Above: photo of the incident scene, from the report.
(Originally published at 6:55 p.m. MST November 22, 2017)
The French government has released a report about an incident that occurred August 1, 2016 at Ajaccio. As best we can tell from the document, which is in French of course, is that a CL-415 experienced a mechanical failure in the right side landing gear while taxiing and turning left onto a runway before takeoff on a fire mission. When one of the components broke, the gear partially collapsed, causing the aircraft to tip to the right, coming to rest on the float under the wing tip.
Thankfully the crew was not injured.
The report appears to indicate that the problem was related to a maintenance issue due to a translation error in a technical document.
1er août 2016, Ajaccio : accident au roulage du Canadair CL415
Conclusion BEAD-Air «Affaissement du train d’atterrissage droit au roulage, par rupture d’un de ses composants suite à une erreur de maintenance générée par une faute de traduction dans une documentation technique». pic.twitter.com/XmZASZ9UBz
The Marine Corps investigation into the crash of an MV-22 Osprey tilt-rotor aircraft May 17 in Hawaii determined that it was caused by dust stirred up by the rotor wash.
After making multiple attempts to land in brown-out conditions, the buildup of debris on the turbine blades and vanes led to a compressor stall in the left engine, which decreased lift and resulted in the hard landing and fire.
The report found that pilot performance and an improper site survey of the landing zone led to the accident, resulting in the deaths of two and injuries to 20 on board.
The potential for the Osprey to deliver water or personnel to fight wildfires was evaluated by the Marine Corps in tests with a 900-gallon water bucket. They recommended that the aircraft not exceed 90 knots with a bucket and 50 knots when dropping water.
The Osprey is a tilt-rotor aircraft capable of vertical or short takeoff and landing. When airborne, it can cruise at over 300 mph, can carry 24 to 32 troops, or 15,000 pounds of external cargo.
The National Interagency Fire Center has released their annual summary of wildfire activity in 2013. In the aviation section one of the stats we always find interesting is the number of requests for large air tankers that are unable to be filled (UTF). That is, when firefighters officially submit a request for an air tanker but there are none available because all of them are committed to fires, they are on their day off, or they have a mechanical problem.
An air tanker having a day off is ridiculous, especially when the fleet size has atrophied from 44 at the beginning of 2002 down to nine when the 2013 fire season began. But that is the way the U.S. Forest Service writes their contracts for large air tankers.
During the 2002 fire season the wings literally fell off two air tankers, killing five aviators, causing the USFS to begin grounding the older museum pieces that summer, continuing the process into 2004. Since then the UTF rate has been climbing. Much of the time when firefighters need air tankers there are none available, reaching a high of 48 percent in 2012.
After 2004 when the groundings settled down and the fleet size ranged from 9 to 21, the average UTF rate was 26 percent. In 2013 it was 21 percent. Before the two wing failures, with 40 air tankers on contract the average UTF rate was 7 percent for 2000 through 2001.
In articles like this pointing out how the air tanker fleet has decreased by 75% over the last 11 years, we usually mention that air tankers don’t put out fires. Under ideal conditions of moderate burning conditions without a strong wind, they can sometimes slow down a fire making it easier for firefighters on the ground to make better progress and actually stop the fire. It is one tool in the toolbox. But an *aggressive, prompt, initial attack with overwhelming force both on the ground and from the air is more likely to keep a new fire small than what we have seen in recent years with reductions in the number of firefighters and aircraft. An aggressive attack can prevent a small fire from becoming a megafire that can cost over $100 million.
In 2013 there were nine fires with suppression costs exceeding $10 million. The Rim Fire in and near Yosemite National Park ran up bills amounting to $127 million.. And those dollar figures do not include the damage to privately owned property or the lives lost. Information provided by the USFS shows that 11,625 homes burned in wildfires over the last three years; and they don’t have records for ALL structures that burn in wildfires across the nation. If those houses had an average value of $100,000, we are looking at a monetary value of $1.1 trillion. During that three year period 60 people were killed in wildfires, including firefighters and local residents.
While the number of acres burned in wildfires in the United States in 2013 (minus Alaska) was lower than the recent trend, the number of air tanker requests that were filled (1,017) was four times higher than the average between 2002 and 2012, which was 252 per year. The year with the second highest number of filled requests since 2002 was 2011 when large air tankers were requested 407 times.
We are at a loss to come up with a reason for the unprecedented increase in the number of filled requests, in a year that had the fourth lowest number of acres burned in the lower 49 states in the last 10 years. The number of requests for large air tankers was 1,343, compared to an average of 434 per year.
The information in this report might be 100 percent right and truthful. But, sadly, we are now forced to look at these and other statistics coming out of Boise and the Interagency Fire Center and consider that they may or may not be accurate. We learned a lesson after the U.S. Forest Service issued their “FY 2013 Aviation Safety Summary” last month which claimed there were no USFS aircraft accidents in the last three years. At least four accidents since 2008 with a total of nine fatalities, including the 2012 crash of the MAFFS air tanker on a USFS fire which killed four aviators, do not show up in their stats. Nor are they even mentioned anywhere in the report. Their use of imaginative criteria for leaving out certain accidents made it appear that they had a pretty good accident record, when the opposite is true.
That lesson learned means we now have to look at these Boise reports and question their accuracy. This is really unfortunate. It casts doubt on reports and statistics that might have the potential for us to learn other lessons that could enhance the safety of firefighters at the point of the spear — busting their asses out on hot, steep, dusty, smoky, rocky slopes in the middle of nowhere for weeks at a time.
The U.S. Forest Service has released an aviation safety report titled “FY 2013 Aviation Safety Summary” which theoretically analyses, or at least lists, accident trends. Their presumed safety goal, although we could not find in the report any goals or objectives, is to reduce accidents. We were astounded to read on page 4 a statement that was repeated in various ways on pages 8, 18, and 33:
The Forest Service did not have any accountable accidents again in FY 2013; this was the third year in a row without an accident.
That statement was backed up by these two charts, and others in the report:
At least four accidents since 2008 with a total of nine fatalities do not show up in these stats:
2012, June 3: crash of a Neptune air tanker in Utah with two fatalities;
2012, June 3, crash of a Minden air tanker at Minden, Nevada (one landing gear did not lower), irreparable damage, no fatalites;
2012, July 1, crash of a MAFFS air tanker in South Dakota, four fatalities.
There may have been other accidents between 2004 and 2007 that also were not listed.
We checked with the USFS about the discrepancy and spokesperson Jennifer Jones told us that the accidents “were not included in the document because it was a U.S. Forest Service aviation safety report and the airtankers were under the operational control of other agencies when the accidents occurred, so they are not considered reportable accidents for the U.S. Forest Service.”
It turns out that if an air tanker under contract to the USFS is flying on a fire for another agency and crashes, the USFS will not include that accident in the report. However, the MAFFS air tanker crashed while making a drop on the White Draw fire on the Black Hills National Forest.
A statement in the report absolves the USFS from responsibility for accidents involving military aircraft:
Military aircraft remain under the operational control of the military even while supporting USFS operations.
Fire suppression management is under civilian control.
And later on page 29:
Second, due to the need for swift reaction to live fires, the practical supervision of executing a MAFFS mission, by default, is under civilian control.
We could not find the word “MAFFS” anywhere in the 33-page FY 2013 Aviation Safety Summary document, or any reference to the nine fatalities we listed above.
In 2012 MAFFS air tankers dropped 2.45 million gallons of retardant on fires, frequently under USFS operational control.
The 2012 landing gear failure on the Minden air tanker was not listed, the USFS said, because “the National Transportation Safety Board determined that it did not meet the definition of an accident”. But part of the definition of an “accident” in this summary report (page 3) is one “in which the aircraft receives substantial damage.”
A reasonable person would think that an aviation summary document that compiled accident statistics would at least mention that aircraft on long term exclusive use contracts to the USFS crashed and killed nine crewmembers, even if they were on temporary loan to another organization for an hour or a few days. The agency selected these aircraft and the contractors, and the fact that there were four major accidents involving their chosen aircraft and contractors deserves mention, at least to honor their service. The nine fatalities and four crashes in a five-year period is a very disturbing trend that should not be ignored. And even more so when you also consider the 2010 accident that does show up in the stats. That one may be the June 26, 2010 accident in which Neptune’s T-44 went off the end of the runway at Rocky Mountain Regional Airport (Jeffco) near Denver due to a hydraulic system failure.
If the USFS analyzed the crash trends involving their contractors, including those occurring on non-USFS fires, they might find, for example, they should reconsider the specs in the contracts, the crash history of contractors, the suitability of aircraft designed for maritime patrol in the 1950s that are then used for flying in and out of canyons under air frame stresses the engineers did not consider, and the age of the aircraft. If what you are doing is not working, and these crashes and fatalities indicate it is not, then you need to do something different. The next-generation air tanker concept is a step in the right direction, but using jet airliners to fly into canyons is a concept that needs to be proven.
At a minimum, future reports should have a separate section to list the mishaps and accidents that involve their contracted aircraft even if they are on a non-USFS fire. And, accidents that involve MAFFS air tankers working under an agreement with the USFS, and accidents that result in major damage, should be listed as reportable accidents, regardless of specific jargon used by the NTSB.
It should not make any difference, for statistical, reporting, and accident prevention purposes, if the cause of an accident is mechanical, weather, or pilot error — they all should be recorded and reported. If the objective is learning lessons and preventing future accidents. they must be tracked and remembered. Splitting hairs and using imaginative criteria for leaving out certain accidents can turn the entire accident reporting program into a farce.
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.