Summary of the investigation into the Iron Complex fire, 9-fatality helicopter crash

Carson helicopters

Yesterday we provided live coverage of the National Transportation Safety Board’s all-day meeting about the 2008 crash of the Sikorsky S-61N helicopter on the Iron Complex fire near Weaverville, California in which nine firefighters died. The pilot-in-command, a U.S. Forest Service check pilot, and seven firefighters were fatally injured; the copilot and three firefighters were seriously injured. The helicopter was operated by Carson Helicopters, Inc. of Grants Pass, Oregon.

According to the NTSB, there was “intentional wrong-doing” by Carson Helicopters that under-stated the weight of the helicopter and over-stated the performance of the helicopter in the documents they provided to the USFS when bidding on their firefighting contract. The NTSB estimated that the actual empty weight of the helicopter was 13,845 pounds, while Carson Helicopters stated in their contract proposal that the weight was 12,013 pounds. For the purpose of load calculations on the day of the crash, the pilot assumed the weight to be 12,408 pounds, which was 1,437 pounds less than the actual weight estimated by the NTSB. According to the NTSB, for the mission of flying the firefighters off the helispot, the helicopter was already over the allowable weight even without the firefighters on board.

In addition, here is an excerpt from the NTSB report:

The altered takeoff (5-minute) power available chart that was provided by Carson Helicopters eliminated a safety margin of 1,200 pounds of emergency reserve power that had been provided for in the load calculations.

The pilot-in-command followed a Carson Helicopters procedure, which was not approved by the helicopter’s manufacturer or the U.S. Forest Service, and used above-minimum specification torque in the load calculations, which exacerbated the error already introduced by the incorrect empty weight and the altered takeoff power available chart, resulting in a further reduction of 800 pounds to the safety margin intended to be included in the load calculations.

The incorrect information—the empty weight and the power available chart—provided by Carson Helicopters and the company procedure of using above-minimum specification torque misled the pilots to believe that the helicopter had the performance capability to hover out of ground effect with the manifested payload when, in fact, it did not.

The NTSB has notified the Department of Transportation’s Inspector General that Carson’s actions may merit a criminal investigation.

The NTSB and the FAA seem to have a rocky relationship. Some of the recommendations that the NTSB makes to the FAA following accident investigations are ignored, which frustrates the NTSB. This was evident a couple of times in the meeting yesterday. The AP reports on an example of this tension that affected the NTSB’s ability to investigate the Iron 44 fire fatal accident:

Two months after the accident, the FAA office in charge of overseeing Carson received letters from two pilots with knowledge of Carson’s operations who expressed concern that the company was miscalculating helicopter weights, investigators said.

Investigators said that if FAA had provided NTSB with that information at the time, it would have helped them figure out sooner that the weight calculations were faulty. FAA was a party to the accident investigation and its inspectors were aware of the investigation, they said.

However, FAA dismissed the allegations and didn’t provide the letters to NTSB until about a year later after the investigators made a general request for documents related to the agency’s oversight of Carson after the crash, investigators said.

Carson surrenders FAA certificate, but may still be operating in Afghanistan

It was reported by the FAA after the NTSB meeting on Tuesday that Carson Helicopters has surrendered their FAA Certificate, which is equivalent to an operating license. However, they may still be flying for the military as a subcontractor. The Mail Tribune in Medford, Oregon reported in January, 2009 that Carson Helicopters signed a contract with a subsidiary of Blackwater Worldwide (which recently changed their name to “Xe”) to use seven of their Sikorsky S-61 helicopters in Afghanistan. The contract, worth $605 million through 2013, is for the helicopters to transport supplies; they will not be involved in combat.

Fuel Control Unit missing

Conspiracy theory enthusiasts will enjoy speculating about the fuel control unit that went missing after it was gathered as evidence. The NTSB says the part played no role in the accident and that both engines were operating at full power during the accident. However, Carson is saying the crash was caused when one engine experienced a loss of power caused by the part that later disappeared. If Carson can successfully deflect blame to the company that manufactured the part, or at least establish some doubt about the accident’s cause, it may reduce their financial liability.

Who regulates wildfire aviation?

The answer is: nobody. The FAA claims they have no authority to regulate the aviation activities of other federal agencies or state and local governments. This authority has to be granted by Congress, which has shown no interest in becoming involved in the aviation safety of firefighters. And the federal agencies, or at least the U.S. Forest Service as proven in this accident, generally do not have the aviation expertise to inspect and regulate their own agency-owned or contracted aircraft. Good luck in trying to not think about this the next time you’re climbing into a helicopter at a fire. (Let’s see – got hard hat, gloves, line gear, tool, life insurance.)

NTSB report

We have a copy of the NTSB’s Conclusions, Probable Causes, and Recommendations, released yesterday, on our Documents page. Some of the highlights are below.

Probable Cause

1. Carson’s intentional understatement of the helicopter’s empty weight;

2. The alteration by Carson of the power available chart to exaggerate the helicopter’s lift capability;

3. Carson’s practice of using unapproved above-minimum specification torque in performance calculations that, collectively, resulted in the pilots’ relying on performance calculations that significantly overestimated the helicopter’s load-carrying capacity and did not provide an adequate performance margin for a successful takeoff; and insufficient oversight by the U.S. Forest Service and the Federal Aviation Administration.

Contributing to the accident was the failure of the flight crewmembers to address the fact that the helicopter had approached its maximum performance capability on their two prior departures from the accident site because they were accustomed to operating at the limit of the helicopter’s performance.

Recommendations for the U.S. Forest Service

  • Develop mission-specific operating standards for firefighter transport operations that include procedures for completing load calculations and verifying that actual aircraft performance matches predicted performance, require adherence to aircraft operating limitations, and detail the specific Part 135 regulations that are to be complied with by its contractors.
  • Create an oversight program that can reliably monitor and ensure that contractors comply with the mission-specific operating standards [as detailed in the first recommendation].
  • Provide specific training to inspector pilots on performance calculations and operating procedures for the types of aircraft in which they give evaluations.
  • Require that a hover-out-of-ground-effect power check is performed before every takeoff carrying passengers from helispots in confined areas, pinnacles and ridgelines.
  • Review and revise policies regarding the type and use of gloves by firefighting personnel during transport operations, including, but not limited to, compatibility with passenger restraints and opening emergency exits.
  • Review and revise your contract requirements for passenger transport by aircraft so that the requirement to install shoulder harnesses on passenger seats provides improved occupant crashworthiness protection consistent with the seat design.
  • Require that helispots have basic weather instrumentation that has the capability to measure wind speed and direction, temperature, and pressure and provide training to helitack personnel in the proper use of this instrumentation.
  • Modify your standard manifest form to provide a place to record basic weather information and require that this information be recorded for each flight.
  • Require all contracted transport-category helicopters to be equipped with a cockpit voice recorder and a flight data recorder or a cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data.

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UPDATE, November 28, 2011:

We obtained a copy of the response from the FAA in regard to the NTSB’s recommendations for the FAA which were specified in the report. It is HERE, and is a 1.5 MB pdf file.

Author: Bill Gabbert

After working full time in wildland fire for 33 years, Bill Gabbert now writes about it from the Black Hills. Google+

7 thoughts on “Summary of the investigation into the Iron Complex fire, 9-fatality helicopter crash”

  1. I don’t understand, with all the evidence against Calson, why this company does not face criminal prosecution? To me, this was murder if not manslaughter. Can anyone ask and/or answer this question?

    1. Nick-

      As we wrote in the article:

      The NTSB has notified the Department of Transportation’s Inspector General that Carson’s actions may merit a criminal investigation.

      In addition to criminal prosecution, there there have already been civil suits brought against Carson and manufacturers of the helicopter by the victims or their families. And there could be more, especially after the final report is released by the NTSB.

      We wrote on Feb. 13, 2009:

      The families of two firefighters killed in a fiery helicopter crash last August filed wrongful death, negligence and product liability lawsuits Thursday against an Oregon-based helicopter company and three other firms.

      The suits seek $10 million for each of the victims, plus funeral costs.

      But on June 5, 2010:

      The Oregonian newspaper reports that seven of the families of the firefighters that were killed and three that were injured in the crash of the helicopter on the Iron 44 fire in 2008 have reached a tentative settlement in various lawsuits.

      […]

      An attorney representing some of the families said a tentative agreement has been reached with Carson Helicopters, Columbia Helicopters, and the U.S. Forest Service, but the dollar amount is still being finalized. No agreement has yet been reached with Sikorsky, the manufacturer of the helicopter, or General Electric, which built the engines.

      The Oregonian reports that the families of Roark Schwanenberg, the pilot who died, and Jim Ramage, a Forest Service check pilot, as well as surviving pilot William Coultas, did not reach settlements with any of the five defendants.

      I wonder if the settlements would have been any different if the families had waited until after the NTSB released their findings?

      The information released by the NTSB yesterday could provide ammunition that a smart lawyer could use in a civil suit, and possibly in a criminal prosecution, but I am no attorney. Possibly wrongful death or manslaughter?

  2. In 1967 on my first helicopter flight, an Army Major beside me leaned over and said, “Sargent you are flying on the cheapest helicopter that the Army could find. Enjoy your trip.” Nothing in the ensuing years has happened to make me think that the Major was wrong then or now.

    Walking is always safer and you don’t need a load calc.

  3. Absolutely, Carson Helicopter and the myriad of other entities supporting this S-61 should be held accountable for this horrific tragedy. However, why must the US Forest Service and the FAA continue to over-regulate Helicopter Operations on Forest Fires to the extent of degradation of support? We have already endured the over regulation of pesticides to combat the Japanese Pine Beetle and the AMAZING effects of those marvelous decisions by non- foresters and leftist- environmentalist in the ‘70s and ‘80s. The simple matter is to maintain and adhere to a procedural standard and hit the big helicopter operator in the pocket book, to ensure adherence. Additionally, implement procedures to contract with small helicopter operators to infuse healthy competition, the little guys has so much to gain and so much to lose on reputation alone. Therefore, I highly doubt he will screw up the contract and will monitor his operation with more zeal. I challenge the industry or the lay person to look at the private helicopter industry. They will discover that the industry (in the US) is migrating toward an unhealthy “Big Five”

  4. I am wondering what part the USFS Boise office had in this. They seem really gun ho about using a C 130 wing box that has failed twice and now has Canadian certified aircraft scattered all over the US. Did it start with Norbury or Harbour? They all should be investigated and possibly charged as well.

  5. I am mother to Scott Charlson who was killed in this tragedy – that was not an accident in my book. I have tried to search in various ways to find if there is any action being taken by the Dept. of Transportation regarding criminal charges to Carson (per NTSB direction) and Steve Methany in particular who seems to be the person who was directly responsible for altering the weight charts. I have not found any info period. I truthfully think Carson has so much influence in DC that he has pretty much to this point been able to sweep as much as possible under the table. There were civil suits but quite frankly the families were held at arms length as to the proceedings. We did receive a settlement but money is not what is important and it was considerably less than estimated. I am sure big business had their hands in that too. There is still a huge ? in my mind and I feel we have been run over. Three of the families and maybe more are ready to move ahead and come public with our questions and lack of satisfaction especially in criminal prosecution of Carson Helicopters and Steve Methany. My main concern is that no company in the future will have the slightest urge to do what Carson has done and jeopardize the safety of Wildland Firefighters. This fire crew had performed their work and they did it well. They were trusting that all other agencies were doing their work well but that was not the case. If anyone has any suggestions as to how we should proceed please speak up. At this point media seems to be the way we are leaning.

    1. Nina, I am very sorry for your loss, as well as the losses that the other eight families suffered as a result of this preventable crash. It was clear from the results of the NTSB accident investigation that a criminal investigation by the FAA or Department of Transportation is appropriate due to “intentional wrong-doing” by Carson Helicopters. The last I heard Carson received a $605 million contract from the Defense Department (through Blackwater aka Xe) and moved the shady operation of some of their helicopters to Afghanistan. I hope the DOD or Blackwater is not interfering with the DOT investigation, if it was ever started.

      Let me know about any new developments in this case. I agree with you, that we don’t want any more firefighters to suffer the same fate that Scott and the other eight victims did at the hands of Carson, a company that is still advertising on their web site their firefighting helicopters.

      The U. S. Forest Service, the agency that gave the contract to Carson and failed to ensure that the helicopters were operated safely, should be following up vigorously to ensure that the criminal investigation is performed… for the same reasons stated above. But maybe they are too ashamed or scared to do the right thing and want to reduce their own liability, while simultaneously, on purpose or not, reducing Carson’s liability.

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