Flight Safety Information December 8, 2010 - No. 251 In This Issue NTSB Criticizes Contractor, Federal Government In 2008 Weaverville, CA Accident NTSB PRESS RELEASE NTSB: Government aircraft are safety 'orphans'... Libyan carriers' pilots to undergo safety assessment Safety Managment System (SMS) NTSB Criticizes Contractor, Federal Government In 2008 Weaverville, CA Accident Improper Contractor Actions And Insufficient Federal Oversight Led To Fatal Firefighting Helicopter Crash The NTSB on Tuesday determined that a series of improper actions by the contractor and insufficient oversight by the U.S. Forest Service (USFS) and the 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. The NTSB's full report will be available on the website in several weeks. FMI: www.ntsb.gov Back to Top NTSB PRESS RELEASE National Transportation Safety Board Washington, DC 20594 FOR IMMEDIATE RELEASE: December 7, 2010 SB-10-46 IMPROPER CONTRACTOR ACTIONS AND INSUFFICENT FEDERAL OVERSIGHT LED TO 2008 FATAL FIREFIGHTING HELICOPTER CRASH NEAR WEAVERVILLE, CALIFORNIA, NTSB SAYS ********************************************************** 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. The NTSB's full report will be available on the website in several weeks. Back to Top NTSB: Government aircraft are safety 'orphans' WASHINGTON (AP) - Government planes and helicopters are used every day to help protect public safety, as well as countless other tasks. But who is looking after the safety of the flight crews, government employees and other passengers on those aircraft? No one, the National Transportation Safety Board said this week. The Federal Aviation Administration says it doesn't have the authority to regulate the safety of aircraft operated by other federal agencies or state and local governments. And those government agencies, with the exception of the military, generally don't have the aviation expertise to do it themselves. That makes these aircraft - some government-owned, others leased - virtual safety "orphans," said NTSB Chairman Deborah Hersman. Someone, she said, needs to accept this duty. The issue came to the fore Tuesday when the safety board determined after a two- year investigation that a company that provided a helicopter to the U.S. Forest Service for firefighting was responsible for a crash that killed nine people, including seven firefighters, and injured four others in a mountaintop clearing near Weaverville, Calif. The board said Carson Helicopters of Grants Pass, Ore., falsified documents to overstate the performance capabilities of its helicopters in order to win Forest Service contracts. As a result, the Sikorsky S-61N helicopter's pilot underestimated its weight by more than 1,400 pounds while preparing to ferry firefighters from the front lines of a stubborn wildfire in the Trinity Alps Wilderness on Aug. 5, 2008. The chopper was airborne less than a minute when its rotor began to slow. It clipped a tree and fell from the sky, bursting into flames. Even so, there might have been fewer deaths if the helicopter had been equipped with sturdier fuel tanks less likely to rupture on impact, the board said. The installation of cabin seats that weren't crash-resistant and seatbelts with a complicated rotary release mechanism instead of the typical lift-latch release used in airline seatbelts also contributed to the fatalities, it said. The FAA certified the helicopter - which was also used for nongovernment work - for flight without inspecting it first, investigators said. FAA officials who oversaw the safety of Carson's nongovernment-related operations had several opportunities to detect the falsified documents, but failed to do so, investigators said. The Forest Service awarded Carson a leasing contract without verifying the company's claims about the payloads its helicopters were capable of lifting even though other helicopter companies told investigators those claims were suspicious. Carson has notified the FAA that it's surrendering its operating certificate. The company said its own investigation shows the crash may have been due to a faulty fuel mechanism that caused one of the helicopter's engines to lose power. NTSB said both the chopper's engines were working at the time of the accident. The FAA said it's "working on policy clarification" for inspectors who oversee companies that lease aircraft for both government and private use. The General Services Administration, which makes recommendations to federal agencies on air fleet management, said the FAA is responsible for the oversight of aircraft used solely to carry passengers. But the FAA doesn't regulate aircraft engaged in government activities such as firefighting, border patrol, surveying or chasing down crooks. As a result of their investigation, NTSB officials are now asking if other companies that lease planes and helicopters to government agencies are engaged in "a race to the bottom" to maximize profits. "What we don't know is: Are there other operators out there right now also providing inaccurate information to flight crews and the FAA?" said Thomas Haueter, director of NTSB's Office of Aviation Safety. Twenty-three federal agencies operate over 1,600 nonmilitary aircraft. State and local governments operate hundreds more. The issue is not a new one. A Senate investigation in 1991 criticized the lack of binding safety standards and recommended that Congress eliminate the exemption from FAA regulations for government aviation operations. But past suggestions that Congress should authorize the FAA to should assume safety oversight of government aircraft have been quickly doused. "The Forest Service and FAA and their inspectors indicate they aren't even sure what they are supposed to be looking at, and the lines are blurred," Hersman said. "I think neither wants to take responsibility for this is because they don't have the resources to do what needs to be done." Back to Top Libyan carriers' pilots to undergo safety assessment Libyan Airlines and Afriqiyah Airways are to undergo a safety assessment conducted by Lufthansa Consulting, which will include an in-depth examination of its pilot training. Lufthansa Consulting says that a team of six will "identify the areas for possible improvement" in Tripoli and provide a "safety and quality upgrade concept" to the carriers. The assessment comes after the loss, in May, of an Afriqiyah Airbus A330 during an attempt to land at the Libyan capital. Lufthansa Consulting says part of its programme includes a computer-based theory test and simulator assessment for the airlines' 270 captains and first officers. Each pilot will be evaluated to "identify development potential", it says. The programme will run for three months alongside the regular training regime. Lufthansa Consulting will perform the work at flight simulator facilities in Central Europe and northern Africa, adding that it will give the airlines "the chance to upgrade the complete flight deck crew to ensure consistent highest safety standards". Both airlines belong to the state-run Libyan African Aviation Holding Company and are destined to be merged. Source: Air Transport Intelligence news Curt Lewis, P.E., CSP CURT LEWIS & ASSOCIATES, LLC