Good morning and welcome. My name is Debbie Hersman and it is my privilege to serve as the Chairman of the National Transportation Safety Board. This morning, I am joined by my fellow Board members: Vice Chairman Chris Hart, Member Robert Sumwalt, Member Mark Rosekind and Member Earl Weener.
Welcome to the boardroom of the National Transportation Safety Board. This morning, the Board meets in open session as required by the Government in the Sunshine Act. While this is a public meeting, only the Board members and NTSB staff participate in today's discussions.
Three weeks ago, the staff presented to the Board the draft report we are considering today: the August 5, 2008 crash during takeoff of a firefighting helicopter near Weaverville, California.
While the NTSB Board members have had the opportunity to read the proposed accident report and meet with staff, today is the first time that the members of the Board are meeting together to discuss it. Staff has prepared 5 presentations, each of which will be followed by a round of questions from the Board members. We will then consider the report's conclusions, probable cause determination, and proposed safety recommendations.
These are the Board's actual deliberations over the report, and that is the purpose of the Sunshine Act – to provide the public with a window into our decision making process. Some or all of the report may be revised as a result of today's meeting. Approximately 30 minutes after we conclude, copies of the abstract of this report will be available from the NTSB Public Affairs office and on the NTSB's website.
On behalf of my fellow Board members and the entire NTSB staff, I offer our deepest condolences to the families and friends of those who lost their lives and to those injured in this accident. I know several of you are in the boardroom or watching via webcast. Nothing can replace the loss of your loved one or repair the trauma of a life-changing injury. But we do have the opportunity – and the obligation – to take every step possible to ensure that the lessons of this tragedy are well-learned, and that the circumstances are not repeated.
I want to express the Safety Board's appreciation to the many groups and individuals who assisted the Board with this investigation, including the emergency responders on site immediately after the accident, and those who participated in the investigative process. In particular, I would like to recognize the U.S. Department of Defense and U.S. Department of State for providing us with valuable helicopter performance test data on the S-61 helicopter.
On August 5, 2008, a Sikorsky S-61N helicopter crashed during takeoff in the mountains near Weaverville, CA while on a firefighting mission. The aircraft was a public use flight being operated by the U.S. Forest Service through a contract with Carson Helicopters, Inc. Seven firefighters and two crew members lost their lives in the accident, and four others were seriously injured.
As we will discuss today, the NTSB's investigation revealed multiple layers of failures and missed opportunities. The tragedy of this accident is that this firefighting crew never expected that the place where they would experience the greatest danger was not on the mountain battling the flames but in a helicopter during takeoff on a flight back to base. Firefighters are emergency responders. They are trained to work in extremely dangerous situations, and they must be able to trust the system that supports them.
This accident represents a failure of that system.
It was the failure of the operator, Carson, which provided inaccurate and altered documents to the U.S. Forest Service and their crews regarding the accident helicopter's weight and performance charts, and which tacitly approved of its crew using above-minimum torque in the load calculation – all of which overestimated the helicopter's true performance capability and misled the flight crew into believing that they could safely takeoff when, in fact, they could not.
It was a failure of the federal oversight authorities – the U.S. Forest Service and the Federal Aviation Administration – to sufficiently oversee the operator and detect fatal errors and discrepancies that should have been identified, and corrected, before the accident.
Although the U.S. Forest Service's contract with Carson was based on the helicopter's lift performance, the Forest Service did not verify that the helicopter met the payload calculations.
While the Forest Service relied on the FAA to ensure that the aircraft met the Part 135 airworthiness requirements, the FAA inspectors did not inspect the accident helicopter before adding it to Carson's Part 135 operations specifications. This was a missed opportunity for the FAA to identify the discrepancies in the helicopter's weight documents and correct them.
And there was a missed opportunity to make this accident more survivable because FAA regulations did not require the passenger seat harnesses installed in the accident helicopter to go beyond the certification level of the original seats approved nearly 50 years ago, and Carson installed them even though the occupant protection provided was minimal.
Finally, the pilots failed to account for the helicopter operating at the limit of its performance.
As a result, at each step, the margin of safety designed into the system was eroded – with tragic consequences. The report we are considering today is a snapshot in time, a look at the circumstances and operating environment on August 5, 2008. But in many ways the accident that occurred over two years ago was a wake-up call to everyone involved – that the system could not be based on trust alone and, at each step, that trust needed to be verified.
It is encouraging that, in the two years since the accident, we've seen some positive actions to address the systemic failures. For example, the Forest Service now verifies the lift performance of its contracted aircraft, requires operators to install jump seats so that inspectors can observe the flight deck and requires contractors to implement safety management systems. Also, the Forest Service now spot-checks helicopter weights.
In light of these changes, perhaps some of the lessons of this tragedy have already been learned. It is unfortunate that these lessons were learned only after nine lives were lost on that mountainside.