WPR14FA182

The pilot's failure to maintain clearance from the runway during a low-level aerobatic maneuver due to his impairment by an over-the-counter antihistamine. Contributing to the severity of the pilot's injuries were the pilot's lack of fire protective clothing, his inability to egress the cockpit, the rapid spread of the fire, and the decision of the air show's organizers not to have the airport rescue and firefighting services at their highest level of readiness, which delayed arrival of fire suppression equipment.

The highly experienced air show pilot was attempting to cut, with the vertical stabilizer of his biplane, a ribbon that was suspended about 20 feet above and across the runway. He was performing the maneuver on the third day of an open house at a United States Air Force (USAF) base and had successfully accomplished the maneuver on the two previous days, as well as at many previous air shows. After the pilot rolled the airplane inverted for the pass, witnesses observed it descend smoothly to the runway and slide to a stop. As the airplane came to a stop, a fire erupted, and the airplane was completely engulfed in flames within about 90 seconds of the fire's start. The first fire suppression vehicle did not reach the airplane until more than 4 minutes after the fire began, and the fire was extinguished soon thereafter. The investigation did not identify any preimpact mechanical deficiencies or failures of the airplane or any adverse weather conditions that contributed to the abnormal runway contact. Toxicology analysis detected therapeutic amounts of diphenhydramine, an over-the-counter sedating antihistamine, in the pilot's blood, which likely impaired his ability to safely complete the maneuver and resulted in the abnormal runway contact. The pilot was found lying on the upper panel of the cockpit canopy, and the canopy was found unlatched but in its closed position, indicating that when the airplane came to a stop, the pilot was likely conscious and attempted to exit the airplane; however, he was unsuccessful. The investigation was unable to determine when the pilot released his harness restraint system. If he released his harness before attempting to open the canopy, he would have fallen onto the canopy, which would have significantly increased the difficulty of opening the canopy. Even if the pilot did not release his harness before attempting to open the canopy, airframe damage and the canopy opening geometry would have prevented the full opening of the canopy, limiting the pilot's ability to exit. Further, the canopy was not equipped with any emergency egress provisions, such as quick-release hinge pins. Finally, the pilot's lack of a helmet or any fire protection garments increased his susceptibility to thermal injury and reduced his useful time to effect an exit, particularly given the rapidity of the fire's spread. Although initially a survivable accident, the combination of pilot egress difficulties, the rapid fire growth, and the more than 4-minute firefighting response time altered the final outcome. The USAF primarily based its Airport Rescue and Fire Fighting (ARFF) plan for the air show on Department of Defense (DoD) and USAF guidance. In preparation for the open house, the USAF show director had attended an International Council of Air Shows (ICAS) trade show and briefing, where he was provided with ICAS guidance material that advocated the highest state of readiness for the ARFF teams. This entailed prepositioning the ARFF equipment, with the ARFF personnel fully suited in their protective gear, ready for immediate travel to and engagement in the rescue and firefighting efforts. For undetermined reasons, either that information was not communicated to the show organizers and ARFF planners or the responsible personnel and departments elected to disregard it. The organizers and planners made the decision to maintain the facility's ARFF readiness state at the DoD-defined "unannounced emergency" level during the air show, instead of the highest state of ARFF readiness advocated by ICAS. Based on the available evidence, if the ARFF teams had been at the highest state of ARFF readiness, the pilot's likelihood of survival would have been significantly increased. The hazards imposed by low-level inverted flight included inadvertent ground contact, impact damage, and fire. The pilot had multiple strategies available to manage or mitigate the hazards' attendant risks. These included ensuring that he was in appropriate physiological and psychological condition to operate safely, wearing appropriate protective clothing, and ensuring an appropriate level of airplane crashworthiness including occupant escape provisions. The availability of ARFF services represented the final element of the risk management process, necessary only if all the other strategies failed or were otherwise ineffective. In this accident, the pilot either intentionally or unknowingly weakened, defeated, or did not implement several risk mitigation strategies: he was likely impaired by medication, he did not wear any protective clothing, and his airplane was not well-equipped from an occupant-escape perspective. The combination of these factors then resulted in the pilot being fully dependent on the timely arrival of ARFF personnel and equipment for his survival. The failure of the ARFF personnel and equipment to be at their highest level of readiness and to arrive in a timely manner was not the first, but rather the last, failed element of the overall risk-management scheme.

Review of video and still images revealed that fire became visible just as the airplane stopped moving, and some patches of fire were visible on the ground along an apparent fuel trail aft of the airplane. Once the airplane came to a stop, the fire appearance was initially consistent with a "pool fire," which is the combustion of a liquid pooled on the ground. However, the fire enlarged quickly, and within about 50 seconds, the fire encompassed most of the right (downwind) side of the airplane. The airplane was completely engulfed by the fire about 1 minute and 32 seconds after the airplane stopped. Review of the still and video imagery, and the wreckage, indicated that at first the fire was consistent with liberated gasoline spilled on the ground, but the fire developed rapidly thereafter. It began consuming the airplane skin and structure, and damaged the fuel lines and tanks, which permitted the liberation of additional onboard flammable fluids, including gasoline and oil. Review of photographic and other documentation indicated that the flames were no longer visible about 5 minutes and 17 seconds after impact, or about 15 seconds after truck-provided fire fighting agent began contacting the fire. USAF information indicated that the fire was "knocked down" (significantly reduced) about 6 minutes and 38 seconds after it started, and that it was extinguished about 9 minutes after it started. The fire-fighting activities are detailed in a separate section below. According to information provided by first responders, after the fire was extinguished, the pilot was observed to be within the cockpit, lying on his back on the upper canopy frame, with his head towards the tail. The airplane fuselage had settled slightly during or subsequent to the fire, so that the top of the canopy was resting on the runway surface. Photographs taken prior to the recovery of the pilot showed that the movable left side canopy panel was unlatched, but essentially in its closed position, with at least its aft guide pins still in the canopy track. Due to lack of evidence, the investigation was unable to determine when the pilot unfastened his restraint system. With the airplane inverted, release of the restraint system prior to an attempt to open the canopy would result in the pilot's fall onto the canopy, which would interfere with his ability to open the canopy. The pilot was not wearing a helmet, and there was no evidence that he was wearing any garments or equipment designed for thermal/fire protection, including gloves. National Fire Protection Association The National Fire Protection Association (NFPA) is a trade association that develops and distributes standards for fire fighting and rescue response, including airport ARFF equipment and staffing provisions. NFPA establishes recommended airport ARFF equipment and staffing provisions ("level of protection") based on "the largest aircraft scheduled into the airport." NFPA guidance did not cite any standards specifically or exclusively for air shows, airport open houses, or other non-standard situations or events. NFPA Standard 403 (Standard for Aircraft Rescue and Fire-Fighting Services at Airports) included the following specifics regrading ARFF vehicle siting: - ARFF vehicles shall be garaged at one or more strategic locations as needed to meet required response times. - Emergency equipment shall have immediate and direct access to critical aircraft movement areas and the capability of reaching all points within the rapid response area (RRA) in the time specified. - Therefore, the location of the airport fire station shall be based on minimizing response time to aircraft accident and incidents. - The response time of the first responding ARFF vehicle to reach any point on the operational runway and begin agent application shall be within 3 minutes of the time of the alarm. FAA Air Show Guidance and Requirements The USAF/SUU required FAA approval to conduct its open house and air show. FAA approval was granted in the form of FAA Form 7711-1, "Certificate of Waiver or Authorization." Chapter 6 of FAA Order 8900.1 contained the guidance for the issuance of the waiver/authorization. The USAF/SUU ("the applicant") was responsible to apply for the waiver/authorization to the responsible FAA office, which was the Sacramento Flight Standards District Office (FSDO). The Order specified that the FAA inspector assigned to the event "should work closely with the responsible [event] person to develop normal and emergency plans, briefings, and checklists." The waiver for the air show was approved by the FAA on March 28, 2014. Order 8900.1 required that the applicant "should attach current, properly marked maps, drawings, or photographs of the planned area of operation" which must include the "location of the boundaries of the air show demonstration area, the location of the primary spectator area, [and] the location of the emergency vehicles and medical facilities." Order 8900.1 required that a pre-show briefing must occur on every day of the show, and provided guidance in both narrative and checklist form. The guidance specified that attendees should include all air show pilots, the Air Boss, air traffic control, the "fire chief/CRS" [crash/rescue services], and an FAA representative. One of the mandatory elements of the briefing was that "the fire fighting and emergency services equipment available, including their location and the access routes to be kept clear, must be discussed." Travis Fire Emergency Services Flight The Travis Fire Emergency Services Flight (TFES) was established to provide emergency services to Travis Air Force Base (TAFB). The Travis Fire Emergency Service Flight is assigned to the 60th Civil Engineer Squadron, 60th Mission Support Group, 60th Air Mobility Wing, 18th Numbered Air Force, Air Mobility Command. A document entitled the Travis Fire Emergency Services Standards of Cover (SOC) was written by the 60th Civil Engineer Squadron (CES) Fire Emergency Services Flight division to "define the distribution and concentration of fixed and mobile resources available to TFES." The document introduction stated that the "SOC is a system that includes an analysis of risks and expectations to assist in making decisions on force deployment issues." The SOC contained detailed information about ARFF staffing, equipment, and facilities, as well as protocols, priorities, and performance metrics. USAF/SUU Emergency Services Planning The February 2014 edition of the USAF/SUU "Installation Emergency Management Plan" provided detailed guidance on that topic. Appendix 2 ("On Base Aircraft Accident/Major Accident Response") included the following guidance for specific responsibilities and duties: Emergency Communications Center: - Develop safe route if time/situation permits - Dispatch the appropriate resources required for initial response - Maintain contact with responding [incident commander] and responders - Ensure follow-on communications are prioritized and processed Air Traffic Control Tower: - Activate the primary crash phone network - Ensure taxiing and airborne aircraft are advised of emergency information - If feasible, obtain basic overhead survey information from local flights - Ensure [approach control] is informed Review of the ATCT transcripts and other documentation indicated that the relevant items were complied with. USAF and SUU ARFF Guidance and Provisions Department of Defense Instruction (DoDI) 6055.06, ("Fire and Emergency Services Program"), contained the applicable ARFF response criteria pertaining to response time, fire fighting vehicle agent requirements, and minimum ARFF vehicle staffing for its facilities, including SUU. DoDI 6055.06 delineated required response time criteria as a function of which of two categories, "announced" or "unannounced," the particular emergency event falls into. Unannounced emergencies are th