Carson Helicopters has been actively campaigning, challenging the National Transportation Safety Board’s conclusions about the cause of the crash of one of their helicopters in which nine wildland firefighters and pilots died. In 2008 a Carson Sikorsky S-61N crashed on the Iron Complex fire near Weaverville, California. The NTSB, after a 2-year investigation, said on December 7, 2010, that the causes were:
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.
Shortly after the NTSB’s report was released in December, Carson surrendered their FAA Certificate, which is equivalent to an operating license. In addition, the NTSB notified the Department of Transportation’s Inspector General that Carson’s actions may merit a criminal investigation.
Carson has a potential motive to attempt to lay blame for the fatal crash on something other than themselves. They could be trying to save their company from bankruptcy while also trying to avoid being found guilty of possible criminal charges.
Vertical Magazine, a publication that covers news and issues related to helicopters, published a lengthy article on January 26 covering Carson’s recent efforts to change the public perception of the cause of the crash. Here is an excerpt from their article.
Key Areas of Dispute
In response to the NTSB’s December 2010 accident report, Carson wrote a strongly worded letter to the helicopter industry (obtained by Vertical Magazine on Jan. 11, 2011) stating his displeasure with the NTSB and his unwillingness to remain quiet any longer, since he realized his “faith in a fair and impartial investigation had been ill-founded.”
In the six-page letter, Carson accused the NTSB of performing an “arbitrary and one-sided hearing” and shared facts that he claimed were “purposely excluded in the summary of findings.”
He then went on to accuse the NTSB of a number of actions that led to what he believes are false conclusions.
On Monday the National Transportation Safety Board issued a number of recommendations to the U.S. Forest Service following the NTSB’s investigation into the fatal Carson helicopter crash on the Iron Complex fire in 2008 in northern California which killed nine firefighters and helicopter crew members.
On November 29, 2010, the USFS sent a briefing paper to the NTSB outlining some changes they had already made to their fire aviation program in response to the crash.
Here is a summary of the new NTSB recommendations. The complete memo that the NTSB issued to the USFS is below the summary.
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 14 Code of Federal Regulations Part 135 regulations that are to be complied with by its contractors. (A-10-159)
Require its contractors to conduct firefighter transport operations in accordance with the mission-specific operating standards specified in Safety Recommendation A-10-159. (A-10-160)
Create an oversight program that can reliably monitor and ensure that contractors comply with the mission-specific operating requirements specified in Safety Recommendation A-10-159. (A-10-161)
Provide specific training to inspector pilots on performance calculations and operating procedures for the types of aircraft in which they give evaluations. (A-10-162)
Require a hover-out-of-ground-effect power check to be performed before every takeoff carrying passengers from helispots in confined areas, pinnacles, and ridgelines. (A-10-163)
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. (A-10-164)
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. (A-10-165)
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. (A-10-166)
Modify your standard manifest form to provide a place to record basic weather information and require that this information be recorded for each flight. (A-10-167)
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. (A-10-168)
The NTSB also issued some recommendations to the Federal Aviation Administration.
The NTSB’s memo to the USFS is below. (Click the “+” or Fullscreen to see larger versions.)
Shortly before the National Transportation Safety Board held their December 7 meeting about the crash of the Carson helicopter on the Iron Complex fire in which 9 people died, the U. S. Forest Service sent a “briefing paper” to the NTSB that detailed the changes they made to their aviation program as a result of some of the findings of the investigation.
The changes include:
hiring 11 new Aviation Maintenance Inspectors, Helicopter Inspector Pilot, and airworthiness engineer;
the USFS has a 5-year strategy to achieve International Standard for Business Aircraft Operations (IS-BAO) certification;
changes to helicopter contracts in regard to seat belts and seats;
helicopter weighings will be witnessed by a USFS Maintenance Inspector;
passengers will not be transported on Type 1 (large) helicopters until a new “action plan” is completed and an acceptable level of risk is achieved; and
new requirements for inspecting contract helicopter pilots.
The “briefing paper” is below. Click on “Fullscreen” to see a larger version.
William “Bill” Coultas of Cave Junction, Oregon says the National Transportation Safety Board ignored his testimony and came to the wrong conclusion about the cause of the helicopter crash on the Iron Complex fire in 2008 near Weaverville, California in which 9 firefighters and helicopter crew members died.
The NTSB concluded in their public meeting on December 7 that Carson Helicopters intentionally under-stated the weight of the helicopter and over-stated its performance in the documents they provided to the U.S. Forest Service when bidding on their firefighting contract. This led to the helicopter being overloaded, making it impossible for it to gain altitude when it attempted to take off from the Iron 44 helispot at 6,000 feet in the Trinity Alps.
Here is an excerpt from an article in the Mercury News:
…”I was speechless—I could not believe what I was hearing,” [Coultas] said after the NTSB report was released Tuesday. “I was there. I had the best seat in the house. I knew what happened.”
Coultas, 46, is still recovering from severe burns suffered in the August 2008 crash in Northern California that also killed pilot Roark Schwanenberg of Lostine.
Both Coultas and the Schwanenberg family have sued engine manufacturer General Electric, as well as Sikorsky and a maintenance company, Columbia Helicopters, citing engine failure, among other things.
They say the NTSB investigators were responsible for losing engine fuel control parts that would have backed up the copilot’s testimony.
“We want the truth to come out about the loss of engine parts and actual cause of the accident,” said Gregory A. Anderson, an attorney from Ponte Vedra Beach, Fla., who represents both the Coultas and Schwanenberg families.
Lawyers for the three companies did not immediately respond to e-mails Friday from The Associated Press seeking comment on the litigation.
The NTSB concluded that aircraft owner Carson Helicopters Inc. of Merlin deliberately understated the weight of its Sikorsky S-61N helicopter.
The report also said both the U.S. Forest Service and the Federal Aviation Administration failed to notice the understatement.
Carson Helicopters said in a statement that a clogged fuel control unit and other issues were responsible for the crash. The company also laid the blame for underestimating the weight of the aircraft on the actions of an unnamed single manager.
In their public meeting on December 7 the NTSB said the fuel system parts played no role in the crash and that the engines were operating at full power as it attempted to take off.
It was announced last week that Carson Helicopters surrendered their FAA certificate, equivalent to a license to operate, but last year the company 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.
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.)
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.
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.
