Zero Accidents Attributable to Forest Service This Year The following information relates to Vendors with Forest Service contracts For the purpose of

Transcription

1 Zero Accidents Attributable to Forest Service This Year The following information relates to Vendors with Forest Service contracts For the purpose of lessons learned.

2 Changes in Investigations and Reporting Public Use Vs Civil Operational Control Determined by NTSB Time lines will be longer, Causal Factors determined by NTSB

3 Information Sharing 49 CFR Ch VIII (b) NTSB states that Parties to the investigation may relay to their respective organizations information necessary for purposes of prevention or remedial action. However, no information concerning the accident or incident may be released to any person not a party representative to the investigation before initial release by the Safety Board without prior consultation and approval.

4 The NTSB has not finalized or determined probable cause for all of the accidents at this time. This is preliminary information, subject to change, and may contain errors. Any errors will be corrected when the final report has been completed. The information is for accident prevention purposes only.

5 On January 17, 2012, the Forest Service officially attained the Gold Standard Status among Federal Aviation Operators for meeting best aviation safety practices. Analysis of this event resulted in the following lessons learned:

6 First time in the history of FS aviation organization, we experienced a zero accident year in Accident s determined charged to unit in Operational Control by NTSB

7 Dedicated Employees working over the past five years to develop and implement Safety Management Systems. Focus on risk assessment and safety assurance. Contract requirements for the operators to adopt SMS based safety programs. Oversight that assures high quality standards.

8 Bell 205 A Kern County California Tehachapi, California September 4, 2011 Injuries: None

9 Forest Service Exclusive use contracted aircraft Aircraft was supporting Kern County firefighting efforts on the Canyon Fire (Non-FS Operation) On Sept 4, 2011, at approximately 1445 hours, N205WW (H 522), a Bell 205A, sustained substantial damage when the pilot attempted to execute an emergency landing due to an in-flight malfunction. The downwind landing was hard, spreading the skids and causing significant damage. 9

10 Air attack was over the fire and providing aerial supervision The mission was to provide structure protection and spot fire suppression approximately 3 miles South of Mountain Valley airport (L94)

11 Another type 2 and a type 1 helitanker were also operating in the immediate area under control of Kern County Fire. H-522 was operating with a Bambi Bucket hooked directly to the cargo hook. The aircraft was on approach for a water drop.

12 With the aircraft at 100 feet AGL and 10 KTS over the drop spot, the pilot heard a low RPM horn, and then noticed an illuminated caution light. He jettisoned the load and executed a left pedal turn to exit the canyon and move away from the fire. 12

13 The pilot checked his Rotor/Engine RPM gauge and noticed the needles were split, with rotor rpm at the 4-5 o clock position and engine rpm at 6 o clock. 13

14 The pilot interpreted indications to be the result of a governor failure. The pilot spotted and maneuvered toward an area suitable for an emergency landing.

15 The pilot commenced manual governor procedures. As he pulled collective, he felt rotor RPM decrease and noticed the gauge indicating 90% NR. At approximately and losing both altitude and rotor RPM, he lowered the collective, establishing an autorotation into the LZ. 15

16 Location of Jettisoned Bambi Bucket Accident Landing Zone

17 Damage : Landing skids minor damage to sheet metal around the landing skid cross tube mounts Damage to aft tail boom section.

18 Tail stinger was bent upward Greenhouse plexiglass section over the left side pilot cockpit broken. RH tail boom near tail skid

19 Chin bubble mounted mirror bar bent and lower wire cutter assembly was partially separated Lower rotating beacon was separated. Bent mirror bar and lower wire cutter

20 Pilot in Command has total PIC time hours and 915 hours time in model. Completed Emergency Procedure Training on 5/10/11. Pilot who landed in accident LZ after accident occurred, needed 46 lbs torque (max 52 lbs) to land, indicating strong tail wind. 20

21 Pilot had 400 ft to troubleshoot and select proper course of action. Once determined, pilot followed procedure for failed governor yet failed to adequately restore rotor RPM. Tear-down revealed a failure in the Engine N2 Tachometer Generator shaft (Engine RPM indicator system). 21

22 Pilot Jettisoned load when situation got bad. Pilot diagnosed situation, developed a plan and stuck to it. Altitude limited time for pilot to troubleshoot problem. A hard landing in an open area is better than uncontrolled crash in trees.

23 Eurocopter AS 350-BA N230 CH Juneau, Alaska September 26, 2011 Injuries: None

24 Aircraft landing on Ridge to pick up 2 Forest Sciences Lab personnel working on a weather station nearby. Helicopter manager on-board. NTSB has categorized the accident as a part 135 operation, not public use. Same aircraft/crew landed in accident LZ approx 3 hours prior to drop off scientists.

25 About 1230, the aircraft landed on top of ridge at an elevation of about 3100 ft. Pilot locked collective and set engine to flight idle for 2 minute cool-down. About 30 to 90 seconds into cool-down, pilot noted vegetation down-slope and to his right being buffeted by wind.

26 A strong gust of wind lifted the helicopter about 5 feet and rolled it onto its left side. When motion stopped, the pilot secured the engine and both crew exited the right side door. The manager called dispatch and a helicopter was sent to pick up the crew and passengers. The crew was taken to hospital for medical evaluation and released.

27 The mission utilized a Project Aviation Safety Plan. Pilot landed N/NE into perceived prevailing wind.

28 There was a forecast for prevailing wind shift from S to N and associated turbulence the hour before and during the accident. Recorded gusts in the area at 22 mph from the East. LZ was along a ridge line with steeply sloping terrain dropping off toward the East.

29 The LZ was south of considerably higher rugged terrain.

30 Incidents With Potential

31 PSD operations in support of the Horseshoe 2 incident, burning out fuels around a mobile repeater site. The crew consisted of the pilot, burn boss, and the PSD operator/helicopter manager.

32 After lighting the area around the repeater site, the flight moved to check an area where ground crews were going to burn out around several structures. The flight was on scene about 35 minutes before heading back towards the repeater site to evaluate the progress of the burnout.

33 Smoke was becoming worse and the crew decided to fly under the smoke column. The pilot descended to about ft AGL and 40 knots. Due to degraded visibility the pilot turned back, slowing the aircraft and making a right 180 degree turn.

34 The aircraft encountered an un-contolled right yaw while making the turn in the drainage along Forest Service Road 42. The aircraft encountered three 360 degree spins before the pilot was able to arrest the yaw rate, 50 ft above the tree-line.

35 Helicopter path winds

36 The crew concluded that everyone was ok and that there were no mechanical problems and everyone agreed to continue flying. After about15 or 20 minutes, the crew felt that winds and turbulence was starting to exceed their comfort level and the flight returned to the heli-base.

37 The pilot was highly qualified in type aircraft and has participated in teaching High Altitude Flying. Helicopter was operating in the vicinity of the FS 42 road under the influence of right quartering tail wind.

38 Aircraft was operating in Mountainous terrain at approximately 5000 ft MSL. Winds were 20 to 30 knots. Temp: 96 F Aircraft was heavy but within satisfactory limits. Aircraft flying as slow airspeed After PSD operations, the crew continued operating as a reconnaissance platform.

39 FAA advisory circular USFS IASA (safety alert) PSD crew exposed needlessly in recon mission.

40 The Bell 407 is not normally recognized for LTE. The pilot never stopped flying the aircraft and had a backup plan. Even though left turns are preferred for maneuvering at low airspeed and high weight, conditions will not always be conducive to provide that option. If a right turn is your best direction, compensate by increasing airspeed and or altitude prior to making the right turn.

41 June 15, 2011 T-885 Pike/San Isabel National Forest Region 2, Fremont County Airport Canon City, Colorado

42 Structure protection, dropping fire retardant on Duckett fire. Aircraft had been operating out of Fremont County airport from The aircraft was under a DOI National On- Call contract. Aircraft repositioned to Buena Vista airport due to shortage of retardant at Fremont County. Aircraft had made last drop and was returning to Fremont County to standby.

43 Winds 150 v 210 (AWOS) Temperature: 92F (AWOS) Density Altitude 8800 (AWOS) Wind Event- Pilot entered the Fremont County Airport area around 1316, winds developed to 21 mph with gusts to 40 at around the same time.

44 The pilot) to received the current weather information 12 miles out. The pilot approached the airport from the Northwest to enter a downwind to runway 11. On final approach, the pilot noticed a large dust devil or thermal crossing the runway and decided to abort the landing attempt and continue heading down runway 11.

45 The pilot decided to land on Runway 17. The pilot flew a high observation pass of the runway to check wind conditions and continued to land on runway 17.

46 The pilot entered a left traffic pattern for runway 17 and, after crossing runway threshold, he encountered a wind shear, causing the aircraft to suddenly drop approximately 80 to 100 feet N

47

48 The pilot increased power and touched down about 200 beyond the approach end of the runway. On rollout, and, just after crossing taxiway A1, he encountered a left wind shear forcing the aircraft to the right. He applied rudder, brake and power for additional directional control.

49 He applied full take off power. as the aircraft drifted right, departing the runway in a banked left turn. The left leading edge of the wing contacted a runway marker.

50 The impact broke off the marker and damaged the leading edge, lower wing skin, left aileron and contacted the left lower trailing edge wing tip.

51 The pilot continued into the air, setting up for a landing on runway 29, landing uneventfully, he taxied back to the airtanker base.

52 June 24, 2011 Heli-Tanker 719 Coronado National Forest Region 3, Sierra Vista Arizona

53 The aircraft was a CH54, N719HT on a National Exclusive Use Contract. They were assisting crews with water drops on the Monument fire. The aircraft was coming in for a second drop on a specific tree.

54 Smoke conditions made the drop area difficult to find. The aircraft made a 30 knot down canyon approach for a split drop at 200 feet (AGL) and around 100 feet above the tree top.

55 Immediately after the drop, the crew heard a loud bang and noticed the right side chin bubble broken. The PIC jettisoned the remainder of the load and returned to the helibase

56 Snorkel hose length was measured at 18 feet 8 inches. The snorkel pump housing impacted both left main landing gear outboard tire and right side chin bubble. A witness in the vicinity of the water drop saw the snorkel hose swinging violently and stated the hose seemed much more flexible than others he had seen.

57 Alignment inputs on final approach to the drop may have created /amplified swinging of the snorkel. Two variety of hoses, some pilots thought the white variety of hose to be noodley.

58 The potential of the snorkel hose impacting other parts of the aircraft, including the main rotor system, exists. Bottom edge of chin bubble

59 May 14 June 12, 2011 Multiple Aircraft Region 3, Large Fires

60 During a 4 week period from May through June, 2011, large fire activity was occurring along the Arizona and New Mexico border with extensive use of Air-tankers, Heli-tankers, helicopters and coordination aircraft. Received four reports of airspace conflicts indicating conditions that could lead to a mid-air collision. One un-reported conflict was discovered during research into one of the reported incidents.

61 Horseshoe 2 Fire, a Type-1 heli-tanker and Type-2 helicopter with long-line had a near miss with approximately 700 ft separation. Air attack distracted and overloaded while working an evacuation of spike camps. Mission changed since AM brief. Helicopters not aware of each others presence. No HELCO. One aircraft transitioning N-S while other was E-W, creating intersection.

62 Horseshoe 2 fire Two conflicts in one day, Heli-tankers and type-2 Helo supporting ground firefighters. Heli-tanker encountered conflict with a Lead setting up a tanker drop. Later that afternoon, Heli-tanker came out of smoke and saw an un-announced ASM making dry runs through the area he was working.

63 Large numbers of aircraft working the area with ASM and Lead aircraft. HELCOs not used. Emergent missions, with little or no brief with other aircraft. Long ATGS transition radio traffic. Radio traffic extremely heavy, air crew were turning down certain frequencies and not hearing warning calls.

64 Wallow Fire Helicopters working out of the Springerville heli-base entering FTA without establishing radio contact. Traffic conflicts were occurring between these helicopters and air-tankers / lead planes.

65 Heli-base was just outside and North of the Fire Traffic Area (FTA). Helicopters were supporting fire activity South of the FTA, direct flight most expedient route. Insufficient time to contact ATGS.

66 Area Command was being transported from one town in the southern part of a large FTA to a town just inside the Northern boundary of the same FTA. The FTA was divided into 3 zones with a different Air attack for each zone. Area command aircraft had near miss with Air Attack in the second zone they were entering enroute to destination.

67 Area Command aircraft took off from Reserve and had radio contact with zone 2 air attack. Zone 1 air attack was being relieved and its relief was reconning the area before pass-down. Zone 1 aircraft was unaware the Area Command aircraft was entering their zone. 60 nm Show Low Zone 1 Zone 2 Reserve Fire Traffic Area Willow

68 High traffic encountered with both Rotor and Fixed wing. Incidents occurred during the afternoon. Morning missions briefed in controlled environments with little distraction. Afternoon, emergent missions develop that miss the opportunity for crews to get clear and complete information. Radio traffic was generally heavy. Transition radio conversations were tying up air to air frequency.

69 Transition is a particularly vulnerable period until the coordination rhythm is restored. Critical radio calls not received and position calls were sometimes not made. Aircraft experiencing incidents involved at least one aircraft that was not in radio communication with the other and was unaware of its location. Helicopter water operations and fixed wing tanker drops are still set up without fences to ensure separation.

70 Air Attack crews were experiencing high workloads resulting in reduced attention to the helicopter coordination. FTA procedural discipline begins to breakdown as radio traffic becomes intense. When the FTA is close to a base, aircraft are inside the 7 mile area as soon as they are airborne. Teams interviewed agreed there was a need for a HELCO when air operations got complex.

71 On March 09, 2012 the NTSB released it s Probable Cause and Contributing Factor for this 3 fatality accident (Pilot and 2 FHP employees were only soles on board) The aircraft was heading towards William T. Piper Memorial Airport, near Lock Haven, PA when the engine failed within 5 miles of the airport.

72 Probable Cause: The total loss of engine power resulting from the fatigue failure of the engine's number 2 cylinder exhaust valve. The fatigue failure was due to valve guide wear that led to excessive clearance between the valve and valve guide.

73 Contributing Factor: Contributing to the accident was the contract operator s lack of compliance with its own maintenance procedures, which, if followed, would have prevented the accident.