Sad news is nothing new for the National Championship Air Races – there have been 29 deaths associated with the races in its 47-year history. However, the ten deaths and dozens of injuries (some extremely serious) resulting from a plane crash and explosion on September 16, 2011 have brought attention to the safety of air racing.
Although full details of the causes of the crash and explosion have not been determined by the National Transportation Safety Board, we can begin a comprehensive root cause analysis with the information available so far by building a Cause Map. First, we capture the basic details (such as the date and time of the incident) in the Outline. Then we record the impacts to the goals. In this case, there was a significant impact to the safety goal, considering the high number of deaths and significant injuries. The customer service goal can be considered to be impacted because the spectators at the show were not sufficiently protected from injury. (The FAA grants approval to air shows based on safety of the spectators from a crash.) The remaining days of the race were cancelled – an impact to the schedule goal. The plane was destroyed, an impact to the property goal, and the resulting NTSB investigation will cause an impact to the labor goal because of the resources required to complete the investigation.
Once we have captured these impacts to the goals, we can use them to begin the analysis. The injuries and deaths occurred from the plane crashing into the VIP section and the subsequent explosion which resulted in shrapnel injuries. The pilot lost control of the plane and did not have sufficient time to recover (as evidenced by there being no indication that he made a distress call). It’s unclear what exactly caused the loss of control; however, the plane had been modified to increase its speed, which would have impacted its stability in flight. Additionally, photos taken just before the crash appear to indicate that a portion of the tail fell off, but the reason why has not yet been discovered. What happened to the tail section, and how the modifications affected control of the plane, are questions the NTSB will examine in their report.
Because of the goal of an air race – traveling around a course at low altitudes and high speeds – it’s no surprise that the pilot did not have sufficient time to recover control before crashing. Given that these conditions are expected during air races – and appear to be an acceptable risk to pilots, who continue to race even with the high number of crashes and fatalities that result – it appears that there needs to be more consideration of how spectators are protected from crashes and the shrapnel that can result from the destruction of a plane.
When more evidence is gathered, more information can be added to the Cause Map. Once that occurs, the NTSB can examine the causes contributing to the deaths at the air race, and make recommendations on how future deaths can be avoided.
To view the Outline and Cause Map, please click “Download PDF” above.