NTSB Cites Flutter As Cause of Reno Air Race Crash

The NTSB has determined that the probable cause of the Galloping Ghost’s crash at last year’s Reno Air Races was flutter. No surprise there -- I wrote about flutter within hours of the accident. At its presentation, the NTSB even showed the same NASA video demonstrating flutter that I had posted last year.

Flutter can occur whenever an aircraft is flown faster than it is designed to fly. As it turned out, Jimmy Leeward, the pilot of Galloping Ghost, exceeded by nearly 40 mph the aircraft’s previous top speed without any previous testing to determine if the aircraft would be able to resist flutter at the new speeds. As it turned out, it couldn’t. Board member (and pilot) Robert Sumwalt was highly critical of Leeward’s decision to fly the aircraft in competition without first testing it at race speeds:

If you want to go out and fly fast and try to win, that's one thing. If you're modifying an aircraft without fully understanding how the modifications can affect the aerodynamics, you're playing Russian roulette.”

A loose trim tab assembly contributed to the flutter’s onset. The assembly came apart because the lock nuts that held it in place had been reused multiple times. That’s a no-no. Each time locknuts are removed and then re-tightened, they lose a bit of their ability to grip. That’s why once removed, locknuts should always be replaced with new.

What was surprising was the NTSB’s sentiments concerning “assumption of risk”.  According to the NTSB board chair Deborah Hersman:

At the heart of the tragedy was the fatal intersection in transference of risks from participant to observers. One moment, spectators were thrilled at the spectacle of speed only to have it followed by inescapable tragedy. The pilots understood the risks they assumed. The spectators assumed that their safety had been assessed.”

Those sentiments echoed what I wrote here.  Judging from readers’ comments to that post, many disagree.

Transcript of the NTSB presentation here.

All this blog's Reno Air Crash posts here.

Reno Air Crash: NTSB Critical of Race Organizers' Tracking of Aircraft Discrepancies

No conclusion yet as to exactly what caused the Galloping Ghost to crash last September at the Reno Air Races. But the interim report the NTSB issued today disclosed that the Galloping Ghost experienced an “upset” 6 seconds before it lost its left elevator trim tab. That, in turn, caused the aircraft to go out of control.  None of that  information is really new, and was discussed shortly after the accident in this post and in the post's many thoughtful comments.Galloping Ghost vs. Unmodified P-51D

The NTSB also issued safety recommendations that specifically questioned whether the Galloping Ghost had been properly tested at race speeds or otherwise evaluated for resistance to “flutter;” an aerodynamic phenomenon that can destroy an aircraft in seconds. But that’s not news either -- flutter and its possible role in this crash was discussed the day after the crash here.

There is one fact, however, that we didn’t know before. Race officials inspected the aircraft just before the race and determined that the aircraft’s trim tab’s screws were too short. But the NTSB could find no documentation that the screws had been replaced and the discrepancy resolved before the race started. Though the race inspector stated that he verified that all the aircraft’s discrepancies had been resolved, the NTSB recommended that, in the future, race organizers develop a system that tracks discrepancies found during pre-race technical inspections and ensures that they have been resolved before an aircraft is allowed to race As the NSTB put it:Trim Tab - Reno NTSB

without a method to track discrepancies to resolution, conducting pre-race inspections is of limited value.

The NTSB’s interim report doesn’t say whether the screws were, in fact, replaced. For that, we’ll have to wait for the NTSB to issue its factual report. But even without a system for race officials to track discrepancies, whenever a mechanic performs any work on an aircraft, he is supposed to record that work in the aircraft’s maintenance logs.  If there’s no entry in the Galloping Ghost’s logbooks showing that the screws were changed, that’s evidence that the work wasn’t done, or at least wasn’t done properly.

Besides recommending that race officials establish a better system of ensuring that aircraft discrepancies are repaired before race time, it issued recommendations that would, among other things:  

  • Require race pilots to be trained to tolerate or avoid high g-loadings;
  • Revise the mathematical formulas used to lay out the race courses;
  • Require aircraft to be tested at race speeds before they be allowed to compete; and
  • Require pilots to practice on the actual race course before being allowed to compete.

 

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NTSB to Quiz Air Show Industry Leaders

The NTSB says that during tomorrow’s hearing, it will be looking to industry leaders to give it a “deeper understanding of regulations” bearing on the operation of the nation’s air shows. Of course, the only regulatory body that has the authority to control air shows is the FAA. But what the Board will find -- if it asks the right questions -- is that for the most part, the industry regulates itself. According to one veteran air racer, Howie Keefe, the FAA is more or less “hands off” when it comes to air show safety. From Martha Bellisle’s article in the Reno Gazette-Journal:

Keefe said the industry is largely self-regulated because the pilots and engineers are the most qualified to determine whether another pilot can handle a certain race or course or whether a certain design can handle the stress of a trick or race. ‘The classes themselves can say yes or no to a person who wants to race — if they can’t do a roll, they can’t race,’ Keefe said. ‘The FAA can’t do that. We rely on the expertise of the people in the industry to make the decisions.’

Perhaps a “hands off” policy is fine for the participants. But not so much for the spectators, who expect that if the FAA approves an event, it is overseeing the event’s safety in some meaningful fashion, and not merely turning the reins over to the event sponsors.

This Board says that the purpose of tomorrow’s public hearing is to help it investigate future air show accidents. But this Board is more assertive than past boards. There’s little doubt that it will find the FAA’s oversight lacking. The question is whether it will do anything about it.

Reno Air Race Disaster: Airport Seeks to Influence NTSB Investigation

The NTSB excludes family members from its accident investigations.  But it allows those who may have caused or contributed to a crash to participate.  That's an obvious conflict of interest.  As a result, NTSB probable cause findings are not always impartial.  Instead, they tend to favor the industry players.  Reno-Tahoe International

The industry players have long argued that, while they may be allowed behind closed doors to assist the NTSB in their investigations, they would never seek to influence the investigation's outcome. 

Yeah, right.

The Reno-Tahoe Airport Authority, which owns Reno-Stead Airport, has dropped the pretense of "just wanting to help the NTSB find out what happened."  Rather, it has gone whole-hog in seeking to actually influence the investigation of the Reno Air Race Disaster.  In fact, it has hired professional help from a Washington lobbying firm. 

You won't find that information on the Airport Authority's website.  But you will find it in papers filed in Washington, DC. According to  The Hill:

The Reno-Tahoe Airport Authority has hired Gephardt Government Affairs to lobby on the “government investigation of crash at Reno Air Races,” according to new lobbying forms released this week.

An NTSB investigation is not supposed to be a political process.  It's hard to imagine anything more inappropriate than hiring lobbyists to influence its outcome.

But that is what it has come to. 

Thankfully, we still have the jury system.  No lobbying allowed there.  Everything has to be done in open court, for all to see.

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Reno Air Race Lawsuits and the Assumption of Risk Defense

There are obvious dangers inherent in events such as the Reno Air Races. The victims of the disaster were undoubtedly aware of those dangers and attended the event anyway. Does that mean they should not be able to file lawsuits to obtain compensation for their loss? 

Not at all.

Granted, Life is Full of Risks

There are risks involved in most everything. We take a chance every time we cross the street. But it’s nonetheless reasonable for us to believe we will be safe when we are in the crosswalk. When we use the crosswalk, we are where we are supposed to be.

If an SUV hits someone in the crosswalk, we may all agree it was “just an accident.” Yet, we require the driver to compensate the pedestrian for his injuries. If the driver couldn’t see the pedestrian because the crosswalk was poorly designed, we might require the city to compensate the pedestrian. In either case, we don’t tell the pedestrian that he is out of luck because he assumed the risks of getting hit by a car.

It doesn’t matter that the driver had a very good driving record up to that point in time. While we don’t punish those responsible for an accident, we do hold them accountable and require them to compensate the person who, through no fault of their own, is seriously hurt.

The victims at Reno undoubtedly understood that there were risks associated with the Air Races. But they were exactly where they were supposed to be. Sure, the crash was an accident. But that doesn’t mean whoever is responsible for the injuries – whether that is a mechanic or a course designer -- shouldn’t compensate the victims for their losses.

The Race Sponsors Were Supposed to Provide Patrons with a Safe Viewing Area

Some say that Nevada law lets sponsors off the hook for injuries to spectators.  And it's true that, in Turner v. Mandalay Sports Entertainment, the Nevada Supreme Court said that a baseball stadium was not responsible for serious injuries a fan sustained when she was struck by a foul ball. But in that case, the fan was not in the viewing area. Had the fan been injured in a viewing area, the result might have been different. That’s because the court recognized that a ballpark has a duty to provide the patrons with at least some designated safe seating.

Once a stadium owner or operator complies with the rule's requirements by providing sufficient protected seating, the owner or operator has satisfied the legal duty of protection owed to its patrons.

The Reno Air Race victims were in the designated viewing area. They were exactly wReno Air Race Tickethere they were supposed to be. But it appears that the sponsors failed to ensure that the area was safe. Turner v. Mandalay would thus seem to support the victims’ claims for compensation, not undercut it.  

The Language on the Ticket Is Not a Contract

A reader of this post noted that, according to the tickets sold for the event, the spectators voluntarily assumed all the risks and released the event sponsors from liability for any injuries.  Isn’t that the end of the matter?

No.

Sure, a spectator can, by contract, agree ahead of time not to sue if he is injured, even if the person who caused the injury was negligent. But for there to be a contract, there has to be an agreement. If the spectator actually signed something, then that would be one thing. Without the victim’s signature, the fine print on the ticket won’t be binding on anyone. 

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Reno Crash Victims' Lawsuits Against the FAA Will Face Hurdles

The FAA was supposed to protect the Reno Air Race spectators by, among other things, assuring that the race course design was safe. It failed to do so. Do the victims have a right to bring a lawsuit against the FAA?

Sovereign Immunity.

The FAA or, more accurately, the United States government can be sued just like any other individual, when it’s negligence contributes to a citizen’s injury or death. There are some important limitations, however. For example, the FAA cannot be sued if it’s employee -- in committing the negligent act -- was acting within his discretion. Rather, the “Discretionary Function Exception" protects the government from liability in those circumstances. The government can, however, be sued when someone is injured or killed as a result of an FAA employee’s failure to follow the FAA’s own rules. The theory is that, when in that circumstance, the employee had no “discretion.” If he was supposed to follow rules, and didn’t, and as a result someone is killed or injured, the government is liable.

FAA’s Involvement in the Reno Air Races.

The FAA approved the pilots, the planes, and the design of the course. For purposes of illustration, let’s discuss only the design of the course. For an FAA employee to approve a race course, the course design must meet certain requirements. FAA Order 8900.1 spells those out in detail. Some of the math involved is set forth on the right. The math is a bit complicated. But in short, the requirements are supposed to ensure that a plane is never pointed at the crowd, and to otherwise keep the spectators safe if something goes wrong with a plane or a pilot.

If a proposed course design didn’t comply with the requirements set forth in Order 8900.1, and an FAA employee approved it nonetheless, the FAA is potentially liable. That’s because the employee has no discretion to approve a course that doesn't comply with the rules. If a course doesn't comply with the rules, the FAA employee is supposed to reject it.

What if the course design complied with the requirements of Order 8900.1, but the victims prove that the Order’s requirements were too lax to protect the public from harm, and that they should have been more stringent? Then the victims will have a much harder time suing the government. Deciding what the rules should be is a task likely within the FAA’s discretion. Thus, the government would assert the “discretionary function” defense to the victims’ lawsuit.

 Reno Race Course Design

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Reno Air Race Disaster No Freak Accident

Hall of Fame aerobatic champion Patty Wagstaff says that it was just bad luck that Jimmy Leeward's accident involved spectators.

At the speeds Leeward was moving, had the malfunction occurred four seconds earlier or later, or almost anywhere else on the course, it would have terminated in the desert.  This was not an accident waiting to happen – this was a freak accident.

Patty, this was not the first time that flutter sent a highly modified warbird out of Patty Wagstaffecontrol during the Reno Air Races.  It happened in 1998, when flutter ripped a trim tab from a P-51 called "Voodoo."  Bob Hannah, the pilot, immediately found himself heading straight up, just as Jimmy Leeward did.  Hannah lost consciousness from the high g-loading, but regained his senses as the aircraft rolled over the top.  Unlike Leeward, Hannah landed safely.

So, though it's too early to say for certain, it looks like Leeward's precise airframe failure -- or something pretty darn close -- actually happened before.  And sure, Leeward's failure could have just as easily occurred somewhere else along the nine mile course, and not at show center. But that doesn't make it a "freak accident," any more than losing at Russian Roulette can be considered a freak accident. 

Nope. This was an accident waiting to happen.

The warbird pilots push their aircraft to their limits and beyond.  That's why it's called "Unlimited" racing.  No one would deny pilots, fully aware of the risks they are taking, the right to fly their aircraft to the point of destruction.  It is, after all, their own lives that they are risking over the Nevada desert.  But they should not be permitted to place spectators at risk.  Pilots might be willing to flirt with death.  But that's not what spectators bargain for.

Sorry, Patty.  Leeward's crash was no "freak accident."  And suggesting it was is not fair to the victims.

 

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Reno P-51 Pilot a Hero?

That's what some press reports are saying.  Had Jimmy Leeward not maneuvered the stricken plane as he did, things could have been much worse.

"The way I see it, if he did do something about this, he saved hundreds if not thousands of lives because he was able to veer that plane back toward the tarmac,” Johnny Norman, who was at the show, told the Associated Press.

That's a nice thought.  But it's probably not true.  Leeward likely was unconscious for most of the accident sequence, unable to veer the aircraft anywhere.

This isn't the first time a P-51 lost its trim tab at the Reno Air Races.  It happened once in 1998, when flutter ripped a trim tab from a P-51 called "Voodoo." Bob Hannah, the pilot, immediately found himself heading straight up, just as Jimmy Leeward did.  Hannah lost consciousness from the high g-loading, regained his senses as the aircraft rolled over the top, and saved the aircraft.  

As reported by AvWeb,

You OK Bob?" called Hinton. "Yea, this thing just popped big time," replied Hannah. What Hannah didn't mention is that the g-load from the quick pull-up had caused him to black out. He finally managed to reach the throttle and reduced Voodoo's power. At that point Hannah radioed that he "(wasn't) out of it yet," but he wasn't thinking clearly. Later, he declared a mayday and made a perfect landing. . . . On the ground one could see what cause Voodoo's problems during the race. The left elevator torque tube failed when the elevator trim fluttered and departed the plane.

It's quite possible that Leeward blacked out just like Hannah did in 1998 but, unlike Hannah, never regained consciousness. 

TGalloping Ghost Cockpitake a look at the two pictures of Leeward's aircraft, the "Galloping Ghost."  The photo on the left is the cockpit before takeoff.  Leeward's helmet is clearly visible.  The frame on the right is the cockpit during the dive, a second before impact.  Leeward is nowhere to be seen.  Perhaps he is slumped over, unconscious.  Regardless, it's hard to imagine that Leeward was in any position to control the aircraft's flight path.

Galloping Ghost/Jimmy Leeward

 

 

 

 

 

 

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Reno P-51 Mustang Lost Elevator Trim Tab

This photo, taken moments before the crash, shows that the P-51 had lost its left elevator trim tab. (I've circled the spot where the trim tab should be.) Without the trim tab, the aircraft may have been uncontrollable.

AP Photo/Grass Valley Union/Tim O'Brien

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Original Photo by Tim O'Brien, Grass Valley Union (AP).)

Why did the aircraft lose its trim tab?  One possibility is "flutter," an aerodynamic phenomenon that can, once it starts, damage a control surface quite suddenly.  Here's a NASA video of flutter in action.

 

 

 

An aircraft is at risk of flutter when its airspeed pushes up against or exceeds its design limits.

 

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