WPR09TA356

NTSB accident investigation · Bell 212 · Willow Creek, CA · July 21, 2009

Accident · FatalFinal report
Date
July 21, 2009, 10:10 local (17:10 UTC)
Place
Willow Creek, CA
Injuries
1 fatal, 5 uninjured
Damage
No damage
Phase of flight
Maneuvering
Aircraft
N212HPBell 212
Defining event
Maneuvering-hover: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
USDA Forest Service
FAA report
20090721017989A
Case key
74322

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

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Probable cause

The rappeller's failure to properly latch the rappelling harness to the rappelling assembly before exiting the helicopter.

Findings · 2

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.

Action: incorrect action performancePersonnel issues › Action/decision · PassengerBell 212: 1 caseAll aircraft: 1,386 casesProbable cause
Use of equip/infoPersonnel issues › Task performance · PassengerBell 212: 1 caseAll aircraft: 111 casesProbable cause

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 purpose of the flight was to conduct proficiency rappel training. During a preflight equipment check, one of the rappellers identified a broken "Kong" clip on the Tri-link/J-hook interface on the harness. He replaced the Kong clip with a rubber O-ring (an authorized substitution) and then he returned to the helicopter. Minutes later, with the helicopter in a stabilized hover, witnesses on the ground reported that they observed the rappeller transition from inside the helicopter to the port side skid, then fall down the rope at excessive speed. Postaccident examination of the rope and harness assembly revealed that the rappeller's J-hook was attached to the Sky Genie and rope; however, the J-hook was not attached to the Tri-link and harness. A broken O-ring, believed to be the O-ring used to center the Tri-link and J-hook, was found on the ground approximately 30 feet from where the harness assembly was located. Evidence obtained during the investigation suggests that the rappeller's Tri-link and J-hook were not mechanically linked (prior to the rappeller transitioning to the skid), but rather inadvertently linked together with a non load-bearing O-ring used to center the latching devices. Examination of the J-hook, Sky Genie, Tri-link and harness by investigators from the US Forest Service revealed no evidence of malfunction or defect.

Factual narrative

On July 21, 2009, at 1010 Pacific daylight time, a helitack firefighter was killed during an un arrested descent during a rappelling operation from a Bell 212 helicopter, N212HP, near Willow Creek, California. The airline transport pilot, spotter and three remaining rappellers were not injured. The helicopter was operating under contract to the United States Department of Agriculture, Forest Service by Heli-1 Corporation, as a visual flight rules (VFR) public use flight, in support of firefighting efforts, when the accident occurred. Visual meteorological conditions prevailed for the local flight. The flight originated from a helibase at Willow Creek at 1004; no flight plan was filed for the local flight. The helicopter was not damaged. A representative from the US Forest Service reported that the purpose of the flight was to conduct proficiency rappel training (required every 14 days for helitack crew members that are not actively conducting operational rappel assignments) from the helicopter. The rappelling equipment utilized in this operation consists of a harness, Tri-link, J-hook, O-ring/Kong clip and Sky Genie. The Sky Genie is a descent control device that is connected to a 1/2-inch diameter, 250-foot long, braided nylon rappel rope. Normally, the harness is attached to the Tri-Link, and the Tri-link is mechanically linked to the J-hook, which is mechanically clipped to the Sky Genie and rope. The Kong clip/O-ring (non load bearing) is used to center the J-hook at the apex of the Tri-link in an effort to avoid side loading during rappel operations. Prior to commencing the operation, a rappel equipment check was conducted. The equipment check revealed a broken "Kong" clip on the Tri-link/J-hook interface on the harness of accident rappeller (R-2). The Kong clip was replaced with a rubber O-ring (an authorized substitution for a Kong clip) and R-2 returned to the helicopter. Approximately 6 minutes later, with the helicopter established in 225-250 foot hover, R-2 connected his J-hook to the Sky Genie. Witnesses on the ground reported seeing R-2 transition to the port side skid and then falling down the rope at an excessive speed. Post accident examination of the rope and harness assembly by investigators from the US Forest Service revealed that the R-2's J-hook remained attached to the Sky Genie; however, the J-hook was not mechanically attached to the Tri-link and harness. A broken O-ring was found approximately 30 feet from where the harness assembly was located, and is believed to be the O-ring that was attached to R-2's Tri-link. Examination of the J-hook, Sky Genie, Tri-link and harness by investigators from the US Forest Service revealed no evidence of malfunction or defect. Investigators reported that examination of the rappel equipment indicated that R-2's Tri-link and J-hook were not mechanically linked prior to exiting the helicopter. Examinations by investigators indicated that the Tri-link and J-hook were only held in place bythe rubber O-ring. Investigators from the US Forest Service reported that the rappel equipment was checked by the rappeller and spotter prior to the accident. The helicopter was not damaged and no mechanical malfunction or failure was reported.

Aircraft

Registration
N212HP
Reported as
Bell 212
Category
Helicopter
Serial number
30951
Airframe hours
7,829
Engines
P&W PT6 SERIES, 500 horsepower, turbo shaftP&W PT6 SERIES, 500 horsepower, turbo shaft
Damage
No damage
Flight
Public aircraft - federal · Public use
Operator
USDA Forest Service
Registered owner
Sierra Nevada Holdings Inc
Airworthiness certificate
Standard, Transport
Last inspection
100 hour · July 17, 2009
Departed
PVT · Willow Creek, CA
Destination
PVT · Willow Creek, CA
Airport
PVT · Willow Creek Helibase

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
None
Certificates
Flight instructor, Airline transport, Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 2, With waivers/limitations
Last flight review
November 5, 2008
Seat
Right
Flight hours
6,200 total · 550 in this make and model · 6,000 as pilot in command · 30 in the last 90 days · 10 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F

Docket · 5

The files NTSB released with the investigation on February 11, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 MB in all.

FAA reports on this event · 1

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