The NSW Rural Fire Service has come under criticism from the Australian aviation watchdog after an investigation into the fire-fighting plane crash that killed three Americans helping out during the Black Summer bushfires.
Ian McBeth, Paul Hudson and Rick DeMorgan came to Australia to fight the devastating bushfires and died when their large air tanker crashed in a blaze on January 23, 2020.
The Australian Transport Safety Bureau (ATSB) released its report Monday on the crash in the Snowy Mountains region of NSW.
It found that the RFS sent the aircraft to an area of adverse conditions, with no aerial surveillance, and relied on the pilot to assess the risk without providing all the required information.
The pilot of the air-surveillance plane had turned down the job due to bad weather and the crew of a loose Boeing 737 had reported that they would not return to the seat of the fire either.
The ATSB said the crew of the Lockheed EC-130Q large air tanker that crashed was most likely unaware of these two decisions by other pilots.
“While this was just one of the other risk factors the crew would consider when accepting a job, having this information would have allowed them to make a more informed decision about weather conditions,” the report said.
The predicted and actual weather conditions in the region on the day of the crash were dangerous gusts of wind, likely exacerbated by the fires and the local terrain.
The crew judged the conditions to be unsuitable and instead were sent some 58 kilometers to the east, where conditions were much the same.
The ATSB found that the plane likely came to a stop as it climbed after it dropped fire retardant on the Good Good burn site near Peak View, north of Cooma.
The RFS and the aircraft operator were jointly responsible for risk mitigation in firefighting operations, which necessarily take place in a high-risk environment, the ATSB said.
The agency’s report identified a number of issues with risk mitigation.
Coulson Aviation, the Canadian company contracted to operate the tanker for the RFS, did not have adequate operational risk assessments or a maintained risk register.
The company has improved its risk assessments and procedures and training for pilots who encounter wind shear in response, the ATSB said.
The RFS had limited policies and procedures for large air carriers and their surveillance, and no procedures for unsupervised deployment.
There was also no policy to manage job rejections or to communicate those rejections internally or to other pilots in the area.
The RFS advised the ATSB that it would order airspace management reports, appoint an air tanker coordinator, review qualified pilots’ records, and review safety doctrine among other measures.
However, the agency said the RFS had not yet committed to taking security measures that would mitigate the risks of issues identified in the report.
It advised the agency to address the lack of policies on aerial surveillance and communication of job denials.
The ATSB said the investigation was delayed and limited because there was no recording of the accident on the cockpit voice recorder, which contained only audio from a 2019 US flight.