Today, December 7, 2010, the National Transportation Safety Board conducted a Board Meeting about the August 5, 2008 crash of the Sikorsky S-61N helicopter on the Iron Complex fire near Weaverville in northern California that killed nine firefighters. The meeting was broadcast on a live webcast which we watched. The notes below were taken in real time during the webcast. It was not possible to pause or “rewind”, so there are probably errors and omissions, for which we apologize in advance. But we did the best we could, with limited multi-tasking and typing skills.
We originally covered some of the details of the NTSB’s Factual Report on the crash HERE. As we said then, one of the most startling facts the NTSB discovered is this:
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.
More information:
- The presentations made during the meeting can be found on the NTSB web site HERE. They may only be available for three months.
- The Accident Docket, a list of NTSB documents related to the accident, can be found HERE.
- A recorded version of the webcast is now available HERE on the NTSB site. It may only be available there for three months.
- The Conclusions, Probable Causes, and Recommendations. (This link takes you to a copy of the document that we placed on Wildfire Today’s Documents page.)
After the meeting the NTSB issued a press release. We included it at the bottom of this article.
The meeting was held in Washington, DC, and the times shown below are Eastern Time. Below, the most recent updates are at the top.
4:23 – After a closing summary statement by Chairman Hersman, the board adjourned.
4:15 – Robert Sumwalt proposed, and the Board voted enthusiastically to approve, that the report be amended to include “Carson Helicopter, Inc.” in the title. During the meeting today, there was severe criticism of Carson, especially for their “intentional wrong-doing”. Some family members of the crash victims in the audience (which was never shown on camera) applauded the work of the investigative staff. Zoë (Zoëy) Keliher received special recognition for the investigative work that she performed. Other investigators, when they uncovered a surprising or extremely important fact, were said to have had a “Zoëy Moment”.
4:09 – Chairman Hersman said the Public Use area of aircraft operations, under which fire aviation falls, is an “orphan” in the regulatory system. She said the FAA needs to recognize and correct this. “We don’t want to investigate any more crashes like this”, she said.
3:58 – While they are reading the list, HERE is a link to a page that lists, and has photos of, the five members of the NTSB. Robert Sumwalt spoke more, and asked more questions, than the other four members. But they all were very professional, knowledgeable, brought up good points, and asked excellent questions of the investigators and witnesses.
3:53 – They just finished reading a list of probable causes, and now are reading 20+ recommendations. I can’t type that fast, but we’ll attempt to get a written copy.
3:48 – Robert Sumtwalt faulted the USFS for their lack of oversight before the accident, but praised them for the actions they took afterwards.
3:45 – Vice Chairman Christopher Hart is discussing the “intentional wrong-doing” of Carson Helicopters. It will be listed first on the list of probable causes. Some of the members seemed to be stunned by the “intentional wrong-doing” that was discovered during the investigation. Hart said the NTSB and FAA investigators and inspectors are not trained in criminal investigations.
3:41 – Robert Sumtwalt is praising the investigators for the detailed approach they took, and the fact that they did not take the easy way out of blaming pilot error.
3:39 – There is discussion about a few of the findings.
3:30 – They just read a 33-item list of findings.
3:07 – The Board is taking a break until 3:15. They just finished a lengthy discussion about the fuel filters, and will probably make a recommendation about requiring a higher quality filter for the aircraft, even though this did not play a role in this crash.
2:52 – Some components of the fuel control unit went missing after the accident. The investigators from the NTSB and FAA that had seen the parts felt that those parts had no role in causing the crash. However representatives from Carson had said they believed the parts played an important role in causing the crash.
2:48 – The two fuel filters for the engines were 25% and 50% blocked. But there is a bypass valve that allows fuel flow even if the filters are completely blocked. The engines had sufficient fuel flow at the time of the crash.
2:45 – In the continuing discussion about the problems passengers had with the seat belt buckle, Chairman Deborah Hersman said, “The worst thing that I can imagine is a crash where the passengers survive but can’t get out.”
2:32 – None of the surviving passengers were able to open the rotary buckle on their seat belts after the crash. This was due to the unfamiliarity with the uncommon buckle, and the leather gloves they were required to wear. Prior to boarding the helicopter they were given a verbal briefing about the seat belt, but there was no demonstration about how to operate it.
2:30 – There was discussion about the performance of the passenger seats during the accident, and if it is feasible to upgrade the seat in this old helicopter design. Some aircraft seats are rated to withstand a 16 G force, but the seats in the Carson helicopter were only rated to 4 G. Some seats became dislodged from their mounting locations during the crash.
2:25 – The firefighters that survived the accident said they had problems operating the rotary seat belt buckle while wearing the required leather gloves.
2:24 –
2:22 –
2:06 – They just took a break and are scheduled to be back at 2:15.
2:02 – I just caught the tail end of one investigator’s comment. It was something about a Carson employee doing something that resulted in their being fired. Did anyone pick up on what was said about this?
2:01 – If accurate weight and performance data had been submitted to the USFS prior to the awarding of the contract, five of the ten Carson helicopters would not have been eligible to be considered for the contract.
1:59 – I don’t know if it’s just me, but I’m having occasional problems in staying connected to the live webcast. Right now I can’t get it at all. OK, now it’s back. I refreshed the page and it began playing again.
1:38 – The FAA had been notified before the accident that Carson had a problem with understating or misrepresenting the weights of their aircraft, but they still did not “focus like a laser” on Carson. If they had, they should have detected the weight problem. If the accurate weight and performance data of the helicopter had been used in the load calculations on the day of the accident, the pilots would have known that the aircraft did not have the ability to carry ANY passengers.
1:34 – Chairman Hersman said earlier that she would give the inspectors “the benefit of the doubt”, but now she was “going to bring down the hammer”.
1:23 – Question from a board member: are the FAA inspectors trained to detect intentional misrepresentation of performance data? An NTSB investigator said “not to my knowledge” and, “they are not trained as criminal investigators”.
1:11 – Three investigators said the discrepancies on the helicopters’ performance data paperwork submitted by Carson should have been picked up quickly by FAA inspectors who deal with this every day. It took weeks for the NTSB accident investigators to detect the discrepancies.
1:00 – They are defining public vs. civil aircraft. Public aircraft basically violate the FAA rules that govern civil aircraft, and are used for purposes such as dropping chemicals, transporting firefighters, and rappelling into a fire. USFS firefighting aircraft are public aircraft, according to legislation.
12:49 – Tom Haueter: normally when a carrier makes significant additions to their fleet and also adds passenger carrying services as Carson did, it would trigger enhanced oversight and inspections by the FAA, but it did not happen in this case.
12:47 – Robert Sumwalt: The USFS can’t provide continuous oversight because they don’t have the aviation expertise. The NTSB plans to make recommendations to correct the insufficient oversight of the FAA and the USFS.
(Note: we have noticed in other NTSB accident investigations that frequently the NTSB, which investigates accidents, makes recommendations on accident prevention that are sometimes ignored by the FAA, which regulates the operation of aircraft. This appears to frustrate the NTSB at times.)
12:45 – 
12:38 – The USFS inspected the helicopter in June of 2008 as part of the contracting process.
12:36 – They are back from lunch and are beginning a presentation on “oversight”.
11:30 – They are breaking for lunch, and are scheduled to resume at 12:30 ET. We will also resume at that time. They have completed two of five presentations so far.
11:28 – The FAA gives an exemption to older aircraft, such as the crashed helicopter, from requiring a flight data recorder. This ship did not have one that worked, but did have a cockpit voice recorder.
11:24 – Soon after the crash and also in a statement a few days ago, the co-pilot said the helicopter did not reach “topping” on the takeoff that resulted in the crash. However, the investigators determined that on the three takeoffs that day from the helispot where the crash occurred, the ship did reach topping.
11:17 – Chairman Hersman, saying that “we don’t want to let the flight crew off the hook”, asked what should we expect the crew to do, regarding the performance of the helicopter relative to the predicted performance. One witness said the crew should compare the actual performance to the performance predicted by the load calculations, and if different, figure out why.
11:12 – One witness said the flight crew carefully reviewed the load calculations, and they had a check pilot with them, “grading” their performance, so they may have been even more by-the-book that day than usual. The crew followed the established procedures, but they were provided with an inaccurate weight and performance data of the helicopter by Carson.
11:06 – Nine of ten Carson Helicopters were about 500 pounds heavier than the weights shown on the documents submitted to the US Forest Service for contracting purposes. USFS contracts specify that actual weights be used, rather than weights derived from formulas.
11:02 – On three flights that day from the helispot where the crash occurred, the helicopter engines upon takeoff were operating at 100% ( or they were “topping”) which is unusual when carrying passengers, since there is no safety margin. Normally, the copilot would call out to the pilot when that occurs, but the cockpit voice recorder showed that it was not always announced, indicating that “topping” was not abnormal for Carson operations, or at least for that flight crew.
10:50 – Technical discussions continue about the engine power, the power that was delivered to the rotors, and the speed of the rotors at the time of the crash. More talk about Carson altering the performance documents to show that the helicopters could carry the weight of cargo or passengers.
10:37 – Chairman Hersman asked Tom Haueter why Carson would bid on a contract when accurate weights of the helicopter showed they had no ability to carry cargo or passengers. Haueter said they did not ask Carson that question.
10:32 – The understatement of the weight of seven to eight helicopters and falsified performance documents were intentional by Carson.
10:20 – Board member Robert Sumwalt noted the “gumshoe detective work” done by the NTSB investigators. Six months after the crash, the USFS canceled the contract with Carson, noting that only 5 of the 10 Carson helicopters would have qualified for the USFS contract specification, based on their actual correct weights.
10:18 – Summary of Keliher’s presentation:
10:16 – Even without the firefighters on board, the helicopter was already over the allowable weight. With the information provided by Carson, the flight crew thought the ship’s weight was within the allowable weight.
10:11 – Keliher goes into detail, explaining the “erosion of the safety margin” and the errors involved when Carson determined the weight and performance information for the helicopter. “Resulted in a negative safety margin”.
10:08 – Zoë Keliher, discussed operations of the helicopter.
10:00 – During the attempted takeoff, the helicopter engines were at close to 100% power.
9:40 – The Chair of the Board, Deborah Hersman, gave an opening statement which included:
- There was a failure of oversight authority by US Forest Service & Federal Aviation Administration.
- The FAA did not inspect the helicopter before authorizing Part 135 (ability to carry passengers).
- USFS did not verify the weight of the helicopter.
- The certification of the helicopter was based on trust of the vendor, Carson Helicopters, but the trust needs to be verified.
- USFS is now checking weights (the weight of the helicopter was 1,437 more than that reported by the vendor, Carson Helicopters.
************************************************************
NTSB PRESS RELEASE
************************************************************
National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: December 7, 2010
SB-10-46
************************************************************
IMPROPER CONTRACTOR ACTIONS AND INSUFFICENT FEDERAL
OVERSIGHT LED TO 2008 FATAL FIREFIGHTING HELICOPTER CRASH
NEAR WEAVERVILLE, CALIFORNIA, NTSB SAYS
************************************************************
The National Transportation Safety Board today determined
that a series of improper actions by the contractor and
insufficient oversight by the U.S. Forest Service (USFS) and
the Federal Aviation Administration (FAA) led to the August
5, 2008, fatal crash of a Sikorsky S-61N helicopter near
Weaverville, California. The contractor’s actions included
the intentional alteration of weight documents and
performance charts and the use of unapproved performance
calculations.
Contributing to the accident was the failure of flight
crewmembers to address issues related to operating the
helicopter at its maximum performance capability.
Contributing to the fatalities and survivors’ injuries were
the immediate and intense fire that resulted from fuel
spillage from the fuel tanks that were not crash resistant,
the separation from the floor of the cabin seats that were
not crash resistant, and the use of an inappropriate
mechanism on the cabin seat restraints. The pilot-in-
command, the safety crewmember, and seven firefighters were
fatally injured; the copilot and three firefighters were
seriously injured.
On August 5, 2008, a Sikorsky S-61N helicopter (N612AZ),
which was being operated by the USFS as a public flight to
transport firefighters battling forest fires, impacted trees
and terrain during the initial climb after takeoff at a
location about 6,000 feet above sea level in mountainous
terrain near Weaverville. The USFS had contracted with
Carson Helicopters, Inc. (CHI) of Grants Pass, Oregon, for
the services of the helicopter, which was registered to CHI
and leased to Carson Helicopter Services, Inc. (CHSI), also
of Grants Pass.
“The probable cause of this accident had to do with Carson’s
actions and the oversight entities’ inactions,” said NTSB
Chairman Deborah A.P. Hersman. “Carson engaged in a bargain
that violated the trust of their crewmembers, the
firefighters that they carried onboard, and the aviation
industry. But the FAA and the Forest Service did not hold up
their end of the deal to oversee Carson’s actions. Public
aircraft have been made the orphans of the aviation
industry. It’s now time for the FAA and other government
agencies to step up and take responsibility.”
In order to prevent similar accidents and to improve the
survivability of such accidents when they do occur, the NTSB
issued 11 new recommendations to the FAA and reiterated one
from 2006. Ten recommendations were issued to the USFS.
Recommendations to the FAA include oversight of 14 Code of
Federal Regulations Part 135 operators with aircraft that
can operate part of the time as public aircraft and part of
the time as civil, clarification of oversight
responsibilities for public aircraft, accuracy of hover
performance charts, pilot performance, fuel tank
crashworthiness, and occupant protection.
To the USFS, the NTSB recommended the development of
mission-specific operating standards for firefighter
transport operations, a requirement that its contractors
adhere to these standards, and the creation of an oversight
program that can monitor and ensure contractor compliance
with all standards and requirements. Other issue areas for
the USFS recommendations included pilot training, occupant
protection, weather instrumentation, and onboard recorders.
A synopsis of the NTSB report, including the probable cause,
conclusions and safety recommendations, will be available on
the NTSB website.
The NTSB’s full report will be available on the website in
several weeks.
# # #
NTSB Media Contact: Bridget Serchak
202-314-6100
No Bill, David was not involved. But, we grieve with these families and are indignant at the insufferable negligence. It is untoward when corners-are-cut because of money. Hopefully justice will prevail. Keep hammering away at your reporting, it’s great !
We have been researching this tragic event. This is a great and informative blog / website, thanks to who ever wrote it. Great work. Hope they nail them criminally.
Thanks for the kind words. I don’t recognize the name, Dave Lewis. Was he involved in the crash of the helicopter on the Iron Complex fire?
I beleive that a major revamping of the FireLine Handbook published by the NWCG also needs updating in the section regarding the use of Helicopters. It should include a required check list with a mandated safety briefing and Flight Crew (Crew Chief)demonstration with a individual performance check on seat belt utilization, crash position, evacuation procedures for all Passengers. A Mandatory weight safety margins adding 40% to known body weight for the manifest in calculating total weight of the added personnel. This will account for unknown weight or incorrect weights reported by passengers as well as cover PPE additions and basic equipment carried on board
This is the same government that had over-site responsibilities for the offshore drilling rigs. The is the same government that was to monitor banks and Wall St.
One would think that at some point in time, one of these regulators would go to jail for criminal negligence, when the do-do hits the fan on their watch.