# NTSB LAX99GA005: Grumman TS-2A, N416DF, Banning, CA, October 5, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: October 5, 1998, 12:36 local (19:36 UTC) - Place: Banning, CA - Coordinates: 33.939666, -116.969566 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.9397&lon=-116.9696&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 15, 1999 - Report: Approved by Office Director - NTSB case key (mKey): 44099 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX99GA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/44099/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=44099 - Page: https://openairdocs.org/ntsb/LAX99GA005 ## Probable cause The pilot misjudged his maneuvering altitude. Factors to this accident were the mountainous terrain, tailwind conditions, and turbulence in the area. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, maneuvering - aerial application - terrain condition - mountainous/hilly - weather condition - tailwind (contributing factor) - weather condition - turbulence,terrain induced (contributing factor) - low altitude flight/maneuver - misjudged, pilot in command (cause) ## Analysis The air tanker pilot was on a fire suppression mission with fire retardant chemicals aboard, and had made two previous drops on the fire line. Another tanker and spotter pilot witnessed the last drop approach, and reported that the pilot was turning from base leg to the westerly drop heading downwind while in a 60-degree left bank. The aircraft suddenly rolled left to 90 degrees, and at that point the left wing tip struck the terrain. The winds were estimated by the tanker pilots to be 25 to 30 mph with gusts to 40 plus from the east. The pilots also reported turbulence and bad air. Airmet Tango was issued for turbulence and isolated severe conditions mainly below 10,000 in the vicinity of canyons and passes. ## Factual narrative HISTORY OF FLIGHT On October 5, 1998, at 1236 hours Pacific daylight time, a Grumman TS-2A, N416DF, operated under 14 CFR Part 91 by the California Department of Forestry (CDF) as Tanker 96, was destroyed during a collision with mountainous terrain near Banning, California. The government owned aircraft was maintained and pilot services provided by San Joaquin Helicopters (SJH), a private contractor. The pilot was fatally injured. Visual meteorological conditions prevailed for the flight. The aircraft was on a fire suppression mission at the time of the accident and carrying fire retardant chemicals. According to the CDF, the tanker pilot made two previous drops on the Mt. Edna fire line. The tanker pilots are directed by spotter aircraft orbiting the fire. The accident pilot was directed by the spotter aircraft to tag onto the previous drop of Tanker 75. According to the pilot of Tanker 75, he had dropped in the same area, but in the opposite direction due to a gap between the previous drop and the rest of the line they were attempting to build. He stated that the drop was basically into the wind and he encountered severe turbulence but no loss of flight control. However, he had experienced a momentary loss of control on the previous drop while orbiting the fire approximately 1,000 feet agl and 1/4 mile west of the accident site in a left bank (approximately 15 degrees). The aircraft rolled 45-60 degrees. He concluded that there was a severe "rotor" effect coming off the ridges on the east side of the fire. Another tanker pilot and an U.S. Forest Service (USFS) spotter pilot witnessed the approach to the drop area. They reported that the pilot was turning from base leg to the westerly drop heading while in a 60-degree left bank. The aircraft suddenly rolled further left to 90 degrees, at which point the left wing tip struck the terrain prior to releasing retardant. According to the CDF Aviation Management, the minimum approved descent altitude for a retardant drop is 150 feet above vegetation/terrain. Pilots and ground personnel estimated the winds to be 25 to 30 mph with gusts of 40 mph from the east. One pilot called the estimate conservative. They also reported turbulence and bad air. Airmet Tango had been issued for turbulence and isolated severe conditions mainly below 10,000 in vicinity of canyons and passes. The aircraft was based at Fresno, California. The pilot had flown from Fresno to the Mt. Edna fire site with retardant on the morning of the accident. After the initial drop, he landed at Hemet-Ryan Airport, reloaded with retardant, and dispensed the load on the fire line. On the last drop, he reloaded, refueled, and departed at 1229 and crashed at 1236. The combined totals of flight time for the pilot on the day of the accident was about 2:42 hours. PERSONNEL INFORMATION San Joaquin Helicopters employed the airline transport rated pilot as a seasonal employee who had flown three fire seasons with them. The pilot had also flown numerous seasons with other contractors as a tanker pilot. He was type rated in 11 heavy aircraft and 4 additional with VFR limitations. At the start of the 1998 fire season he reported 16,680 total flight hours, with 865 hours in the TS-2A aircraft. He also reported 2,970 hours as a tanker pilot. On December 16, 1997, the pilot was issued a first-class medical certificate with restrictions that he wear glasses for distant vision and possess glasses for near vision. At the beginning of the April 30, 1998 season, the pilot was given a pilot proficiency evaluation that consisted of an oral evaluation of aircraft systems, limitations, normal and emergency procedures, and fire-fighting mission questions. Also addressed were ground operation issues for aircraft flight log, preflight, checklist, taxi technique, and takeoff computations. The pilot was evaluated during an actual flight of 40 minutes. The details of the total evaluation are attached to this report. On September 21, 1998, at the Fresno Air Attack Base the pilot satisfactorily completed a PIC proficiency check and instrument training under the provisions of 14 CFR 61.57. He also demonstrated the skill and knowledge requirements as required by 14 CFR Part 137.19. The pilot was on a normal day-off schedule the day before the accident. The day of the accident his day started about 0800. Prior to departing Fresno at 0912, he flew a proficiency flight of 12 minutes. At the time of the accident he had been on duty about 4:36 hours. According to contract #7CA51199 part four, section K, 4.7.4 Flight time in state-owned aircraft: Flight time shall not exceed a total of 7 hours per day. AIRCRAFT INFORMATION The ex-military aircraft was made available from long term storage to the California Department of Forestry and Fire Protection for Forest and Wildlife Conservation. The Federal Aviation Administration (FAA) issued a Special Airworthiness Certificate in the restricted category on June 20, 1985. The operating limitations specify, in part: . . . no person may operate this aircraft for other than the purpose for which the special airworthiness certificate was issued (Forest and Wildlife Conservation) and in accordance with operating limitations contained in FAR 91.313 with special operating limitations to operate over densely populated areas, in congested airways, from busy airports where passenger transport operations are being conducted and those contained herein . . . . Maintenance was provided by the contractor, San Joaquin Helicopters, under 14 CFR 91.409 (F), a continuous airworthiness program. The aircraft flight hours and maintenance data reflected in this report were obtained from the CDF Aviation Management. According to the maintenance contractor inspection schedule, the last annual inspection was performed on April 14, 1998, at 10,676.4 hours. A 100-hour inspection was conducted on July 31, 1998, at 10,776.4 hours. The annual inspection of the aircraft is routinely performed by SJH during the winter months after the fire season. Prior to the aircraft going back on-line for a fire season, the CDF performs a 27 page S-2 Operations Acceptance Check. A copy of the detailed check is included in this report. The aircraft was refueled with 357.8 gallons (full fuel) of 100LL aviation fuel after repositioning from Fresno to the Mt. Edna fire, dispensing a load of retardant, and landing at Hemet. Preliminary Stall Speed vs Angle of Bank calculations were made using the NAVAIR 01-85SAA-1 operations manual and estimating the weight to be 25,876 pounds. A 60-degree bank could generate a stall at 94 knots; a 70-degree bank could generate a stall at 110 knots. The accident site density altitude was estimated about 6,600 feet. At the time of the accident the aircraft had accumulated 10,848.7 total flight hours. On the day of the accident the pilot flew the aircraft .2 hours for proficiency prior to departing for Hemet. The flight time from Fresno to Hemet was 1:35 hours. The aircraft performed two retardant drops from the Hemet base. The combined flight totals for the day were 2:42 hours. The aircraft was fitted with an 800-gallon Aero Union Corporation Grumman S-2 retardant tank system. The doors are opened and closed by hydraulic actuators controlled electrically through a relay system. The airplane's 1,500 p.s.i. hydraulic system supplies the energy. On March 15, 1999, the Safety Board visited the CDF facilities located at Mather, California. A pilot generated test procedure similar to the Aero Union procedure for the retardant tank operational systems was discussed and examined. A brief functional test of a tanker door system was performed. On March 16, 1999, Tanker's T-100 and T-93 retardant tank operating systems were ground tested in all modes with the engines running. The tests following the written procedures met the requ ## Aircraft - Registration: [N416DF](https://openairdocs.org/deregistered/N416DF-1999-02-04), registration cancelled 1999-02-04, S/N 136704 (OpenAirDocs) - Reported make and model: Grumman TS-2A - Registry model: [Grumman TS-2A](https://openairdocs.org/model/grumman-ts-2a) (registry code 3951110) (OpenAirDocs) - Category: Airplane - Serial number: 613/136704 - Airframe hours: 10849 - Engines: Wright 1820-82B 1475 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Public aircraft, Part 91 - Registered owner: California Dept Of Forestry - Airworthiness certificate: Special, Restricted (Special) - Last inspection: 100 hour, July 28, 1998, 4 hours before - Departed: HMT, HEMET, CA - Destination: HMT, HEMET-RYAN, CA - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; airline transport; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 16,680 total, 865 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 15 knots, gusting 26 - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 28 °F - Observed at: BUO, 8 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19981005028329A](https://openairdocs.org/incident/19981005028329A), Oct 5, 1998: Grumav TS2A, Banning, CA, Destroyed, 1 fatal. California dept of forestry public use acft was on a fire fighting mission when it crashed under unkn circumstances.(-23) on October 5, 1998, at 1236 hours… ## Docket (25 files) The files NTSB released with the investigation on June 2, 1999, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=44099. 5.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1/2 (item 1, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105326&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%2F2-Master.PDF - Supplement A (item 2, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105323&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105324&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement K (item 4, .PDF, 283 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105325&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Witness Statements (item 5, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435289&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Maps or Charts of Accident Area, Wreckage Diagrams (item 6, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105328&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area,%20Wreckage%20Diagrams-Master.PDF - Weather Reports and Records (item 7, .PDF, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105329&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Grumman S-2 Operations Acceptance Check (item 8, .PDF, 697 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105330&FileExtension=.PDF&FileName=Grumman%20S-2%20Operations%20Acceptance%20Check-Master.PDF - Grumman S-2 Retardant Tank System Operations Manual (item 9, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105331&FileExtension=.PDF&FileName=Grumman%20S-2%20Retardant%20Tank%20System%20Operations%20Manual-Master.PDF - S-2 Weight and Balance Information (item 10, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105332&FileExtension=.PDF&FileName=S-2%20Weight%20and%20Balance%20Information-Master.PDF - Fueling Information (item 11, .PDF, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435290&FileExtension=.PDF&FileName=Fueling%20Information-Redacted.PDF - Ryan Air Attack Aircraft Time Use (item 12, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105334&FileExtension=.PDF&FileName=Ryan%20Air%20Attack%20Aircraft%20Time%20Use-Master.PDF - Pilot Information (item 13, .PDF, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435291&FileExtension=.PDF&FileName=Pilot%20Information-Redacted.PDF - Aircraft Information (item 14, .PDF, 686 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435292&FileExtension=.PDF&FileName=Aircraft%20Information-Redacted.PDF - Stall Speed vs Angle of Bank (item 15, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105337&FileExtension=.PDF&FileName=Stall%20Speed%20vs%20Angle%20of%20Bank-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 16, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435293&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 17, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435294&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 18, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40435295&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. View of accident looking north-northwest. The smoke is kept close to the downhill terrain by the strong winds. Picture taken by a firefighter in the area. (item 19, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105341&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20accident%20looking%20north-northwest.%20The%20smoke%20is%20kept%20close%20to%20the%20downhill%20terrain%20by%20the%20strong%20winds.%20Picture%20taken%20by%20a%20firefighter%20in%20the%20area.-Master.PDF - Photo 2. View of the ringed red retardant release button. (item 20, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105342&FileExtension=.PDF&FileName=Photo%202.%20%20View%20of%20the%20ringed%20red%20retardant%20release%20button.-Master.PDF - Photo 3. View of the emergency salvo push button located on the instrument panel. (item 21, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105343&FileExtension=.PDF&FileName=Photo%203.%20View%20of%20the%20emergency%20salvo%20push%20button%20located%20on%20the%20instrument%20panel.-Master.PDF - Photo 4. View of the retardant system controls. (item 22, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105344&FileExtension=.PDF&FileName=Photo%204.%20%20View%20of%20the%20retardant%20system%20controls.-Master.PDF - Photo 5. View of the airspeed indicator and center grimes "armed" light. (item 23, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105345&FileExtension=.PDF&FileName=Photo%205.%20%20View%20of%20the%20airspeed%20indicator%20and%20center%20grimes%20%22armed%22%20light.-Master.PDF - Photo 6. View of the initial point of contact by the left wing tip looking west. CDF Photo (item 24, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105346&FileExtension=.PDF&FileName=Photo%206.%20%20View%20of%20the%20initial%20point%20of%20contact%20by%20the%20left%20wing%20tip%20looking%20west.%20%20CDF%20Photo-Master.PDF - Photo 7. An aerial view of the first point of impact (left wing tip #1), and the wreckage scatter area #2. CDF Photo (item 25, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40105347&FileExtension=.PDF&FileName=Photo%207.%20%20An%20aerial%20view%20of%20the%20first%20point%20of%20impact%20(left%20wing%20tip%20%231),%20and%20the%20wreckage%20scatter%20area%20%232.%20%20CDF%20Photo-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.