News & commentary about aerial firefighting, air tankers, and helicopters
Three Americans were killed in the 2020 New South Wales accident
The Australian Transport Safety Bureau (ATSB) has released their final report on the January 23, 2020 crash of a C-130, Air Tanker 134, Bomber 134 (B134) as it was known in Australia. All three crewmembers were killed just after dropping retardant on a fire for the Rural Fire Service (RFS) in New South Wales, Australia.
It was very windy on January 23, with a forecast for the possibility of mountain waves. Before the incident a bird dog, similar to a lead plane, and Bomber 137 (B137), a Boeing 737, was tasked to drop on a fire in the Adaminaby area. Based on the weather the bird dog pilot declined the assignment. After B137 made a drop on the fire, the crew reported having experienced uncommanded aircraft rolls up to 45° angle of bank (due to wind) and a windshear warning from the aircraft on-board systems.
After completing the drop, the B137 crew sent a text message to the bird dog pilot indicating that the conditions were “horrible down there. Don’t send anybody and we’re not going back.” They also reported to the Cooma FCC that the conditions were unsuitable for firebombing operations. During B137’s return flight to Richmond, the Richmond air base manager requested that they reload the aircraft in Canberra and return to Adaminaby. The Pilot in Command (PIC) replied that they would not be returning to Adaminaby due to the weather conditions.
B134 was also dispatched to the fire at Adaminaby. While they were in route, the PIC of B137 called to inform them of the actual conditions, and that B137 would not be returning to Adaminaby.
After arriving at Adaminaby, the PIC of B134 contacted the air operations officer at the Cooma FCC by radio and advised them that it was too smoky and windy to complete a retardant drop at that location.
The Cooma air operations officer then provided the crew with the location of the Good Good Fire, about 58 km to the east of Adaminaby, with the objective of conducting structure and property protection near Peak View. Again, there was no birddog operating with the air tanker.
The C-130 went to Peak View as the only aircraft on scene. After dropping a partial load of retardant out of the 4,000-gallon tank the aircraft then made a left turn which resulted in a tail wind and it climbed for approximately 10 seconds to about 170 feet above the drop height. Following this, the aircraft was observed descending. It was seen at a very low height above the ground, in a slight left bank, immediately followed by a significant left roll as the left wing struck a tree just before ground impact. The three crewpersons were fatally injured and the aircraft destroyed.
The ATSB determined from a combination of witness video and real-time position and flight path data, that the aircraft’s climb performance degraded. Subsequently, while at a low height and airspeed, it was likely the aircraft aerodynamically stalled, resulting in a collision with terrain. In the limited time available, the remainder of the fire-retardant load was not jettisoned prior to the aircraft stalling.
As there were only about 10 seconds between the climb performance degrading and the likely stall, there was limited time available for the crew to identify and respond to the situation. Past research shows pilot recognition time of windshear can be expected to be about 5 seconds, and the emergency dump function would take a further 2 seconds. However, in the absence of the cockpit audio recording, it could not be determined if the crew had considered or called for an emergency dump of the remaining load. Therefore, for reasons undetermined, the remaining 25,000 pounds of retardant was not jettisoned during the accident sequence.
The ATSB established that jettisoning the remaining load would have lowered the stall speed and optimised the aircraft’s climb performance. This was also confirmed from the simulator testing. Nonetheless, it was not possible to determine if jettisoning the remaining load, taking into account the time available, and typical recognition and response times, would have prevented the collision with terrain. The outcome of the July 1, 2012 crash in South Dakota of MAFFS 7, a US Air Force C-130 where the crew did jettison the load, is an example of when this action may not be sufficient to avoid a collision with terrain.
Beginning on page 17, the report includes a lengthy discussion about wind shear and mountain waves. It defines wind shear as “a wind direction and/or speed change over a vertical or horizontal distance.”
From the report on page 21:
“The accident aircraft was not fitted with a windshear detection system as it was built in 1981, prior to such technology becoming available. Likewise, the operator’s other C-130 aircraft did not have this system. Retrofitted systems suitable for the C-130 have since become available. However, the operator advised that they had not considered installing these systems into their C-130 fleet. Further, it was not required by regulation or contract to be installed.
“On 10 July 2022, in response to the draft report, Coulson Aviation advised that aerial firefighting operate in very dry environments conducive to active fires. Therefore, with minimal or nil moisture present in the atmosphere it could be concluded that a forward-looking windshear detection system would provide little to no advance warning of a windshear event. They further indicated that their crews were highly experienced in recognising windshear events and crew reaction times would be as timely, if not quicker than a reactive-based system. The operator further advised that this statement was based on ‘rational conclusion’ based on experience supported by informed opinion. The ATSB was unable identify any research that supported this comment.”
While the New South Wales RFS was not an aviation organization or directly responsible for flight safety, they were closely involved in the aerial operation, being responsible for determining the task objectives and selecting aircraft for the task. The ATSB found that the RFS had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision. In addition, they did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation. Such policies and associated procedures would provide frontline personnel with the required steps to effectively and safely manage taskings, and provide guidance for decision-making.
It was also identified that while not applicable to the accident crew, the RFS procedures allowed aircraft operators to determine when pilots were initial attack capable. This was inconsistent with their intention for pilots to be certified by the United States Forest Service certification process.
The ATSB also determined that the New South Wales Rural Fire Service had limited large air tanker policies and procedures for aerial supervision requirements and no procedures for deployment without aerial supervision. The RFS did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation.
While not contributing to the accident, the aircraft’s cockpit voice recorder did not record the accident flight and had not worked for weeks or more after having being automatically triggered off by some event during training flights. This resulted in a valuable source of safety information not being available to the investigation, which not only increased the time taken to determine contributing factors to the accident but also limited the extent to which important safety issues could be identified and analysed.
What has been done as a result
As a result of this investigation, Coulson Aviation has incorporated a windshear recovery procedure into their C-130 Airplane Flight Manuals and plan to introduce simulator-based recurrent windshear training. Related to the consideration of risk in aerial firefighting operations, they have also implemented a pre-flight risk assessment to be completed by the pilot in command prior to the first tasking of the day. They will also be introducing a three-tiered risk management approach of organizational risk, operational risk, and tactical/mission risk, to be utilized during the upcoming fire season in Australia. Further, Coulson Aviation has updated their pre-flight procedures to incorporate a cockpit voice recorder system check before each flight. Lastly, the Retardant Aerial Delivery System software was reprogrammed so that the system will not require re-arming between partial load drops where less than 100% was selected.
The ATSB has issued two safety recommendations to Coulson Aviation. These are to further consider:
The New South Wales Rural Fire Service advised the ATSB that they intend to take the following actions in response to this accident:
While the ATSB acknowledges the commitment to undertake reviews and research, at the time of publication the New South Wales Rural Fire Service had not yet committed to adopting any safety action that would reduce the risk associated with the three identified safety issues to an acceptable level. As such, the ATSB has issued three safety recommendations to the RFS to take further action:
Britton Coulson, Co-President of Coulson Aviation, told Wildfire Today, “We worked very closely with the ATSB to provide them with all the information that they requested. We are pleased that they acknowledged the progress we made with their recommendations.”
The final 4 mb report can be downloaded.
The article was edited on August 30 to include a section on wind shear.
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Oh good. The RFS will put in place more procedures that they and some operators will later ignore when inconvenient. Add it to the list.
For years I’ve been saying that heavy tankers should not be in the business of dropping on fires in mountainous terrain without the run being assessed by a birddog with an experienced firefighter on board. Sadly, this report validates my thinking.
I’m also saddened that the potential for wind shear / rollers on the leeward side of a ridgeline was not taken into account by the crew, given the prevailing wind conditions. I’m quite surprised that this principle of mountain flying was not mentioned.
You don’t know what was taken into account by the crew.
The experienced firefighters are in the tanker.
An experienced ground pounder is not the person to evaluate the run into a drop for flight conditions; he’s there to evaluate the fire and fire needs, and coordinate with ground personnel on use of aerial resources. With the exception of the rare lead who has flown a tanker, the lead knows his training, but does not know the fire from the perspective of the pilot flying the tanker. The only person truly qualified to evaluate the conditions over the fire with respect to the use of a specific tanker type and load, is the tanker pilot.
In lieu of that, a lead is useful and valuable, and sometimes invaluable from a safety perspective (I say that as one who credits a lead pilot with saving my life); the lead can certainly enter a fire run unencumbered with a heavy load, and is more maneuverable, with more disposable thrust, more immediately available, with less mass and intertia. That said, the lead is also not nearly as susceptible to the effects of windshear, and does not have the limitations of performance that a tanker may have when heavy and entering the drop; there are advantages and disadvantages, but don’t mistake the presence of a lead of ATGS or combination platform, for the experience in the tanker cockpit.
Ultimately the pilot in command of a tanker is responsible for the safe outcome of the drop, and a good tanker pilot uses all available resources, including lead (“bird dog”) aircraft. There is, however, a reason that we are initial-attack carded.
I did a drop several years ago in Southern Arizona, in which the lead planned the exit uphill. I wasn’t able to drop going in, which meant either jettisoning the load, or attempting to carry it out with diminished performance, down air, rotors, turbulence, and some degree of windshear. I had been in the area on previous drops, could see it coming, and declined to go all the way into the hole where the lead wanted me. I went around. The lead questioned my decision; I pointed out the uphill climb, and the lead responded that it shouldn’t be a problem, because he was able to do it. I pointed out, back on the ground at the tanker base, that what the lead was able to do was not what I was able to do, given my performance; over the fire, we agreed on an opposite direction run with a good exit, and made the drop. Leads are valuable resources, but ultimately only the tanker pilot knows his performance and capability, and the authority and responsibility is his to accept or reject the drop. This is true with, or without a lead.
A statement was made many years ago regarding what we do, and I don’t have the quote in front of me, but the gist was straight forward; let’s not pile on the pilots of that tanker for their decisions or actions; they believed in what they were doing so much that they bet their lives on their choices, as do we all when we commit. We should not forget that it’s possible to do everything right, and still lose; a constant reminder to check and re-check and check again, before we do, and to continually move to leave ourselves an out.
A crew succumbed to windshear, a potential aerodynamic stall, decreased performance, and ultimately lost the fight on the exit; that does not mean they did not take those factors into account, but only that the elements they encountered in real time, in a dynamic combination of conditions, ultimately exceeded their effort to escape. There before the grace, go we all.
Well said and I agree with all….
I appreciate the thoughtful discussion and have great respect for your experience on the front line. If my comment on the wind shear was seen as piling on, that wasn’t my intention. As pilots we hopefully get a chance to defend our decisions and actions. When it goes wrong, questions will be asked. Those questions help the rest of us learn from past misfortunes. They come with the territory.
I do want to comment on the incident you related where you were given a run with a climbing exit. I assume that occurred because there was no SOP or training for the lead pilot to inform them that a climbing exit was not allowed. I’ve worked in a system where lead pilots were given SOPs and training that made them think like a heavy tanker pilot. Part of their SOP was no climbing exits. Period. It works very well.
Any system that has its vulnerabilities exposed will either strive for change or have change forced upon it. In spite of the known risks, in my mind, the loss of these three men is unacceptable. There remain many opportunities to plug the holes in layers of Swiss cheese identified in the ATSB report. It’s good to acknowledge the inherent risks of the business. It’s better to look more broadly for ways to minimize them, even when that means thinking outside of our own box.
“Thinking like a tanker pilot” is not the same as being a tanker pilot. I’ve done countless drops and exits that did involve an uphill drop or exit; It may be a mild climb, it may be completing a run up a saddle, etc. We don’t fly up canyons and we don’t box ourselves in, but it would be a misnomer to suggest that we don’t drop uphill. Of course we do. We simply do so within the capabilities of the aircraft at that time and place.
It’s axiomatic that a drop on any given day may be safe, but not safe the day before or after, given changing conditions. Perhaps wind, perhaps visibility; perhaps weight, fuel load, temperature, lighting, etc. We look at what goes on in the moment. I’ve made drops in which the run into the drop, a descending pass on the drop target, was glass-smooth, good solid air, but fell apart at the last moment with an express elevator ride down, or just violent turbulence. That happens; all kinds of conditions can happen. We have to look at what we have right now, because what we had an hour ago may have been different, and in an hour it’s certainly going to be different, too. That may be performance, drift, and numerous other factors.
Regarding uphill exits or drops, on numerous occasions I’ve had a lead advise me that the drop is slightly uphill, or involves an exit that might be uphill; it’s not climbing Mt. Everest uphill, but it isn’t flat and it isn’t downhill. Generally the lead will advise on the conditions, his confidence level on the exit, and will advise that he’s been in there and how it was for him. Fair enough. There’s no magic bullet which says the drop must be accepted, and there’s always the options of negotiating: I can’t do that, but I can do this, what do you think? I’ve done that many times, as I’m sure have we all. It might be the direction of the run, the particular target, left turn vs. right turn, or whatever, but we all look at the drop with a critical eye and use our judgement to either accept what’s given, reject it, or suggest another way. It happens all the time.
There are also those occasions, and there have been many, when the lead might advise what’s there, and I’ll follow on a drop in which I see very little. The lead has been working the fire, knows the terrain, knows the exit, and has a working plan. I’m placing a lot of faith and trust in that lead: we all do. I’ve done drops in which I see little other than the leadplane’s beacon. A few years ago I did a drop with five SEATs in which each SEAT saw the preceding aircraft beacon, but little else, following a Citation into the drop, in Nevada. Full brief before going, talk on the way in, and an exit plan. There was no down hill, given the terrain, but there was a lot of rising terrain. We made a turn toward water, where there was no rising terrain, and exited the smoke that way.
I flew for an operator (one of the best employers I’ve ever had), who screened pilots initially in a light airplane; went out in terrain and had them fly drop runs and talk about it. One of the exercises on those screening flights was a drop in a saddle; part of it downhill, part of it flat, part of it up. Part of the evaluation was to see how the pilot might tackle that situation, and it did involve seeing how the pilot worked the uphill portion. The turn around and do it downhill meant a turning exit or an exit into rising terrain, whereas taking the drop uphill had a good down exit after…advantages and disadvantages either way. How the individual saw it and planned and executed it said something about his mindsset and thought process, which opened some dialogue. Like all things, there is more than one way to paint the fence, and there are also wrong ways to paint the fence. Sometimes the difference is glaringly obvious, and sometimes it’s deceptively subtle. Sometimes it doesn’t matter, and sometimes, it really does.
We’re all paid for our judgement in determining which is which, and a good lead, and a good tanker pilot, uses all the resources to evaluate, including the input of others over the fire. In the end, we’re each responsible for our own actions, after making the best decision we can under the real-time circumstances. Sometimes the options are clear. Sometimes, they’re not.
Wilson, the 86-page report does cover the issue of wind shear beginning on page 17. I just created and added to the article a 3-D map that shows the wind direction and the terrain, plus a couple of paragraphs from the report.
“Formalize and establish a “Large Air Tanker Co-ordinator” role description, to be positioned on the State Air Desk during heightened fire activity”
This is exactly what they DON’T need! The Sydney Air Desk is a huge reason why that flight crew are now in Valhalla. Further centralizing decision making at the Sydney Air desk is the ANTITHESIS of what NSW needs. Leave the airspace decisions in the hands of the Air Attack Supervisors (ATGS’s)…not some clown sitting hundreds of miles away at a keyboard!!!!
Anonymous. I’ve gone back and forth about replying to your article over the last few days, but I feel like I need to. I was the captain of 137 that day. It was myself and a ridiculously over qualified copilot. I respect you for stepping up and painting a better picture for us about what transpired in Cooma before we arrived. I’ve had a lot of open thoughts about how we ended up in that situation, and your submission paints a better picture.
I’ve been flying for the RFS on and off since 2016. I’ve flown the DC-10 and 737 for them. I take quite a bit of pride in the program because I’ve got to watch it grow year after year. The Australians deserve an air program they can be proud of, that they made.
Yesterday my family and I had an uneventful drive through Weed, CA. I stopped to charge my car in Shasta because they have a park with a stream where my kids can play. About 10 minutes into jumping across the water, our car quit charging. As I walked up the hill to troubleshoot, I started hearing sirens. I looked toward Black Butte, to see a column I’ve only seen a handful of times in the first 15 minutes of a fire. The sirens kept coming. I looked at my Watch Duty app before we got back in the car, and saw the order for 75 Engines, 16 Crews, 20 dozers, 8 Tankers and several copters being reported. Shortly after we got back on the road my boss and co workers flew overhead. Resources were passing us heading North all the way till we got to our destination in Chico.
After a night with family, I was thinking about your comment above. Something wasn’t sitting right. Then it hit me. All our policies, and procedures we have in the US were almost entirely written in blood. We have had year after year of tragic losses of fire fighters, civilians, and pilots. Every year there is an improved iteration of the last, where we are able to place an order as big as the one I listed above, and have it safely filled. If the lead aircraft in were to deem the air or situation unsafe, we would shut down the air operation. However, that’s not the way it’s always been. The legends that taught me how to keep myself alive and be effective in a tanker told me what the Wild West was like. When caging a radial engine was a few time a year event. When the wind side of the mountain was factored into climb performance on an exit. When the FTA was like an intersection in Calcutta, the first one to honk had the right of way.
Point is, we didn’t get as good as we are overnight. A lot of our own have paid the ultimate price for us to learn and adapt in how to do it properly. We’re still not perfect, but fire is the most dynamic thing I have ever been around.
I don’t think we need to be slandering the State Air Desk on a public forum. We, as Americans, went down to support them in their time of need. I’m not so sure that time has expired. I’m not saying they shouldn’t be held accountable for the actions that day. I lost three friends that day. I don’t think you heal from that. With the amount of press that is surrounding the final report being released, there will be a big shake up down there. We need to remain as allies to offer any help they may need on the backside of this whole thing, to make sure, from a dispatch perspective, this doesn’t happen again.
The State Air Desk did not single handedly bring the aircraft down, I think we can all agree on that. There were other factors that we have been after action reviewing ever since. The biggest help I have received in coming out of this mentally has been a friend/mentor high up in the BLM charging me with, “Now it’s up to us to teach the next generation how to keep themselves alive.” It’s the only space we can make an appreciable difference in as operators. Again, thank you so much for telling your side of the story. I respect the vulnerability of putting yourself out there like that. We are in this together, and I’m not just saying that because I’m some kind of hippie that drives a Tesla….
Thank you for your comments, Shawn.
Thank you for the Forum Bill.
Shawn, I was going to highlight a few sentences you wrote, but your whole comment needs to be read a couple times. Great thoughts.
Thanks Mike. Coming from you that really means a lot.
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