Flight Operations - Breaking The Chain
In the past couple of years, the Aviation Safety Vortex attempted to go beyond the nuts and bolts of accidents, and dig deeper into the human performance issues that contribute to poor decision-making, and subsequently to bent helicopters. The following article, submitted by a Canadian helicopter pilot, deals with a classic dynamic rollover event - nothing new there. What is very interesting is that the pilot recognized, albeit too late, that his own fatigue, dehydration and malnourishment were significant contributing factors in the accident. Two of these topics were recently covered in Vortex articles I Need a Drink (Issue3/2002) and Perchance to Dream (Issue2/2003). Remember, including some self-study into the physiological factors that affect our bodies while flying, is a good idea for our "recurrent training".
After twelve accident- and incident-free years flying single engine helicopters across western Canada and the U.S., I was feeling quite confident about my abilities as a pilot. I enjoyed my work, I was receiving regular compliments from customers for getting their work done safely and efficiently, and my company recognized my hard work with promotions, endorsements, cash bonuses, and pay-raises. Life was treating me well.
I hadn't had a visit from the proverbial "Murphy" yet.
The fire season had just started when I returned from a relaxing three-month holiday with my family. My first two days back to work were on a remote forest fire with a Bell 206?a routine task in familiar territory. I had hauled firefighters and their equipment many times before, and dumped countless buckets of water on fires. I flew the allowed maximum of 8 hr* on each of the first two days. At the end of each day, I flew my helicopter to the nearest company base, where I filled out my logbooks, had supper, and had a good sleep in an air-conditioned motel room. The summer was looking busy and profitable.
On the third day, I went back to the same fire after having had a good breakfast and feeling well rested. It was an unusually hot day with some wind, so I was hoping for some of my favourite work on a fire - water bucketing. However, after I set 20firefighters out to work, the fire boss had me sling in camp gear, as he expected this to be a campaign fire. I was a bit sceptical of this, as I was worried that I might be expected to stay in the rough camp. The truck driver had dumped all the camp gear at the staging area, and I had nobody to help load up the nets and roll barrels. That meant that every time I arrived at the staging point, I had to get out of the helicopter, load the nets and attach my longline. It was hot, dry, and smoky, and I was getting hungry and irritated. But I wasn't going to let the fire boss know that my frustration level was getting high, as I enjoyed the job and didn't want any complaints about me. I certainly wasn't going to allow another pilot - or worse, a competitor - take this dream job away from me. By the time I had all the camp gear flown in from the nearest road staging point and picked up the crews, my flight log showed I had flown 7.6hr - just enough time remained for me to return to base. I was hungry, thirsty, hot, tired, and dirty, and looked forward to a shower, dinner, and an air-conditioned motel room.
I informed the fire boss of my pending "time-exed" status. He said that the camp cook had seen some bears in the area, and asked me to stay at the camp for a few more hours, even though I was nearing the end of my 12-hr duty day. So, in the spirit of cooperation, I put on a brave face and helped the fire crew set up the tents. While they were eating, I carried boxes of groceries, rolled barrels of fuel, cleaned up my helicopter, and fixed a loose wire on my longline. I didn't worry about getting something to eat, because, after all, I was going back to town for a hot meal and a shower at the motel.
After my 12-hr duty day had expired, the fire boss asked me to stay the night, as he was concerned about bears in the area. I made one more round trip to the staging area with him for some more firefighting equipment and to look for the bears. Twenty-four revenue hours in three days would be a good pay cheque. When we got back to camp, the camp cook told me that there was nothing left for supper. As it was now getting dark and I had flown my maximum hours as well as exceeded my duty day, I had no choice but to grin and bear it. There was no hot supper, shower, or air-conditioned motel room for me that night, but I wasn't going to complain. No supper was just the start of the bad news, as I was then told that there was not sufficient room for me in any of the sleeping tents, but I could sleep in the supply tent. Being a resourceful pilot, I pulled out the emergency sleeping bag from the helicopter, and looked in the supply tent. Nothing but gravel and some broken boxes of dry macaroni. I didn't want to be called a whiner, so I made the best of it.
I spent a cold, uncomfortable night lying on gravel with no mattress or pillow, listening to rodents eat the spilled macaroni. I was up at 3 a.m., wishing I had never taken this particular job. I was hungry, dirty, sweaty, and in desperate need of a shower and a change of clothes. Everybody else was sleeping, and I didn't want to make any noise in the kitchen tent looking for something to eat and drink, so I cleaned my helicopter some more, carried out a real thorough pre-flight inspection, and stood up some fuel barrels in anticipation of another busy day.
At about 6a.m., the cook was up, and I asked if I could get something to eat or at least to drink. "Get out of here! You (expletive deleted) pilots think you are so important! I'll call you when breakfast is ready and not a minute sooner!" Good morning to you, too.
At 7a.m., just as the regular firefighters were sitting down for breakfast, the local fire centre called on my handheld VHF-FM radio to inquire if I was available for initial attack on another fire. I checked with the fire boss, who decided to accompany me. The helicopter was full of fuel, but my stomach wasn't. Still, getting out of that grumpy cook's way was most appealing.
We worked on the second fire for about 4hr before another helicopter showed up to relieve me, and the fire boss and I returned to our camp low on fuel. By this time, there were 20firefighters ready to go to work. I re-fuelled and set out the crew and their equipment in about 2 hr of flying time. The crews understood that I needed to refuel the helicopter, but I still had not had supper, breakfast, a shower, or anything to drink. Just as I was about to shut the helicopter down for some badly needed nourishment, the fire boss came running over and informed me that I had to go to the staging area to pick up a radio operator and some more supplies. OK, one more trip, and then I could get something to eat and drink.
I began to give the new radio operator my standard safety briefing, but she informed me that she didn't need one. One of those types. Back at camp, a pressing need to deliver some lunches to the fire line meant another delay in getting some food and drink. My level of frustration was getting a little bit higher every minute.
By this time, fire activity was picking up, and I was confident I could keep going. The radio operator was cluttering up our already congested radio frequency with many requests to "say again." The impatience in the voices of the firefighters echoed my frustration with her incompetence and poor attitude.
Back at camp, I politely asked for a break so I could get something to eat and drink. The fire boss wasn't happy about my request, as he only had one helicopter to work with, but he accepted. In the middle of my two-minute cool-down, a very excited firefighter with an irritating high-pitched voice screamed on the radio, "Help me! I'm getting burned to death!" I quickly did another hot re-fuelling, and the fire boss jumped back in. A quick reconnaissance of her area showed she was in no immediate danger, but the fire boss advised me to keep an eye on her. Then the usual requests were coming in to us by radio, "Tell Dave to turn up the pump." "Bring me a strangler." "I need some water buckets over here." "Bring me some more hose." By this time, my mouth was very dry and my stomach was feeling like it was going to collapse. The possibility of fatigue and frustration getting in the way of sound judgment never crossed my mind, as I just wanted to please the customer.
As we were circling the fire, the fire boss told me he needed me to work late that night, as he was going to require me to sling in some more groceries and camp supplies after I picked up the crews. I thought, "Marvellous. Here I go again, another day without being able to sit down for a real dinner. By the time I finish, there won't be enough daylight left to fly back to town for a good night's sleep, so it'll be another night in that tent. And how am I going to fudge my logbooks to avoid showing that I exceeded my flight and duty time limitations?"
The next task was to move a firefighter and some hose from the top of a hill to another location. As we approached the grassy knoll, I could see the firefighter carrying the hose across a steep slope with some burned-out stumps. Not an ideal location, but picking him up there would save him walking 200ft up the hill, and get me that much closer to food and drink.
At this point, it seemed like my peripheral vision was getting rapidly narrower. The area was tight, and there were a lot of stumps, but nothing I recognized as being overly hazardous. I was not able to advise the firefighter of my plans because of the steady radio chatter, but as I approached, I saw him crouch down. My thoughts were, "Perfect, this guy is a pro. He can see that I am going to pick him up here, and he's making it easy for me. This will go really smoothly. I'll do a quick toe-in landing with him at my left rear door, and he can jump right in. What a way to impress the fire boss!"
I was hot, hungry, thirsty, and sweaty, my shirt and helmet were sticking to me like glue, and I hadn't slept for about 34hr. Not a very glamorous situation. I informed the radio operator that we were picking up Bravo10 at pad7. After what seemed like an eternity on a very busy radio, I got the reply, "Roger, copy you picking up Bravo7 at pad10." More frustration.
Just as I was about to settle the front of the skids between some stumps, I remembered that I still needed to correct the radio operator's misunderstanding. Then the high-pitched voice came over the radio again, "Hurry up! Help me! I'm getting burned to death!" The radio chatter really picked up now, as all 20firefighters offered their advice at the same time. The fire boss, who was sitting on my left side, said, "Let's hurry and check up on her!" Fatigue, hunger, thirst, and high mental workload combined to turn me into an unthinking robot. Compulsive instinct was replacing sound decision making.
As I closely monitored the position of my main rotor near a tree, and the front right skid inches from a stump, I heard the fire boss gasp on the live intercom. I looked up to see what the problem was, and the firefighter who had seemed to be making my toe-in landing so easy had just stood up and was moving up the hill with the roll of hose, just as he had been told to do, right under the main rotor!
I was now out of options. My brain failed to function, and it seemed like I was viewing the world in black and white. I was completely out of energy. All I could do was pull on the collective and hope I could lift the helicopter up before the unsuspecting firefighter walked into the rotor. This is the time that Murphy decided to pay his visit. My right skid hooked the stump, and even though I had been well trained to avoid pulling collective in this situation, the combination of an impending decapitation and sheer fatigue meant that this long chain of events resulted in a classic dynamic rollover.
One fine helicopter destroyed, but thankfully no injuries.
Looking back on the situation now, I had had every opportunity to shut the flight operations down until I had something to drink and eat, or I could even have requested a relief pilot because I was very tired. It's funny how customers tolerate delays to refuel the helicopter, as they see running out of fuel as a serious hazard, but the pilot is regarded as a machine who doesn't need to sleep, eat, or drink.
This account of the events leading up to a preventable accident is not an attempt to blame the firefighters. The cause of this accident was my decision to perform a tight toe-in landing among some stumps, rather than wait one or two minutes to pick the firefighter up at a much better location. This was a day when normal decision-making processes were affected by hunger, dehydration, accumulated stress and fatigue - factors that I have personally found to be in abundance on many job sites, but especially fires. The regulators at Transport Canada have tried to enforce rest time with complex flight and duty time regulations, but this was a situation where the pilot was severely fatigued, but well within the regulations.
Now when I read accident reports in the Vortex, I imagine there were usually a lot of human factors that resulted in the accident besides just the last few seconds before the terrible sound of the rotor blades hitting the ground; customer pressures, company pressures, or worst of all, self-imposed pressures. One thing I have learned from my experience on that terrible day is that I never want to be hanging in an upside down helicopter again.
Recognize that fatigue is hazardous, admit when you are tired, and break the chain of events!
Author's name withheld on request
* Maximum flight times and duty times as established by Forest Service, not Transport Canada.
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