# NTSB WPR09TA356: Bell 212, N212HP, Willow Creek, CA, July 21, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Final report - Date: July 21, 2009, 10:10 local (17:10 UTC) - Place: Willow Creek, CA - Coordinates: 40.946388, -123.632499 - Nearby events: https://openairdocs.org/map.md?lat=40.9464&lon=-123.6325&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-hover: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Fatal - Injuries: 1 fatal, 5 uninjured - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: USDA Forest Service - NTSB case key (mKey): 74322 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09TA356 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74322/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74322 - Page: https://openairdocs.org/ntsb/WPR09TA356 ## Probable cause The rappeller's failure to properly latch the rappelling harness to the rappelling assembly before exiting the helicopter. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Passenger (probable cause); cases with it: [Bell 212, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1181420), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Passenger (probable cause); cases with it: [Bell 212, 1 case](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=1181420), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-hover: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Bell 212, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=1181420), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## 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](https://openairdocs.org/aircraft/N212HP), registered now, S/N 30951, built 1979 (OpenAirDocs) - Reported make and model: BELL 212 - Registry model: [Bell 212](https://openairdocs.org/model/bell-212) (registry code 1181420) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6 series](https://openairdocs.org/engine/pratt-whitney-pt6-series) (registry code 52033, turbo-prop) (OpenAirDocs) - Category: Helicopter - Serial number: 30951 - Airframe hours: 7829 - Engines: P&W PT6 SERIES 500 horsepower turbo shaft; P&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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: none; 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 ## 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 20090721017989A](https://openairdocs.org/incident/20090721017989A), Jul 21, 2009: Bell 212, Willow Creek, CA, No damage, 1 fatal. (-23) On July 21, a rappeller sustained fatal injuries from an un-arrested descent out of a helicopter from an altitude of approximately 200 feet. The accident… ## Docket (5 files) The files NTSB released with the investigation on February 11, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74322. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325247&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Preliminary Accident Investigation Summary for NTSB (item 2, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325248&FileExtension=.PDF&FileName=Preliminary%20Accident%20Investigation%20Summary%20for%20NTSB-Master.PDF - Forest Service Safety Alert (item 3, .PDF, 540 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325250&FileExtension=.PDF&FileName=Forest%20Service%20Safety%20Alert-Master.PDF - Harness Configuration and Pictures (item 4, .PDF, 352 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325252&FileExtension=.PDF&FileName=Harness%20Configuration%20and%20Pictures-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325254&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.