2019 Incident Statement
On July 27, 2019 during Mooney Caravan XXII, two aircraft collided in flight. The incident was immediately reported to the National Transportation Safety Board (“NTSB”) after landing. The existing NTSB reports are available here and here.
This Report (1) states the facts of the incident and (2) identifies specific changes to Mooney Caravan procedures, protocols and practices on a going-forward basis. In addition, all Caravan clinic participants and attendees at future Caravans to Oshkosh will be briefed on “lessons learned” and the implemented changes to Caravan future procedures and processes as a direct result of the learning from this incident. This presentation will be available publicly as well as presented separately for all interested pilots at AirVenture 2020 and possibly in the future.
1. FACTUAL SUMMARY:
The Mooney Caravan is a large formation flight dedicated to facilitating a safe and enjoyable mass arrival into EAA/AirVenture Oshkosh each year. It is organized into Elements of two or three aircraft, divided into Sections (dictated by the number of total Elements), and has a single ship Element as Tail.
The last two (22nd and 23rd) Elements (Victor and Whiskey) were each two-ship Elements. V, W and Tail were executing a previously discussed and briefed plan to join as a 4 ship Element to be photographed and videoed from Tail, the camera aircraft, during the Caravan flight. Aerial photography has been and is routinely used for educational and promotional purposes, including future training and sponsor support. Whiskey Element was to close on Victor’s right side; then Tail was to maneuver to the right for the video and photos.
Weather and arrival timing prevented any of the five involved pilots from flying together in Madison before the Oshkosh flight. Among other preparations, the five pilots conducted a same-day briefing and walk-through immediately after the general Caravan mission briefing. The photo mission was not briefed to all pilots in the general Caravan briefing.
Shortly after departure and while closing on V Element, W2 passed underneath and ahead of W1. W2 reported unexpectedly strong wake turbulence and losing sight of W1, but no Blind Call was made. In addition, unbriefed speed changes of several preceding elements were occurring simultaneously.
W1 saw W2 pop up to his front-right and maneuvered down and left. W1 and W2 were not aware of any contact at the time, nor were V1, V2 or Tail. W1 and W2 reformed, and all aircraft continued the flight as briefed. Upon landing in Oshkosh, physical evidence of contact was discovered on the upper rudder of W2 and right wingtip of W1.
2. CHANGES IMPLEMENTED FOR 2020 CARAVAN
Published Objective Organizational Standards: Guidelines for (1) Qualification Levels, (2) Lead Guidelines and (3) Safety Guidelines supplementing FFI materials have been established and are currently being utilized at regional formation clinics. No regional or “clinic-by-clinic” variations are permitted. Each clinic will have a designated Caravan Operations representative responsible for overseeing adherence to objective Caravan qualification standards and basic syllabi for demonstrated proficiency, specifically including contingency and emergency maneuvers.
Qualified Safety Pilots:
Caravan Operations has identified and will maintain a roster of Caravan pilots meeting the published criteria for Safety pilot. Only these pilots will serve as Safety pilots for the organization, and will enforce objective standards uniformly without regard to region or other external pressures.
Flight Proficiency Records (“FPRs”):
FPRs are to be maintained by individual pilots and completed by qualified Safety pilots to evidence demonstrated proficiency in all maneuvers, including blind and other emergency procedures.
Caravan Qualification Standards:
Adopted and published objective standards to which all Caravan participants will be held are to be verified in advance of every Caravan flight. These include:
- A pre-flight briefing establishing the flight objective is a proficiency flight, with use of published Caravan procedures, including Go/No-Go Decision Matrix and briefing of all published maneuvers to be performed, including emergency procedures and contingency plans,
- Demonstration of proficiency in ALL maneuvers including appropriate contingency and emergency procedures;
- Inclusion of a qualified safety pilot in the cockpit of the proficiency aircraft to ensure the new pilot is making appropriate control inputs, recognizes developing undesired aircraft states, and focuses on lead at all times,
- The proficiency flight MUST occur within six calendar months prior to the intended Caravan flight (ex: no earlier than January of the same calendar year for the July Caravan to Oshkosh).
Element Lead training and checkout will include demonstrated proficiency in contingency and emergency procedures, wake turbulence mitigation and avoidance, maintaining element to element spacing without changing airspeed, execution of the Caravan flight profile with only two briefed speed changes: (1) to accelerate to cruise speed simultaneously after full Caravan flight has established level flight and (2) full Caravan flight slows simultaneously in preparation for descent, and flying the correct approach profile of one-dot above RNAV glideslope to land on pre-briefed runway ‘dot’.
Caravan Main Briefing:
The main Caravan Brief should include and emphasize:
- All maneuvers anticipated for the mass formation, including contingency plans.
- All maneuvers are VISUAL; sight must be maintained of preceding aircraft at all times.
- Contingency and Emergency procedures (blind/lost sight, breakout, aborts, termination).
- No un-briefed speed changes.
All passengers will be specifically briefed on wake turbulence, formation procedures, avoiding distractions, and Cockpit Resource Management (CRM). It is recommended that the Caravan mass arrival not be a passenger’s first formation flight.
Basic Formation Flying Standards:
The Caravan profile includes only interval takeoffs, straight ahead rejoins, station keeping in route and fingertip during climb, descent, turns, and Element or single ship landings.
Cross-unders, Element take-offs, “Blind” and/ or other emergency procedures, are practiced to proficiency in Clinics. A simulated Caravan flight with 2 or 3-ship Elements may also be conducted if led by qualified Lead pilots for training purposes.
Adoption and Enforcement of “Advanced” Formation Flying Standards:
Advanced maneuvers, such as Element rejoins and 4 ship flights, will only be conducted by qualified persons in accordance with the procedures of FFI/FAST as accredited. Where appropriate and led by appropriately credentialed pilots in accordance with such organizations’ procedures, advanced maneuvering can occur at Caravan clinics among qualified pilots as determined by these accredited organizations and Caravan Operations.
The Mooney Caravan is committed to safety, proficiency, continuous improvement and ongoing re-evaluation of procedures and materials. To this end, the above report summarizes both the 2019 incident as well as our path forward to ensure a safe and enjoyable mass arrival into EAA/AirVenture Oshkosh.