NTSB Releases Safety Recommendations in Warbird Midair Final Report

The recommendation was one of several the safety agency made Thursday as part of its final report into its investigation of a 2022 midair collision during a warbird airshow. In November 2022, all five aboard a Boeing B-17G Flying Fortress, known as Texas Raiders, and the pilot of a Bell P-63F Kingcobra were killed when the fighter aircraft sliced into the bomber, severing the tail during the Commemorative Air Force’s Wings Over Dallas airshow. 

Earlier this week, the NTSB said its investigation found that the accident was the result of inadequate planning, as well as a lack of appropriate oversight and administrative risk controls. In particular, no altitude deconfliction procedures were established and discussed during the preshow briefing, NTSB said

Per the NTSB analysis, the accident pilots had limited ability to see and avoid each other’s airplane due to flight path geometry and out-the-window view obscuration by aircraft structures. Investigators said that the air boss’ deconfliction strategy was “ineffective because the flight paths of the B-17G and the P-63F converged as each pilot maneuvered toward their respective show lines.”

Airshows are supposed to be very scripted, as the pilots are assigned specific altitudes to fly, and placement, known as"'show lines," keep the aircraft from flying directly over the spectators. These altitudes and show lines are established and discussed during the pre-show briefing that all pilots are required to attend.

As part of the briefing, procedures for correcting altitude conflictions are discussed. Altitude deconflictions procedures are established in the event pilots find themselves at an improper altitude during the flight.

The B-17G and P-63F were registered to the American Airpower Heritage Flying Museum. Both aircraft were part of the Dallas-based CAF, a nonprofit organization dedicated to preserving and showing historical aircraft. All the pilots flying in the show were volunteers with the CAF. 

During postaccident interviews, several crewmembers of the other airplanes performing in the airshow said they were confused by the air boss’ long stream of instructions, which included nonstandardized terminology to impart directives to the pilots. Audio of the airshow revealed multiple times when pilots “stepped on” each other's transmissions as they tried to get clarification on the instructions provided.

Before the accident, the bomber group and the fighter formation completed a pass in front of the crowd from right to left from the spectators’ perspective. Investigators said that  the airplanes were setting up for the next pass from left to right when the air boss issued directives for the fighter formation to pass on the left side of the bomber group of airplanes and then cross in front of them.

"Although the fighter lead pilot was confused by the air boss’s unclear directives, the fighter lead pilot and the position 2 fighter pilot visually ensured separation from the bomber group airplanes when passing and crossing in front of the Boeing B-17G before mistakenly aligning with the incorrect show line," NTSB said.

The flight path for the fighter lead and position 2 fighter airplanes passed the bombers on the left side before crossing in front of the Boeing B-17G. The Bell P-63F was in a descending left banked turn when it struck the left side of the Boeing B-17G near the trailing edge of the left wing before both airplanes broke apart in flight. The NTSB said it reviewed hundreds of photographs and video of the collision that show the airplanes disintegrating upon impact and the wings forward section of the B-17G cartwheeling to the ground in a ball of flames and black smoke.

The NTSB found that the FAA and the International Council of Air Shows (ICAS) had “not adequately considered the need to better mitigate the collision risks associated with performances involving multiple dissimilar aircraft."Fighters are faster and more maneuverable than the bombers, it said, but lack much visibility from the cockpit, especially when the aircraft is banked in such a way its belly is to another airplane, or visibility is blocked by an aircraft structure such as a wing.

Other safety issues uncovered included a lack of a risk assessment plan, unclear communication directives, the lack of requirements for recurrent evaluations of air bosses, inadequate airshow safety assessment and reporting issues within the CAF, and insufficient regulatory oversight.

The NTSB determined that the probable cause of this accident was the air boss’ and airshow event organizer’s lack of an adequate, pre-briefed aircraft separation plan for the airshow performance. Instead, the airshow relied upon the air boss’ real-time deconfliction directives and the see-and-avoid strategy for collision avoidance, which allowed for the loss of separation between the Boeing B-17G and the Bell P-63F airplanes. 

NTSB also cited a lack of FAA guidance for air bosses and airshow event organizers on developing plans to ensure the separation of aircraft that are not part of an approved maneuvers package, as well as a lack of requirements and guidance for recurrent performance evaluations of air bosses.

​As a result of this investigation, the NTSB made several recommendations to the FAA, CAF,  and ICAS to improve safety, which include having the two groups work together with other airshow industry stakeholders to develop standardized terms to help ensure the clarity and brevity of air boss-provided directives to performers.

Recommendations include:

NTSB said the CAF lacked a "strong, clearly defined safety risk assessment plan resulted in airshow production decisions that were not systematically developed to determine acceptable levels of risk and were susceptible to influences unrelated to safety, including pressures to deviate from the intended limitations on when revenue passenger rides could be conducted during air show operations."

During the past two years, CAFhas worked closely with accident investigators, according to Leah Black, vice president of marketing for the organization.. 

"The information published by the NTSB reinforces the understanding we have gained throughout this process," Block told FLYING in an email. "These accidents are thoroughly examined to help uncover any opportunities for ongoing safety improvements. We are reviewing information as it comes in and are carefully considering how it may impact our operations in the future."