improperly loaded. These accident pilots not only failed 

to maintain airspeed to prevent a stall and/or spin from developing but also did not 

perform the necessary procedures to recover the airplanes from the stall/spin condition. 

The pilot of the Cessna 205 that crashed May 25, 1997, in Homestead, Florida, had 

leveled the airplane at 3,500 feet and slowed it with the intent of allowing one parachutist 

to jump from the airplane before transporting the other parachutists on board to higher 

altitudes. As the first parachutist prepared to jump from the airplane, the airplane’s left 

wing and nose dropped, and it entered a spin to the left. The airplane descended to the 

ground, and the pilot and five parachutists were killed; the parachutist who egressed at 

3,500 feet survived. The investigation found that the commercial pilot failed to maintain 

airspeed as he slowed the airplane for the first parachutist’s jump and that he failed to 

apply spin recovery emergency procedures. (See figure 3 below.)

A similar scenario occurred in the June 21, 2003, Cushing, Oklahoma, accident, when 

the commercial pilot of the Cessna 182H failed to maintain airspeed while parachutists 

were egressing, and the airplane entered a spin. A witness on the ground radioed the pilot 

and asked what was wrong, and the pilot replied that he was in a spin and did not know 

what to do. Although most of the parachutists managed to egress the spinning airplane, 

two were seriously injured, and the pilot was killed. 

Figure 3. Wreckage of the Homestead, Florida, accident airplane.
Pilot Training and Proficiency Issues

National Transportation Safety Board 14

SPECIAL

Investigation Report

Also, on July 31, 1999, a Beech 65-A90, crashed shortly after takeoff in Marine City, 

Michigan, killing the pilot and nine parachutists. Witnesses reported that the airplane 

seemed to be operating normally during taxi and takeoff but that the airplane did not 

climb any higher than 150 to 250 feet above ground level before it banked steeply to the 

left, its nose dropped, and it crashed to the ground. The investigation determined that the 

pilot stalled the airplane, which had no preexisting failures or conditions that would have 

prevented normal operation.

In addition, although the recent April 19, 2008, accident in Mount Vernon, 

Missouri, involving a Cessna P206 remains under investigation, information provided 

by two surviving parachutists indicated that the airplane had climbed to 10,500 feet msl 

for the parachutists to egress. One parachutist opened the door and noticed that the 

airplane had overshot the drop zone by about 1 mile and informed the pilot. She stated 

that, as the airplane started to make a right turn, the stall warning horn sounded, and the 

airplane “rolled off on its right wing” and entered a spin. Two parachutists were killed, 

the commercial pilot and one parachutist were seriously injured, and three parachutists 

were not injured. 

3.4 Inadequate Performance of Emergency Procedures

In the 12 accidents that involved a loss of engine power (11 shortly after takeoff 

and one at 3,700 feet msl), nearly all of the pilots allowed the airplanes to stall and/or 

performed other critical procedural mistakes while responding to the engine emergencies.10

For example, the commercial pilot involved in the previously referenced de Havilland 

DHC-6-200 accident in Perris, California, feathered the wrong propeller after the airplane 

lost power in one engine. Further, the investigation found that the operator failed to 

provide the pilot adequate training in the airplane.

In addition, in the previously referenced Celina, Ohio, accident (in which the pilot’s 

failure to ensure that the Cessna 205 had a sufficient amount of fuel on board resulted in 

engine power loss during takeoff), the pilot also did not effectively perform emergency 

procedures, such as maintaining airspeed and gliding toward a suitable landing area, after 

the engine lost power. According to a pilot‐rated witness, a field in front of the airplane 

could have been used for an emergency landing; however, the pilot lost control of the 

airplane, and it descended in a spin. 

Similarly, the commercial pilot of the Cessna 182A involved in the East Moriches, 

New York, accident also failed to use a suitable landing area following a loss of engine 

power. The Safety Board found that the accident was caused, in part, by the pilot’s 

improper decision to attempt to stretch his approach in order to reach the runway instead 

of landing the airplane adjacent to the runway.

10 Six of these accident airplanes were also subject to weight and balance issues that, depending on 

the circumstances in each individual accident, could have adversely affected the pilots’ ability to maintain 

airspeed following the loss of engine power.
Pilot Training and Proficiency Issues

National Transportation Safety Board 15

SPECIAL

Investigation Report

Beyond possessing a current, valid airman medical certificate and a commercial 

pilot certificate (for revenue flights) or a private pilot certificate (for personal flights), no 

special qualifications are necessary for a pilot to perform parachute jump operations. 

Although most of the accident pilots met these qualifications,11 some of the pilots had 

little or no initial or recurrent training relating to parachute operations or in the airplanes 

that they were flying. For example, the Celina, Ohio, accident pilot was hired the day of 

the accident and received a briefing and a familiarization flight before he began flying 

parachutists; he had about 2 hours total experience in the Cessna 205 he was flying. 

Currently, there are no requirements for pilots to receive specialized parachute operations 

training or to demonstrate proficiency with the operations or the aircraft that they fly. 

Parachute operations pilots must comply with only the flight‐review requirements 

of 14 CFR 61.56, which specify that pilots must, within the preceding 2 years, receive a 

minimum of 1 hour of flight training and 1 hour of ground training that cover a review 

of Part 91 rules and the maneuvers and procedures necessary for the pilot to demonstrate 

that he or she can safely exercise the privileges of the pilot certificate. This review can be 

accomplished in any aircraft for which the pilot is rated to fly; therefore, it would be possible 

for a pilot who flies parachutists for revenue in a 23‐seat, twin‐engine, turbine‐powered 

DHC‐6‐200 to fulfill the flight review requirements with an authorized instructor in a 

2-seat Cessna 152.12 In contrast, other revenue operations pilots, such as those who fly 

Part 135 on-demand operations, are subject to initial and recurrent pilot testing programs, 

which include annual requirements for pilot testing on aircraft performance, operating 

limitations, and weight and balance for each type of aircraft flown, as well as competency 

checks to determine pilot competence in practical skills and techniques in the class or type 

of aircraft that they fly, as specified in 14 CFR 135.293. 

The Safety Board is concerned that the accident pilots, all of whom were entrusted 

to fly parachutists as passengers, were deficient in performing critical, basic airmanship 

tasks and procedures and that these deficiencies, most of which likely could have been 

prevented with appropriate and effective training, contributed to the loss of numerous lives. 

The Board recognizes that parachute jump operations include a wide variety of aircraft 

and operators; however, the Board notes that, using various mechanisms, the FAA has 

successfully implemented pilot training, examination, and/or flight check requirements 

for a variety of operations. Examples of such mechanisms include ground training, 

flight training, and endorsement requirements (such as those required for high‐altitude 

operations and high‐performance or conventional landing gear aircraft) and flight checks 

(such as those required for Part 135 pilot‐in‐command and instrument proficiency or for 

authorization to deviate from certain special regulations pertaining to air tours). 

The Safety Board concludes that the current flight review requirements for pilots 

contained in 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 

11 The Celina, Ohio, accident pilot did not have a current airman medical certificate. The Honolulu, 

Hawaii, accident pilot, who was a private pilot, was recorded in the accident report as “unqualified” to perform 

the flight.

12 Further, if the pilot owned only a single‐seat aircraft, the pilot could complete the flight review in that 

aircraft; the authorized instructor would observe the flight from the ground.
Pilot Training and Proficiency Issues

National Transportation Safety Board 16

SPECIAL

Investigation Report

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. The Safety Board 

further concludes that 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. Therefore, the 

Safety Board believes that the FAA should 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.

The Safety Board also believes that the FAA should 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 competence in 

practical skills and techniques in each type of aircraft. 

FAA Advisory Circular (AC) 105‐2C, “Sport Parachute Jumping,” contains 

suggestions for improving the safety of parachute jump operations and is intended to 

assist operators, pilots, and parachutists with complying with the regulations that pertain 

to parachute jump operations. Although the AC is an established source of safety guidance, 

the Safety Board notes that AC 105-2C, which has not been updated since January 2, 1991, 

contains only basic information regarding pilot responsibilities with regard to weight and 

balance calculations and proficiency, and it contains little to no information regarding 

pilot training and examination programs, preflight inspections, emergency procedures, 

and parachutist egress procedures. Therefore, the Safety Board believes that the FAA 

should revise the guidance materials contained in AC 105-2C 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. 

In addition, because of the USPA’s knowledge of parachute operations and its 

ability to widely disseminate safety information to both members and nonmembers, 

the Safety Board believes that, once 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, the USPA should distribute this revised AC to its members 

and encourage adherence to its guidance.
National Transportation Safety Board

SPECIAL

Investigation Report

17

4. Federal Aviation Administration

Oversight and Surveillance Issues

As evidenced in many of the previously discussed accidents, many operations 

exhibited deficiencies; for example, eight of the accident airplanes were dispatched in 

unairworthy condition. Many of these discrepancies likely could have been detected by 

FAA inspectors had adequate direct surveillance visits been performed. The Safety Board 

has long been concerned with the adequacy of FAA surveillance of parachute operations 

and, on occasion, has determined that inadequate surveillance was a factor in an accident. 

A number of accidents in the 1980s and 1990s prompted the Board to recommend in 1994 

that the FAA improve its surveillance of parachute operations. This section discusses 

those accidents, the Board’s recommendation, the FAA’s action in 1994 to increase its 

surveillance of parachute operations, and the accidents that have occurred since FAA’s 

action. 

4.1 Accidents Preceding Increased Surveillance Action

On September 29, 1985, a Cessna 208 crashed in Jenkinsburg, Georgia, killing 

the pilot and 16 parachutists. The airplane lost engine power on takeoff due to, in part, 

the operator’s improper fuel servicing. Fuel recovered from various locations within the 

airplane’s fuel system was contaminated with water, iron contaminants, and foreign 

material appearing to be brown algae, and dark, stringy material was found in the 

airplane’s fuel filters. The operator fueled the airplane from 55‐gallon drums that were 

stored in a manner that allowed rainwater to leak through the filler caps, and the airplane 

had a history of fuel contamination problems. The Safety Board cited both the operator’s 

improper servicing of the airplane and the operator’s operation of the airplane with 

known equipment deficiencies as the probable causes of the accident and cited the FAA’s 

inadequate surveillance of the operation as a factor.

Fuel quality issues were noted in the Perris, California, de Havilland DHC‐6‐200 

accident, as well. Fuel recovered from the airplane’s forward fuel tank, the airport fuel 

truck, and the airport’s main underground tank was heavily contaminated with water, an 

emulsifying agent, and bacterial growth. Had the FAA conducted adequate surveillance 

of the operator, the contaminated fuel at the airport may have been detected.

In addition, on September 7, 1992, a Beech C-45H crashed shortly after takeoff in 

Hinckley, Illinois, following a loss of engine power in its left engine. The engine that lost 

power had been inactive for 18 years without preservation before it was installed on the 

airplane by noncertificated personnel; however, a certificated airframe and powerplant 

mechanic with an FAA inspection authorization reported that he inspected the personnel’s 

work and signed the airplane’s logbooks for the airplane’s annual inspection. After the 

installation, the airplane was flown about 184 hours since its most recent annual inspection, 

and there was no record of a subsequent 100‐hour inspection. These maintenance program 
Federal Aviation Administration Oversight and Surveillance Issues

National Transportation Safety Board 18

SPECIAL

Investigation Report

deficiencies, in particular, the operator’s failure to comply with inspection requirements, 

likely could have been detected by adequate FAA surveillance.

Following these accidents, on February 17, 1994, the Safety Board issued Safety 

Recommendation A‐94‐19, which asked the FAA to do the following: “Direct flight 

standards district offices [FSDOs] to increase their surveillance of sport parachute operations 

and comply with their associated operations bulletins regarding parachute operations.” 

Safety Recommendation A‐94‐19 was classified “Closed—Acceptable Action” on May 31, 

1995, after the FAA’s November 21, 1994, response that it had published Notice 1800.134, 

“Required National Flight Standards Program Work Functions,” on July 8, 1994, to 

provideinstructions to FSDOs for the development and execution of annual national work 

program guidelines. In its response to the Board, the FAA stated that Notice 1800.134 

“directs principal operations inspectors to perform increased interior and exterior ramp 

inspections” of parachute operations aircraft, to include particular attention to inadequate 

aircraft maintenance, contaminated fuel, inadequate training of pilots, pilot inattention to 

weight and balance and to aircraft operating limitations issued for parachute operations, 

among other areas. In its May 31, 1995, correspondence to the FAA, the Board closed the 

safety recommendation based on its understanding that Notice 1800.134 “requires” FAA 

inspectors to perform increased surveillance.

4.2 Accidents Since Increased Surveillance Action 

The Safety Board notes that FAA Notice 1800.134 is no longer a current document. 

However, information in current FAA Order 8900.1, “Flight Standards Information 

Management System,” is based, in part, on the former Notice 1800.134 and contains similar 

guidance for inspectors in Volume 6, “Surveillance,” Chapter 11, “Other Surveillance,” 

Section 5, “Surveillance of Sport Parachute Activities.” However, the current information 

serves as guidance information only; such surveillance is not a mandatory task for 

inspectors. The current national flight standards work program guidelines listed in FAA 

Order 1800.56H contain no surveillance requirements for parachute operations.

The Safety Board notes that 16 of the 32 fatal parachute operations accidents reviewed 

in this report occurred after the FAA implemented the guidance in Notice 1800.134. These 

accidents claimed the lives of 77 people. Because few of the accident reports detailed 

FAA surveillance activity data for the respective operators, and because the FAA does 

not retain such data indefinitely, the Board is unable to determine whether or not FAA 

surveillance of parachute jump operators increased. However, a review of FAA Program 

Tracking and Reporting Subsystem (PTRS) data and Safety Performance Analysis System 

(SPAS) data for the operators of the three most recent parachute operations accident 

aircraft in the Safety Board’s database (a nonfatal accident involving a Cessna 208B that 

lost engine power on June 1, 2008, in Greensburg, Indiana;13 a nonfatal accident involving 

13 The 14 parachutists on board parachuted to safety following the loss of engine power, the 

cause of which has not yet been determined. The accident, CHI08LA144, was under investigation at the 

time of this report. Preliminary information for the accident is available at the Safety Board’s website at 

<http://ntsb.gov/ntsb/query.asp>.
Federal Aviation Administration Oversight and Surveillance Issues

National Transportation Safety Board 19

SPECIAL

Investigation Report

a de Havilland DHC-6-200 that sustained substantial damage during descent on June 29, 

2008, near Baldwin, Wisconsin;14 and the previously referenced April 19, 2008, Mount 

Vernon, Missouri, accident) revealed that two of the operators had no records of FAA 

surveillance visits. However, the Mount Vernon, Missouri, accident operator received 

an operations surveillance visit on December 7, 2007, and the airplane involved in the 

Baldwin, Wisconsin, accident received a ramp check on April 25, 2004, while being flown 

by an operator in Texas.

Although the Safety Board is pleased with the content of the FAA’s parachute 

operations surveillance guidance materials contained in Order 8900.1, the nonmandatory 

surveillance is not effective. A comparison of the accidents that occurred in the 14 years 

before the safety recommendation was closed (1980 to mid‐1994) with the accidents that 

occurred in the 14 years since (mid‐1994 to present) revealed little difference in their 

respective causes, factors, and other safety issues, with the exception of a reduction in 

contaminated fuel accidents. In addition, several of the accidents that occurred since the 

FAA’s action show that the operators were deficient in specific areas, such as inadequate 

aircraft maintenance, inadequate training of pilots, and pilot inattention to weight and 

balance, that should have been targeted for particular attention from inspectors.

The Safety Board recognizes that the FAA has limited resources; however, as shown 

in this special investigation, numerous parachute jump operators, some of which carried 

thousands of revenue passengers annually, exhibited unacceptable deficiencies that could 

have readily been identified during FAA inspections, had any or adequate inspections 

occurred. For example, the Sullivan, Missouri, accident airplane was maintained at the 

operator’s discretion using an independent maintenance facility. According to the mechanic 

who performed many of the airplane’s most recent repairs, he would bring discrepancies 

to the operator’s attention, but the operator would decide which items should be repaired; 

the mechanic would perform only the maintenance that he was paid to perform. The 

mechanic recalled that the airplane’s autofeather system had been inoperative since the 

operator acquired the airplane in 2001 and that the operator did not want him to repair 

it. The mechanic ensured that the system was deactivated and that a “DEACTIVATED” 

placard was placed in the cockpit near the autofeather switch. However, the operator did 

not have an FAA‐approved minimum equipment list for the airplane and, therefore, was 

not authorized to dispatch the airplane with any inoperative equipment. 

The investigation of the July 31, 1999, accident involving a Beech 65-A90 that 

stalled during climb after takeoff in Marine City, Michigan, killing the pilot and nine 

parachutists, revealed that the operator’s airframe and engine maintenance records for 

the airplane’s required inspections were incomplete and that there were no records of 

compliance with five air worthiness directives (ADs) applicable to the accident airplane. 

Compliance with ADs is mandatory for all operators.

14 The pilot declared an emergency and landed the airplane safely; the 14 parachutists had 

egressed before the emergency occurred. The accident, CHI08LA190, was under investigation at the 

time of this report. Preliminary information for the accident is available at the Safety Board’s website at 

<http://ntsb.gov/ntsb/query.asp>.
Federal Aviation Administration Oversight and Surveillance Issues

National Transportation Safety Board 20

SPECIAL

Investigation Report

The investigation of the September 10, 1995, accident in West Point, Virginia, 

involving a Beech 65 that crashed following a loss of power in one engine on takeoff 

for undetermined reasons,15 killing the pilot, 10 parachutists, and 1 person in a house 

(see figure 4 below), revealed that the airplane’s cabin seats had been removed, but 

maintenance records did not indicate when. Further, the maintenance records did 

not contain recalculated weight and balance information to correspond with other 

modifications (the accident airplane was loaded over its maximum gross weight and 

beyond its aft cg limit at the time that it crashed). 

Further, the airplane’s aft boarding door had been removed for parachute 

operations; however, the accident airplane model was not on an FAA-approved eligibility 

list of aircraft eligible for flight with the aft boarding door removed. In addition, the 

operator had an FAA‐approved flight manual supplement (FMS) that had been altered to 

give the appearance that the door removal was authorized for the accident model airplane; 

the unaltered FMS listed model “A65” as eligible, but the operator’s copy had been altered 

to remove the “A,” giving the appearance that model “65” was eligible.

The maintenance discrepancies on these three airplanes likely could have been 

detected with adequate surveillance that included, at a minimum, a visit to the operator 

and examination of each airplane’s maintenance logs. A review of PTRS and SPAS data 

15 Before the accident flight, the pilot and parachutists fueled the airplane from plastic jugs, at least one 

of which may not have been clean; this practice could have introduced a risk of contaminating the airplane’s 

fuel.

Figure 4. Remains of the house impacted by the West Point, Virginia, accident airplane.
Federal Aviation Administration Oversight and Surveillance Issues

National Transportation Safety Board 21

SPECIAL

Investigation Report

showed that at least one of these operators (the Sullivan, Missouri, accident operator) had 

no record of surveillance visits pertaining to maintenance and operations.16 This operator, 

which had been in business for more than 12 years at the time of the accident, averaged 

about 10,000 to 12,000 passengers per year, with a maximum of 15,000 passengers in 1 year. 

Although the number of surveillance visits, if any, performed on the other two operators is 

not known, the persistence of such airworthiness discrepancies on the airplanes suggests 

that the operators received either minimal or inadequate surveillance with regard to 

aircraft maintenance.

The Safety Board notes that, in addition to maintenance discrepancies that 

could have been detected with adequate maintenance surveillance visits, many of the 

operational deficiencies observed with the accident operators could have also been 

detected and corrected and the accidents prevented. For example, a ramp check could 

determine whether or not a pilot had appropriately computed the airplane’s weight and 

balance for a flight, and a review of the operator’s flight logs and data could provide 

an indication about whether or not the operator enforces the practice for all pilots and 

all flights. Similarly, an operations surveillance visit could provide an inspector some 

indication of the adequacy of an operator’s pilot training program.

As these examples show, parachute jump operator deficiencies have persisted 

after the publication of FAA guidance materials calling for increased surveillance. 

These accidents also show that surveillance of operators has been inconsistent. The 

FAA’s action to increase surveillance, therefore, did not have the effect that Safety 

Recommendation A-94-19 intended. The Safety Board concludes that the FAA’s oversight 

and surveillance of parachute jump operators have been inadequate to ensure that operators 

are properly maintaining their aircraft and safely conducting operations. Therefore, the 

Safety Board believes that the FAA should require direct surveillance of parachute jump 

operators to include, at a minimum, maintenance and operations inspections. 

16 Of these six accidents, only the Sullivan, Missouri, accident investigation provided FAA surveillance 

activity records for the operator. The investigation found three SPAS records of FAA contacts with the operator; 

these were related to the operator’s airspace waiver requests. 
National Transportation Safety Board

SPECIAL

Investigation Report

22

5. Conclusions

5.1 Findings

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.
National Transportation Safety Board

SPECIAL

Investigation Report

23

6. Recommendations

The National Transportation Safety Board recommends that the Federal Aviation 

Administration:

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‐08‐63)

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‐08‐64)

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‐08‐65)

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 competence in practical skills and techniques in each 

type of aircraft. (A‐08‐66)

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. (A-08-67)

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

minimum, maintenance and operations inspections. (A‐08‐68)
Recommendations

National Transportation Safety Board 24

SPECIAL

Investigation Report

The National Transportation Safety Board recommends that the United States Parachute 

Association:

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‐08‐69)

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‐08‐70)
National Transportation Safety Board 25

SPECIAL

Investigation Report

7. Appendix A

Safety Recommendations Pertaining to Survivability 

Issues for Parachutists 

Open Safety Recommendations

Following the Safety Board’s investigation of the July 29, 2006, accident in Sullivan, 

Missouri, the Board issued four safety recommendations related to more effective restraints 

for parachutists. The recommendations were issued on September 16, 2008.

The following recommendations were issued to the Federal Aviation Administration 

(FAA):

A-08-71

Conduct research, in conjunction with the United States Parachute 

Association [USPA], to determine the most effective dual-point restraint 

systems for parachutists that reflects the various aircraft and seating 

configurations used in parachute operations.

A-08-72

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. 

The following recommendations were issued to the USPA:

A-08-73

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.
Appendix A

National Transportation Safety Board 26

SPECIAL

Investigation Report

A-08-74

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.

Safety Recommendations A‐08‐71 through ‐74 are classified “Open—Await 

Response.”

Closed Safety Recommendations

Previously, following the Safety Board’s investigation of the April 22, 1992, 

accident in Perris, California, the Board issued seven safety recommendations (three to 

the FAA and four to the USPA) regarding parachutists’ seating and restraints. These 

recommendations were issued on February 17, 1994. 

The following recommendations were issued to the FAA:

A-94-16

In conjunction with industry, USPA, and CAMI [Civil Aerospace 

Medical Institute], develop and test universal restraint systems capable 

of providing adequate protection to parachutists similar to that 

provided for seated passengers. (Class II, Priority Action) 

In response to this safety recommendation, CAMI, in conjunction with the 

Parachute Industries Association and the USPA, performed a series of dynamic sled tests 

to evaluate various types of restraint systems and occupant orientations for parachutists 

and produced a report on its findings.1

 Although none of the restraint methods tested 

were capable of providing protection to parachutists “similar to that provided for seated 

passengers,” as requested, the FAA responded to the Safety Board on March 26, 1999, 

that the testing identified possible improvements in restraining parachutists and that it 

is not possible to provide the same level of protection for floor‐seated parachutists that is 

afforded to occupants in seats. As a result, because the FAA’s testing identified possible 

improvements in restraining parachutists, the Board determined that the FAA’s actions 

met the intent of Safety Recommendation A‐94‐16 and classified it “Closed—Acceptable 

Action” on January 4, 2000.

1 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).
Appendix A

National Transportation Safety Board 27

SPECIAL

Investigation Report

A-94-17

In conjunction with industry, USPA, and CAMI, provide for the seating 

of parachutists to assure an adequate level of crash energy absorption 

in the event of a survivable aircraft accident. (Class II, Priority Action) 

In a November 2, 2000, letter to the Safety Board, the FAA reported that, because of 

the typically small size of the aircraft used in parachute operations, the installation of an 

energy‐absorbing structure, such as crushable seating or modified flooring, would impact 

the flight mission by substantially reducing payload and adequacy of cabin emergency 

evacuation. The FAA further reported that such modifications would also significantly 

alter the performance and handling qualities of the aircraft and significantly change the 

airplane design and that any requirements for such a design change for existing airplanes 

“would constitute a ban on sport parachuting as it is known today. Consequently, the 

FAA does not intend to continue efforts to address the attenuation of vertical energy.” As 

a result of the FAA’s response, Safety Recommendation A‐94‐17 was classified “Closed—

Unacceptable Action” on March 9, 2001.

A-94-18

Amend 14 CFR [Code of Federal Regulations] 91.30 to require each 

parachutist or other passenger who is seated on an aircraft cabin floor 

to use restraint systems. The restraint system must be designed, tested, 

and approved to provide a level of occupant protection similar to that 

provided for passengers in forward and aft facing seats that have a 

safety belt and shoulder harness. (Class II, Priority Action)

In response to this recommendation, the FAA reported that 14 CFR 91.107 already 

requires parachutists seated on an aircraft cabin floor to use restraint systems and that, 

although no restraint system for floor‐seated parachutists could provide a level of protection 

similar to that provided to seated passengers, if an improved restraint system were 

developed and installed, the parachutists would automatically be required to use it. In a 

January 4, 2000, response letter to the FAA, the Safety Board acknowledged that regulations 

require parachutists to use restraints and that FAA guidance materials and actions since 

the recommendation was issued have resulted in improved operator adherence to the 

requirements. The Board also acknowledged that, despite CAMI’s testing, no restraint 

system could be found that would meet the intent of the safety recommendation. As a 

result, Safety Recommendation A‐94‐18 was classified “Closed—Acceptable Alternate 

Action” on January 4, 2000.

The following recommendations were issued to the USPA:

A-94-20

Revise the USPA operations manual to require restraint system use 

during takeoffs and landings. (Class II, Priority Action)
Appendix A

National Transportation Safety Board 28

SPECIAL

Investigation Report

A-94-21

Publish and distribute the content of this recommendation letter to all 

USPA members. (Class II, Priority Action)

In response to Safety Recommendations A‐94‐20 and ‐21, the USPA developed 

the USPA Skydiving Aircraft Operations Manual and distributed it to its group member 

facilities, completed its manual revisions, and published multiple magazine articles 

(including at least one that referenced the Safety Board’s letter in its entirety) emphasizing 

seatbelt use. As a result, Safety Recommendations A‐94‐20 and ‐21 were each classified 

“Closed—Acceptable Action” on August 11, 1997.

A-94-22

Participate in the design, development, and testing of a universal 

restraint system that would provide adequate protection for parachutists 

seated on an aircraft floor. (Class II, Priority Action)

The USPA participated, as requested, in the previously referenced CAMI testing 

of seating for parachutists; therefore, Safety Recommendation A‐94‐22 was classified 

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

A-94-23

Participate in the design, development, and testing of seating for 

parachutists that would provide an adequate level of crash energy 

absorption in the event of a survivable aircraft accident. (Class II, 

Priority Action)

On June 2, 1997, the USPA informed the Safety Board that it had obtained samples 

of energy‐absorbing material that could potentially be used as floor seating material in 

parachute operations airplanes but that it had not developed a plan, or been informed 

by the FAA of a plan, to test the material. After the USPA did not respond to follow‐up 

correspondence from the Board in 1997 and 2000 requesting updates on USPA’s progress, 

Safety Recommendation A‐94‐23 was classified “Closed—Unacceptable Action” on June 5, 

2001.

Previous Safety Recommendation Pertaining to Federal 

Aviation Administration Surveillance of Parachute 

Operations 

The Safety Board’s investigation of the April 22, 1992, accident in Perris, California, 

also resulted in a recommendation regarding FAA surveillance of parachute operations. 

The following safety recommendation was issued to the FAA on February 17, 1994: 
Appendix A

National Transportation Safety Board 29

SPECIAL

Investigation Report

A-94-19

Direct flight standards district offices to increase their surveillance of 

sport parachute operations and comply with their associated operations 

bulletins regarding parachute operations. (Class II, Priority Action)

Safety Recommendation A‐94‐19 was classified “Closed—Acceptable Action” on 

May 31, 1995, after the FAA responded on November 21, 1994, that “the FAA agrees 

with this recommendation” and that the FAA had published Notice 1800.134, Required 

National Flight Standards Program Work Functions, on July 8, 1994, to provide guidance 

to flight standards field offices on the development and execution of annual national 

work program guidelines. The FAA stated that the notice directed principal operations 

inspectors to perform increased interior and exterior ramp inspections of parachute 

operations aircraft, paying particular attention to inadequate aircraft maintenance and 

contaminated fuel, the use of restraint systems by parachutists during flight, the use of 

unapproved crewmembers’ seatbelts, inadequate training of pilots, pilot inattention to 

weight and balance, and aircraft operating limitations issued for parachute operations.
National Transportation Safety Board 30

SPECIAL

Investigation Report

Appendix B

Accident Synopses

Salisbury, North Carolina (ATL80FA051)

On June 8, 1980, a Cessna 172, N8866B, crashed near Thompson Farm Airport 

in Salisbury, North Carolina, following a partial loss of engine power during takeoff. 

The private pilot and one parachutist were killed. The airplane’s annual inspection was 

overdue, water and dirt were observed in the gascolator, sludge was observed in the 

engine, and the engine’s No. 6 exhaust valve was sticking. 

The National Transportation Safety Board determined that the probable cause of 

the accident was the inadequate maintenance and inspection of the airplane and the pilot’s 

inadequate preflight preparation, failure to abort the takeoff, and failure to maintain flying 

speed. Factors contributing to the accident were the partial loss of power; excessive wear 

on the engine pistons; sticking of the valve assembly; and water and other contaminants 

in the fuel. 2

Loveland, Colorado (DCA81AA015)

On April 17, 1981, a Cessna TU206A, N4862F, collided in flight with a Handly 

Page HP-137 airplane in Loveland, Colorado. Two parachutists on board the parachute 

operations flight were killed, the airline transport pilot and two other parachutists 

received serious injuries, and one parachutist received minor or no injuries. All 13 people 

(the airline transport pilot, 2 flight crewmembers, and 10 passengers) on board the other 

airplane, which was an on‐demand air taxi commuter flight operated under 14 Code of 

Federal Regulations (CFR) Part 135, were killed. The pilot of the parachute operations flight 

climbed the Cessna through 12,500 feet above mean sea level (msl) and in controlled 

airspace without communicating with air traffic control (ATC) personnel and without 

operating an altitude‐encoding transponder; the flight was not in radar contact with 

an ATC facility. The air taxi commuter, which was in normal cruise flight, was in radar 

contact with ATC; however, ATC personnel issued no traffic advisories. The horizontal 

collision angle of the two airplanes was about 45°. Regulations allowed for and the ATC 

center permitted parachute jump operations both in and adjacent to airways. 

The Safety Board determined that the probable cause of the accident was the 

Cessna pilot’s failure to follow approved procedures/directives and the failure of both 

pilots to see and avoid the other airplane. Factors contributing to the accident were the 

rules, regulations, and standards for [ATC] personnel. 

2 The probable causes of older accidents in the Safety Board’s database, including this accident, are 

provided in list form rather than as a probable cause statement. The probable cause statements provided for 

this accident and the following eight accident synopses are paraphrased from the lists.
National Transportation Safety Board 31

Appendix B

SPECIAL

Investigation Report

Beaumont, Texas (FTW81FA079)

On April 25, 1981, a Cessna TU206B, N3414L, operated by a parachuting club, 

crashed in Beaumont, Texas, following an in‐flight separation of a jump door window, 

which became wrapped around the horizontal stabilizer and obstructed the flight control 

surfaces there. The private pilot was killed, and none of the parachutists, who had 

successfully egressed the airplane, were injured. The pilot, who had accumulated 9 hours 

in the airplane type, exceeded the designed stress limits of the airplane during cruise 

flight. In addition, at the time of takeoff, the airplane was loaded to 7 inches behind its aft 

center of gravity (cg) limit. 

The Safety Board determined that the probable cause of the accident was the pilot 

exceeding the designed stress limits of the airplane, which resulted in the flutter of the 

door frame and the subsequent obstruction of the flight control surfaces on the horizontal 

stabilizer. Factors contributing the accident were the in‐flight separation of door’s window 

and the improperly loaded airplane. 

Honolulu, Hawaii (LAX82FA024)

On December 5, 1981, a Beech C-45H, N8185H, entered a spin during a turn toward 

the jump area at altitude and crashed into water near Honolulu, Hawaii. The private pilot 

and 10 parachutists were killed. One parachutist, who was one of four parachutists who 

attempted to egress, survived but was seriously injured. The investigation found that the 

airplane was loaded to about 10 inches behind its aft cg limit. 

The National Transportation Safety Board determined that the probable cause of 

the accident was the pilot’s failure to maintain flying speed and that factors contributing to 

the accident included the following: the pilot’s inadequate preflight planning/preparation, 

the pilot’s lack of qualifications to operate the airplane, and the improper loading of the 

airplane.

Taft, California (LAX83FA012)

On October 17, 1982, a Beech C-45H, N403SE, crashed shortly after takeoff from 

a private airport in Taft, California. The commercial pilot, an observer on board, and 

12 parachutists were killed. According to a witness on the ground, shortly after the 

airplane departed, the engine power was reduced to climb power, and the landing gear 

was retracted. The airplane climbed to about 150 feet above ground level (agl), then its 

nose pitched up, and it rolled to the left and crashed in a steep left-banked, nose-down 

attitude.

Examination of the airplane revealed extensive ground fire damage but no evidence 

of preimpact mechanical discrepancies. The maximum certificated gross weight for the 

airplane was 8,750 pounds (lbs) with an aft cg limit of 117.6 inches. Although the amount 

of fuel on board at the time of the accident was not determined, the investigation found 

that, if the airplane had carried no fuel weight, its loading would have been about 580 lbs 
National Transportation Safety Board 32

Appendix B

SPECIAL

Investigation Report

over its maximum gross weight. If the airplane carried 100 gallons of fuel, its estimated 

gross weight would have been about 9,939 lbs with the cg at 121 inches. 

The Safety Board determined that the probable cause of the accident included the 

following: the pilot’s inadequate preflight planning/preparation and the pilot exceeding 

the airplane’s weight and balance limitations. 

Marseilles, Illinois (CHI83FA365)

On August 6, 1983, a Cessna 182, N6351A, crashed while returning to Prairie 

Lake Airport in Marseilles, Illinois. The commercial pilot was killed, and none of the 

four parachutists, who had jumped from the airplane at 9,000 feet msl, was injured. The 

airplane was observed flying level about 500 feet agl in the approximate position for the 

left downwind leg for runway 36. About 1/2 mile north of the normal turn point for the 

base leg, the airplane entered a steep, descending left turn. Examination of the wreckage 

revealed no evidence of malfunction. Toxicology performed on and examination of the 

pilot revealed no evidence of an incapacitating problem. The Safety Board cited the 

probable cause of the accident as undetermined.

Silvana, Washington (DCA83AA036)

On August 21, 1983, a Lockheed L-18-56, N116CA, entered a steep bank and 

spiraled nose down and crashed nearly vertically on the ground in Silvana, Washington. 

The commercial pilot, the second pilot, and 9 parachutists were killed; 2 parachutists were 

seriously injured; and 13 parachutists were not injured. The airplane was at 12,500 feet 

when parachutists began to egress; the operator’s usual procedure involved slowing the 

airplane to 95 to 100 knots, extending the landing gear and approach flaps, and reducing 

power on the left engine. The first parachutists who exited the airplane reported that 

they were unaware of any problem, but, after exiting the airplane, they saw it enter the 

bank and spiral down. Sixteen parachutists were able to egress, but three impacted the 

airplane’s stabilizer. 

Examination revealed that the airplane was equipped with 1 jumpseat and 24 floor 

seatbelts for parachutists. Its cabin door had been removed, and an unapproved step and 

four handholds had been installed outside and forward of the cabin door area. Also, the 

airplane had been loaded behind its aft cg limit, and the trim actuator was found in a 

position corresponding with full nose-up trim.

The Safety Board determined that the probable cause of the accident included the 

following: the operator’s improper supervision, the pilot exceeding the airplane’s weight 

and balance limitations, and the pilot’s inadvertent stall.
National Transportation Safety Board 33

Appendix B

SPECIAL

Investigation Report

Dublin, Virginia (ATL85FA072)

On December 30, 1984, a Cessna 182A, N4963D, struck a parked van with its 

landing gear and crashed near New River Valley Airport in Dublin, Virginia. The private 

pilot was killed. The flight was returning to the airport after the parachutists had egressed. 

The airplane was observed to fly over the drop zone, make a 180‐degree turn to the left, 

and then line up on a van that was parked on a ridge. The airplane descended to 10 to 

30 feet agl and made a low-altitude, high-speed run toward the van. A witness reported 

that the airplane appeared to dip under a low powerline in its path and that its landing 

gear then struck the van.

The Safety Board determined that the probable cause of the accident was the 

pilot’s improper decision to perform buzzing and the pilot’s misjudgment of the proper 

glidepath and altitude.

Jenkinsburg, Georgia (ATL85MA286)

On September 29, 1985, a Cessna 208, N551CC, operated by Air Carriers Express 

Service, Inc., crashed following a loss of engine power during takeoff from the sod runway 

at West Wind Sport Parachute Center in Jenkinsburg, Georgia. The airline transport pilot 

and 16 parachutists were killed. The airplane had climbed to about 300 feet agl when the 

power loss occurred; the airplane then banked steeply left and spiraled nose down to 

the ground. The airplane was configured to carry up to 18 parachutists. Fuel recovered 

from various locations within the airplane’s fuel system was contaminated with water, 

iron contaminants, and foreign material appearing to be brown algae. Milky-colored fuel 

recovered from the engine’s fuel control was about 34 percent water and contained iron 

contaminants. Dark, stringy material was found in the airplane’s fuel filters. The operator 

fueled the airplane from 55-gallon drums that contained contaminated fuel. These drums 

were stored in a manner that allowed rainwater to leak through the filler caps. 

The investigation revealed that the airplane had been operated for several weeks 

with known contamination of the fuel system. The owner/operator was informed by 

qualified maintenance personnel on at least two occasions of the need to purge and clean 

the airplane’s fuel system before further flight; however, he continued to operate the 

airplane. On at least one occasion, the airplane was flown after contaminated fuel samples 

were repeatedly obtained. The airplane’s flight manual states that all drain valves should 

be thoroughly drained until there is no evidence of water or sediment contamination 

before the flight. 

Also, the airplane’s stall warning circuit breaker was occasionally disengaged 

so that the warning would not startle the parachutists; however, damage precluded 

determination of the circuit breaker’s preimpact position during the accident flight. The 

airplane was about 370 lbs over its maximum allowable gross weight and 1 inch forward 

of its forward cg limit. The parachutists did not use restraints, and lack of Federal Aviation 

Administration (FAA) surveillance of the operation was noted. 
National Transportation Safety Board 34

Appendix B

SPECIAL

Investigation Report

The Safety Board determined that the probable cause of the accident included 

the following: the operator’s improper maintenance/service of the aircraft/equipment, 

the operator’s operation of the airplane with known deficiencies, the pilot’s failure to 

maintain airspeed, the pilot’s inadvertent stall/spiral, and fuel contamination/water. The 

contributing factors included the following: a disengaged circuit breaker and disabled 

warning system, fuel system contamination, the pilot’s improper use of procedures, and 

the FAA’s inadequate surveillance of the operation.

Perris, California (LAX88FA241)

On June 30, 1988, a Helio HST-55A, N9991F, operated by Perris Valley Skydiving, 

crashed while returning to Perris Valley Airport in Perris, California.3 The airline transport 

pilot was killed; none of the parachutists, who had already jumped from the airplane, was 

injured.4

 During the airplane’s descent, the pilot was communicating with an air traffic 

controller and receiving radar advisories. After the airplane descended below 4,000 feet 

msl, the controller terminated the advisory services but then immediately advised the 

pilot to check for a stuck microphone switch. The airplane descended in an extreme, 

nose-low attitude and collided with a camping trailer and building. Examination of the 

airplane revealed that the elevator trim was found in the full nose-down position, and no 

other malfunctions were found. 

The Safety Board determined that the probable cause of this accident was the failure 

of the electrical stabilizer trim control that resulted in an uncommanded full nose-down 

elevator trim command.

Estacada, Oregon (SEA91FA038)

On December 31, 1990, a Cessna 182B, N7288E, crashed during a forced landing 

into a tree farm following a loss of engine power shortly after takeoff from Beaver Oaks 

Airport, near Estacada, Oregon. Two parachutists were killed, the private pilot was 

seriously injured, and one parachutist received minor injuries. The temperature at the 

time of the accident was 40° Fahrenheit (F), and the dew point was about 36° F; this 

combination falls within the range favorable to induction system icing. The investigation 

revealed that the engine’s muffler cones were missing from the engine. 

The Safety Board determined that the probable cause of the accident was engine 

power loss due to carburetor ice and missing muffler cones as a result of inadequate 

maintenance inspection. In addition, the pilot failed to maintain adequate airspeed during 

the forced landing, which resulted in a stall. 

3 Two accidents referenced in this report occurred in Perris; the other accident, which involved a 

de Havilland DHC‐6‐200, is referenced more frequently.

4 The report narrative did not indicate how many parachutists were initially on board. According to the 

factual report’s form data, the airplane could seat 10 passengers.
National Transportation Safety Board 35

Appendix B

SPECIAL

Investigation Report

Osceola, Wisconsin (CHI91FA088B)

On February 3, 1991, a Cessna 182, N6384A, collided in flight with a Piper PA‐28 

after departing L.O. Simenstad Municipal Airport in Osceola, Wisconsin. The private pilot 

and the four parachutists on board the Cessna (a high‐wing airplane) and the certificated 

flight instructor and student pilot on board the Piper (a low‐wing airplane) were killed. 

Shortly before the accident, the pilot of parachute operations flight had departed 

runway 10 in formation with another airplane (not the Piper). After takeoff, the pilot of 

the parachute operations Cessna discontinued the formation and departed the airport 

to the southeast, and the other airplane that had been in the formation departed to the 

northeast. About the same time, the Piper approached airport. No witnesses observed the 

collision. The parachute operations Cessna and the Piper converged and collided about 

1.5 miles southeast of the airport, became entangled, and struck the ground together. The 

two accident airplanes converged laterally while on flight paths that angled toward each 

other. 

The Safety Board determined that the probable cause of the accident was the failure 

of the pilots in both aircraft to see and avoid the other airplane.

Perris, California (LAX92MA183)

On April 22, 1992, a de Havilland DHC-6-200, N141PV, operated by Perris Valley 

Aviation Services, crashed during takeoff from Perris Valley Airport, Perris, California, 

following a loss of power in the airplane’s right engine. The commercial pilot, the second 

pilot, and 14 parachutists were killed; six parachutists were seriously injured. Immediately 

after the airplane lifted off, the right engine lost power, the right wing lowered to about 

90o, and the airplane crashed adjacent to the runway.

The ground loader stated that he had fueled the airplane from the airport fuel 

truck and that the flight crew did not sump the airplane’s fuel tanks after the airplane was 

fueled. Examination of the airplane’s forward fuel tank, which provides fuel to the right 

engine, was found to contain about 8 gallons of a heavily contaminated mixture of water, 

an emulsifying agent, and bacterial growth. Both the airport’s fuel truck, which contained 

fuel transferred from the airport’s underground tank the evening before the accident, 

and the underground tank contained the same contaminated mixture. Examination of the 

wreckage revealed that the left propeller control was seized in the feather position and 

that the left propeller blades were in the near-feather position. 

The Safety Board determined that the probable causes of this accident were the 

pilot-in-command’s inadvertent feathering of the wrong propeller following an engine 

power loss and the failure of the operator to ensure that the pilot was provided with 

adequate training in the airplane. Factors related to the accident were: water contamination 

of fuel in the airport storage tanks, the operator’s lack of fuel quality control procedures, 

improper fuel servicing, improper preflight by the pilot(s), and exceeding the gross 

weight/forward cg limits of the airplane.
National Transportation Safety Board 36

Appendix B

SPECIAL

Investigation Report

Hinckley, Illinois (DCA92MA048)

On September 7, 1992, a Beech C-45H, N3657G, operated by Hinckley Parachute 

Center, lost power in its left engine and crashed during takeoff in Hinckley, Illinois. The 

commercial pilot and 11 parachutists were killed. After the airplane lifted off, witnesses 

saw it flying at low altitude with smoke trailing from its left engine. Its wings tipped back 

and forth, then one wing dropped, struck the ground, and the airplane crashed. All of the 

parachutists were found in the center part of the fuselage with no evidence of restraint 

use.

Examination of the engine revealed that a supercharger bearing had failed in 

the left engine. Examination also revealed that the left propeller blades were found in 

an intermediate position between the operating range and the feathered position; the 

propeller’s feathering motor relays were not recovered for examination. The left propeller 

had been changed several weeks before the accident, and there was no evidence that the 

left propeller had ever been successfully cycled to the full-feathered position. The operator 

and the pilots were not aware that the manufacturer, Hamilton Standard, issued Service 

Bulletin (SB) 657, recommending that full‐feather checks be performed every 30 days.

The left engine was installed between January and April 1992 by noncertificated 

personnel; however, both the parachute center’s owner and a certificated airframe and 

powerplant mechanic with an FAA inspection authorization reported that the mechanic 

told the noncertificated personnel what to do on the airplane and that the mechanic 

subsequently signed the airplane’s logbooks for the airplane’s annual inspection after 

the work was completed to the mechanic’s satisfaction.5

 The airplane had flown about 

184 hours since the last annual inspection, and there was no record of a subsequent 

100-hour inspection. 

Before installation on the accident airplane, the left engine had been inactive for 

about 18 years without preservation; it was last overhauled in February 1967 and had 

accumulated about 465.9 hours over the next 5 years before the airplane on which it was 

installed (not the accident airplane) was kept outside at an airport in central Florida. It 

remained there until August or September 1990, at which time an individual purchased 

the airplane and donated it to a museum located near Shreveport, Louisiana. The airplane 

was flown from Florida to Virginia and then to the museum, arriving on May 2, 1991. The 

pilots for each respective flight reported that the left engine used about 1/2 to 1 gallon 

of oil per hour, and one pilot reported that he believed that this was due to a badly 

worn or deteriorated supercharger seal and that the engine needed to be overhauled. 

The Hinckley Parachute Center owner purchased both engines and transported them to 

Hinckley between October and November 1991, installing the left engine on the accident 

airplane in early 1992.

The Safety Board determined that the probable cause of the accident was inadequate 

maintenance and inspection by the operator, which resulted in an engine power loss 

during the critical takeoff phase of flight. In addition, the pilot did not or was unable to 

5 Some of the information for this synopsis was obtained from the public docket for the accident.
National Transportation Safety Board 37

Appendix B

SPECIAL

Investigation Report

attain a full-feather position on the left engine propeller, which would have most likely 

enabled the airplane to sustain minimum control airspeed.

East Moriches, New York (NYC93FA154)

On August 14, 1993, a Cessna 182A, N5010D, owned and operated by Skydive 

Long Island, Inc., crashed during an attempted return to the runway following a loss of 

engine power shortly after takeoff from Spadaro Airport in East Moriches, New York. 

The commercial pilot was killed, and the four parachutists were seriously injured. Several 

witnesses saw the airplane take off and reported that the engine did not sound like it was 

running normally. The airplane was observed to lose altitude on the downwind leg for 

the runway. The airplane then turned toward the runway, one wing struck the runway, 

and the airplane crashed. The computed estimated weight of the airplane at takeoff was 

2,692 lbs. The maximum allowable takeoff gross weight is 2,650 lbs. 

The airplane was powered by a Continental O‐470‐L engine equipped with 

Superior Air Parts pistons; the pistons carried the part number SA626992 and casting 

number SA632936. Engine logbook records disclosed that the engine had accumulated 

3,369.2 hours total time at the time of the accident with 547.1 hours since engine overhaul. 

The engine received its last overhaul on December 8, 1980.

Examination of the engine revealed that the skirt of the No. 3 piston was missing 

and that the other pistons were cracked. The cracks in each piston were oriented along 

the longitudinal axis of each piston and originated in sharp corners on the inside of each 

piston skirt. The Safety Board’s metallurgical examination of the piston pieces revealed 

that, for all of the pistons, the lower skirt area surface showed the presence of sharp casting 

recesses and that a series of elongated surface shrinkage cavities were present along the 

recess line. The cracks appeared to originate from the shrinkage cavities. The crack on 

one piston was opened up, and examination revealed that the propagation of the crack 

resulted from fatigue.

The Safety Board determined that the probable cause of this accident was engine 

failure due to a fatigue failure of the No. 3 piston. The fatigue failure was a result of 

inadequate manufacturing. In addition, the pilot made an improper decision during 

the forced landing by attempting to stretch his approach to reach the runway instead 

of landing in terrain adjacent to the approach end of the runway. As a result, the pilot 

lost control of the airplane, and it stalled on the runway. A factor that contributed to the 

accident was the overgross weight of the airplane.

Tremont City, Ohio (NYC94FA128)

 On July 16, 1994, a Cessna R172K, N1124V, operated by Mad River Airport, crashed 

during takeoff from Mad River Airport, near Tremont City, Ohio. The commercial pilot 

and three parachutists were killed. Witnesses reported that the airplane’s takeoff appeared 

normal but that the airplane leveled off about 200 feet agl. It then descended about 50 feet 
National Transportation Safety Board 38

Appendix B

SPECIAL

Investigation Report

and continued forward for a moment before its right wing dropped, and it entered a steep 

descent and crashed into wooded terrain along the extended centerline of the runway. 

No preimpact mechanical malfunction was found with the airplane. The airplane’s 

passenger door, right front seat, and rear seat had been removed for the parachute 

operations flight; however, no record of a new weight and balance computation for the 

modifications was found. The airplane was estimated to be 76 lbs over its maximum 

takeoff weight. The accident flight was the pilot’s first parachute operations flight and 

first flight with the airplane’s door removed. 

The Safety Board determined that the probable cause of the accident was the 

failure of the pilot to maintain control of the airplane. A factor related to the accident was 

the pilot’s lack of experience in the type of operation. 

West Point, Virginia (NYC95MA220)

On September 10, 1995, a Beech 65, N945PA, operated by the Peninsula Sky Diving 

Club, crashed following a loss of power in one engine during takeoff from the West Point 

Municipal Airport, West Point, Virginia. The airline transport pilot, 10 parachutists, and 

1 person in a house were killed. Witnesses reported that they heard an engine misfiring 

during the airplane’s takeoff and that they observed the airplane level off during the initial 

climb and start a shallow right turn. The bank angle gradually increased from shallow to 

steep as the nose dropped and the airplane descended. Other witnesses observed that the 

airplane was in a steep dive just before it crashed into the rear of a house and caught fire.

The airplane had flown seven parachute operations flights before the accident 

flight that day. After the seventh flight, the airplane needed refueling, but the quantity 

of fuel in the airport’s underground fuel storage tank was below the electric cutoff level. 

A pilot witness stated that “it was suggested that we could, by using a hand pump, get 

some more fuel from the airport tank.” The witness and others, including parachutists, 

manually pumped fuel into containers and carried them to the airplane to refuel it. A 

witness described that two jugs were used at first, and then another one was found in the 

hangar. A small amount of liquid that smelled like fuel was dumped from the jug before 

it was used in refueling the accident airplane.

Examination of the airplane revealed that the postaccident fire destroyed the 

accessory sections of both engines. Examination of the airplane disclosed evidence that 

the right engine had been shut down and that the right propeller had been feathered; 

however, no preimpact mechanical failure was found. A sample of excess fuel was 

obtained from the tank that was used to refuel the airplane, but no observable quantity of 

water or contamination was found. 

Investigators calculated that, for the accident flight, the airplane’s maximum gross 

weight was exceeded by 149.6 lbs and that the cg was 2.87 inches aft of the aft limit. Also, 

the airplane’s seats and cabin door had been removed for parachute operations; however, 

the Beech 65 was not on the FAA-approved eligibility list for operation with its door 
National Transportation Safety Board 39

Appendix B

SPECIAL

Investigation Report

removed. The operator provided investigators a flight manual supplement (FMS) that 

appeared to authorize such door removal, but examination of the document revealed that 

it had been altered by an unknown person. An unaltered FAA-approved FMS contained 

a signed and dated eligibility block that listed model “A65”; however, the copy of the 

document provided by the operator had been altered to remove the “A,” thus, falsely 

giving the appearance that Beech “65” was eligible.6

In addition, the airplane’s maintenance records did not indicate when the cabin 

seats were removed, but an FAA Form 337 showed floor‐mounted seatbelts installed 

on October 16, 1990. The form stated that the aircraft weight and balance had been 

recalculated and logbook records updated. No such weight and balance figures were 

found in the logbooks. Additional modifications were made in May and June 1995 and 

Form 337s were submitted. The Form 337s stated that the airplane’s weight and balance 

had been recalculated and the records updated; however, no entries were made in the 

airframe logbook.

The Safety Board determined that the probable cause of the accident was the pilot’s 

inadequate preflight preparation, his failure to ensure the airplane’s proper weight and 

balance, and his failure to obtain/maintain minimum control speed, which resulted in a 

loss of aircraft control after loss of power in one engine. A factor relating to the accident 

was the loss of power in the right engine for undetermined reasons.

Homestead, Florida (MIA97FA173)

On May 25, 1997, a Cessna 205, N8214Z, registered to Uninsured 205 LSG 

Corporation and operated by Skydive, Inc., entered a spin at 3,500 feet and crashed near 

Homestead General Airport, Homestead, Florida. The commercial‐rated pilot and five 

parachutists were killed. One parachutist jumped before ground impact, deployed her 

chute, and landed uninjured. 

The surviving parachutist stated that the flight was to climb to 3,500 feet and that 

she was to jump from that altitude. The flight was then to climb to a higher altitude for 

the remaining parachutists to jump. The flight reached 3,500 feet, the pilot slowed the 

airplane, and the parachutist took the jump position on the platform mounted on the right 

main landing gear. She stated that the wind resistance at this time was not as great as it 

had been during past jumps. As she waited for the jump signal from the jump company 

owner, he moved from the back of the aircraft to the right front seat area, which she 

had vacated. Shortly after this, the airplane’s left wing dropped, and the airplane began 

turning to the left. The nose then dropped, and the airplane began to spin to the left. After 

an unknown number of turns, the parachutist jumped from the aircraft. As she descended 

using her parachute, she observed that the airplane continued to descend in a spin and 

crashed. 

Postaccident examination of the airplane’s structure, flight controls, engine, and 

propeller showed no evidence of precrash mechanical failure or malfunction. A review 

6 Some of the information for this synopsis was obtained from the public docket for the accident.
National Transportation Safety Board 40

Appendix B

SPECIAL

Investigation Report

of the pilot’s logbook and flight training records showed that the pilot received ground 

instruction in spin entry and spin recovery techniques but that there was no record that he 

had ever performed spins or spin recoveries in an aircraft. FAA regulations require that 

a private or commercial pilot receive ground instruction in spin entry and spin recovery 

techniques but does not require the private or commercial pilot to have performed spin 

entry and spin recovery techniques in an aircraft. 

The Safety Board determined that the probable causes of the accident were the 

pilot-in-command’s failure to maintain airspeed as he slowed for a parachutist to jump 

from the aircraft and his failure to apply spin recovery emergency procedures before 

ground impact. Contributing to the accident were the pilot-in-command’s lack of training 

in spin recovery emergency procedures in an aircraft and the FAA’s failure to require that 

a pilot demonstrate spin entry and spin recovery techniques in an aircraft.

Bremerton, Washington (SEA97FA201)

On September 1, 1997, a Cessna 182C, N9015T, operated by Blue Skies Skydiving 

Adventures of Dupont, Washington, collided with terrain shortly after takeoff from 

Bremerton National Airport, Bremerton, Washington. The commercial pilot and four 

parachutists were killed. The operator reported that the accident flight was to have been 

the last skydiving flight of the day and that the airplane, after departing from runway 19, 

climbed to about 300 to 500 feet agl before turning to the left and back toward the airport 

runway. Another witness stated that, during the left turn, the airplane increased its left 

bank until the airplane was approximately on a heading parallel to runway 1 and that the 

airplane’s nose then dropped vertically and the airplane went into a one-half-turn spin. 

The airplane crashed into a shallow ravine and caught fire about 900 feet south of the 

departure end of runway 19, to the left of the runway’s extended centerline. 

No evidence of preimpact conditions interfering with normal operation was 

found during on-site examination or in follow-up examinations of the airplane’s engine, 

propeller, and carburetor. A gross weight computation (based on airplane empty weight, 

reported fuel loading, and occupant and parachute weight estimates) indicated that the 

airplane was about 38 lbs over its maximum gross weight at the time of the accident. 

The Safety Board determined that the probable cause of the accident was the pilot’s 

failure to maintain adequate airspeed in a climbing turn at low altitude, resulting in a stall 

and impact with terrain. A factor was the pilot exceeding the aircraft’s maximum takeoff 

gross weight limitation.

Smithfield, Rhode Island (IAD97FA117)

On September 6, 1997, a Cessna 182E, N3286Y, operated by Boston-Providence 

Skydiving Center, impacted the terrain during a forced landing on initial climbout at North 

Central Airport, Smithfield, Rhode Island. The commercial pilot and four parachutists 

were killed, and one parachutist received serious injuries. 
National Transportation Safety Board 41

Appendix B

SPECIAL

Investigation Report

The airplane’s flight log indicated that it had flown eight skydiving flights earlier 

that day and that the airplane was fueled one flight before the accident flight. Witness 

statements indicated that the airplane departed and climbed to about 200 to 300 feet 

agl, then the engine lost power. The witnesses reported that the airplane pitched up to 

a nose-high attitude, rolled left, and descended until ground impact about 90o off the 

runway heading. Examination revealed that the airplane came to rest in an upright 

position, against the treeline of a wooded area. The propeller was found under the right 

wing. One blade was bent aft 90o with lengthwise scratching. The engine was test run, and 

no mechanical malfunctions were found. 

No dated weight and balance calculations were located for the airplane, but 

handwritten weight and balance notes removed from the airplane indicated empty weight 

and balance figures for the airplane with the jump door installed. An estimated weight 

and balance for the accident flight was calculated, which revealed that the airplane’s 

estimated takeoff weight was 2,930 lbs with an estimated cg of 48.67 inches. According to 

the pilot operating handbook for the airplane, the maximum allowable takeoff weight for 

the airplane was 2,800 lbs with a cg range of 38.39 to 47.32 inches.

The Safety Board determined that the probable causes of the accident were a loss 

of engine power for undetermined reasons and the pilot’s failure to maintain control of 

the airplane.

Grain Valley, Missouri (CHI98FA106)

On March 21, 1998, a Cessna U206G, N506SD, caught fire and crashed while 

approaching the airport near Grain Valley, Missouri. The commercial pilot and five 

parachutists were killed. The flight was at 3,700 feet msl when the pilot canceled the 

operation with the FAA approach controller without explanation. Three witnesses at the 

airport said that the airplane had smoke and flames coming from the airplane’s cowl and 

along the windshield as it approached the airport. They said that the airplane banked 

right at a low altitude and that its right wingtip struck the ground. 

The investigation revealed that the engine, left side of the fuselage, bottom of the 

left wing and strut, horizontal stabilizer, and elevator were covered with oil film. The 

engine’s oil filler tube was missing. The three filler-tube mounting screws were not found 

at the accident site. The upper threads of two of the three filler-tube mounting screw 

holes were deformed upward. The third screw hole threads were not deformed. The No. 6 

cylinder valve rocker arm cover had five of its six screws missing, and the remaining screw 

was loose. The No. 6 cylinder’s bottom spark plug lead nut was disconnected; its threads 

were not pulled. Examination of the engine revealed about 70 percent of the oil screen was 

covered by silver and bronze metallic debris. Holes were observed on the engine’s left 

crankcase section near cylinder Nos. 2 and 6. The engine’s internal components suffered 

damage typical of oil loss and heat distress, and the fracture features on the engine’s 

fractured left crankcase section were typical of overstress. 
National Transportation Safety Board 42

Appendix B

SPECIAL

Investigation Report

The Safety Board determined that the probable cause of the accident was the 

pilot’s inadequate preflight inspection, the partial loss of oil, and the resulting rod failure. 

A factor was the pilot’s failure to maintain flying speed.

Celina, Ohio (IAD99FA043)

On May 9, 1999, a Cessna 205, N8157Z, operated by Grand Lake Skydiving, was 

destroyed during a collision with terrain following a forced landing after takeoff from 

Lakefield Airport in Celina, Ohio. The commercial pilot and five parachutists were killed. 

Several witnesses reported that, during climb after takeoff, the airplane’s engine sputtered 

briefly then lost power. One pilot‐rated witness reported that the engine “sputtered twice 

... and then nothing, pure silence. I ran to where I could see the plane and it was in a spin. 

... The plane came straight down. There was no forward motion. He had all that field 

in front of him. Why in the heck he didn’t get the nose down, I don’t know.” Witnesses 

reported that three parachutists exited the airplane while it was spinning but that the 

airplane was too low; one witness estimated the airplane was about 300 feet agl when the 

first parachutist jumped. The parachutists did not achieve successful deployment of their 

parachutes and did not survive.

A review of jump logs and conversations with the operator revealed that the pilot 

flew three lifts of jumpers to about 10,000 feet. Each flight was about 30 minutes long, and 

the accident flight occurred during the fourth lift. The airplane departed on its first lift 

with 30 gallons of fuel and was not refueled before the accident flight. Examination of the 

airplane revealed 8 ounces of fuel were drained from the selected tank. A leak test revealed 

no leaks, and all fuel system components were operational with no preimpact anomalies. 

The parachuting club did not have a standard operating procedures document, and the 

club operator reported that club operations were at his direction. 

According to the operator, the pilot was hired the day of the accident and was 

briefed on refueling procedures and how to measure fuel quantity in the tanks. The 

operator said that he provided briefings and demonstrated to the pilot in the airplane its 

flight characteristics, flight patterns, and jump procedures and that the pilot performed 

three takeoffs and landings during a 1.3‐hour familiarization flight. 

The operator provided weight and balance information, individual occupant 

weights, and a seating plan for the accident flight. The maximum gross weight for the 

airplane was 3,300 pounds and the aft cg limit was 47.27 inches aft of datum. Weight 

and balance figures for the accident flight were computed at a fuel weight of 60 pounds. 

Preliminary calculations revealed the airplane weighed 3,060 pounds with the cg at 

48.30 inches aft of datum. A weight and balance was also computed using the same 

figures, minus the first parachutist that departed the airplane. The calculations revealed 

the airplane weight to be about 2,898 pounds and the cg 48.76 inches aft of datum.

The pilot held a commercial certificate with ratings for airplane single‐engine 

land and instrument airplane. The pilot also held a private pilot certificate for airplane 

multi‐engine land, visual flight rules only. The pilot’s most recent third class medical 
National Transportation Safety Board 43

Appendix B

SPECIAL

Investigation Report

certificate was issued July 9, 1997. Records revealed that the pilot’s commercial certificate 

was issued on May 1, 1999; however, according to 14 CFR 61.39, “... to be eligible for a 

practical test for a certificate or rating issued under this part, an applicant must: Hold at 

least a current third class medical certificate, if a medical certificate is required.” 

The Safety Board determined that the probable cause of the accident was the 

pilot’s failure to refuel the airplane, which resulted in fuel exhaustion and a loss of engine 

power. Also causal to the accident was the pilot’s failure to maintain aircraft control after 

the power loss. Factors in the accident were a lack of published operational or safety 

procedures for the parachute club and the operator’s failure to verify the pilot’s medical 

qualifications. 

Mokuleia, Hawaii (LAX99LA190)

On May 22, 1999, a Beech B90, N301DK, operated by Pacific International Skydiving 

Center, crashed into the Pacific Ocean near Dillingham Airfield Airport, Mokuleia, Hawaii, 

and sank to a depth of about 156 feet. The airline transport pilot was not found and was 

presumed to have been killed; the 13 parachutists had already jumped from the airplane 

and were not injured.7 Ground witnesses observed that the airplane descended into the 

ocean in a left-wing-low, nose-down attitude. They did not hear the engines sputtering or 

popping or see the airplane make any erratic movements during its descent. Postaccident 

examination of the airframe, engines, and propellers revealed no preexisting impact 

anomalies.

Parachutists indicated that the two previous flights had been conducted at altitudes 

of at least 18,000 feet and that, during the accident flight, the parachutists jumped from 

20,000 feet. One parachutist stated that, during the accident flight, he felt sick and was 

having a difficult time breathing because they had been at 20,000 feet for an unusually 

long time before making the jump. He further stated that a couple of the parachutists 

had paid the pilot to get him to climb to that altitude for the last jump. Other parachutists 

reported that, before exiting the airplane on the accident flight at 20,000 feet, they asked 

the pilot if he was okay. They noted that he had been unable to maintain a steady course 

and that he did not respond well to minor course corrections; one parachutist reported 

that, when the pilot was asked to turn the airplane 5°, he would turn it 90° and that he was 

zigzagging in the air. 

No supplemental oxygen was found onboard the airplane during the recovery 

or subsequent examination of the wreckage, and no parachutists reported observing 

the pilot use supplemental oxygen. The airplane manufacturer noted that the airplane’s 

pressurization system would have been rendered inoperable due to a nonsealed cockpit 

door. According to 14 CFR 91.211, Supplemental Oxygen: “No person may operate a civil 

aircraft of U.S. registry ... at cabin pressure altitudes above 14,000 feet msl unless the 

required minimum flight crew is provided with and uses supplemental oxygen during 

the entire flight time at those altitudes.” Hypoxia is defined as a physiological condition 

7 Some of the information for this synopsis was obtained from the public docket for the accident.
National Transportation Safety Board 44

Appendix B

SPECIAL

Investigation Report

in which a person is bereft of needed oxygen. Judgment is poor and reaction time delayed. 

Total incapacitation, coupled with a loss of consciousness, can occur with little or no 

warning.

In addition, one of the parachutists stated that the accident flight was made after 

sunset and was performed without any lighting devices. Witnesses on the ground agreed 

that the accident happened about 20 to 25 minutes after sunset and that they noticed 

parachutists in the air with no lighting devices. According to 14 CFR 105.33, each person 

that jumps between sunset and sunrise should be equipped with a means of producing 

light that is visible for at least 3 miles. In addition, according to the chart supplement for 

the Pacific region, parachute jumps may be made at Dillingham Airfield up to 16,000 feet 

without filing a notice to airmen. According to an FAA inspector, during the accident 

flight, the pilot had not made any of the required radio calls to ATC, as required by 14 CFR 

105.14. The inspector further noted that a review of the recorded radar data for the area 

disclosed that the airplane’s transponder had not been turned on.

The Safety Board determined that the probable cause of the accident was the 

pilot’s incapacitation due to the effects of hypoxia from repeated flights to altitudes above 

18,000 feet msl without supplemental oxygen.

Marine City, Michigan (CHI99MA269)

On July 31, 1999, a Beech 65-A90, N518DM, operated by Parahawks Skydiving 

Center, crashed shortly after takeoff from Marine City Airport in Marine City, Michigan. 

The airline transport pilot and nine parachutists were killed. Witnesses reported that the 

airplane seemed to be operating normally during taxi and takeoff but that, during the 

climbout, the airplane did not climb above 150 to 250 feet agl. Witnesses report that the 

airplane entered a steep left bank, its nose dropped, and it crashed to the ground. Damage 

to the cockpit section of the wreckage indicated a nose-down crush angle of about 80o. 

Examination of the engines and propellers revealed no preexisting failures 

or conditions that would have prevented normal operation. The engines exhibited 

indications of rotation, and the witness marks on both sets of propellers were consistent 

with the propellers operating in the governing range at impact. Control continuity was 

established from the right aileron, elevator, and rudder. The investigation revealed that 

the maintenance records for the airplane’s required inspections were incomplete8

 and that 

there were no records of compliance with five airworthiness directives applicable to the 

accident airplane.9

8 The last inspection (Phase 1) entered in the maintenance records for the airframe was completed 

on August 25, 1997, and the last entries in the left and right engine logbooks were recorded on February 18, 

1998. A mechanic reported that he performed the airplane’s Phase 2 and Phase 3 inspections and that the 

last phase inspection (Phase 3) was completed on June 30, 1999. Work orders for the accident airplane 

and partially completed Beech Phase 2 and Phase 3 inspection forms, which did not specifically identify the 

accident airplane, were on file at the mechanic’s place of work.

9 According to the FAA inspector’s report in the public docket for the accident, with regard to the 

airworthiness directives, “without additional information these have to be considered not complied with.”
National Transportation Safety Board 45

Appendix B

SPECIAL

Investigation Report

The investigation also revealed Michigan State Motor Vehicle and court records 

indicating that the pilot had a history of arrests and convictions related to offenses 

involving alcohol and operating a motor vehicle. The first conviction on record was 

October 28, 1991, which resulted in a suspension of his driver’s license for 6 months. The 

second conviction was on August 9, 1996, which resulted in a 3-month suspension of his 

driver’s license. On September 11, 1998, the pilot was arrested on a charge of Operating 

Under the Influence of Liquor. The case had not come to trial at the time of the accident. 

According to the police report, the pilot was stopped about 0038 for improper lane use 

(weaving between the lanes of an interstate highway). The pilot failed a sobriety test and 

a preliminary breath test. A blood alcohol test indicated a reading of .12 grams of alcohol 

per 100 milliliters of blood. The arresting officer noted that “[The pilot] was advised that I 

suspected he was under the influence, and would be requesting him to take some sobriety 

test. At this point, [the pilot] asked me to just let him go, if I didn’t let him go, he would 

lose his job.”

The safety officer for the Parahawks Skydiving Center reported that, before the 

accident, he was unaware that the pilot had a record of alcohol-related offenses. The 

Parahawks Skydiving Center main pilot reported that he knew that the pilot had one 

driving while intoxicated incident but had not known of another offense. Both the safety 

officer and the main pilot reported that they learned about the accident pilot’s other 

alcohol-related offenses through newspaper articles written after the accident.

Although postaccident toxicology tests for the pilot detected quantities of ethanol 

in some specimens, it was not possible to determine the source of the ethanol and whether 

or not it could be attributed to ingestion or postmortem ethanol formation. Although 

witnesses reported that the pilot had attended a party the night before the accident 

(Parahawks Skydiving Center was having its annual celebration that weekend), a police 

officer (a recreational parachutist who saw the pilot about 20 minutes before the accident 

flight) described the pilot as being in a good mood, smiling, and laughing. He stated that 

he talked with the pilot and observed no evidence of any effects of alcohol. Similarly, 

another witness who saw the pilot about 40 minutes before the accident reported that she 

and the pilot drank coffee together while he checked the weather for the day. She reported 

that the pilot seemed sharp and well rested.

The Safety Board determined that the probable cause of the accident was the pilot’s 

failure to maintain adequate airspeed, which resulted in a stall, in‐flight loss of control, 

and collision with the ground. 

Bryan, Texas (FTW99FA261)

On September 18, 1999, a Cessna 182A, N4803D, operated by Ags Over Texas, 

crashed following a loss of engine power during takeoff from Coulter Field Airport near 

Bryan, Texas. The commercial pilot and the four parachutists were killed. Witnesses 

reported that, after takeoff, the airplane was climbing through about 300 to 400 feet agl 

when smoke became visible coming from the engine compartment. One witness reported 

that the airplane turned toward the runway and that the witness “thought it was going 
National Transportation Safety Board 46

Appendix B

SPECIAL

Investigation Report

back to Coulter Field Airport. A few seconds later I saw it go straight down.” Another 

witness stated that “the aircraft appeared to stall. The right wing dropped quickly, and 

the aircraft spun in, nose down, spin[ning] to the right, making one complete revolution 

before impacting the ground.” 

Examination of the engine revealed that the No. 6 cylinder head was separated 

where the cylinder attaches to the barrel. Metallurgical examination revealed that the 

cylinder head separated from its cylinder barrel as a result of fatigue cracking originating 

in the cylinder head thread. The cylinder displayed three work-order numbers on the 

flange skirt, indicative of the cylinder having had many hours of time in service and 

having been worked on at least three times. At the time of the accident, the engine had 

accumulated about 354 hours since overhaul. During that overhaul, six Nu-chromed 

overhauled cylinders were installed. It could not be determined how many hours the 

cylinders had accumulated nor how many times they had been overhauled. There is no 

requirement to track cylinder hours or overhaul occurrences.

The Safety Board determined that the probable cause of the accident was the pilot’s 

failure to maintain aircraft control, resulting in an inadvertent stall. A factor was the loss 

of engine power as a result of fatigue cracking and separation of the No. 6 cylinder head.

Fentress, Texas (FTW01LA132)

On May 27, 2001, a de Havilland DHC‐6, N125PM, collided in flight with a 

parachutist who had egressed another airplane (a Beech King Air 90) during a formation 

flight in the vicinity of Fentress, Texas. The parachutist who collided with the airplane was 

killed. Neither the commercial pilot and the 21 parachutists on board the de Havilland 

nor the commercial pilot and 8 parachutists on board the King Air were injured. Both 

airplanes, which were operated by Skydive San Marcos of Fentress, Texas, were being 

flown to perform a formation drop of parachutists from 14,000 feet msl. 

The operator reported that this was the first formation drop flight for either pilot 

in a multi‐engine airplane. Parachutists reported that the King Air and the de Havilland 

were initially in the correct formation with the King Air slightly behind, slightly right, and 

slightly lower than the de Havilland. Three parachutists climbed out of the King Air in 

preparation for the jump, and in the time that it took for those parachutists to climb out 

and for the loadmaster to tell the parachutists to exit, the King Air had flown past and was 

above the de Havilland.

The pilot of the King Air stated that the airplane approached the de Havilland’s 

right side and was “a little fast.” The King Air pilot reported that, upon seeing the de 

Havilland getting closer, the pilot decided to pitch and bank right to get more space and 

try to slow down. At that time, the pilot of the King Air lost visual contact with the de 

Havilland. Parachutists egressed from the King Air, and one parachutist collided into the 

right propeller of the de Havilland and began spinning out of control. The de Havilland 

pilot reported that “something suddenly hit the airplane” on what he thought was the 
National Transportation Safety Board 47

Appendix B

SPECIAL

Investigation Report

right wing. The airplane started to vibrate, and the pilot shut down the right engine. Both 

airplanes were landed without further incident.

One parachutist, a videographer, who had egressed from the King Air, reported 

seeing the spinning parachutist. The videographer caught the spinning parachutist and 

deployed her reserve parachute by pulling the reserve handle; however, the reserve 

parachute did not fully inflate “due to being cut by the propeller.” The spinning parachutist 

fell to the ground. The reserve parachute was found deployed.

The Safety Board determined that the probable cause of the accident was the King 

Air pilot’s inadequate in‐flight planning/decision in that he failed to remain in the agreed 

on formation position, resulting in one of his [parachutists] contacting the propeller of the 

de Havilland airplane. A contributing factor was the lack of total experience of both pilots 

in multiengine formation air drop flights.

Cushing, Oklahoma (FTW03FA174)

On June 21, 2003, a Cessna 182H, N8548S, operated by Oklahoma Skydiving Center, 

crashed following an in‐flight loss of control near Cushing, Oklahoma. The commercial 

pilot was killed, two parachutists were seriously injured, two parachutists received minor 

injuries, and one parachutist was not injured. One witness, who was standing next to the 

skydiving hangar, observed one parachutist jump from the airplane and then observed 

the airplane bank to the left and enter a “nose dive, spinning in circles.” Then, the witness 

observed two more parachutists exit the airplane. Another witness, who had a radio, 

observed the airplane “turn left and go into a flat spin, rotating to the left.” The witness 

radioed the pilot and asked what was wrong, and the pilot replied that he was in a spin 

and did not know what to do. The witness replied, “flaps and power.” When the airplane’s 

altitude was about 800 feet, the witness heard the engine go from a low power setting to 

a high power setting and noticed another parachutist jump out. The airplane appeared to 

slow down from its rotation and descended below the trees.

One parachutist, who was seated on the right side of the airplane next to the exit 

door, reported that, when the airplane was about 3,500 to 4,000 feet, he helped the first 

jumper out without incident. After observing the jumper for a few seconds, he closed the 

door and turned to assist the second jumper. The parachutist reported that, at this point, 

he heard the “stall buzzer” go off, felt the airplane pitch down and to the right, and heard 

the pilot say that the airplane had stalled. Then, the parachutist opened the door and said 

“emergency, everyone out!” 

Another parachutist, seated back-to-back to the pilot, reported that the airplane 

seemed to have a difficult time reaching 3,500 feet, the altitude designated for jumping. 

According to the parachutist, after the first jumper exited the airplane, the airplane started 

to turn left, and a buzzer went off. The parachutist reported that, as the buzzer was going 

off, the jumpmaster started talking to the pilot, then the nose of the airplane dropped 

“very quickly.” The parachutist heard the jumpmaster say, “Get ready for your emergency 

procedures, we have an emergency!” The jumpmaster then turned around, opened the 
National Transportation Safety Board 48

Appendix B

SPECIAL

Investigation Report

door, and jumped out. The parachutist tried to help one of the other jumpers exit the 

airplane, but she would not move, so the parachutist crawled to the door and fell out.

A third parachutist reported that the airplane’s left wing “pointed almost straight 

down” and that he thought the plane was “going to roll.” The pilot “corrected a little bit” 

but then banked again. The parachutist stated that the pilot got very busy and instructed 

everyone to leave the airplane. The parachutist stated that they started shuffling around 

to try and help one of the other jumpers exit the airplane. He stated that he moved up 

behind the pilot’s seat and was looking at the jumpmaster and that the jumpmaster dove 

out. As the parachutist was helping one of the other jumpers, he pushed out the jumper 

who was also helping him, so he grabbed the last remaining jumper and started pushing 

her toward the door. He stated that he heard the airplane’s engine “rev” and mentioned 

to the other jumper that he thought that the pilot had regained control of the airplane. He 

reported that the next thing he remembered was waking up with paramedics attending 

to him.

Examination of the airplane revealed that it impacted terrain in a wings-level 

attitude. No anomalies with the airplane were found. According to the factual report 

for this accident, the airplane was equipped with a Continental O‐470‐R engine that had 

accumulated 2,652.4 hours since major overhaul. 

The Safety Board determined that the probable cause of the accident was the pilot’s 

failure to maintain airspeed, which resulted in an inadvertent stall/spin.

Jacksonville, Florida (MIA05FA017)

On October 30, 2004, a Cessna P206, N2588X, registered to PTP, Inc., and 

operated by Jacksonville Extreme Sports, crashed shortly after takeoff from Herlong 

Airport, Jacksonville, Florida. One parachutist was killed, the commercial pilot and three 

parachutists were seriously injured, and one parachutist received minor injuries. Several 

witnesses at the airport reported that, shortly after the airplane lifted off, it entered a steep, 

nose-high attitude then pitched nose down, rolled left, and disappeared behind trees. 

One parachutist reported that the airplane pitched up after becoming airborne. He 

moved forward and noticed that the pilot was “frantically” moving the elevator trim wheel 

4 or 5 times toward the nose-down direction. The parachutist stated that the airplane then 

descended in a left-wing-low attitude. The parachutist and several witnesses at the airport 

reported hearing no discrepancies with the engine.

According to the factual report for this accident, the airplane was equipped in 

2001 with a new Teledyne Continental Motors IO-550-F engine that had accumulated 

1,774 hours since new. Examination of the airplane revealed no evidence of preimpact 

failure or malfunction of the engine, and flight control continuity was confirmed for 

roll, pitch, yaw, and pitch trim. The elevator trim tab actuator was measured and found 

extended approximately 1.2 inches, which is consistent with about 10° tab down (airplane 

nose up). The airplane’s before‐takeoff checklist indicates to set the elevator trim to the 
National Transportation Safety Board 49

Appendix B

SPECIAL

Investigation Report

takeoff setting; the maximum elevator trim trailing-edge-down takeoff setting is 4o. The 

pilot reported that he had twice previously performed takeoffs in the accident airplane 

when the elevator trim was in the full nose-up position and that, during those occasions, 

he moved the elevator trim to the nose-down direction and continued the takeoff.

The Safety Board determined that the probable cause of the accident was the 

improper setting of the elevator trim by the pilot-in-command, his failure to follow the 

checklist related to elevator trim setting, and his failure to maintain [airspeed] during 

climb after takeoff, resulting in an inadvertent stall, uncontrolled descent, and in‐flight 

collision with terrain.

Deland, Florida (MIA05LA096)

On April 23, 2005, a de Havilland DHC-6, N24HV, operated by Skydive Deland, 

Inc., collided with a cinematographer parachutist during the downwind leg for landing 

at Deland Municipal-Sidney H. Taylor Field, Deland, Florida. The cinematographer 

parachutist was killed, and the commercial pilot and 13 parachutists were uninjured. The 

airplane incurred substantial damage to the left wing.

The pilot stated that, after the 14 jumpers left the airplane at 13,500 feet, southwest 

of the airport, he started his descent to the northeast. He approached the airport from 

the northeast, overflew the airport, and made a left turn to enter the downwind leg for 

runway 23. He stated that he saw some parachutes on the ground and some in the air and 

that he believed that he had accounted for all jumpers. As he turned left, he saw a flash of 

colors and felt an impact and drag from the left wing. He landed the airplane as soon as 

possible. 

Radar data indicated that the airplane was about 1,300 feet msl when it was 

approaching the runway from the northeast; the airport elevation is 79 feet msl. The 

airplane flew about 1,100 feet msl over runway 23 near midfield and was between 900 to 

800 feet msl during the left bank entering the downwind for runway 23. The last radar 

capture showed the airplane at 300 feet msl as it approached runway 23. One parachutist 

stated that the parachute landing zone was located on the airport adjacent to the left side 

of runway 30. The published traffic pattern attitude for the airport is 1,000 feet agl for 

propeller airplanes.

One of the master tandem jumpers on the accident flight stated that the pilot did 

not give a briefing on which runway or approach he was going to use. The company’s 

procedure is for the parachutists to avoid crossing runways below 1,000 feet and to stay 

about 300 feet away from the runways and for the pilot to avoid jumpers at all times. Due 

to the amount of jumps that are performed per day, there is no briefing before each flight. 

Approaches and runway selection depends on the individual pilot. A representative of 

the operator stated that only verbal guidance is given to the pilots to follow the FAA 

rules and that it is left to the pilots’ discretion for approaches and runway selection. The 

acting airport manager stated that there is no agreement for airport operations between 

Skydive Deland and the city. Several pilots at the airport stated that, for several years, 
National Transportation Safety Board 50

Appendix B

SPECIAL

Investigation Report

they communicated with the city regarding safety concerns with approaches and runway 

selection by the parachute jump operator. They stated that the city did not correct the 

situation. 

The Safety Board determined that the probable cause of the accident was the pilot’s 

inadequate visual lookout.

Sullivan, Missouri (CHI06FA210)

On July 29, 2006, a de Havilland DHC-6-100, N203E, operated by Skydive 

Quantum Leap, crashed into trees and terrain following a loss of engine power in the 

right engine shortly after takeoff from Sullivan Regional Airport near Sullivan, Missouri. 

The pilot and five parachutists were killed, and two parachutists were seriously injured. 

According to photographic evidence provided by a witness, the airplane was taxied onto 

the runway from an intersecting taxiway about 1,700 feet from the runway’s west end; 

the airplane began its takeoff roll to the west from that location. Witnesses at the airport 

reported that they saw the airplane take off and climb to about treetop height, then they 

heard a “poof” or “bang” noise and saw flames and smoke coming from the right engine. 

Witnesses reported that the airplane lost some altitude but regained it, then flew at a 

level altitude about treetop height and turned to the right, disappearing from their view 

behind the treeline. Another witness, who was in the back yard of a residence located 

about 1/2 mile northwest of the end of the runway, stated that she saw the airplane flying 

straight‐and‐level but very low, then it dived nose first to the ground.

Disassembly examination of the left engine revealed rubbing in the compressor 

and turbine sections. No preimpact anomalies were detected. Disassembly of the right 

engine revealed that the compressor turbine disk was intact and its attached blades10 were 

fractured. Microscopic examination of the fracture surfaces revealed features consistent 

with overload. No preimpact anomalies were observed forward of this point in the 

engine’s gas path. The left and right engines had accumulated 5,829 hours and 6,493 hours 

since overhaul, respectively. According to Pratt & Whitney SB 1803R1, the manufacturer’s 

recommended time between overhaul for the engines is 3,600 hours.11

Examination of both propellers revealed no preimpact anomalies. Examination of 

the right propeller assembly revealed that the blades were at high angles at impact, which 

corresponds to a feather or near-feather condition and that the blades cycled from high to 

low pitch when air pressure was applied to a fixture attached to the hub’s mounting flange. 

Because of the impact damage to the cockpit propeller lever controls, it was not possible 

to determine their preimpact positions. The investigation revealed that the propeller 

autofeather system had been inoperative since the operator acquired the airplane in 2001 

and that its status was placarded in the cockpit. According to 14 CFR 91.213, no person 

may take off in a turbine‐powered airplane with inoperative instruments or equipment 

10 The compressor turbine blades were FAA PMA blades manufactured by Doncasters, Inc,, Turbo 

Products Division, part number T-023401J.

11 Pratt & Whitney Canada reported that it had no documentation indicating that the operator had 

requested to participate in a TBO extension program.
National Transportation Safety Board 51

Appendix B

SPECIAL

Investigation Report

installed unless an FAA‐approved minimum equipment list (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.

The FAA’s St. Louis FSDO had jurisdiction over the geographic area that included 

Skydive Quantum Leap’s operations. Following the accident, a review of FAA Program 

Tracking and Reporting Subsystem (PTRS) data and Safety Performance Analysis System 

(SPAS) data showed three SPAS records of FAA contacts with Skydive Quantum Leap 

regarding the operator’s Certification of Waiver or Authorization Application requests for 

airspace associated with the parachute operations. No PTRS or SPAS data showed records 

of any FAA contacts with the operator for maintenance or operations surveillance. 

The Safety Board determined that the probable cause of the 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.

Marion, Montana (SEA07FA119)

On May 12, 2007, a Cessna 182C, N8771T, collided with terrain while maneuvering 

for a precautionary landing shortly after takeoff from Carson Field Airstrip, Marion, 

Montana. The commercial pilot and four parachutists were killed. Witnesses observed 

the airplane take off from runway 32, make a 180o turn toward the south, and then fly 

downwind and parallel to the runway at an altitude of between 300 and 500 feet agl. 

Near the end of the runway, the airplane made a left turn onto the base leg for runway 32, 

followed by a steep turn to the final approach before nosing into the ground and bursting 

into flames. 

Examination of the airplane revealed that the engine’s oil cap was not attached to 

the oil filler tube. As a result of the engine’s oil filler cap not being secured to the oil filler 

tube, it is reasonable to expect that an amount of oil would have escaped the engine and 

blown back over the pilot’s windscreen, thereby obstructing his vision. Further, weight 

and balance information for the flight indicated that the airplane was about 165 lbs over its 

maximum gross takeoff weight. The obstructed windscreen, coupled with the airplane’s 

gross takeoff weight being exceeded, would most probably explain the pilot’s loss of 

control while attempting to return to the runway. No preimpact anomalies were noted 

with either the airframe or the engine.

The Safety Board determined that the probable cause of the accident was the 

pilot’s failure to maintain aircraft control while maneuvering to reverse direction. Factors 

included the airplane exceeding its maximum gross takeoff weight, improper preflight by 

the pilot by not securing an oil cap, the low altitude, and an obstructed windshield. 
National Transportation Safety Board 52

Appendix B

SPECIAL

Investigation Report

Mount Vernon, Missouri (DEN08FA078)

On April 19, 2008, a Cessna P206, N2537X, operated by Freefall Express Skydiving, 

Inc., impacted terrain following an in‐flight loss of control near Mount Vernon, Missouri. 

Two parachutists were killed, the commercial pilot and one parachutist were seriously 

injured, and three parachutists were not injured. This accident was under investigation at 

the time of this report’s release.12

According to two of the surviving parachutists, the airplane had climbed to 

10,500 feet msl, and the pilot signaled for one of the parachutists to open the door. When 

she did, she noticed that the airplane had overshot the drop zone by about 1 mile, and 

she informed the pilot. She stated that, as the airplane started to make a right turn, the 

stall warning horn sounded, and the airplane “rolled off on its right wing” and entered a 

spin. Three parachutists exited the airplane and parachuted to safety. A fourth parachutist 

broke her right leg as she exited the airplane, but she parachuted to safety. The reserve 

parachute on the fifth parachutist deployed but became entangled around the tail of the 

airplane; she was killed. The sixth parachutist, who also did not survive, was found inside 

the airplane.

Examination of the accident site revealed that the airplane impacted trees and 

terrain and came to rest in a nose-down, slightly inverted attitude. Chop-like marks were 

evident on several tree trunks. Preliminary examination of the airplane revealed that flight 

control continuity was established.

12 Preliminary information is subject to change and may contain errors.