C-130 tanker that crashed in Australia is likely at a standstill, report finds

B134 rugged circuit showing wind direction.

The Australian Transport Safety Board (ATSB) has released its final report into the January 23, 2020 crash of a C-130, Air Tanker 134, Bomber 134 (B134) as it was known in Australia. The three crew members were killed shortly after dropping retardant on a fire for the Rural Fire Service (RFS) of New South Wales, Australia.

It was very windy on January 23, with a forecast of the possibility of mountain waves. Prior to the incident, a bird dog, similar to a lead aircraft, and a Bomber 137 (B137), a Boeing 737, were tasked to come across a fire in the Adaminaby area. Due to the weather, the bird dog pilot refused the mission. After B137 crashed on fire, crew reported experiencing uncommanded aircraft rolls to 45° bank angle (due to wind) and wind shear warning from aircraft on-board systems.

Preliminary report ATSB crash Air Tanker 134 Australia
Flight path of N134CG (white). Source: Google Earth, Aireon and RFS tracking data, annotated by ATSB.

After completing the drop, the B137 crew texted the bird dog pilot that the conditions were “awful out there. Don’t send anyone and we won’t go back. They also reported to the Cooma FCC that conditions were not conducive to firebombing operations. On the B137’s return flight to Richmond, the Richmond Air Base Manager instructed them to reload the aircraft in Canberra and fly back to Adaminaby. The pilot in command (PIC) replied that they would not be returning to Adaminaby due to weather conditions.

Tanker 134 in Medford, Oregon
Tanker 134 in Medford, Oregon on July 27, 2019. Photo by Tim Crippin.

B134 was also dispatched to the Adaminaby fire. While en route, B137’s PIC called to advise them of the actual conditions and that B137 would not be returning to Adaminaby.

After arriving at Adaminaby, the captain of the B134 radioed the FCC flight operations officer from Cooma and advised that there was too much smoke and wind to perform a retarder drop at that time. place.

The Cooma Air Operations Officer then provided the crew with the location of the Good Good Fire, approximately 58 km east of Adaminaby, in an effort to ensure the protection of structures and property near Peak View. Again, there was no birddog operating with the air tanker.

The C-130 went to Peak View as the only aircraft there. After dropping a partial load of retardant from the 4,000 gallon tank, the aircraft then made a left turn which resulted in a tailwind and it climbed for approximately 10 seconds at approximately 170 feet above height of fall. 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 severe left roll as the left wing struck a tree just before ground impact. All three crew members were fatally injured and the aircraft destroyed.

Timeline, B134 crash

The conclusions of the report

The ATSB determined, from a combination of witness video and real-time position and flight path data, that the aircraft’s climb performance had degraded. Subsequently, while at low altitude and speed, it is likely that the aircraft stalled aerodynamically, resulting in a collision with terrain. In the short time available, the remainder of the fire load was not jettisoned before the aircraft stalled.

As only about 10 seconds elapsed between the degraded climb performance and the likely stall, the crew had little time to identify and react to the situation. Previous research shows that the pilot recognition time of wind shear can be around 5 seconds, and the emergency dump function would take an additional 2 seconds. However, in the absence of the cockpit audio recording, it could not be determined whether the crew had considered or requested an emergency dump of the remaining load. Therefore, for undetermined reasons, the remaining 25,000 pounds of retardant was not jettisoned during the accident sequence.

The ATSB determined that jettisoning the remaining load would have reduced the stall speed and optimized the aircraft’s climb performance. This was also confirmed by simulator tests. Nevertheless, it was not possible to determine whether jettisoning the remaining charge, given the time available and the 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 jettisoned the load, is an example of where this action may not be enough to avoid a collision with the terrain.

Although the New South Wales RFS was not an aviation organization nor directly responsible for flight safety, it was closely involved in the air operation, being responsible for determining task objectives and selecting aircraft for the task. The ATSB found that the RFS had limited policies and procedures for large air tankers regarding aerial supervision requirements and no procedures for deployment without aerial supervision. Additionally, they had no policy or procedures in place to manage task rejections, or to communicate this information internally or to other pilots working in the same area of ​​operation. Such associated policies and procedures would provide front-line staff with the necessary steps to safely and effectively manage tasks and provide guidance for decision-making.

It was also determined that, while not applicable to the crash crew, RFS procedures allowed aircraft operators to determine when pilots were capable of attacking initially. This was inconsistent with their intention to have pilots certified through the United States Forest Service certification process.

The ATSB also determined that the New South Wales Rural Fire Service had limited policies and procedures on large air tankers for aerial surveillance requirements and no procedures for deployment without aerial surveillance. The RFS had no policy or procedures in place to manage task rejections, or to communicate this information internally or to other pilots working in the same area of ​​operation.

Although not contributing to the accident, the plane’s cockpit voice recorder did not record the accident flight and did not work for weeks or more after being was automatically triggered by an 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 required to determine contributing factors to the accident, but also limited the extent where important safety issues could be identified and analyzed.

What was done as a result

As a result of this investigation, Coulson Aviation incorporated a wind shear recovery procedure into its C-130 aircraft flight manuals and plans to introduce recurring simulator wind shear training. In terms of considering risk in aerial firefighting operations, they have also implemented a pre-flight risk assessment that must be completed by the captain before the first task of the day. They will also introduce a three-tier risk management approach, namely Organizational Risk, Operational Risk and Tactical/Mission Risk, which will be used during the upcoming fire season in Australia. Additionally, Coulson Aviation has updated its pre-flight procedures to incorporate a cockpit voice recording system check before each flight. Finally, the Retardant Aerial Delivery System software has been reprogrammed so that the system does not require re-arming between partial load drops where less than 100% has been selected.

The ATSB issued two safety recommendations to Coulson Aviation. These are to be considered further:

  • Installation of a wind shear detection system on their C-130 aircraft to minimize the time required for aircrews to recognize and react to an encounter, especially when operating at low altitudes and low speeds;
  • Incorporate predictable external factors into their pre-flight assessment tool to ensure that the overall risk profile of a task can be consistently assessed by crews.

The New South Wales Rural Fire Service has advised the ATSB that it intends to take the following actions in response to this accident:

  • Commissioned an independent report on the management of the airspace in which aircraft operate in support of firefighting activities;
  • Formalize and establish a description of the role of “large tanker coordinator”, to be placed on the State Air Office during intense fire activity;
  • Undertake an immediate audit, in conjunction with the operators, of pilots qualified as initially capable of attack and ensure that the appropriate records are accessible to RFS personnel;
  • Undertake detailed research to identify best practices (nationally and internationally) relating to task rejection and aerial supervision policies and procedures, and initial attack training and certification.
  • Undertake a comprehensive review of RFS aviation doctrine to incorporate the results of the above research into existing policies and procedures;
  • Promulgate revised doctrine detailing task rejection policies and procedures and aerial oversight requirements to all operational personnel, pilots/crews and other key stakeholders. This must be reinforced during the air operators briefing organized each year before the bushfire season;
  • Provide the National Aerial Fire Center and National Fire Agencies with copies of updated doctrine relating to these issues.

Although the ATSB acknowledges the commitment to undertake reviews and research, at the time of publication the NSW Rural Fire Service has not yet committed to safety measures that would reduce the risk associated with the three identified security issues to an acceptable level. As such, the ATSB has issued three safety recommendations to the RFS for further action:

  • To address the lack of policies and procedures for staff to effectively manage and communicate task rejections based on operational security concerns;
  • To address the lack of policies and procedures regarding minimum aerial oversight requirements and the use of initial attack to assist frontline personnel in making acceptable risk-based tasking decisions ;
  • To disambiguate with interpretation of ‘Initial Attack’ in NSW and Australian Capital Territory Aviation Standard Operating Procedures.

Britton Coulson, co-chairman of Coulson Aviation, told Wildfire Today: “We have worked closely with the ATSB to provide them with all the information they have requested. We are delighted that they recognized the progress we have made through their recommendations.

The 4MB final report can be downloaded.

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