LAX08PA259

NTSB accident investigation · Sikorsky S-61N · Weaverville, CA · August 6, 2008

Accident · FatalClass 1Final report
Date
August 5, 2008, 19:41 local (Aug 6, 2008, 02:41 UTC)
Place
Weaverville, CA
Injuries
9 fatal, 4 serious
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N612AZSikorsky S-61N
Defining event
Initial climb: Collision during takeoff/land
Weather
Visual (VMC)
Status
Completed · report January 25, 2011
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Parties
Washington, D.C., AAI-100
Safety recommendations
Yes
FAA report
20080805857529A
Case key
68616

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

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 U.S. Forest Service and the Federal Aviation Administration.

Contributing to the accident was the failure of the flight crewmembers to address the fact that the helicopter had approached its maximum performance capability on their two prior departures from the accident site because they were accustomed to operating at the limit of the helicopter’s performance.

Contributing to the fatalities were the immediate, intense fire that resulted from the spillage of fuel upon impact 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 release mechanism on the cabin seat restraints.

Findings · 12

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

LoadingAircraft › Aircraft handling/service · Related operating infoSikorsky S-61N: 1 caseAll aircraft: 35 casesProbable cause
Aircraft capabilityAircraft › Aircraft oper/perf/capability · Related operating infoSikorsky S-61N: 1 caseAll aircraft: 57 casesProbable cause
Culture: standard operating practicesOrganizational issues › Management · OperatorSikorsky S-61N: 1 caseAll aircraft: 10 casesProbable cause
KnowledgePersonnel issues › Experience/knowledge · PilotSikorsky S-61N: 1 caseAll aircraft: 5 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · FAA/RegulatorSikorsky S-61N: 1 caseAll aircraft: 61 casesProbable cause
Oversight: oversight of operationOrganizational issues › Support/oversight/monitoring · Other government Sikorsky S-61N: 1 caseAll aircraft: 61 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Flight crewSikorsky S-61N: 2 casesAll aircraft: 792 casesProbable cause
Fuel system: fuel storageAircraft › Aircraft systems · DesignSikorsky S-61N: 1 caseAll aircraft: 60 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionSikorsky S-61N: 1 caseAll aircraft: 1,695 cases
WindEnvironmental issues › Conditions/weather/phenomena · Availability of related infoSikorsky S-61N: 1 caseAll aircraft: 110 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10-06.

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), located at an elevation of about 6,000 feet in mountainous terrain near Weaverville, California. The pilot-in-command, the safety crewmember, 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. of Grants Pass. Visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan had been filed.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10-06.

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), located at an elevation of about 6,000 feet in mountainous terrain near Weaverville, California. The pilot-in-command, the safety crewmember, 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. of Grants Pass. Visual meteorological conditions prevailed at the time of the accident, and a company visual flight rules flight plan had been filed.

Aircraft

Registration
N612AZ
Reported as
Sikorsky S-61N
Category
Helicopter
Engines
General Electric CT58-140, turbo shaftGeneral Electric CT58-140, turbo shaft
Damage
Destroyed
Fire
On-Ground
Flight
Public aircraft - federal · Public use
Operator
USDA Forest Service
Departed
NONE · Weaverville, CA
Destination
NONE
Flight plan
Company VFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Injuries
Fatal
Certificates
Commercial, Airline transport
Flight hours
20,286 total · 8,166 in this make and model
Role
Co-pilot
Injuries
Serious

Weather

Conditions
Visual (VMC)
Wind
150° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 36 °F
Altimeter
29.82 inHg
Observed at
RDD

Docket · 236

The files NTSB released with the investigation on September 16, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Operations 2-operations group chairman's factual reportItem 1 · PDF · 72 pages · 4.2 MBOperations group chairmani��s factual report-errata sheetItem 2 · PDF · 2 pagesOperations 2-attachment 01_subpoenaItem 3 · PDF · 2 pages · 118 KBOperations 2-attachment 02_operating certificatesItem 4 · PDF · 4 pages · 185 KBOperations 2-attachment 03_load calculations performed by PICItem 5 · PDF · 4 pages · 249 KBOperations 2-attachment 04_ pilot's recordsItem 6 · PDF · 53 pages · 3.0 MBOperations 2-attachment 05_pilots' duty hoursItem 7 · PDF · 2 pages · 232 KBOperations 2-attachment 06_copilot recordsItem 8 · PDF · 33 pages · 2.2 MBOperations 2-attachment 07_chsi training manualItem 9 · PDF · 282 pages · 2.1 MBOperations 2-attachment 08_aircraft contract daily diary OAS-137Item 10 · PDF · 4 pages · 279 KBOperations 2-attachment 09_load calculation formItem 11 · PDF · 5 pages · 1.1 MBOperations 2-attachment 10_ihog chapter 7 helicopter load calculations and manifestsItem 12 · PDF · 9 pages · 2.4 MBOperations 2-attachment 11_ihog appendix a helicopter management forms and checklistsItem 13 · PDF · 36 pages · 345 KBOperations 2-attachment 12_chsi provided chart c 06-27-08Item 14 · PDF · 1 page · 129 KBOperations 2-attachment 13_original manifestsItem 15 · PDF · 9 pages · 517 KBOperations 2-attachment 14_chc weight documentation charts a b and cItem 16 · PDF · 21 pages · 2.3 MBOperations 2-attachment 15_chart a and c comparisonsItem 17 · PDF · 8 pages · 109 KBOperations 2-attachment 16_calibration recordsItem 18 · PDF · 1 page · 431 KBOperations 2-attachment 17_prior accident-incidentsItem 19 · PDF · 14 pages · 3.2 MBOperations 2-attachment 18_chsi provided chart a and bs 8-11-07 and 01-04-08Item 20 · PDF · 12 pages · 2.5 MBOperations 2-attachment 19_der provided weight documents 12-07Item 21 · PDF · 13 pages · 567 KBOperations 2-attachment 20_weight from airworthiness conformity inspection 08-06-07Item 22 · PDF · 1 page · 358 KBOperations 2-attachment 21_weight for test flight from subpoenaItem 23 · PDF · 1 page · 60 KBOperations 2-attachment 22_chart b from subpoena 12-26-07Item 24 · PDF · 1 page · 50 KBOperations 2-attachment 23_chart a from subpoena 08-11-07 01-04-08 and 03-25-08Item 25 · PDF · 12 pages · 1.0 MBOperations 2-attachment 24_chart b from subpoena 01-04-08Item 26 · PDF · 1 page · 50 KBOperations 2-attachment 25_chart c from subpoena 03-25-08Item 27 · PDF · 1 page · 99 KBOperations 2-attachment 26_subpoenaed email from chi to chsi confirming weights 03-28-08Item 28 · PDF · 1 page · 30 KBOperations 2-attachment 27_subpoenaed email from chsi to chi confirming weights 05-05-08Item 29 · PDF · 2 pages · 108 KBOperations 2-attachment 28_chsi fleet chart bs submitted to usfs for 2007 bidsItem 30 · PDF · 12 pages · 694 KBOperations 2-attachment 29_chsi fleet chart bs submitted to usfs for 2008 bidsItem 31 · PDF · 11 pages · 571 KBOperations 2-attachment 30_chsi fleet weights and performance submitted to usfs for 2008 bidsItem 32 · PDF · 1 page · 51 KBOperations 2-attachment 31_bid submitted to usfsItem 33 · PDF · 6 pages · 385 KBOperations 2-attachment 32_roc scale repair-calibration stationItem 34 · PDF · 1 page · 69 KBOperations 2-attachment 33_load calculation form instructionsItem 35 · PDF · 2 pages · 196 KBOperations 2-attachment 34_ Sikorsky's communications with FAA regarding 25 minute power available chartItem 36 · PDF · 6 pages · 222 KBOperations 2-attachment 35_usfs power check form from ihogItem 37 · PDF · 5 pages · 578 KBOperations 2-attachment 36_power checks performed by pilots of ht 766Item 38 · PDF · 4 pages · 1.2 MBOperations 2-attachment 37_chsi provided supplement 5 figure 1Item 39 · PDF · 1 page · 156 KBOperations 2-attachment 38_FAA provided supplement 5Item 40 · PDF · 8 pages · 1.4 MBOperations 2-attachment 39_supplement 7Item 41 · PDF · 18 pages · 2.6 MBOperations 2-attachment 40_chsi provided supplement 8Item 42 · PDF · 42 pages · 13.5 MBOperations 2-attachment 41_FAA provided supplement 8Item 43 · PDF · 19 pages · 2.5 MBOperations 2-attachment 42_FAA provided supplement 9Item 44 · PDF · 19 pages · 2.2 MBOperations 2-attachment 43_supplement excerpts charts provided to pilots at helibase in-football-Item 45 · PDF · 11 pages · 1.3 MBOperations 2-attachment 44_email from chsi chief pilot instructing pilots to change charts supplement 8 and 9Item 46 · PDF · 13 pages · 9.2 MBOperations 2-attachment 45_comparison of performance charts provided by chsi and FAAItem 47 · PDF · 49 pages · 26.2 MBOperations 2-attachment 46_performance calculations on charts provided by chsi and FAAItem 48 · PDF · 9 pages · 11.2 MBOperations 2-attachment 47_height-velocity diagramItem 49 · PDF · 1 page · 861 KBOperations 2-attachment 48_chsi charts submitted to usfs for 2008 bidItem 50 · PDF · 15 pages · 1.0 MBOperations 2-attachment 49_liquid tank installation STCItem 51 · PDF · 2 pages · 318 KBOperations 2-attachment 50_hoist installation STCItem 52 · PDF · 2 pages · 320 KBOperations 2-attachment 51_composite main rotor blade component cards installed 08-14-07Item 53 · PDF · 3 pages · 252 KBOperations 2-attachment 52_liquid tank component card installed 03-25-08Item 54 · PDF · 1 page · 55 KBOperations 2-attachment 53_ag air component card installed 12-26-07Item 55 · PDF · 1 page · 63 KBOperations 2-attachment 54_ht 766 helicopter activity reportItem 56 · PDF · 4 pages · 202 KBOperations 2-attachment 55_usfs inspector evaluation of ht 766Item 57 · PDF · 1 page · 50 KBOperations 2-attachment 56_ht 766 registrationItem 58 · PDF · 1 page · 35 KBOperations 2-attachment 57_chsi organization chartItem 59 · PDF · 1 page · 36 KBOperations 2-attachment 58_subpoenaed email stating chi pays for chsi employeesItem 60 · PDF · 1 page · 50 KB
All 236 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.