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Safety Recommendation Details

Safety Recommendation A-10-168
Details
Synopsis: On August 5, 2008, about 1941 Pacific daylight time, a Sikorsky S-61N helicopter, N612AZ, impacted trees and terrain during the initial climb after takeoff from Helispot 44 (H-44),1 located at an elevation of about 6,000 feet in mountainous terrain near Weaverville, California. The pilot-in-command, the safety crewmember,2 and seven firefighters were fatally injured; the copilot and three firefighters were seriously injured. Impact forces and a postcrash fire destroyed the helicopter, which was being operated by the U.S. Forest Service (USFS) as a public flight to transport firefighters from H-44 to another helispot. 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), of Grants Pass.3 Visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan had been filed. The National Transportation Safety Board (NTSB) determined that the probable causes of this accident were the following actions by Carson Helicopters: 1) the intentional understatement of the helicopter’s empty weight, 2) the alteration of the power-available chart to exaggerate the helicopter’s lift capability, and 3) the 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 USFS and the Federal Aviation Administration (FAA).
Recommendation: TO THE UNITED STATES DEPARTMENT OF AGRICULTURE, FOREST SERVICE: 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.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Aviation
Location: Weaverville, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: LAX08PA259
Accident Reports: Crash During Takeoff of Carson Helicopters, Inc. Firefighting Helicopter Under Contract to the U.S. Forest Service, Sikorsky S-61N, N612AZ
Report #: AAR-10-06
Accident Date: 8/5/2008
Issue Date: 12/27/2010
Date Closed:
Addressee(s) and Addressee Status: United States Department of Agriculture, Forest Service (Open - Acceptable Response)
Keyword(s): Federal Civilian Operations

Safety Recommendation History
From: NTSB
To: United States Department of Agriculture, Forest Service
Date: 3/17/2016
Response: We note that the USFS no longer contracts for Type I (heavy) helicopters. We point out, however, that this recommendation is for all contracted transport-category helicopters, regardless of their type. We would like to know whether you have exclusive use contracts for any transport category helicopters and, if so, we ask you to require that they be equipped as we recommend. Pending our receipt of this additional information and completion of the recommended action, Safety Recommendation A 10-168 remains classified OPEN—ACCEPTABLE RESPONSE.

From: United States Department of Agriculture, Forest Service
To: NTSB
Date: 11/12/2015
Response: -From James Hubbard, Deputy Chief for State and Private Forestry: If type 1/ heavy helicopters are utilized for transport category missions in the future, these specifications will be included in contract requirements. The FS does not contract for or use type 11 heavy helicopters for firefighter transport.

From: NTSB
To: United States Department of Agriculture, Forest Service
Date: 5/1/2015
Response: In your February 14, 2011, letter regarding these recommendations, you described actions you were taking at that time to address them. On July 13, 2011, we classified Safety Recommendations A-10-159 through -164, and -166 through -168, “Open?Acceptable Response” based on the information you had provided in your letter. However, we have not received any more information about your actions in the 4 years since then. We generally expect that the actions we recommend can be completed within 5 years; therefore, we ask that you provide an update on the actions that you have taken or are taking to satisfy these recommendations. Pending our receipt of your timely reply providing the details we are requesting, Safety Recommendations A-10-159 through -164, and A 10-166 through -168, remain classified OPEN—ACCEPTABLE RESPONSE.

From: NTSB
To: United States Department of Agriculture, Forest Service
Date: 7/13/2011
Response: The NTSB notes that the USFS plans to require compliance with Part 135 regulations and company operating specifications for CVR and FDR recorder installation. Pending completion of the recommended action, Safety Recommendation A-10-168 is classified OPEN—ACCEPTABLE RESPONSE.

From: United States Department of Agriculture, Forest Service
To: NTSB
Date: 2/14/2011
Response: Thank you for your letter of December 27, 2010, containing Safety Recommendations A 10-159 thru A-10-168 for the Sikorsky helicopter crash near Weaverville, CA that occurred on August 5, 2008. The Forest Service has given this serious review and the thorough work that NTSB has done in the investigation of this tragic mishap is appreciated. The Forest Service accepts the recommendations of NTSB. This report has resulted in further review of our policy, business processes and program emphases. That review and corresponding adjustments will undoubtedly improve and strengthen our management of rotor winged aircraft. Additionally, we hope to work with the FAA to further clarify and discuss public use operations. Several changes have already been implemented. Examples are: • Personal verification and consistent documentation of all contract helicopter weights through the witnessing of weighing the aircraft and validation of weight and balance records against the contractor's bid proposal. • The hiring of eight additional oversight personnel. All will receive indoctrination training at the FAA training academy. • Performance of Safety Management Systems (SMS) audits of contract aircraft at least once during the contract period while in the field. The specific recommendation responses are attached. Thank you for the effort and diligence that went into your report. USFS Response: USFS will require compliance with 14 CFR Part 135 regulations and company operating specifications for cockpit voice recorder and flight data recorder installations. Action Plan: • The Agency will continue to engage in dialog with the FAA as it pertains to this issue.