Thoughts about the Air Force report on the crash of MAFFS #7

(Revised at 9:22 MT, November 30, 2012)

It takes a while to digest the 49-page report on the July 1 crash of MAFFS #7, the military C-130 air tanker. Earlier we posted a summary of the report, but here are some additional thoughts.

MAFFS crash, radar at 1733L
MAFFS crash, radar at 1733, five minutes before the crash.

The radar image above, 5 minutes before MAFFS #7 impacted the ground at 1738 local time, recorded a very large thunderstorm cell southwest of the crash site. The middle of the concentric circles is the location of the crash. The circles indicate 5, 10, and 15 nautical miles from the impact site. The light green areas may have been virga, rain that was not reaching the ground. The red, light brown, dark green, and possibly the yellow areas were most likely rain, accompanied by strong winds. The longest east-west line is the South Dakota/Nebraska state line. The longest north-south line is the boundary between Wyoming and the states of South Dakota and Nebraska.

In addition to the C-130 working on the fire, there was also a Bureau of Land Management Air Supervision Module aircraft which was flown by a lead plane pilot and also carried an Air Tactical Group Supervisor. It was acting as the lead plane at the time of the accident.

Wildfire Today was the first to report the day after the crash that:

The ASM/Lead experienced a severe downdraft while approaching the intended retardant drop zone with the C130 in trail. This is being investigated by the US Forest Service as a separate Incident With Potential.

The third fixed wing aircraft to arrive at the White Draw fire that was mentioned in the report served as Air Attack. It was piloted from the left seat by Air Attack 3 (AA3 in the report), and in the right seat was the Air Tactical Group Supervisor. Both were employed by the State of South Dakota.

Before the crash, the air attack aircraft encountered sudden updrafts and downdrafts with airspeed fluctuations between 20 to 40 knots, which forced the aircraft into bank angles of approximately 90 degrees.

Here are some interesting passages from the report that discuss the weather conditions:

At 17:38:18L, MP1 ordered an e-dump of the retardant, which was immediately conducted. At the same time, Firefighter 1 (FF1) a ground firefighter, was located approximately 1.5 miles west-southwest of the future mishap site. FF1 witnessed the MA [mishap aircraft] jettison their retardant load, at which time she experienced variable surface winds with estimated gusts up to 50 miles per hour. At the same time, in Air Attack, ATGS observed the smoke lying down and “sheeting” of the fire, indicating to him “hellacious” surface winds. ATGS and AA3 lost altitude, experienced updrafts and downdrafts with airspeed fluctuations of 20 to 40 KIAS and severe turbulence. Air Attack lost an estimated 1,000 ft due to the weather conditions. ATGS did not see the MA jettison the retardant load.

Between 1730L and 1745L, Incident Commander 1 (IC1), a member of the Army National Guard, was traveling on a motorcycle, southbound on Highway 18 approximately seven miles north of Edgemont attempting to get to an 1800L meeting at the White Draw Fire incident command center in Edgemont, South Dakota. While heading towards Edgemont, IC1 witnessed the MA flying to his right, approximately one mile away, making a bank as the MA prepared for their approach to the drop area. IC1 lost sight of the MA while going down the hill towards Edgemont, at that same instant, IC1 was “hit with this extreme, fierce wind”. IC1 described it as side wind because it “pushed me over to the other side of the highway”.

The MAFFS crew received a briefing on the weather for the Arapahoe fire they dropped on earlier in Wyoming, but they did not have any specific weather information on the weather for the White Draw fire in southwest South Dakota and no update was requested when they were diverted to that fire.

From the report:

On 1 July 2012 at 1650L, the National Weather Service issued a severe thunderstorm watch for northeast Wyoming and western South Dakota encompassing the area surrounding Edgemont, South Dakota and the White Draw Fire. The severe thunderstorm watch, valid from 1650L to 2300L, was issued for potential hail up to two inches in diameter and wind gusts up to 70 miles per hour. However, there was no evidence the MC requested or received forecast weather information for South Dakota or the White Draw Fire area at any time on 1 July 2012.

After dropping on the Arapahoe fire in Wyoming, the MAFFS was dispatched to the Highlands fire west of Custer, South Dakota. But en route they were diverted to the White Draw Fire which was 24 miles southeast of the Highlands Fire.

At that time I was taking photos at the Highlands Fire and the Oil Creek Fire, the latter being farther west  across the state line near Newcastle, Wyoming. Between 1730 and 1830 I remember seeing massive, very dark thunderstorm clouds to my southeast. The photo below taken at 1715 is looking south toward the Highlands Fire. In the background the dark clouds farther south can be seen.

Highlands Fire
Highlands Fire, 1715 MT, July 1, 2012. Photo by Bill Gabbert

From 1630 until 1645 a Canadian “Bird Dog” and a CV-540 were over the Highlands fire. They were asked to drop, but refused, saying there were too many people on the ground in the intended drop area. It would be interesting to know where they went after being released from that fire, or if the weather affected the decision about their destination.

CV-540, T44, over Highlands Fire
CV-540, T44, over Highlands Fire, at 1708 MT, July 1, 2012. Photo by Bill Gabbert

The MAFFS has a capacity of 3,000 gallons, but each time MAFFS #7 reloaded that day they refilled with less retardant. At the White Draw fire it was only carrying 2,346 gallons which it split into two drops on the fire.

Crew rest or fatigue were not issues, according to the report.

Regarding the radio transmissions from the lead plane pilot saying “I got to go around” after encountering the downdraft and coming within 10 feet of the ground, and a few seconds later calmly advising the MAFFS to “drop your load when you can”, (meaning an emergency release of retardant to lighten the load, enabling the aircraft to more easily maneuver) the report said:

MAFFS aircrew members attested that a call for a go around is most commonly heard regarding misalignments for drops rather than urgent situations. It is possible that [the lead plane’s] call for a go around while meant to abort the mishap drop, was not interpreted by the [MAFFS Crew] as significantly urgent, based on their prior experience.

According to the report the overall flying experience of the MAFFS crew was high.

However [the pilot, the aircraft commander] had limited experience as a MAFFS aircraft commander and [the navigator] was participating in his first MAFFS mission. [The pilot] was a current and qualified Senior Pilot with over 1,900 total C-130 hours, however prior to the day of the mishap he had accomplished only seven drops as a MAFFS copilot and zero drops as a MAFFS aircraft commander.

The second pilot was more experienced with MAFFS and served as a MAFFS instructor pilot for this sortie.

The emergency locator transmitter (ELT) failed to activate when the C-130 crashed. One of the survivors called 911 on his cell phone and reported the crash but he said he didn’t know where he was.

The flight data recorder for the C-130 was found and shipped to the Air Force Safety Center for data retrieval and analysis. The report said the last 12.8 hours of data on the device were corrupt and unusable for investigation purposes.

There was no evidence that aircraft weight or the MAFFS unit in the cargo hold were factors in the crash. “Prior to the mishap, the MAFFS unit was operating at 100 percent capability and an emergency dump was successfully completed.”

About 34 minutes after the crash, firefighting helicopter crews assigned to the fire that were on the ground at the nearby Edgemont Municipal Airport were notified about the crash. But they were unable to fly at that time due to heavy rain, gusty winds, and a low ceiling. While waiting, an EMT loaded medical equipment on N935CH, call sign 5CH.

At the time of the crash the air attack ship was at 1,500 feet above the ground and following the MAFFS aircraft, observing the drop. On that pass the air attack ship had their hands full, experiencing extreme turbulence which resulted in bank angles of approximately 90 degrees. After the crash it had to leave the area due to the strong turbulence and the approaching thunderstorm. It loitered at a safe distance for about 30 minutes before it was able to access the area again, after which it led one of the fire’s helicopters, H-535, to the site.

During the last pass, the lead plane over-temped (or “smoked”) the aircraft engines while attempting to recover from being pushed down to within 10 feet of the ground and had to go to the Rapid City Airport.

When the weather improved, the two helicopters, N911FS, call sign H-535 (from the San Bernardino National Forest in southern California), and 5CH, departed and proceeded toward the mishap site. When they landed at the site at approximately 1850, the EMT on 5CH met the survivor who was still talking to the 911 operator on his cell phone. The EMT assessed and began treating him while the other helicopter crewmembers searched for other survivors, eventually finding the second survivor “wandering near the mishap site”. Helicopter 5CH transported both survivors to the Custer Airport, about 10 minutes away. One of them was then flown by an emergency medical helicopter to Rapid City while the other went by ground ambulance to a hospital.

As Wildfire Today reported on September 17, the pilot and at least two crewmembers of H-535 were given awards for their actions related to the crash. It is possible that others involved in the emergency response to the incident also received awards.

MAFFS 7 awards
Firefighters Daniel Diaz (center), Kevin Walters (left), and pilot Chuck MacFarland (right) receive their awards for their actions following the crash of MAFFS 7. Photo credit: San Bernardino National Forestx

Wildfire Today has an article about the differences between a military and a US Forest Service accident investigation.

 

A paragraph in this article was revised November 30, 2012 to clarify the actions of the air attack and lead plane immediately after the crash.

10 thoughts on “Thoughts about the Air Force report on the crash of MAFFS #7”

  1. Regarding the activity of the Air Attack and Lead B-5 immediatly after the crash, the report states they “. . . attempted to get back into the mishap site, but the turbulence was too strong. Due to the thunderstorm over the White Draw Fire area, . . . Air Attack had to loiter approximately 30 minutes for the storm to pass before reaching the mishap site.”

    1. Thank you Phil. I modified that section after you pointed out the info in the report which was embedded in the weather section. I also talked with someone that has intimate knowledge of the incident who provided even more details and incorporated that as well.

  2. As we progress into an age of “new” aircraft with all weather capability it’s good to reference the progression of this storm, and know the characteristics of cell development and proper airborne whether radar use.

    Now…precipitation intensity by itself is not a very good indicator of how strong a storm is, but If you watch the development of this cell you see a couple traits that make it indicative of a very strong cell. First is the gradient of the return on the trailing edge (how sharply it goes from blue to green, to amber, to red). Cells with strong gradients have significant vertical sheer in them which turns to horizontal near the ground. On the trailing edge (SW corner) of this storm you go straight from blue to red returns…this was a very strong cell.

    Second, is the asymmetry of the gradient. One might say the accident was on the other side of the storm cell away from the steep gradient. The steep gradient is there on the NW side also, but it’s disguised. The asymmetry is caused by the storm tops reaching extreme heights where strong winds aloft lay the top of the storm over creating that characteristic anvil shape. What your seeing in the radar return is the virga coming out of the anvil. Many times in storm cells such as this it’s not virga but hail coming out of the anvil. Never fly under a storm anvil…never.

    I strongly recommend anyone intending to fly around convective activity have weather radar equipped aircraft (XM is not weather radar) and to take Archie Trammell’s course on airborne weather radar and storm avoidance. He is the Godfather of aircraft radar, and his course teaches you everything you’ll ever need to know about radar and storm avoidance. His voice will put you to sleep so you may have to watch the videos more than once, but his knowledge is invaluable.

    1. Good points, Holmes. When the MAFFS and the lead got to the fire, though, the cell was 15-20 miles west of them, and visibility under it was clear all the way to Casper. It didn’t look then near as ugly as that radar image (10 minutes later) would have one believe.

      1. I don’t want to be construed as fixing blame…that’s not productive, and it’s insulting to the crews involved who where/are dedicated to this profession. I’m sorry if it came of that way. I’m a strong believer that we are only as good as the resources were given to do this job successfully, and can’t help but wonder if the outcome would’ve been different if they had taken Trammell’s course.

        Archie Trammel has personally taught thousands of professional aviators from airlines pilots to military pilots, and thousands more have watched his videos. I highly recommend his course.

      2. This is right out of Archie’s manual. Very good stuff to know…I hope he doesn’t mind that I’m copying it…

        “…a cell with a steep gradient on one side and a shallow one on the other is a cell that, most likely, is leaning over aloft – and cells that lean tend to develop into steady-state super cells”

        “If the gradient is steep…the storm should be considered hazardous. But do not assume, as pilot were once taught, that the shear and hazard are where the steep gradient lies. It may be anywhere in the storm system”

        Here is the storm right when B-5 and MAFFS-7 hooked up for the first drop:

        1. Tried to post a pict but it stripped the HTML code. If you downloaded the report it’s the 1722L radar picture

  3. I read the mishap report … nothing but more questions … obviously, they shouldn’t have been there in that weather but …

    When we had a low slow and heavy related mishap in the Navy we usually reviewed the aerodynamics and aircraft performance capabilities too. Don’t see that in this investigation other than a simulator flight. What does the specific excess power curve look like for this mishap? Is there a sufficient safety margin for the MAFFS C-130 mission considering the normally turbulent environment?

    What are the standard operating procedures for this environment? What is the recommended drop speed and configuration? Was it utilized?
    Is the standard “dash 1” windshear recovery procedure adequate for this circumstance? Is cockpit instrumentation adequate for windshear recovery?
    What windshear recovery training is given to C-130 crews? Is there a currency requirement for windshear training? Is it the same training given to MAFFS crews?

    Is there a standard plane to plane communications protocol? Was it utilized? What are the standard voice communications utilized for this mission? What is the difference between “drop your load when you can”, “go around”, or “abort”? Is there a distinction?

    Since this was a mixed military – federal mishap, who reviewed lead plane/ATGS qualifications, training, currency, and experience? Why wasn’t it included as part of the military investigation in order to provide “immunity” to the lead plane crew?

  4. Bill

    Once again u have outdone yourself!! Great work!! On getting this info out,

    One can ascertain through this report the detail that goes into a safety review and inside of the four plus months…… it was well written and written without pulling too many punches.

    The USAF identified a number of their own problems during and after mission execution that led up to accident aircraft crash.

    The ops tempo hasn’t changed for the USAF / USAF REs and US Air Guard, nor will it in the future.

    One can sure bet after the loss of human life to this extent, and the loss of a 43 million dollar USD aircraft, there are going to be some potential changes to the MAAFS program that the Combatant Commanders are going to insist upon for next season and the LMA’s may have to adopt to the military saying what they will do with their assets and quite possibly institute some reqs that say to the LMA’s……….you lead plane folks will have to train more to get a better CRM between Lead Acft and MAAFS C130’s.

    Apparently there is enough “blame” to go around. The cold hard facts are that just because the LMA’s “train” once a year with the MAFFS folks, it apparently is not enough.

    One can argue till the cows come home about low time vs high time pilots in both civ and mil environments, solo lead pilots vs two person cockpits, be it PIC/ SIC or PIC ATGS ASM combos etc yada yada yada

    The real issue will become (hopefully) that the training all of us pilots that were trained to circumnavigate a thunderstorm by 20-25 miles and 5-20 that the military becomes a hardened fact in the future……..one whiff of a thunderstorm in the area of a potential low level environment…….the pilots immediately get to call a NO BS we are outta here decision to fly another day.

    Being watching folks….these aircraft are the USAF combatant commanders aircraft with an MOU attached…….lives and 43 million dollar aircraft are surely not worth ANY Pondo pine and other SW SD species, especially during a building or potential building thunderstorm.

    To put it in a scale….I have flown in C182 aircraft in outflow thunderstorm winds…..30 miles out from a thunderstorm…… it sure left an impression on me for future flying…..I have not quit yet. But one gets to appreciate fast building thunderstorms no matter the size aircraft,,,,,

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