SIKORSKY S-61N near Weaverville, CA — 2008-08-06
- Date
- 2008-08-06
- Location
- Weaverville, CA, USA
- Aircraft
- SIKORSKY S-61N
- Registration
- N612AZ
- Category
- Helicopter
- Highest injury
- Fatal
- Fatalities
- 9
Probable cause
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 U.S. Forest Service and the Federal Aviation Administration. 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.
NTSB narrative
The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-10-06. 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.
NTSB coding
Evidence available
- CVR
- Video
- FDR / data
- Photos
- 236 docket documents
Docket documentsshowing 50 of 236
- Cockpit Voice Recorder 12 - Addendum to Group Chairman's Sound Spectrum Studycvr
- Cockpit Voice Recorder 12 - Errata to Group Chairman's Sound Spectrum Studycvr
- Cockpit Voice Recorder 12 - Group Chairman's Sound Spectrum Studycvr
- Cockpit Voice/ Flight Data Recorder 12 - Factual Report of Group Chairmancvr
- Additional Information Provided by Carson Helicopters on December 2, 2010form
- Additional Information Provided by Sikorsky on December 2, 2010form
- Additional Information Provided by USFS on November 29, 2010form
- Additional Information from Witnessform
- Aircraft Performance 13 - Addendum 1 to the Helicopter Hover Studyform
- Aircraft Performance 13 - Addendum 2 to the Helicopter Hover Studyform
- Aircraft Performance 13 - ERRATA to the Helicopter Hover Studyform
- Aircraft Performance 13 - Helicopter Hover Studyform
- FAA response to NTSB information request 10-282form
- Information Regarding 10 Micron Airframe Fuel Filtersform
- Maintenance Records 11 - Attachment 10-Input Freewheeling Unit Informationform
- Maintenance Records 11 - Attachment 11 - Transmission Inspection Panel Informationform
- Maintenance Records 11 - Attachment 9-Main Gear Box Informationform
- Operations 2 - Attachment 03: Load Calculations Performed by PICform
- Operations 2 - Attachment 09: Load Calculation Formform
- Operations 2 - Attachment 104: S-61N instrument panel diagrams showing pilot & copilot focus areas. Information provided by Sikorsky and CHI Chief Pilotform
- Operations 2 - Attachment 110: Information from FAA Concerning Addition of N612AZ, N103WF, N61NH, and N725JH to CHSI's Part 135 Operations Specificationsform
- Operations 2 - Attachment 11: IHOG Appendix A, Helicopter Management Forms and Checklistsform
- Operations 2 - Attachment 20: Weight from Airworthiness Conformity Inspection (08/06/07)form
- Operations 2 - Attachment 30: CHSI Fleet Weights and Performance Submitted to USFS for 2008 Bidsform
- Operations 2 - Attachment 33: Load Calculation Form Instructionsform
- Operations 2 - Attachment 35: USFS Power Check Form (From IHOG)form
- Operations 2 - Attachment 36: Power Checks Performed by Pilots of HT 766form
- Operations 2 - Attachment 45: Comparison of Performance Charts provided by CHSI and FAAform
- Operations 2 - Attachment 46: Performance Calculations on Charts Provided by CHSI and FAAform
- Operations 2 - Attachment 64: Iron Complex Fire Information (Helibase Locations)form
- Operations 2 - Attachment 66: Trinity Helibase Informationform
- Operations 2 - Attachment 77: Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1form
- Operations 2 - Attachment 78: Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (USFS)form
- Operations 2 - Attachment 89: Human Performance Interviewsform
- Survival Factors 6 - Attachment 7, FAA Forms 8110-3form
- FAA Inspector Statement Regarding Visit to Trinity Helibase on August 7, 2008interview
- Operations 2 - Attachment 105: First Flight out of H44 Passenger Statementsinterview
- Operations 2 - Attachment 107: Dave Wolf's Statementinterview
- Operations 2 - Attachment 72: Witness Interviewsinterview
- Operations 2 - Attachment 74: Other Pertinent Interviewsinterview
- Operations 2 - Attachment 76: Copilot Interviewinterview
- Operations 2 - Attachment 79: Statement of Party Representatives to NTSB Investigationinterview
- Operations 2 - Attachment 79A: Statement of Party Representatives to NTSB Investigationinterview
- Operations 2 - Attachment 84: Miscellaneous Interviews 2 (added)interview
- Operations 2 - Attachmnet 75: Miscellaneous Interviewsinterview
- Statement of Party Representatives to NTSB Investigationinterview
- Affidavit of Roger Douglass dated December 3, 2010other
- Carson 2008 Flight Testother
- Carson 2009 Flight Testother
- Carson Comments on H44 Approach and Landing Studyother
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