2008 — June 20-Nov, Wildfires, esp. Iron, Alps Complex fires, Trinity Co., CA — 14

–33  Wikipedia. “2008 California wildfires.” 9-9-2018 edit; cites Cal Fire. 2008 June Fire Siege.[1]

–15  Aanestad. “California burning: It’s time for real action.” Mountain Democrat, Placerville, CA, 8-27-2008, A6.

–14  CAL FIRE. 2008 Fire Siege Timeline, “Executive Summary,”, p. 8 and Part IV, p. 65.[2]

 

Summary Timeline

 

June 20-21: Lightning storm ignites over 2,000 fires. CAL Fire, CA.gov. 2008 Fire Siege. 2012.

 

June 22: Over 600 new lightning fires; esp. Butte, Mendocino, Shasta, Plumas, Trinity counties.[3]

 

June 23: Evacuations ordered in Solano, Napa, Shasta, Trinity, Lassen, Butte, Mendocino counties.[4]

 

July 1: Gap Fire started in Santa Barbara County.[5]

 

July 3: 1st death. Anderson Valley vol. firefighter recruit Bob Roland; Mendocino Complex fire.[6]

 

July 11: 2nd death disclosed; Van Scott West, 61, Concow, Butte County, in remains of house.[7]

 

July 25: 3rd death. Olympic Nat. Park firefighter Andrew Palmer hit by falling tree; Iron Complex.[8]

 

July 26: 4th death. Daniel Packer, Chief, East Pierce Co. Fire, WA; from injuries; Panther Fire.[9]

 

Aug 5: Contract helicopter crash; Iron/Alps Complex fire; 9 killed, 4 injured survivors.[10]

 

Sep 11: Curtis Hillman, road grader operator, dies from injuries sustained on Aug 25.

 

Fatalities (Alphabetical)[11]

 

  1. Blazer, Shawn, 30. Firefighter, Grayback Forestry, Inc.                   Medford, OR.
  2. Charlson, Scott, 25. Firefighter. Grayback Forestry, Inc.                 Phoenix, OR.
  3. Gomez, Edrik, 19. Firefighter, Grayback Forestry, Inc.                    Ashland, OR.
  4. Hammer, Matthew, 23. Firefighter, Grayback Forestry, Inc.            Ashland, OR.
  5. Hillman, Curtis, 77. Contract equipment operator.                           Happy Camp, CA.
  6. Packer, Daniel, 44. Fire Chief, East Pierce Fire & Rescue.              Bonney Lake, WA.
  7. Palmer, Andrew, 18. Firefighter, Olympic National Park.                Port Townsend, WA.
  8. Ramage, Jim, 63. Helicopter Pilot, Inspector, USDA Forest Ser.     Redding, CA.
  9. Renno, Steven, 21. Firefighter, Grayback Forestry, Inc.                   Cave Junction, OR.
  10. Rich, Bryan, 29. Firefighter, Grayback Forestry, Inc.                       Medford, OR.
  11. Roland, Bob, 63. Volunteer firefighter, Anderson Valley Fire Dept. Boonville, CA.
  12. Schwanenberg, Roark, 54. Helicopter Pilot. Carson Helicopters.    Lostine, OR.
  13. Steele, 19. Firefighter, Grayback Forestry, Inc.                                Ashland, OR.
  14. West, Van Scott, 61. Civilian, house in Butte County                      Concow area, CA.[12]

 

Fatalities (17, as attributed to a particular fire)[13]

 

—  2  Butte Lightning Complex. Civilian, Concow area; 1 off-duty firefighter. Cal Fire. 2008, 96.

–10  Iron Complex. July 25 firefighter, falling tree; Aug 5 helicopter crash. Cal Fire. 2008, p115.

—  2  Klamath Theater Fire. CAL Fire. 2008 June Fire Siege, p. 91.

—  1  Mendocino Lightning Complex fire. Anderson Valley volunteer firefighter. Cal Fire, p.122.

—  1  Panther Fire. July 26, Chief Daniel Bruce Packer, 49, Lake Tapps, WA. Cal Fire, p. 127.[14]

—  1  Siskiyou Complex. Road grader operator Curtis Hillman dies Sep 11 from Aug 25 injury.[15]

 

Narrative Information

 

CAL FIRE overview: “In June 2008, a series of dry thunderstorms swept across California igniting more than 1,750 fires. Despite the great number of starts, severe burning conditions and limited resources, initial attack efforts by fire fighters contained more than 500 fires during the first few days of the siege.[16] While there were many early successes, some fires in remote areas continued to burn throughout the summer. By autumn, the June Fire Siege had burned more than 1.2 million acres and taken the lives of thirteen firefighters. A wildland fire siege of this magnitude with so many fires burning so many acres over such a long period of time is unprecedented in California’s modern fire suppression history.

 

“During the siege over 350 structures were destroyed and hundreds of millions of dollars of property and natural resources were damaged. Thousands of people were evacuated and smoke adversely effected air quality for weeks at a time. Weather and fuel conditions and competition for resources made fire control efforts difficult, requiring strong cooperation and coordination among federal, state, and local fire fighting agencies….” (CAL FIRE. 2008 Fire Siege. “Intro.”)

 

CAL FIRE: “The fires had a great impact on people and society. During this fire siege, thirteen people were killed and many fire fighters were injured. The fires destroyed 186 homes, 1 commercial building…183 other structures, and caused hundreds of millions of dollars in property and natural resource damage.” (CAL FIRE. 2008 Fire Siege. “Introduction,” p. 11.)

 

June 20: “….The Trabing Fire started that afternoon north of Watsonville, in Santa Cruz County, when a vehicle’s exhaust system ignited a series of fires along a ¾ mile stretch of road. Those fires spread rapidly into a large eucalyptus grove and merged into a single fire which threatened hundreds of structures and forced the evacuation of about 2,000 people and 220 horses and other livestock. There were also two ongoing, large wildland fires burning: the Clover Fire and the Indians Fire. While the response to these fires was a sizeable resource commitment, numerous interagency wildland firefighting resources remained available for new initial attack fires.

 

“By late afternoon and evening, thunderstorm cells and dry lightning strikes moved in along the coast from Big Sur, north to Humboldt County. As early reports started to accumulate, the magnitude of the lightning event and resulting fire situation revealed itself; the 2008 June Fire Siege was under way. By midnight on Friday, suppression efforts were initiated on 14 fires in Southwestern Mendocino County between Boonville and Point Arena…. (p. 29)

 

June 21: “Around 2 a.m. on Saturday, June 21st, the lightning activity increased with hundreds of downstrikes in Mendocino, Humboldt, and Trinity counties. A low pressure trough moved through northern California on Saturday, intensified the lightning activity, swept north and east, and brought heavy concentrations of lightning strikes to Butte, Tehama, Shasta, and Lassen counties….More than 5000 lightning strikes were recorded in the Northern California area during a 33-hour period….” (CAL Fire, CA.gov. 2008 Fire Siege. Pp. 29-30.)

 

June 23: “Evacuations were ordered for multiple fires near residential areas in Solano, Napa, Shasta, Trinity, Lassen, Mendocino and Butte Counties….” (CAL Fire. 2008 Fire Siege, p. 33.)

 

July 1: “By July 1, 1,459 fires spanned across 435,894 acres of land.” (CAL Fire. 2008 Fire Siege, p. 44.)

 

July 2-Aug 5: “The 2008 June Fire Siege continued until the fall rains came for some of the complexes. The remaining portion of this report highlights the significant events that occurred during the next 34 days. During this time period a critical wind event caused a major expansion of all fires, and additional lightning ignited more fires. This segment is marked by severe tragedy

with 13 firefighter fatalities directly related to the fires….” (CAL Fire. 2008 Fire Siege, p. 57.)

 

July 3: “The First Life Lost.…Volunteer Fire Fighter…recruit Bob Roland, 63, of Anderson Valley, CA passed away during the early morning of July 3, 2008 after suffering fatigue and respiratory difficulties. He was assigned to the Oso Fire in the Mendocino Lightning Complex….” (CAL Fire. 2008 Fire Siege, pp. 57-58.)

 

July 11: “Officials disclosed that the body of a civilian fire victim was found in the smoldering remains of a house in the Concow area on the Butte Complex. The victim was later identified as Van Scott West, 61 of Concow.” (CAL Fire. 2008 Fire Siege, p. 65.)

 

July 25: “Fire Fighter Fatality. On July 25, 2008 Andrew Jackson Palmer, an 18 year old fire-fighter from Olympic National Park in Washington, is fatally injured when he is struck by a falling tree. Palmer’s engine crew was assigned to the Iron Complex as a falling team to remove hazardous trees along the fireline ahead of mop-up crews.” (CAL Fire. 2008 Fire Siege, p. 72.)

 

July 26: “A Third Fire Fighter Fatality. The Panther Fire took the life of Daniel Packer, Chief of East Pierce County Fire and Rescue in Lake Tapps, Washington. Packer, while scouting fireline locations as a Division Supervisor, deployed his fire shelter when fire activity increased and succumbed to fatal injuries from burns and smoke inhalation.” (CAL Fire. 2008 Fire Siege, pp. 72 and 75.)

 

Aug 5: “Final Tragedy of the Siege….At approximately 7:45 p.m., a contract helicopter, ferrying firefighters from a helispot on the Buckhorn Fire in the Iron/Alps Complex crashed and caught fire, killing 9 of the 13 occupants. Aboard the helicopter were the pilot, copilot, FS pilot-inspector, and 9 contract fire-fighters from Grayback Forestry of Medford, OR. The surviving copilot and 3 firefighters were hospitalized with moderate to severe injuries.” (CAL Fire. 2008 Fire Siege, p. 76.)           — See Separate section below on NTSB report on this accident.

 

Sep 11: “There was an additional fire fighter fatality as 77 year old Curtis Hillman, a member of the Karuk Indian Tribe, died on September 11 from head injuries sustained August 25 while operating a road grader on the Six Rivers National Forest.”  (CAL Fire. 2008 Fire Siege, p. 79.)

 

Alps Complex Fires: “Although no injuries or fatalities were reported for the Alps Complex, the Buckhorn Fire (which transferred to the Iron Complex on July 4) is the site of the tragic helicopter crash on August 5 which resulted in 9 fatalities and 4 hospitalizations.” (CAL Fire. 2008 Fire Siege, p. 86.)

 

Butte Lightning Complex Fires: “….One of the biggest problems was the presence of strong, gusty down-canyon winds that frequently occurred at night in the Feather River Canyon. These winds, accentuated by a Foehn wind event, caused the fire to jump Highway 70, and push the fire into Concow. During this run the fire traveled 8 miles, re-burned through several fires that had been previously declared contained, and merged 17 fires into one fire called the Camp. Approximately 50 residences were destroyed and 1 civilian life is lost.”[17] (CAL Fire. 2008 Fire Siege, p. 97.)

 

Iron Complex Fires: “The Iron Complex became the site of some of the most tragic events of the 2008 California Fire Siege – the death on July 25 of an 18 year-old firefighter assigned to an engine due to a fatal tree falling accident; and on August 5, a helicopter crash killed 9 people and

critically injured 4 others.” (CAL Fire. 2008 Fire Siege, p. 115.)

 

Mendocino Lighting Complex Fires: “….a volunteer firefighter from the Anderson Valley Volunteer Fire Department lost his life fighting these fires.” (CAL Fire. 2008 Fire Siege, p. 122.)

 

Panther Fire: “….On July 26, Chief Daniel Bruce Packer, 49, of Lake Tapps, Washington, assigned as a Division Group supervisor suffered fatal injuries which resulted from thermal burns and smoke inhalation after he deployed his fire shelter when the fire activity suddenly increased.” (CAL Fire. 2008 Fire Siege, p. 127.)

 

Siskiyou Complex Fires: “….On September 11 Curtis Hillman, a road grader operator injured on August 25, succumbed to his injuries.” (CAL Fire. 2008 Fire Siege, p. 136.)

 

From NTSB Report on Helicopter Crash and Fire

 

Aug 5, NTSB: “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.

 

“The National Transportation Safety Board determines 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).

 

“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.

 

“The safety issues discussed in this report involve the accuracy of hover performance charts, USFS and FAA oversight, flight crew performance, accident survivability, weather observations at helispots, fuel contamination, flight recorder requirements, and certification of seat supplemental type certificates. Safety recommendations concerning these issues are addressed to the FAA and the USFS.” [p. x.]

 

“….About 1630, the helibase manager informed the pilots and the helitack[18] crew of a request for a hand crew repositioning mission. Based on a forecast of lightning for the high mountainous areas that night, USFS management had decided to transport two hand crews from H-44, which has an elevation of 5,980 feet, to Helispot 36 (H-36), which has an elevation of 1,531 feet…The hand crews were conducting ground-based firefighting operations to suppress the Buckhorn fire, one of the fires in the Iron Complex fire system. H-44 was located on the northern boundary of the Buckhorn fire near an actively burning area of timber. Neither the pilots nor the helitack crew had previously been to H-44…. [p. 2.]

 

“After refueling and taking off on third transfer of firefighters: “Ground witnesses stated that, as the helicopter began to lift off, the rate of climb appeared very slow, and the helicopter’s movement was labored. One witness stated that the takeoff was at “extremely slow speed and low altitude,” while another witness stated that the helicopter was “moving extremely slow, inconsistent with the last two departures.” The witnesses reported that the helicopter began to move forward in a nose-low configuration and drift sideways to the right. The helicopter continued to move forward and then began losing altitude as it continued down slope. One witness described the takeoff as follows:

 

After a vertical ascension of about 20 feet, the helicopter began to move forward and about 40 feet to the right. As the helicopter continued forward toward a section of lower trees, the belly of the fuselage contacted trees; it appeared as though the helicopter would fit between trees, though the main rotor blades were not high enough to clear the trees. Debris began to fly from the surrounding trees and the helicopter settled into the vegetation.

 

“The helicopter collided with the trees and subsequently impacted the down sloping terrain, coming to rest on its left side…Almost immediately after the impact, witnesses saw smoke and fire coming from the wreckage. One witness reported that both engines continued to run for about 30 seconds after the helicopter impacted the ground.” [pp. 7-8.]

 

“….An assessment of the surrounding trees revealed evidence of main rotor blades contacting several trees between the departure point and the main wreckage. Of these trees, the one closest to the departure point was a pine tree located about 65 yards south-southeast of the departure point. The ground elevation of the tree was 5,931.6 feet, and the height from the base of the tree to the blade contact point was about 49.5 feet….” [pp. 43-44.]

 

“The helicopter was found on a downward slope of about 15° to 20°; it was resting on its left side with its nose down slope from its tail boom. The magnetic heading of the wreckage was about 155°. A postcrash fire had consumed most of the helicopter’s airframe and structure forward of the tail boom. Solidified molten metal was noted in several areas of the wreckage and in the impact area. Sections of the helicopter’s lower fuselage structure, including all fuel tank cells and the cabin flooring, were consumed by the postcrash fire. Most of the forward fuselage, including the cockpit and the electronics compartment, was inverted and consumed by fire…”

[p. 44.]

 

“At the request of the Trinity County Coroner’s Office, the remains of the nine persons fatally injured in the accident were examined by Forensic Medical Group, Inc., Fairfield, California. Their cause of death was determined to be ‘combined blunt force trauma and thermal injury.’” [p. 45.]

 

“….All three surviving firefighters reported that they were not familiar with the operation of the rotary buckle on their restraints and that they experienced difficulty releasing their restraints. One survivor stated that he was accustomed to flip latch buckles and did not understand how the rotary buckle released. After the crash, he could not release his restraint buckle, so he pulled the shoulder restraints off and wiggled out of the lap belt. Another survivor stated that he thought that he needed to push a button on the center of the buckle and turn the buckle to release it. When he could not release the buckle, he also pulled the shoulder restraints off and wiggled out of the lap belt. The third survivor stated that he had problems fastening his restraint and described it as “pretty tricky.” After the impact, he attempted to release his restraint by turning the buckle, but it would not unbuckle. He pulled the shoulder restraints off and started to crawl out of the lap belt, but his seat separated from the floor and went with him. He freed himself from the seat by pushing the lap belt off of his hips….

 

“All of the survivors sustained multiple serious injuries and burns and were transported to hospitals.” [p. 48.]

 

“….The buckles from 15 of the 18 passenger restraints were identified. Ten of the 15 buckles were fully latched with the lap belt latch and both shoulder harness latches engaged. Four of the 15 buckles were partially latched: one had the lap belt latch and one shoulder harness latch engaged, and three had only the lap belt latch engaged. One of the 15 buckles had no latches engaged.” [p. 55.]

 

“Previous Related Safety Recommendations…Safety of Public [governmental/non-commercial] Firefighting Aircraft.

 

“On April 23, 2004, as a result of the investigative findings of three in-flight breakups of firefighting aircraft, the NTSB issued Safety Recommendations A-04-29 through -31 to the DOI and the USFS and Safety Recommendation A-04-32 to the FAA. In its safety recommendation letter, the NTSB noted that, since public firefighting flights are not statutorily required to comply with most FAA regulations or subject to FAA oversight, the DOI and the USFS, as the operators of these flights, are primarily responsible for ensuring the safety of these operations. The NTSB’s investigations revealed that, although the DOI and the USFS attempted to compel safe operations through the use of contract language that required compliance with FAA regulations, their oversight and infrastructure were not adequate to ensure safe operations. The NTSB concluded that these agencies must ensure the continuing airworthiness of their firefighting aircraft, which includes monitoring the adequacy of their maintenance programs. To address this issue, the NTSB issued Safety Recommendations A-04-29 through -31, asking the DOI and the USFS to do the following:

 

Develop maintenance and inspection programs for aircraft that are used in firefighting operations that take into account and are based on: 1) the airplane’s original design requirements and its intended mission and operational life; 2) the amount of operational life that has been used before entering firefighting service; 3) the magnitude of maneuver loading and the level of turbulence in the firefighting environment and the effect of these factors on remaining operational life; 4) the impact of all previous flight hours (both public and civil) on the airplane’s remaining operational life; and 5) a detailed engineering evaluation and analysis to predict and prevent fatigue separations. (A-04-29)

 

Require that aircraft used in firefighting operations be maintained in accordance with the maintenance and inspection programs developed in response to Safety Recommendation A-04-29. (A-04-30)

 

Hire personnel with aviation engineering and maintenance expertise to conduct appropriate oversight to ensure the maintenance requirements specified in Safety Recommendation A-04-29 are met. (A-04-31)

 

“In addition, in its April 23, 2004, safety recommendation letter, the NTSB noted that aircraft used for public firefighting flights may also be used for civil flights during the portion of the year that they are not under contract to the USFS or the DOI. When operated as civil aircraft, they are governed by FAA regulations and subject to FAA oversight. The NTSB concluded that the FAA’s oversight of these aircraft will be of limited value if it does not take into account factors associated with the public firefighting operations that can have a direct bearing on airworthiness, such as flight hours and structural stresses. Therefore, the NTSB issued Safety Recommendation A-04-32, asking the FAA to do the following:

 

Require that restricted-category aircraft used for any part of the year in firefighting operations be maintained in accordance with appropriate maintenance and inspection programs that take into account and are based on: 1) the airplane’s original design requirements and its intended mission and operational life; 2) the amount of operational life that has been used before entering firefighting service; 3) the magnitude of maneuver loading and the level of turbulence in the firefighting environment and the effect of these factors on remaining operational life; 4) the impact of all previous flight hours (both public and civil) on the airplane’s remaining operational life; and 5) a detailed engineering evaluation and analysis to predict and prevent fatigue separations. (A-04-32)

[pp. 83-84.]

 

“On October 21, 2004, the NTSB stated that, to implement this recommendation, the FAA needed to take more action than providing technical advice.” [p. 85.]

 

“2. Analysis….

 

“Based on a review of all available records and interviews of pilots, mechanics, and other personnel involved in the helicopter’s operations during 2007 and 2008, NTSB investigators determined that the most recent accurate weighing documents for the helicopter were the Perkasie-prepared Charts A and B for the January 4, 2008, weighing and the Chart C dated March 25, 2008. Using these charts and accounting for the weight of equipment known to be installed or removed from that weighing to the time of the accident, the NTSB determined that the empty weight of the helicopter was 13,845 lbs, which was 1,437 lbs heavier than the empty weight of 12,408 lbs that CHSI[19] provided to the accident helicopter’s pilots….” [p. 90.]

 

“The NTSB concludes that the PIC[20] followed a Carson Helicopters procedure, which was not approved by the helicopter’s manufacturer or the USFS, and used above-min spec torque in the load calculations, which exacerbated the error already introduced by the incorrect empty weight and the altered takeoff power available chart, resulting in a further reduction of 800 lbs to the safety margin intended to be included in the load calculations.

 

“In summary, the PIC unknowingly used two separate pieces of erroneous information in his preflight load calculations: the empty weight and the power available chart. Additionally, the PIC followed a company procedure that was not approved by the USFS and used above-min spec power in performing the load calculations. For the PIC’s load calculation at 6,000 feet PA[21] and 32°C, these discrepancies resulted in overestimating the helicopter’s maximum allowable payload by 3,437 lbs. (1,437 lbs for the incorrect empty weight + 1,200 lbs for the altered power available chart + 800 lbs for the use of above-min spec torque = 3,437 lbs.) Immediately before attempting the accident takeoff, the pilots referred to this incorrect load calculation that indicated that the helicopter had the capability to HOGE[22] with a maximum payload of 2,552 lbs and compared this to the manifested payload of 2,355 lbs. Since the pilots estimated that the temperature was 12° to 13° below the 32° C temperature that the load calculation assumed and the manifested payload was about 200 lbs lighter than the load calculation allowed, they determined that the helicopter should have performance in excess of that predicted by the load calculation. Because of the incorrect load calculation, when initiating the accident takeoff, the pilots believed the helicopter was “good to go” with capability beyond that required to HOGE.

 

“With correct information and using min spec torque, the load calculations would have indicated that at 6,000 feet PA and 32° C the helicopter could not carry any payload. Clearly, a correct load calculation would have deterred the pilots from attempting the accident takeoff with the manifested payload of 2,355 lbs. In fact, since the correctly calculated maximum allowable payload was less than zero (-845 lbs as shown in Table 7), in order to comply with USFS standards to carry a payload of 2,355 lbs, the weight of the helicopter needed to be reduced (via removing equipment or carrying less fuel) by a total of 3,200 lbs (845 + 2,355 = 3,200). The NTSB concludes that the incorrect information—the empty weight and the power available chart—provided by Carson Helicopters and the company procedure of using above-min spec torque misled the pilots to believe that the helicopter had the performance capability to HOGE with the manifested payload when, in fact, it did not.

 

“When comparing the PIC’s calculated maximum allowable payload of 2,552 lbs with the manifested payload of 2,355 lbs, the pilots made an additional error in failing to recognize that the inspector pilot’s weight of 210 lbs was not included in the manifested payload. Catching this error and correcting for it would have resulted in an actual payload for the accident flight of 2,565 lbs (2,355 + 210 = 2,565), which would have exceeded the 2,552-lbs allowable payload calculation by 13 lbs. It is unlikely that catching this error would have deterred the pilots from attempting the takeoff, as they would still have believed that the helicopter had performance in excess of that predicted by the load calculation because they estimated that the actual temperature at H-44 was 12 to 13 degrees cooler than the 32° C used for the load calculation.” [p. 92.]

 

“2.4 Oversight…Role of USFS.

 

“During his carding inspection of the accident helicopter in June 2008, the USFS maintenance inspector had an opportunity to examine the helicopter’s weight and balance records, maintenance logbooks, and the helicopter itself. However, USFS procedures required only that the maintenance inspector verify and record certain discrete items, such as the date of the helicopter’s last weighing, its equipped weight, and its bid weight. No requirements existed to review, as part of the carding process, a helicopter’s Charts A, B, and C or to examine the maintenance logbooks for entries recording equipment installations and removals. If this review and crosscheck had been completed during the carding inspection, the maintenance inspector may have detected the same inconsistencies found by NTSB investigators after the accident. Specifically, he may have discovered that the Fire King liquid tank and snorkel (weighing 1,090 lbs) were not installed during the last weighing on January 4, 2008, as Chart A indicated because the maintenance records showed that the tank was not installed until March 25, 2008, about 3 months after the weighing.

 

“Following the accident, the USFS weighed the entire Carson Helicopters fleet and found that 9 of the 10 helicopters under contract were over the weight listed on their corresponding Chart Cs. The 9 helicopters were overweight by amounts ranging from 34 to 1,004 lbs, with an average of 495 lbs. Thus, the weight irregularities were not confined to the accident helicopter but were systemic of the majority of Carson Helicopters’ fleet. Several months after the postaccident weighings, the USFS terminated both Carson Helicopters contracts based on the operator’s “failure to comply with contract terms and conditions.” One of the contract violations identified was that 7 of the 10 helicopters weighed “more than their equipped weight as bid.” Another violation was that when using the helicopters’ actual weights (as determined by the postaccident weighings) and the non-altered RFMS #8 Figure 4,[23] only 5 of the 10 helicopters would have been qualified to bid on the solicitations because the others would not have met the contractual payload requirements.

 

“NTSB investigators reviewed the weight documentation CHI provided in its 2008 bid proposal to the USFS. On the Chart Bs for 8 of the 11 helicopters CHI offered, including Chart B for the accident helicopter, the scale readings were recorded to the nearest tenth of a lb, even though the scales used were only capable of measuring to the nearest lb. In addition, the differences in weight between the left main gear weight and the right main gear weight on these eight helicopters were all exactly 80 lbs. These findings indicate that the weights documented for each landing gear were likely computed mathematically to result in a predetermined, desired total helicopter weight. The NTSB concludes that the lower-than-actual empty weights recorded by Carson Helicopters on the Chart B weighing records for the accident helicopter and 8 of Carson’s other 10 helicopters created the appearance of higher payload capabilities; at their actual weights, the accident helicopter and 5 of the other helicopters would not have met the contractual payload specifications.” [p. 99]

 

“….The USFS had opportunities during its review of CHI’s bid package and its carding inspection of the accident helicopter to discover that the company was using improper weight and performance charts for contract bidding and for actual load calculations but failed to detect these discrepancies. During the bid package review, the power available chart used by Carson to demonstrate the helicopter’s performance capability should have received specific scrutiny by the contracting officer because the USFS was aware that Carson opposed its policy of not allowing use of the 2.5 minute charts for bidding; however, this did not occur….

 

“Further, the USFS missed a last opportunity to detect that Carson was violating approved procedures when, on the day of the accident, the inspector pilot failed to notice that the PIC was using above min-spec torque in completing the load calculations….

 

“Had these discrepancies been detected, the USFS would have required CHI to correct them, which could have prevented the accident. The NTSB concludes that the USFS’s oversight of Carson Helicopters was inadequate, and effective oversight would likely have identified that Carson Helicopters was using improper weight and performance charts for contract bidding and actual load calculations and required these contractual breaches to be corrected.

 

“The NTSB notes that the USFS has made a number of changes in response to this accident investigation, including validating the weight of each aircraft awarded a contract and instituting checks to determine that contractors are in full compliance with the contract during the contract award period. Although the NTSB is encouraged that the USFS has already implemented changes as a result of the accident, the NTSB believes that further oversight improvements are necessary….” [pp. 100-101]

 

“…the NTSB recommends that the USFS develop mission-specific operating standards for firefighter transport operations that include procedures for completing load calculations and verifying that actual aircraft performance matches predicted performance, require adherence to aircraft operating limitations, and detail the specific Part 135 regulations that are to be complied with by its contractors. In addition, the NTSB recommends that the USFS require its contractors to conduct firefighter transport operations in accordance with the mission-specific operating standards specified in Safety Recommendation A-10-159. Further, the NTSB recommends that the USFS create an oversight program that can reliably monitor and ensure that contractors comply with the mission-specific operating standards specified in Safety Recommendation A-10-159.” [p. 102.]

 

“2.4.1.1  Role of USFS Inspector Pilot

 

“The USFS inspector pilot who was evaluating the PIC reviewed the load calculations the PIC had prepared but apparently did not notice that the PIC had used above-min spec torque when completing the load calculations, a procedure that the USFS does not allow. If the inspector pilot had noticed this improper procedure and required the PIC to correct the load calculations, the allowable payload for the 6,000 foot PA and 32° C condition would have been reduced by 760 lbs, which may have reduced the actual payload manifested for the accident takeoff.

 

“During the first and second takeoffs from H-44, the inspector pilot had an opportunity to notice the helicopter’s marginal performance. Although the inspector pilot was seated in the cabin facing rearward, he could see out the side windows and observe the helicopter’s height above the ground. Therefore, he had the opportunity to note the same indications of marginal performance reported by the firefighters on board the helicopter during the first takeoff from H-44, such as the helicopter feeling “heavy, slow and sluggish” and being “below the treetops for quite a while.” However, according to the CVR transcript, he never questioned the PIC about the helicopter’s performance. Given the inspector pilot’s extensive flight experience of over 11,500 hours of flight time in turbine helicopters, it is difficult to understand why the inspector pilot did not notice the helicopter’s marginal performance and express concern about it. However, although the inspector pilot had prior experience evaluating pilots in the S-61, he did not hold an SK-61 type rating, had never flown as PIC of an S-61, and did not have an approval on his USDA/USDI Interagency Helicopter Pilot Qualification Card for the S-61….” [pp. 102-103]

 

“2.4.2  Role of the Federal Aviation Administration

 

“….The FAA had an opportunity to discover the discrepancies in the accident helicopter’s maintenance, performance, and weight and balance documents by performing an inspection when the helicopter was added to CHSI’s Part 135 operations specifications, but inspectors failed to conduct such an inspection or to inspect any of the other three helicopters that were added to the certificate at the same time, even though this addition tripled the size of CHSI’s fleet. If these discrepancies had been detected, the FAA would have required CHSI to correct them, which likely would have prevented the accident. The NTSB concludes that the FAA’s oversight of CHSI was inadequate, and effective oversight would have detected discrepancies in the accident helicopter’s maintenance, performance, and weight and balance documents and required their correction before the helicopter was added to CHSI’s Part 135 operations specifications….” [104]

 

“3. Conclusions…

….

 

  1. Because Carson Helicopters provided an incorrect empty weight to the pilot-in-command, he overestimated the helicopter’s load carrying capability by 1,437 pounds.

 

  1. The altered takeoff (5-minute) power available chart that was provided by Carson Helicopters eliminated a safety margin of 1,200 pounds of emergency reserve power that had been provided for in the load calculations.

 

  1. The pilot-in-command followed a Carson Helicopters procedure, which was not approved by the helicopter’s manufacturer or the U.S. Forest Service, and used above-minimum specification torque in the load calculations, which exacerbated the error already introduced by the incorrect empty weight and the altered takeoff power available chart, resulting in a further reduction of 800 pounds to the safety margin intended to be included in the load calculations.

 

  1. The incorrect information—the empty weight and the power available chart—provided by Carson Helicopters and the company procedure of using above-minimum specification torque misled the pilots to believe that the helicopter had the performance capability to hover out of ground effect with the manifested payload when, in fact, it did not.

….

 

  1. The accident takeoff was unsuccessful because the helicopter was loaded with more weight than it could carry in a hover out of ground effect given the ambient conditions.

….

 

  1. The lower-than-actual empty weights recorded by Carson Helicopters on the Chart B weighing records for the accident helicopter and 8 of Carson’s other 10 helicopters created the appearance of higher payload capabilities; at their actual weights, the accident helicopter and 5 of the other helicopters would not have met the contractual payload specifications.

 

  1. The U.S. Forest Service’s oversight of Carson Helicopters was inadequate, and effective oversight would likely have identified that Carson Helicopters was using improper weight and performance charts for contract bidding and actual load calculations and required these contractual breaches to be corrected.

….

 

  1. The U.S. Forest Service’s inadequate training of the inspector pilot led to the inspector pilot’s failure to correct the pilot-in-command’s improper usage of above-minimum specification torque and contributed to the inspector pilot’s failure to identify the helicopter’s marginal performance on the first two takeoffs.

 

  1. The Federal Aviation Administration’s oversight of Carson Helicopter Services, Inc. (CHSI) was inadequate, and effective oversight would have detected discrepancies in the accident helicopter’s maintenance, performance, and weight and balance documents and required their correction before the helicopter was added to CHSI’s 14 Code of Federal Regulations Part 135 operations specifications.

 

  1. The pilots likely recognized that the helicopter was approaching its maximum performance capability on the two prior departures from Helispot 44 but elected to proceed with the takeoffs because they were accustomed to performing missions where operating at the limit of the helicopter’s performance was acceptable.

….

  1. The surviving firefighters were unable to release the rotary restraints under emergency conditions because they were unfamiliar with the rotary-release mechanism.

 

  1. The leather gloves worn by the firefighters decreased their dexterity, hampering the release of their restraints after the crash.

 

  1. The U.S. Forest Service contract requirement for Carson Helicopters to install shoulder harnesses on the passenger seats did not provide improved occupant protection from injury because Carson Helicopters installed the shoulder harnesses on seats with non-locking folding seatbacks.

 

  1. The designated engineering representative’s failure to follow Federal Aviation Administration guidance materials resulted in his approval of a shoulder harness installation that did not did not improve occupant protection, and in fact, increased the risk of injury to the occupant.

 

  1. The Federal Aviation Administration disregarded its own guidance and condoned the installation of a shoulder harness that did not improve safety, and in fact, increased the risk of injury to the occupant….” [pp. 122-124]

 

(NTSB. Aircraft Accident Report. Crash During Takeoff of Carson Helicopters, Inc. Firefighting Helicopter Under Contract to the U.S. Forest Service, Sikorsky S-61N, N612AZ, Near Weaverville, California, August 5, 2008 (NTSB/AAR-10/06). Washington, DC: NTSB, adopted 12-7-2010.)

 

2015: “Today Steve Metheny, the former Vice President of Carson Helicopters, was sentenced to 12 years and 7 months in prison for falsifying documents that led to the crash of a helicopter in 2008 that killed 9 people. In sentencing Mr. Methey, Ann Aiken, a federal judge for the United States District Court for the District of Oregon, said he violated every oath he ever took when he filed documents to win a $51 million U.S. Forest Service contract.

 

“He was accused of falsifying performance charts and the weights of helicopters his company had under contract to the U.S. Forest Service for supporting wildland fire operations. As of a result of his fraud, a Carson helicopter crashed while trying to lift off with too much weight from a remote helispot on the Iron 44 Fire (or Iron Complex) on the Shasta-Trinity National Forest near Weaverville, California in 2008. Nine people were killed, including the pilot-in-command, a U.S. Forest Service check pilot, and seven firefighters. The copilot and three firefighters were seriously injured.

 

“Mr. Metheny went to great lengths after the crash to attempt to conceal the fraud. When he knew that investigators would be examining the company’s operations, he directed other employees to remove weight from other similar helicopters, including taking off a fuel cell and replacing a very heavy battery with an empty shell of a battery. Some of the employees refused to participate in that deception, with one explaining that he was done lying about the helicopter’s weight….

 

“The Forest Service awarded contracts to Carson, including option years, amounting to over $51,000,000. Carson received $18,831,891.12 prior to the FS canceling the contracts.

 

“The sentencing hearing for Levi Phillips, 45, the former maintenance chief of Carson Helicopters, occurred later the same day. He agreed to cooperate with authorities in the case against Mr. Metheny and pleaded guilty to a single charge of fraud. He was sentenced to 25 months in prison to be followed by 3 years of supervised probation….” (Gabbert, Bill. “Former VP of Carson Helicopters sentenced to 12 years in prison.” Wildfire Today, 6-16-2015.)

 

Sources

 

Aanestad, Sam. “My Turn…California burning: It’s time for real action.” Mountain Democrat, Placerville, CA, 8-27-2008, A6. Accessed 11-17-2018 at: https://newspaperarchive.com/placerville-mountain-democrat-aug-27-2008-p-6/

 

Appeal-Democrat, Marysville-Yuba City, CA. “Tree kills firefighter.” 7-27-2008, p. A3. Accessed 11-17-2018: https://newspaperarchive.com/marysville-yuba-appeal-democrat-jul-27-2008-p-2/

 

Associated Press/Deb Riechmann. “Bush tours Shasta-Trinity National Forest before Napa fundraiser.” Appeal-Democrat, Marysville-Yuba City, CA. 7-18-2008, p. 1. Accessed 11-17-2018 at: https://newspaperarchive.com/appeal-democrat-jul-18-2008-p-1/

 

CAL Fire, CA.gov. 2008 Fire Siege. 2012, 168 pages Accessed 11-17-2018 at: http://www.fire.ca.gov/fire_protection/downloads/siege/2008/2008FireSiege_full-book_r6.pdf

 

Gabbert, Bill. “Former VP of Carson Helicopters sentenced to 12 years in prison.” Wildfire Today, 6-16-2015. Accessed 11-18-2018 at: https://wildfiretoday.com/2015/06/16/former-vp-of-carson-helicopters-sentenced-to-12-years-in-prison/

 

National Transportation Safety Board. Aircraft Accident Report. Crash During Takeoff of Carson Helicopters, Inc. Firefighting Helicopter Under Contract to the U.S. Forest Service, Sikorsky S-61N, N612AZ, Near Weaverville, California, August 5, 2008 (NTSB/AAR-10/06). Washington, DC: NTSB, adopted 12-7-2010, 175 pages. Accessed 11-18-2018 at: https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR1006.pdf

[1] Does not provide a page number reference. Have read the full report twice, one before seeing Wikipedia piece and once afterwards. There is no mention of 32 fatalities.

[2] Thirteen people engaged in fire-fighting-related work, and one civilian who did not evacuate.

[3] CAL Fire. 2008 June Fire Siege, “Siege Summary Part II: June 20-30,” p. 30.

[4] CAL Fire. 2008 June Fire Siege, “Siege Summary Part II: June 20-30,” p. 33.

[5] CAL Fire. 2008 June Fire Siege, “Siege Summary Part IV: July 2-August 5,” p. 57.

[6] CAL FIRE. 2008 Fire Siege Timeline, “Executive Summary,”, p. 8. Died “after suffering fatigue and respiratory difficulties.” CAL Fire. 2008 June Fire Siege. “Siege Summary Part IV: July 2-August 5,” p. 58. An AP report noted this death “has been attributed to a heart attack, said Daniel Berlant, a state fire department spokesman.” (Associated Press/Deb Riechmann. “Bush tours Shasta-Trinity National Forest before Napa fundraiser.” Appeal-Democrat, Marysville-Yuba City, CA. 7-18-2008, p. 1.)

[7] CAL Fire. 2008 June Fire Siege. “Siege Summary Part IV: July 2-August 5,” p. 65.

[8] CAL FIRE. 2008 Fire Siege Timeline, “Exec. Sum.,”, p. 8. Press report notes he was part of a four-member team “dispatched Tuesday to a fire in the Shasta-Trinity National Forest….died while being airlifted to a hospital on Friday [July 25].” (Appeal-Democrat, Marysville-Yuba City, CA. “Tree kills firefighter.” 7-27-2008, p. A3.)

[9] CAL FIRE. 2008 Fire Siege Timeline, “Executive Summary,”, p. 9. Died from burns/smoke inhalation. (p. 75)

[10] CAL FIRE. 2008 Fire Siege Timeline, “Executive Summary,”, p. 9. At p. 76 it is written that “At approximately 7:45 p.m., a contract helicopter, ferrying firefighters from a helispot on the Buckhorn Fire in the Iron/Alps Complex crashed and caught fire, killing 9 of the 13 occupants. Aboard the helicopter were the pilot, copilot, FS [Forest Service] pilot-inspector, and 9 contract fire-fighters from Grayback Forestry of Medford, OR.” See Aug 5 in Narrative Information section below for summary from the National Transportation Safety Board.

[11] CAL FIRE. 2008 June fire siege. “Dedication.”

[12] CAL Fire. 2008 June Fire Siege. “Siege Summary Part IV: July 2-August 5,” p. 65. This death is not included in the fatalities noted on Dedication page — those were all related to fire-fighting operations. Associated Press report notes the victim “didn’t heed evacuation requests.” (Associated Press/Deb Riechmann. “Bush tours Shasta-Trinity National Forest before Napa fundraiser.” Appeal-Democrat, Marysville-Yuba City, CA. 7-18-2008, p. 1.)

[13] Cannot explain why this differs from the descriptions of 14 deaths noted in the body of this report.

[14] Died from thermal burns and smoke inhalation.

[15] CAL Fire. 2008 June Fire Siege. “Appendix I: Complex Summaries,” p. 136.

[16] “The term ‘fire siege’can be defined as multiple fires that burn simultaneously over an extended period of time, over large geographic areas and severely challenge fire suppression resources” (p. 12)

[17] Though not mentioned in the narrative text, the “Statistics” section on previous page notes the death of an off-duty firefighter assigned to the incident.

[18] Helicopter attack.

[19] Carson Helicopter Services, Inc.

[20] Pilot-in-command.

[21] Pressure altitude.

[22] Hover out of ground effect.

[23] Rotorcraft flight manual supplement.