NTSB PR: Jim Cash Awarded Sammie

FOR IMMEDIATE RELEASE:
December 7, 2010

The National Transportation Safety Board today determined that a series of improper actions by the contractor and insufficient oversight by the U.S. Forest Service (USFS) and the Federal Aviation Administration (FAA) led to the August 5, 2008, fatal crash of a Sikorsky S-61N helicopter near Weaverville, California. The contractor’s actions included the intentional alteration of weight documents and performance charts and the use of unapproved performance calculations.

Contributing to the accident was the failure of flight crewmembers to address issues related to operating the helicopter at its maximum performance capability. Contributing to the fatalities and survivors’ injuries were the immediate and intense fire that resulted from fuel spillage from the fuel tanks that were not crash resistant, the separation from the floor of the cabin seats that were not crash resistant, and the use of an inappropriate mechanism on the cabin seat restraints. The pilot-in- command, the safety crewmember, and seven firefighters were fatally injured; the copilot and three firefighters were seriously injured.

On August 5, 2008, a Sikorsky S-61N helicopter (N612AZ), which was being operated by the USFS as a public flight to transport firefighters battling forest fires, impacted trees and terrain during the initial climb after takeoff at a location about 6,000 feet above sea level in mountainous terrain near Weaverville. 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), also of Grants Pass.

“The probable cause of this accident had to do with Carson’s actions and the oversight entities’ inactions,” said NTSB Chairman Deborah A.P. Hersman. “Carson engaged in a bargain that violated the trust of their crewmembers, the firefighters that they carried onboard, 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. 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.”

In order to prevent similar accidents and to improve the survivability of such accidents when they do occur, the NTSB issued 11 new recommendations to the FAA and reiterated one from 2006. Ten recommendations were issued to the USFS.

Recommendations to the FAA include oversight of 14 Code of Federal Regulations Part 135 operators with aircraft that can operate part of the time as public aircraft and part of the time as civil, clarification of oversight responsibilities for public aircraft, accuracy of hover performance charts, pilot performance, fuel tank crashworthiness, and occupant protection.

To the USFS, the NTSB recommended the development of mission-specific operating standards for firefighter transport operations, a requirement that its contractors adhere to these standards, and the creation of an oversight program that can monitor and ensure contractor compliance with all standards and requirements. Other issue areas for the USFS recommendations included pilot training, occupant protection, weather instrumentation, and onboard recorders.

A synopsis of the NTSB report, including the probable cause conclusions and safety recommendations, will be available on the NTSB website.

National Transportation Safety Board
Washington, DC 20594
August 6, 2010

NTSB Safety Recommendation A-10-119 and -120
and Reiteration of NTSB Safety Recommendation A-04-63

The National Transportation Safety Board recommends that the European Aviation Safety Agency:

Modify European Aviation Safety Agency Certification Specifications for Large Aeroplanes CS-25 to ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. (A-10-119)

After the yaw axis certification standard recommended in Safety Recommendation A-10-119 has been established, review the designs of existing airplanes to determine if they meet the standard. For existing airplane designs that do not meet the standard, the European Aviation Safety Agency (EASA) should determine if the airplanes would be adequately protected from the adverse effects of a potential aircraft-pilot coupling (APC) after rudder inputs at all airspeeds. If adequate protection does not exist, EASA should require modifications, as necessary, to provide the airplanes with increased protection from the adverse effects of a potential APC after rudder inputs at high airspeeds. (A-10-
120)

In addition, the National Transportation Safety Board reiterates the following recommendation to the European Aviation Safety Agency:

Review the options for modifying the Airbus A300-600 and the Airbus A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds and, on the basis of this review, require modifications to the A300-600 and A310 to provide increased protection from potentially hazardous rudder pedal inputs at high airspeeds. (A-04-63