A coroner’s inquest found that an inadequate inspection contributed to the crash of an air tanker in New South Wales, Australia.
David Black, 43, died when his M18 Dromader single engine air tanker crashed while fighting a fire at Wirritin in Budawang National Park, 40 kilometers west of Ulladulla, October 24, 2013 when a wing snapped off the aircraft as it was approaching the fire. The crash started another bushfire which, along with high winds, hampered efforts to reach the pilot.
Below is an excerpt from an article at 9news:
[The aircraft] was tested and inspected just over two months earlier by two companies, Aviation NDT and Beal Aircraft Maintenance, but [Deputy State Coroner Derek] Lee said the work was inadequately done.
He wrote in his findings that testing by Aviation NDT used an unauthorised method and did not comply with the mandatory requirements of the Civil Aviation Safety Authority.
Further, the plane’s wings were not removed during a visual inspection by Beal Aircraft Maintenance, meaning that corrosion and cracking on one of the left wing’s attachment lugs was not detected.
By the time Mr Black crashed in October, the Australian Transport Safety Bureau found that cracking on the inner surface of the lug had reached a critical length of 10.4 millimetres and at least 32 secondary micro cracks were also identified.
The engineer behind the visual inspection, Donald Beal, told the inquest the manufacturer’s service bulletin did not mandate removal of the wings, so he didn’t see any need to remove them.
Mr Beal also said there was ambiguity about what visual inspections actually involved, Mr Lee recalled in his findings.
Thanks and a tip of the hat go out to Chris. Typos or errors, report them HERE.
Previously he had been a member of New Zealand’s Special Air Service, a special forces unit of the Army. He served in Afghanistan and was wounded in a firefight with the Taliban after his unit came to the aid of Afghan police when they were attacked at the InterContinental Hotel in Kabul in a five-hour battle.
Police, the Civil Aviation Authority, and the Transport Accident Investigation Commission are investigating the crash.
There are reports that 15 helicopters were fighting the recent wildfires near Christchurch that have burned 600 hectares (1,483 acres).
Our sincere condolences go out to Mr. Askin’s family, friends, and coworkers.
One person was seriously injured in the 2015 crash. The pilot and a USFS employee were killed.
The U.S. Forest Service has released a 90-page “Learning Review” about the March 30, 2015 crash of a helicopter that occurred during prescribed fire operations on a National Forest in Mississippi approximately 20 miles north of Gulfport. The accident took the lives of Forest Service employee Steve Cobb, contract pilot Brandon Ricks, and seriously injured another Forest Service employee on detail from Montana.
The helicopter was igniting a prescribed fire by using a plastic sphere dispenser (PSD), a device that drops small balls that burst into flame after they land on the ground. Steve Cobb was serving as the Firing Boss [FIRB] and the detailed employee was operating the PSD out of the right-rear door.
According to the pilot’s personal flight logbooks, he had accumulated 6,471 total hours of flight experience, about 6,300 hours of which were in the accident helicopter make and model. The owner estimated that the pilot had accrued 22 additional flight hours in the 90 days that preceded the accident.
Before the flight the engine on the helicopter failed to start on the first try, but the second attempt was successful. Later over the prescribed fire the aircraft made about 12 passes over the project and had been flying for about an hour when the crash occurred.
Below is an excerpt from the USFS report:
The PSD operator recalled they “were flying along 25-to-30 feet above the highest tree…things were going really well,” and they were nearly through the first bag of balls when he heard two alarm warning buzzers go off simultaneously or nearly so followed immediately by the pilot stating, “We lost power,” and FIRB saying, “We’re going in; we’re going in.”
The PSD operator swung his right leg over the PSD machine and back inside the helicopter, just as he had practiced in his head when he envisioned this scenario. He didn’t want his leg broken or trapped under the helicopter if it were to roll on its side. As he tightened his lap belt and pushed his back against the seat, hands on his knees in the crash position, he felt the helicopter tip backwards and to the right slightly. The PSD operator believed the pilot initiated this position purposefully, possibly as part of an autorotation. The descent through the tree canopy was not violent, and the helicopter slipped through the trees tail first. The impact with the ground was “abrupt.” The PSD operator felt the lap belt catch him; the impact knocked the wind out of him.
The PSD operator remembers the helicopter coming to rest more or less upright, and it was quiet. The PSD operator could hear breathing over the intercom system and “crackling” as the balls they had just dropped began to establish fire. He thought to himself, “I’m still alive!” He unbuckled the lap belt and unhooked the gunner strap’s tether from the helicopter, then reached forward to jostle the pilot, yelling at the pilot and FIRB, “We gotta get outta here.” He exited the helicopter from the right side and once on the ground, moved towards the front of the aircraft. He yelled again, “We gotta go,” calling each by name while realizing they were unconscious and that he wouldn’t be able to move them with his injuries. As it was, he was having difficulty breathing and standing up. He now heard the roar of the fire that had grown from small individual spots of fire to a wall of flames surrounding them; he knew it was time to move.
He turned and faced the wall of flames and thought, “I just survived a helicopter crash; I am going to live.” He recounted, “I started walking, through the wall of flames 10-to-15 feet thick, then all the glowing ashes on the other side and residual heat…hands over my face and screaming into my hands and saying, ‘Don’t fall, don’t fall’…everything was glowing and I just kept going…I could feel myself burning…the watchband melting on my wrist.” The PSD operator walked approximately 900 feet in a westerly direction to reach the 415A road and the western edge of the burn unit sometime between 1448 and 1451.
After a while he was found by firefighters and was eventually transported by ground ambulance to a waiting air ambulance which flew him to the University of Southern Alabama Hospital in Mobile, Alabama. His injuries included fractures of two cervical and two lumbar vertebrae, left ocular and left side ribs; and intestinal and hernia tears.
The National Transportation Safety Board concluded the helicopter experienced a “loss of engine power for reasons that could not be determined”. The helicopter did not catch fire when it hit the ground, but it was soon ignited by the spreading prescribed fire, hampering the NTSB investigation.
The USFS Learning Review emphasized several issues related to the accident — not necessarily causes, but items for discussion. One was the decision to ignite the project from a helicopter rather than from the ground.
The primary purpose for utilizing helicopters for aerial ignition in this region is to mitigate the exposure of ground resources to the hazards of hand-lighting units. For Unit 1459, like most units on the De Soto Ranger District, a combination of the vegetation, terrain, and fire behavior make hand-lighting units inefficient and hazardous. Flame lengths of greater than four feet combined with difficult walking conditions raise a red flag for a burn boss concerning firefighter safety. Plants such as palmetto (Serenoa repens), gallberry (Llex spp.), ti-ti (Cyrilla racemiflora), and smilax (Smilax spp.) when combined with needles from longleaf, slash, and Loblolly pines can create flame lengths in excess of 10 feet with as little as a two-to-three year accumulation of dead material. These species are also very difficult to traverse. Smilax vines can ensnare firefighters and drip torches and stop them in their tracks. This area also still has some large dead fuel concentrations as a result of Hurricane Katrina. In these areas people working in the woods may encounter downed timber that can stop heavy equipment from forward progress.
Using an airborne resource for igniting a fire rather than personnel on the ground does not eliminate risk. It transfers it.
Another issue was the required flight characteristics of a helicopter while igniting a fire with a PSD. An air tanker when dropping retardant has to fly low and slow to be effective. Similarly, with the current versions of the PSD, a helicopter’s recommended speed should not exceed 50 mph (43 knots), while the preferred altitude is 300 feet above ground level (AGL).
Hovering out of ground effect (HOGE) is the typical flight profile.
The last data from the helicopter provided by the Automated Flight Following (AFF) before the crash indicated it was at 132 feet AGL and traveling at 43 knots.
From the report:
It is clear how organizational processes influenced the acceptance of risk. As a result, risk assessments did not consider the flight profile, as it was already determined that low/slow was necessary in order to accomplish the work. The fact that the recommendations for airspeed and altitude were heavily influenced by the capability of the PSD likely influenced a gradual decay over time of the options and decision space for the pilot to maintain optimal combinations of airspeed and altitude. The fact that this is a successful tool available for conducting prescribed burn operations, sets the stage to “justify” its use, rather than to prompt the agency to look at better options or technology.
The acknowledgement of these flight conditions in agency guides likely affects the deliberate acceptance of a “low and slow” profile as necessary for the accomplishment of the mission. A low/slow flight profile makes sense because it is suggested within written procedure. Over a period of time (4+ decades), confidence and acceptability of the flight parameters strengthens with each successful mission, along with a slight departure from the awareness of the hazards associated with the flight profiles. This is a demonstration of how the production goals creep into mission planning to dominate the protection goals without recognition of such. In this case, all required policy was followed and personnel were conducting their work within the operational norms set up by agency policy and culture.
The Learning Review has numerous recommendations, including modifying the existing PSD machines to enable the helicopter to fly higher and faster. Another is to invent an entirely new method of aerial ignition in order to mitigate the low and slow flight profile.
The investigators concluded that a wing stalled either independently or in combination with an encounter with a wing-tip vortex generated by another aircraft.
Below is the TSB’s Summary of the incident:
An Air Tractor AT-802A on amphibious floats (registration C-GXNX, serial number AT- 802A-0530), operating as Tanker 685, was carrying out wildfire management operations during daylight near Chantslar Lake, British Columbia. Three similar aircraft were working as a group with Tanker 685, which was second in line on a touch-and-go to scoop water from Chantslar Lake. Upon liftoff, control was lost and the aircraft’s right wing struck the water. The aircraft water-looped, and the floats and their support structure separated from the fuselage. The aircraft remained upright and slowly sank.
The pilot received minor injuries, egressed from the cockpit, and inflated the personal flotation device being worn. The third aircraft in the formation jettisoned its hopper load as it continued its takeoff and remained in the circuit. The fourth aircraft jettisoned its hopper load, rejected its takeoff, and taxied to pick up the accident pilot. There was sufficient impact force to activate the on-board 406- megahertz emergency locator transmitter, but the search-and-rescue satellite system did not detect a signal from the emergency locator transmitter until the wreckage was being recovered 6 days later.
The TSB’s findings, in part:
1. A wing stalled either independently or in combination with an encounter with a wing-tip vortex generated by the lead aircraft. This caused a loss of control moments after liftoff, and resulted in the right-hand wing tip contacting the water and in a subsequent water-loop.
2. The operator’s standard takeoff procedures did not specify a liftoff speed for scooping operations. Lifting off below the published power-off stall speed contributed to a loss of control at an altitude insufficient to permit a recovery.
3. The takeoff condition, with the aircraft heavy, its speed below the published power-off stall speed, and a high angle-of-attack contributed to the loss of control.
4. An understaffed management structure during organizational changes likely led to excessive workload for existing managers. This contributed to risks, contained within the standard operating procedures, not being addressed through the operator’s safety management system, resulting in continued aircraft operations below published minimum airspeed limitations.
The report states that Conair hired a safety manager and a company check pilot for the Fire Boss fleet before the 2015 spring training season started. And, Conair adopted a risk mitigation plan for 2015–2016, applicable to the company’s AT-802 fleet. The plan addresses issues mentioned in the TSB report, plus an additional issue identified in-house.
The year following the August 14, 2014 crash on Chantslar Lake there were three incidents that we are aware of that involved Conair AT-802’s:
2015, April 11: An engine failure on Air Tanker 699, an Air Tractor AT-802A, during training resulted in damage to a float upon landing. The incident occurred April 11, 2015 on Harrison Lake, BC, 33 nm NNE of Abbotsford.
The wreckage of the Russian air tanker that was reported missing in Siberia on July 1 has been found. Rescuers found the debris of the Ilyushin IL-76 plane at approximately 2 a.m. Moscow time in the Kachug District, 9 km southeast of the settlement of Rybny Uyan.
A photo posted by Федеральная Авиалесоохрана (@avialesookhrana) on
From the air the in the smoky conditions in the forest the only recognizable part of the aircraft was the tail.
Initially there were conflicting reports on the number of personnel on board, ranging from 9 to 11, but Russian authorities on Sunday confirmed there were 10. The remains of six and one flight recorder have been located. Marines are clearing an area to be used as a helispot.
Below is an excerpt from an article in the New Indian Express:
…A Russian aviation agencies source told TASS news agency that the plane most likely lost control because of interference from hot air from the wildfire that it was trying to douse with water.
“It’s possible that hot air from the wildfires got into the engines, the plane lost propulsion and could not gain altitude, hit the top of the trees and fell,” the source was quoted as saying.
The plane’s tail was discovered by another firefighter on today morning, said the Russian forestry agency’s aviation unit.
Last week another firefighter died on duty in Russia’s far-eastern Kamchatka region, the regional government revealed.
The forestry agency’s aviation unit said today that over 43 thousand hectares of forest land is burning in Russia, mostly in Siberia.
But Russia’s Greenpeace which monitors wildfires via satellite data said government figures are vastly underestimated, with 415 thousand hectares burning in Irkutsk region alone.
A few days ago I stopped by the memorial to MAFFS 7 on Highway 18 in South Dakota. It honors the four people that died when the Modular Airborne FireFighting System (MAFFS) C-130 air tanker crashed in South Dakota exactly exactly four year ago today. MAFFS 7, from the 145 Airlift Wing in North Carolina, was dropping retardant to slow the spread of the White Draw Fire when it encountered turbulent air and crashed, killing Lt. Col Paul K. Mikeal, 42; Maj. Joseph M. McCormick, 36; Maj. Ryan S. David, 35, and Senior Master Sgt. Roberts S. Cannon, 50. Two crew members survived but were seriously injured, Loadmasters Chief Master Sgt. Andy Huneycutt, and Master Sgt. Joshua Marlowe.
The memorial is still in good shape three years after it was installed. It is approximately 6 miles northeast of Edgemont, SD on Highway 18 near the point of origin of the fire (map) where the motor home that started the blaze caught fire while pulling the grade between Edgemont and Hot Springs. The memorial consists of a gravel parking area with room for about six vehicles and has two interpretive panels — one describing the White Draw Fire and the other covers the accident and the four victims.
On Saturday, June 3, families, friends, and coworkers gathered at the Bureau of Land Management’s Interagency Fire Center at the Cedar City Airport in Utah. They were there to honor the two pilots who died June 3, 2012 when the air tanker they were flying, Tanker 11, a P2V, crashed on the White Rock Fire near the Utah-Nevada border west of Cedar City. Killed that day were Captain Todd Tompkins and First Officer Ron Chambless, pilots for Neptune Aviation.
A year ago firefighters in Utah began raising funds to purchase and install two 5-foot tall granite obelisks engraved with the names of the two fallen comrades and featuring a color image of Tanker 11. They were designed to be placed at the crash site, along with an interpretive sign detailing the events.
Saturday after the ceremony at Cedar City, nearly 100 people traveled to see the finished product. The following four photos were provided by Kris Bruington.