NTSB · Safety Recommendation
Safety Recommendation A-10-164
Recommendation
TO THE UNITED STATES DEPARTMENT OF AGRICULTURE, FOREST SERVICE: Review and revise policies regarding the type and use of gloves by firefighting personnel during transport operations, including but not limited to, compatibility with passenger restraints and opening emergency exits.
Safety Issue and Context
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).
Response History
February 5, 2024 · NTSB Correspondence · United States Department of Agriculture, Forest Service
We note that the Forest Service requirements for helicopter transport are specified in the National Wildfire Coordinating Group Standards for Helicopter Operations (NSHO) and the Interagency Standards for Fire and Fire Aviation Operations. We also note that you have revised these documents with an updated policy regarding the type and use of gloves by firefighting personnel and other passengers during transport operations.
The NSHO, which specifies the personal protective equipment requirements for occupants of helicopters operating under contract to the Forest Service, requires all occupants to wear fire-resistant or leather gloves that fit snugly to provide maximum finger dexterity for the wearer. You have also revised passenger briefing guidance and checklists to include seat belt operation and glove fit/dexterity. Further, you have revised your helicopter contracts to require that all restraints use a quick-release buckle, which is easier to operate with gloves than the rotary-style buckles that were installed on the accident helicopter.
We believe your revised glove policy satisfies the intent of this recommendation. Further, the changes you have implemented to ensure that belt operation and glove fit/dexterity are discussed and checked before flight and that all contracted helicopters are equipped with quick-release buckles exceed the intent of Safety Recommendation A-10-164, which is classified CLOSED-- EXCEEDS RECOMMENDED ACTION.
July 21, 2023 · Recipient Response · United States Department of Agriculture, Forest Service
-From Randy Moore, Chief, United States Department of Agriculture, Forest Service: On May 4, 2022, the U.S. Department of Agriculture, Forest Service, noted the response posted to the National Transportation Safety Board website addressing Safety Recommendations following the August 5, 2008, Sikorsky helicopter crash near Weaverville, California. As recorded, the National Transportation Safety Board Safety Recommendations A-10-148 thru A-10-163 and A-10-165 thru A-10-168 have been closed. The Forest Service recognizes the significance of all Safety Recommendations and remains steadfast in addressing the remaining Safety Recommendation A-10-164 noted in this letter.