The release of the Australian Transport Safety Bureau (ATSB) Preliminary Report into the January 27 crash of a Large Air Tanker (LAT) during firefighting operations in NSW allows us to pinpoint the key questions that surround this accident. There are many.
At this early stage of the investigation, the Report limits itself to a description of the sequence of events leading up to the crash, its impact on the aircraft, and the most relevant information points such as the weather. A full set of findings will only be completed in a year or eighteen months' time.
Nevertheless, the Report is useful because it helps us identify the critical questions that need to be answered if the full set of circumstances surrounding the crash are to be understood, and for the appropriate lessons to be learnt. Many of these do not relate to the operation of the aircraft itself, or the actions of the aircrew, but lie within the broader context of their deployment to this fire, firefighting tactics, and decisions over the allocation of resources made by Incident Management Teams (IMTs) during the course of this year's fire season. Not all of these aspects will fall within the scope of the ATSB Investigation, they are, however, central to current and future discussions over the effectiveness of the approaches taken by IMTs in recent times, and their implications for firefighter and community safety.
The C-130 flew into terrain within seconds of making a retardant drop on the Good Good fire, roughly 50km North East of the Cooma-Snowy Mountains airport. This was its first drop of the day, meaning the aircraft was fully laden, and it released about a quarter of a load, leaving it still heavy as it banked to the left above rising ground. A video taken by ground crew captures the drop, and shows the aircraft entering smoke, although it is not clear whether it flew through this or was still in low visibility when it hit the ground. This is the first question to be addressed - did the aircrew lose situational awareness as a result of entering the smoke plume ?
This in turn raises more issues specifically in relation to the drop. Why was this line of attack taken, given the clearly visible smoke at the far end ? This question has additional force when the wind direction is taken into account, approximately five o'clock to the aircraft, in other words a tail wind as it entered the left turn. Furthermore, this wind was gusting heavily, from 25 knots to 39, enough for a SIGMET to have been issued hours earlier. The combination of all these factors points to an obvious explanation as to what happened to cause the crash, however it is still early days so caution is advised before jumping to conclusions.
Even so, whether this is how the accident occurred or not, it was clearly a high risk manoeuvre. It is where the focus has to shift away from the aircrew's actions in flying the aircraft, to the decision making of those who allocated this task to the C-130. Where exactly was the fire at this moment ? What was it threatening ? What was the objective behind the drop ? Was a retardant drop likely to effective given the conditions, both the high wind and the fire behaviour ? Were ground crews on hand to follow up and consolidate the fire break established ? Was this the best use of a LAT or were there better alternatives ?
Part of the context at play here consists of the earlier decision by the crew to abort their original tasking, which was to make drops on the Adaminaby fire. This was done due to poor visibility as a result of smoke. This raises the issue as to how prepared the ICC running the neighbouring Good Good fire were to make good decisions on how to best deploy this newly available asset on their fireground. There is also a question as to whether an Air Attack Supervisor (AAS) in a lead aircraft was on hand to guide the LAT, as is normal procedure. There has been no mention so far, in either witness statements or official pronouncements, as to the presence of a 'bird dog' at the location. Instead we only have testimony that the C-130 completed 'several circuits' before making its final run. How many is several ? A dummy run is the usual practice, however repeated passes may be an indication of hesitation or doubt on the part of the pilots, especially if they did not have the assistance of an AAS. Furthermore, there are reports that in fact the bird dog was on the ground at Richmond Air Base, because its pilot believed conditions were not suitable for flying that day, as did other crews. Clarification on this is needed. Who authorised the flight ? Who did the tasking ? Who did the risk and safety assessments ? If these were left to the crew's own discretion, why was this so ? Were the C-130 pilots set up to fail ?
The diversion to Good Good may also have contributed to an oversight in relation to the significance of the SIGMET, issued that morning and perhaps more relevant to conditions at this fire rather than Adaminaby. Here too, if the crew were left to operate out on their own, the chance of this oversight being picked up would have been reduced. Were they fully aware of the wind conditions at the critical moment ? If not, why was no one in Air Ops looking out for them ?
Part of the difficulty in answering these questions will lie in the surprising development that the Cockpit Voice Recorder (CVR) was not running, no recording of the flight exists. Not only was it not on that day, it turns out not to have been functioning since the aircraft left the United States the previous November. This seems very strange, an explanation is certainly required as to how this was allowed to occur.
All of these issues raise questions as to how Air Operations were being run across all the bushfires where C-130 and other assets were deployed. By its very nature, flying fixed wing aircraft, especially large tankers, very low to the ground through smoke and air turbulence, in mountainous terrain, is an extremely risky activity. This means great care and attention needs to be taken EVERY TIME they are allocated a tasking. IS IT WORTH THE RISK ? This is the key calculation that needs to be made, not by air crew, who are in no position to assess the benefit side of the equation, but by those in control of the fire response, applying their appreciation of what is happening on the ground, where crews are deployed, what is under threat, and what other options exist. These are the critical points that need to come out as the investigation proceeds.
For more on this subject, see the excellent videos produced by Blancolirio (here), himself a highly experienced pilot with first hand knowledge of fire operations. Blancolirio makes some additional points about stress and fatigue and the role they may have played in this accident. See also the comments below his video, which contain some interesting insights and information.
Finally, see our own training course, 'Shoot, Don't Shoot', above all levels 2 and 3, which are directed at those with responsibility for running safe operations in high risk, high consequence environments. Are we setting our frontline operators to succeed, or to fail ? How to know the difference, how to be the difference.
