I want to thank my fellow Board members for their participation today.
In closing, I'd like to recognize the staff of the Safety Board who investigated this accident and produced this excellent report, and in particular, the staff in the Office of Aviation Safety and Office of Research and Engineering.
This was a long and challenging investigation that required investigators to ferret out facts, collect data and disprove key issues beyond what is typically needed. Through tenacity and meticulous follow through of each thread, the staff was able to piece together the story of what happened to this aircraft. Thank you for your exceptional effort.
Today, we've identified why this accident happened. We've talked about a contractor that altered documents exaggerating the performance capabilities of their aircraft. We found a system of oversight that didn't sufficiently monitor the contractor or the contract, so the deficiencies went unaddressed. We identified a crew that didn't heed their helicopter's performance limitations. We identified a fuel tank that wasn't crash-resistant, and cabin seats and restraints that, rather than protecting those on board, actually increased the risk of injury and fatality.
To be clear, the deliberations in the Board room today concluded that the probable cause of this accident had to do with Carson's actions and the oversight entities' inactions. Carson engaged in a bargain that violated the trust of their crew members, the firefighters that they carried on board 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. The premise of oversight, both of the operator and the contract, is ultimately to make sure that everyone puts in an honest day's work and that they work safely, so everyone gets to go home at the end of the day.
Over the years 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.
We believe that the safety recommendations we have adopted today will address these deficiencies and will, if implemented, go a long way toward improving the safety of transporting not only firefighters, but hopefully to encourage improved oversight of public use flights across the U.S.
The lesson of this accident is that we can never be too vigilant. We must be ever watchful to make sure that things are done right, and to be alert to when they are not. This is not an easy task and will require a collective effort. As President Theodore Roosevelt said, "Knowing what's right doesn't mean much unless you do what's right." It's time to do what's right to make sure the tragedy of Iron 44 is not repeated.
Thank you. We stand adjourned.