CEN23MA034

NTSB accident investigation · Boeing B17 · Dallas, TX · November 12, 2022

Accident · FatalClass 1 · MajorFinal report
Date
November 12, 2022, 13:22 local (19:22 UTC)
Place
Dallas, TX · On airport property
Injuries
6 fatal
Phase of flight
Maneuvering
Aircraft
N7227CBoeing B17N6763Bell P63
Defining events
Maneuvering-low-alt flying: Midair collisionManeuvering-low-alt flying: Midair collision
Weather
Visual (VMC) · Day
Status
Completed · report December 4, 2024
Report
Board-adopted by Notation
Investigation class
Class 1
NTSB office
Central Region
Parties
Commemorative Air Force, International Council of Air Shows, FAA AVP-100
Safety recommendations
Yes
Case key
106276

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

the air boss’s and air show event organizer’s lack of an adequate, prebriefed aircraft separation plan for the air show performance, relying instead on the air boss’s 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. Also causal was the diminished ability of the accident pilots to see and avoid the other aircraft due to flight path geometry, out-the-window view obscuration by aircraft structures, attention demands associated with the air show performance, and the inherent limitations of human performance that can make it difficult to see another aircraft. Contributing to the accident were the lack of FAA guidance for air bosses and air show event organizers on developing plans and performing risk assessments that ensure the separation of aircraft that are not part of an approved maneuvers package and the lack of FAA requirements and guidance for recurrent evaluations of air bosses and direct surveillance of their performance.

Findings · 12

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

On November 12, 2022, about 1322 central standard time, a Boeing B-17G airplane, N7227C, and a Bell P-63F airplane, N6763, collided in flight during a performance at the Commemorative Air Force’s (CAF) Wings Over Dallas air show at Dallas Executive Airport (KRBD) in Dallas, Texas. The pilot, copilot, flight engineer, and two scanners on board the Boeing B 17G and the pilot of the Bell P-63F were fatally injured, and both airplanes were destroyed. No injuries to persons on the ground were reported. Both accident airplanes (and six other historic, former military airplanes that were airborne as part of the same performance) were operated by the CAF under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 and a certificate of waiver for the air show. The Boeing B 17G and the Bell P-63F departed from KRBD about 1310 and 1315, respectively, for the local flights.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft · 2

Registration
N7227C
Reported as
Boeing B17 (G)
Category
Airplane
Serial number
44-83872
Built
1944
Airframe hours
9,239
Engines
Wright R-1820-97, 1,200 horsepower, reciprocatingWright R-1820-97, 1,200 horsepower, reciprocatingWright R-1820-97, 1,200 horsepower, reciprocatingWright R-1820-97, 1,200 horsepower, reciprocating
Damage
Destroyed
Fire
Both
Flight
Air race/show · Part 91
Operator
Commemorative Air Force
Registered owner
American Airpower Heritage Flying Museum
Airworthiness certificate
Special, Limited (Special)
Last inspection
AAIP · November 1, 2022 · 11 hours before
Departed
KRBD · Dallas, TX
Destination
Same as departure
Airport
RBD · Dallas Executive
Equipment
Auto-pilot, ADS-B, Electronic multifunction display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N6763
Reported as
Bell P63 (F)
Category
Airplane
Serial number
43-11719
Built
1946
Airframe hours
1,232
Engine
Allison V-1710-135, 1,425 horsepower, reciprocating
Damage
Destroyed
Flight
Air race/show · Part 91
Operator
Commemorative Air Force
Registered owner
American Airpower Heritage Flying Mu
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · March 23, 2023 · 20 hours before
Departed
KRBD · Dallas, TX
Equipment
Handheld GPS, ADS-B

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 3

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N7227C
Age
66
Injuries
Fatal
Certificates
Flight engineer, Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
September 21, 2022
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
28,000 total · 500 in this make and model · 24,000 as pilot in command · 1.7 in the last 30 days
Role
Co-pilot, aircraft N7227C
Age
67
Injuries
Fatal
Certificates
Flight engineer, Flight instructor, Airline transport, Commercial
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 15, 2022
Seat
Right
Restraint
4-point
Toxicology
Performed
Flight hours
25,300 total · 90 in this make and model · 20,000 as pilot in command · 0.3 in the last 30 days
Role
Pilot, aircraft N6763
Age
63
Injuries
Fatal
Certificates
Commercial, Remote, Flight engineer, Airline transport, Flight instructor
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
March 19, 2022
Seat
Single
Restraint
4-point
Toxicology
Performed
Flight hours
34,500 total · 108 in this make and model · 20,000 as pilot in command · 7.8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 14 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 25 °F
Altimeter
30.30 inHg
Observed at
KRBD
METAR
METAR KRBD 121853Z 35014G18KT 10SM CLR 09/M04 A3030 RMK AO2 SLP263 T00891044=

Docket · 53

The files NTSB released with the investigation on March 8, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 172 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1 - N7227CItem 1 · PDF · 9 pages · 7.8 MBPilot/operator aircraft accident report, NTSB form 6120.1 - N6763Item 2 · PDF · 10 pages · 7.5 MBElectronic recorder devices - specialist's factual reportItem 3 · PDF · 11 pages · 2.8 MBAttachment 1 to electronic recorder devices - specialist's factual report - tabular flight dataItem 4 · CSV · 397 KBAttachment 2 to electronic recorder devices - specialist's factual report - tabular system dataItem 5 · CSV · 76 KBAirboss airshow audio recording - group chair's factual reportItem 6 · PDF · 39 pages · 298 KBAirworthiness group chair's factual reportItem 7 · PDF · 11 pages · 5 photos · 568 KBAirworthiness attachment 1 - B-17G maintenance recordsItem 8 · PDF · 137 pages · 48.0 MBAirworthiness attachment 2 - P-63F maintenance recordsItem 9 · PDF · 15 pages · 6.7 MBAirworthiness image reviewItem 10 · PDF · 32 pages · 30 photos · 5.1 MBUAS aerial imagery factual reportItem 11 · PDF · 19 pages · 6.5 MBOperational factors/human performance - group chair's factual reportItem 12 · PDF · 58 pages · 1.3 MBOperational factors/human performance - attachment 1 - commemorative air force personnel interview transcripts and statementsItem 13 · PDF · 541 pages · 1.1 MBOperational factors/human performance - attachment 2 - air boss and observers air boss summaries and transcriptItem 14 · PDF · 232 pages · 774 KBOperational factors/human performance - attachment 3 - icas personnel transcriptItem 15 · PDF · 67 pages · 262 KBOperational factors/human performance - attachment 4 - FAA personnel transcripts and statementsItem 16 · PDF · 142 pages · 577 KBOperational factors/human performance - attachment 5 - interview summaries with eaa and sun-n-fun personnelItem 17 · PDF · 7 pages · 147 KBOperational factors/human performance - attachment 6 - B-17 pilots caf training records [excerpts]Item 18 · PDF · 34 pages · 5.4 MBOperational factors/human performance - attachment 7 - P-63 pilot caf training records [excerpts]Item 19 · PDF · 37 pages · 519 KBOperational factors/human performance - attachment 8 - caf provided pilot flight timesItem 20 · PDF · 2 pages · 126 KBOperational factors/human performance - attachment 9 - P-63 pilot statement of aerobatic competency and formation leader documentationItem 21 · PDF · 3 pages · 792 KBOperational factors/human performance - attachment 10 - wings over dallas certificate of waiverItem 22 · PDF · 78 pages · 17.8 MBOperational factors/human performance - attachment 11 - dallas executive NOTAMS in effectItem 23 · PDF · 3 pages · 53 KBOperational factors/human performance - attachment 12 - FAA 8900.1 chg 693 vol. 3 [excerpts]Item 24 · PDF · 8 pages · 380 KBOperational factors/human performance - attachment 13 - FAA publication ''all about airshows'' [excerpt]Item 25 · PDF · 9 pages · 1.2 MBOperational factors/human performance - attachment 14 - aerobatic competency evaluation manual [excerpt]Item 26 · PDF · 15 pages · 328 KBOperational factors/human performance - attachment 15 - air boss recognition program manual [excerpt]Item 27 · PDF · 29 pages · 554 KBOperational factors/human performance - attachment 16 - FAA letter of authorization on air boss recognition programItem 28 · PDF · 2 pages · 146 KBOperational factors/human performance - attachment 17 - commemorative air force sms refresher training [excerpt]Item 29 · PDF · 14 pages · 2.4 MBOperational factors/human performance - attachment 18 - commemorative air force sms manual -2017Item 30 · PDF · 10 pages · 261 KBOperational factors/human performance - attachment 19 - commemorative air force sms manual - November 2023Item 31 · PDF · 25 pages · 2.7 MBOperational factors/human performance - attachment 20 - FAA living history flight experience [excerpt]Item 32 · PDF · 5 pages · 197 KBOperational factors/human performance - attachment 21 - FAA national policy 8900.604Item 33 · PDF · 4 pages · 419 KBOperational factors/human performance - attachment 22 - wings over dallas preshow briefingItem 34 · PDF · 40 pages · 4.1 MBOperational factors/human performance - attachment 23 - wings over dallas preshow briefing sigh-in sheets and Saturday sequenceItem 35 · PDF · 12 pages · 4.8 MBOperational factors/human performance - attachment 24 - NASA ASRS results for ''see and avoid''Item 36 · PDF · 40 pages · 707 KBMedical factual reportItem 37 · PDF · 15 pages · 209 KBToxicology reportsItem 38 · PDF · 7 pages · 560 KBCertification of party representationItem 39 · PDF · 3 pages · 7.0 MBVideo studyItem 40 · PDF · 14 pages · 999 KBAircraft performance studyItem 41 · PDF · 44 pages · 4.5 MBAircraft performance erratumItem 42 · PDF · 2 pages · 259 KBN7227C ADS-B dataItem 43 · CSV · 2.1 MBN6763 ADS-B dataItem 44 · CSV · 785 KBN24927 ADS-B dataItem 45 · CSV · 3.5 MBN92879 ADS-B dataItem 46 · CSV · 3.0 MBN9643C ADS-B dataItem 47 · CSV · 4.0 MBN5428V ADS-B dataItem 48 · CSV · 3.5 MBN61429 ADS-B dataItem 49 · CSV · 4.9 MBN7227C release of aircraft wreckage, NTSB form 6120.15Item 50 · PDF · 2 pages · 137 KBN6763 release of aircraft wreckage, NTSB form 6120.15Item 51 · PDF · 2 pages · 107 KBIn-flight collision during air show commemorative air force Boeing B-17G, N7227C, and bell P-63F, N6763Item 52 · PDF · 94 pages · 3.5 MBAnimation descriptionItem 53 · PDF · 6 pages · 68 KB