The Air Force report released last week by the Virginia-based Air Combat Command said improper rigging and inadequate oversight caused the death of Shane Krogen, executive director of the High Sierra Volunteer Trail Crew, 30 miles east of Visalia, California, on September 12, 2013.
Mr. Krogen was participating in an environmental clean-up and restoration of a contaminated marijuana grow site in the Sequoia National Forest that was carried out by California Air National Guard’s 129th Rescue Wing. While preparing to be lowered by the hoist on an HH-60G Pavehawk helicopter, a variant of a Blackhawk, Mr. Krogen mistakenly attached the aircraft’s hoist to a non-load-bearing plastic D-ring of a tactical vest instead of to the load-bearing metal D-ring of his harness. When the plastic D-ring broke, Mr. Krogen fell from the aircraft to the ground from an approximate 45-foot hover and sustained fatal injuries.
The report concluded that the helicopter crew’s safety man did not maintain adequate oversight during flight and hoist operations and that Mr. Krogen’s use of his personal equipment “excessively cluttered the area around the load-bearing metal D-ring”, interfering with a safe connection and visual inspection. And, “due to the extremely close proximity of the Yates harness load bearing D-ring in relation to the Condor tactical vest’s non-load bearing D-ring, and the concealment of both D-rings by the cluttered pouches on the Condor tactical vest, which included a handgun, the [safety man] incorrectly concluded the Civilian Fatality was properly secured”.
The report also said that according to the Pentagon only law enforcement personnel should be allowed on counterdrug flights and that Mr. Krogen, as a civilian, was not authorized to be on the helicopter.
Before the rappelling attempt, four people looked at or inspected Mr. Marovich’s rappelling gear: the spotter trainee who installed the “O” ring, Marovich, and in the helicopter a spotter, and another helitack crewperson who did a “buddy check”.
The NTSB report mentions that the pilot was texting on his cell phone the day of the accident, including “during the accident flight”. An article at Bloomberg.com has more details about the texting, including:
…The NTSB documented at least 240 texts sent and received by the pilot during his shift the day of the accident, according to records cited by Bill Bramble, an NTSB investigator. There were 20 such texts with a coworker before and during the accident, the safety board found.
Freudenbert received four texts, three of them from a friend at work, and sent three others during the flight, according to NTSB records. He was planning to have dinner with the coworker, according to the records.
Another 13 texts were logged on his phone in the 71 minutes before the flight, including two during a previous flight, according to NTSB records.
(Originally published April 9, 2013)
The National Transportation Safety Board has released the cause of the crash of an EMS helicopter August 26, 2011 near Mosby, Missouri. The agency’s report concludes the crash, which killed the pilot, flight nurse, flight paramedic and patient, occurred because the helicopter ran out of fuel and the failure of the pilot to execute a successful autorotation.
The finding about the possible reason for the autorotation failure after the engine failure at cruise speed may have implications for other pilots.
Below is the NTSB’s announcement:
“April 9, 2013
NTSB DETERMINES FATAL MISSOURI HELICOPTER ACCIDENT WAS CAUSED BY FUEL EXHAUSTION, POOR DECISION MAKING AND INABILITY TO PERFORM CRITICAL FLIGHT MANEUVER
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.
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.
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.
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.
Today the US Air Force released the full report on the crash of MAFFS #7, the C-130 air tanker operated by the North Carolina National Guard. The accident occurred July 1, 2012 as the aircraft was attempting to drop retardant on the White Draw Fire near Edgemont, South Dakota. There were four fatalities. The two crewmen in the rear of the aircraft were seriously injured but survived. Those two were operating the Modular Airborne FireFighting System (MAFFS) in the cargo hold which enables the C-130 to function as an air tanker, capable of dropping up to 3,000 gallons of fire retardant.
The investigation was led by Brigadier General Randall C. Guthrie, USAFR. Also participating were the following board members: Legal Advisor, Medical Member, Pilot Member, Maintenance Member, Flight Engineer Member, Weather Member, Loadmaster Member, Recorder and two Court Reporters.
The report does not list who the investigation board may have interviewed. Most likely they talked with the crews of the lead plane and air attack and probably other personnel assigned to the fire in various positions, but it would seem to be important to have someone on the board who lives and breathes aerial firefighting. Maybe the “Pilot Member” was MAFFS qualified at least.
We will be writing more about this report in the coming days, but for now, here is the “Opinion Summary” from the report:
I find by clear and convincing evidence the cause of the mishap was Mishap Pilot 1 (MP1), Mishap Pilot 2 (MP2), Mishap Navigator (MN) and Mishap Flight Engineer’s (ME) inadequate assessment of operational conditions, resulting in the MA impacting the ground after flying into a microburst. Additionally, I find by the preponderance of evidence, the failure of the White Draw Fire Lead Plane aircrew and Air Attack aircrew to communicate critical operational information; and conflicting operational guidance concerning thunderstorm avoidance, substantially contributed to the mishap.
On 1 July 2012, at approximately 1738 Local time (L), a C-130H3, T/N 93-1458, assigned to the 145th Airlift Wing, North Carolina Air National Guard, Charlotte Douglas International Airport (KCLT), Charlotte, North Carolina, crashed on public land controlled by the United States Forest Service (USFS), while conducting wildland firefighting operations near Edgemont, South Dakota.
At the time of the mishap all members of the Mishap Crew (MC) were assigned or attached to the 156th Airlift Squadron, based at KCLT. The MC consisted of MP1, MP2, MN, ME, Mishap Loadmaster 1 (ML1) and Mishap Loadmaster 2 (ML2). For the mishap sortie, MP1 was the aircraft commander and pilot flying in the left seat. MP2 was in the right seat as the instructor pilot. MN occupied the navigator station on the right side of the flight deck behind MP2. ME was seated in the flight engineer seat located between MP1 and MP2, immediately aft of the center flight console. ML1 and ML2 were seated on the MAFFS unit, near the right paratroop door. ML1 occupied the aft Modular Airborne Fire Fighting System (MAFFS) control station seat and ML2 occupied the forward MAFFS observer station seat.
After three uneventful sorties, the Mishap Aircraft (MA) entered the White Draw Fire Traffic Area (FTA) in South Dakota. The lead plane for the MA was Lead B-5. Lead planes are responsible for the safe, effective and efficient use of air tanker operations within an FTA. A lead plane is also responsible for leading air tankers to a low-level, where fire retardant can be safely dispensed. Air Tactical Pilot (ATP) piloted Lead B-5 from the left seat and Air Tactical Supervisor (ATS) occupied the right seat. ATS initially acted as the airspace manager for the White Draw FTA. However, prior to conducting the retardant drops a third aircraft, Air Attack, entered the White Draw FTA and took over airspace management duties. Air Attack 3 (AA3) piloted Air Attack from the left seat and Air Tactical Group Supervisor (ATGS) was in the right seat.
Upon entering the FTA, the MC noticed a thunderstorm and witnessed lightning between 10 and 20 nautical miles away. ATP determined two retardant drops were needed. Lead B-5 and the MA performed the first drop precisely on target, but the MA’s airspeed was 10 knots slower than planned. As the MA positioned for the second drop, ME and MN noticed an increase in fire activity and surface winds changing in both velocity and direction. Lead B-5 then experienced a rapid “sinker” and ATP stated, “I got to go around.” ATP struggled to keep Lead B-5 under control. In response, MP2 commanded a go-around “out of this” and MP1 pushed the throttles up. Twelve seconds later, ATP advised the MC to dump their load and the MC complied. Despite MA engines at maximum power, airspeed and altitude continued to deteriorate, ultimately resulting in the mishap. The MA impacted lightly-wooded, rolling terrain and slid through a tree-lined ravine which was approximately eight feet deep, before stopping roughly 410 feet (ft) from the initial point of ground impact. MP1, MP2, MN and ME died in the mishap. ML1 and ML2 survived, but suffered significant injuries.
The mishap aircraft (MA) and a USFS-owned MAFFS unit were destroyed. The monetary loss is valued at $43,453,295, which includes an estimated $150,000 in post aircraft removal and site environmental cleanup costs. There were no additional fatalities, injuries or damage to other government or civilian property.