Contents De Soto Aviation Incident – Accident ...... 4 Foreword ...... 4 Area Map ...... 6 Aviation Incident Information ...... 7 Weather Conditions, Gulf Port, MS (GPT), 1453 CDT ...... 7 Part I – Event Narrative ...... 8 Background ...... 8 Sequence of Events ...... 8 Deciding and Preparing to Burn ...... 8 Ground Operations ...... 12 Aerial Operations ...... 13 Helicopter N50KH Loses Power and Crashes ...... 17 Response to the Incident-within-an-incident ...... 18 Multiple Rescue Efforts ...... 19 External Emergency Response Activities ...... 23 Ensuing Burn Management ...... 25 Aviation Technical Team’s Findings ...... 26 Contract ...... 26 Management ...... 26 Aircraft ...... 27 Aircraft Damage ...... 28 Engine ...... 29 Pilot ...... 29 Crew ...... 30 Weather ...... 31 Emergency Response ...... 31 Mission Operations ...... 32 Part II – Conditions that Supported Decisions and Actions ...... 34 Introduction ...... 34 Value of the Resources ...... 34 Prescribed Fire-acre Targets ...... 39

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Selection of Unit 1459 ...... 42 Risk Management Process ...... 45 Conclusion ...... 50 Part III – Sensemaking ...... 51 Introduction ...... 51 Irreducible Uncertainty ...... 51 Challenging Routines and Assumptions ...... 52 Genuine Curiosity ...... 53 Need for Conversation ...... 53 Individual and Organizational Reflection ...... 54 Effective Relationships ...... 55 Conclusion ...... 56 Safety Action Plan ...... 57 Deliberate Discussions that Challenge the Norm ...... 57 Administrative Response to Unplanned Events ...... 58 Planning and Pre-Season Preparedness Discussions with Emergency Response Partners ...... 58 Aircraft Performance and Mission Profile ...... 59 Aircraft Crew Safety Equipment ...... 60 Aerial Ignition Mission Preparation ...... 60 Aviation Record Keeping ...... 61 Aircraft Incident Response ...... 61 Works Cited ...... 62 Acknowledgements ...... 64 Learning Review Team ...... 64 Review Participants ...... 64 Appendices ...... 65 Appendix A – March 30, 2015 Unit 1459 Area Map ...... 65 Appendix B –Lessons Learned from Those Involved ...... 66 B.1 - Preparing for the Prescribed Burning Season and the Unexpected ...... 66 B.2 - Dispatch Staffing ...... 68 B.3 - Locating the Accident ...... 69

Page 2 of 89 De Soto Aviation Incident Learning Review – Accident B.4 - Helicopter Equipment ...... 69 B.5 - Burn Plans and Crash Rescue ...... 70 B.6 - Notification of Next of Kin/Media ...... 70 B.7 - The Emergency Response ...... 72 B.8 - Medical Certification ...... 73 B.9 - Immediate Incident-within-an-Incident (IWI) Response ...... 74 B.10 - Afterward ...... 74 Appendix C – Sequence of Events ...... 75 Appendix D – Sand-table Exercise – NF in MS FLT (2014) ...... 79 Appendix E – De Soto Aviation PPE Report ...... 81 De Soto Aviation Incident – March 30, 2015 ...... 81 Personal Protection Equipment (PPE) Report ...... 81 Appendix F – Sabine Aviation Incident NTSB Report Excerpt ...... 84 Appendix G – Aviation Acronyms ...... 86

Page 3 of 89 De Soto Aviation Incident Learning Review – Accident De Soto Aviation Incident – Accident Foreword

This report focuses on the context surrounding March 30, 2015 at approximately 14361 when helicopter N50KH experienced a “loss of engine power for reasons that could not be determined” (National Transportation Safety Board, 2016) during prescribed burning operations on the National Forests in Mississippi (NF in MS) De Soto Ranger District, Unit 1459. The accident took the lives of Forest Service employee Steve Cobb, contract pilot Brandon Ricks, and seriously injured another Forest Service employee on detail from Montana. Typically reviews such as this determine significant events, decisions, and actions that led to the unintended outcome and find errors (latent or active) or “holes” in the Swiss cheese2 that allowed the unintended outcome to happen. Concerning the De Soto aviation accident, it may be that we will never find the chain of errors or the holes that led to the catastrophic loss of power of the helicopter over National Forests in Mississippi (NF in MS) on the De Soto Ranger District’s prescribed burn Unit 1459 on March 30, 2015. Additionally, decisions made that day either on the ground or in the helicopter had little if any significant influence on the outcome. Therefore, in this review we must widen our scope to address the decision to burn Unit 1459 and utilize helicopter N50KH for aerial ignitions because that decision enabled the crash and subsequent loss of two human lives and another’s serious injuries—the unintended outcome. Unfortunately, the Swiss cheese model is insufficient to understand the decisions that led to the action of conducting prescribed burning on Unit 1459. These decisions cannot be qualified in the simple terms of “error” or “not error”—a “hole” or “not a hole” in the cheese. Thus, this report will not suggest a simple fix and return to work as usual but instead will explore the conditions that influenced this key decision so as to prompt community discussion. While this specific incident will never happen again, the conditions influential to the outcome are common, and understanding those conditions transfers the learning beyond those directly involved to the wider agency and wildland fire community. Learning from this review combines the contextual reflection of peers with the rich body of academic theory in an effort to move beyond simple adjustments to the current system to challenge assumptions underpinning the accepted norm and cultivate the organization’s capacity to anticipate, respond, and recover from surprising events. The parts of this report that focus on the strategic, operational, and tactical decisions leading to the decision to burn Unit 1459 and the decision to utilize N50KH for aerial ignition lend themselves to organizational and institutional learning. The Learning Review (LR) team’s approach to these parts of the report

1 All times referenced are in Central Daylight Time (CDT) 2 Professor James Reason hypothesizes that most accidents can be traced to one or more of four levels of failure: organizational influences, unsafe supervision, preconditions for unsafe acts, and the unsafe acts themselves. In the Swiss cheese model, an organization's defenses against failure are modelled as a series of barriers, with individual weaknesses in individual parts of the system, and are continually varying in size and position. The system as a whole produces failures when all individual barrier weaknesses align, permitting "a trajectory of accident opportunity," so that a hazard passes through all of the holes in all of the defenses, leading to a failure. (see James Reason’s book, Human Error, Cambridge University Press, 1990).

Page 4 of 89 De Soto Aviation Incident Learning Review – Accident were to look “up and out,” involving a broad range of both internal “peer” and external academic and industry expert3 focus groups in the sensemaking and learning. Alternatively, the parts of the report that focus on the response to the incident after N50KH lost power and crashed were heavily influenced by the lessons learned from those directly involved. The LR team looked “down and in” to these lessons, drawing on the experience of internal and operational focus groups. The resulting sensemaking and learning tended to be operational in nature and readily transferable to other units. Learning from this review that was relevant to Agency leadership or needed national support was included in the Safety Action Plan (SAP) for review and approval by the National Learning Review Board (LRB), signaling support for the selected action items.

3 Specifically we reached out to academics in the fields of Complex Adaptive Systems (CAS) theory, organizational culture, and human dimensions.

Page 5 of 89 De Soto Aviation Incident Learning Review – Accident Area Map

Figure 1: Area map of Unit 1459 and crash site (yellow “+” with black outline). The district office and dispatch are located in Wiggins, MS 15 miles NW of Unit 1459. The Griffin Memorial Airport where N50KH was based is just west of Wiggins.

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Aviation Incident Information

NTSB Identification: ERA15FA173 Date and Time: 30 March 2015 @ 1436 CDT Location: near Saucier, MS Elevation: Approx. 180’ MSL Mission Type: Public Use Aircraft Type: 206L1 Manufacturer: Bell Helicopter Registration: N50KH Operator: T&M Aviation LLC Home Base: Abbeville, LA Operational Control: US Forest Service Procurement: Exclusive Use Type Mission: Aerial Ignition Phase of Flight: Operational (in flight) Persons Onboard: 3 Injuries: 2 fatal, 1 serious Figure 2: This map identifies the approximate accident location. Weather Conditions, Gulf Port, MS (GPT), 1453 CDT Visibility: Day visual meteorological conditions, 10sm, with slight obscuration due to light smoke Temp: 78-79°F (26°C) Dew Pt: 17° Altimeter: 30.15 Wind: 200° (SW) at 07-09 mph w/ gusts to 24 mph Sky Conditions: Clear RAWS: Black Creek Remote Automated Weather Station (RAWS) located approximately 3.78 miles SE of the accident site recorded the following weather readings on 30 March 2015 around the time of the accident. Time °F RH % Wind speed (mph) Wind gust Wind direction (CDT) (mph) 1350 79.0 59 7 16 SSW 1450 78.0 60 9 17 S

Witnesses also reported “shifting winds,” sometimes out of the west.

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Part I – Event Narrative

Background

The Southern Region (R8) of the USDA Forest Service’s National Forest System (NFS) oversees the largest prescribed fire program in the system. Although the region administers only seven percent (13,358,768 acres) of the total NFS acreage, it accounts for over 70 percent of the annual prescribed fire acreage treated. The National Forests in Mississippi (NF in MS) and the De Soto Ranger District are significant components of the regional program, accounting for approximately 18 percent and 8 percent of the annual accomplishments respectively. The De Soto Ranger District typically burns in excess of 75,000 acres4 annually over a 40-day burn season.5 The district’s 2015 prescribed fire season began in January and progressed with above-average burn days but below-average acres. By March 30, the district was about halfway through the burn season and had completed approximately 37 units totaling just over 40,000 acres. About 90 percent of those acres were burned with the help of the exclusive-use contracted helicopters, two Bell 206L-1s operated by T&M Aviation of Louisiana. Detailers had been brought on to help with both ground and air operations, including many who had been returning for several years. The burn program also took advantage of the considerable experience found in the local militia of non-fire employees to support both ground and air operations. Sequence of Events Deciding and Preparing to Burn As was typical during the prescribed fire season, at 0600 on March 30, 2015, the DFMO arrived for work at the De Soto Ranger District office in Wiggins, Mississippi, and the burn boss (RXB2) arrived at the Airey Work Center 15 miles southeast of Wiggins to assess if and where they could conduct prescribed burning that day (see a local map in appendix A). This assessment involved analyzing a complex network of factors, including weather, public events, specific local factors, smoke impacts, fog, and available resources. The two used a wide variety of predictive models, local area expertise, and current forecasts and weather indices to decide which unit(s) would be best suited for the day. Utilizing nearly 60 years and a million acres of combined experience, the DFMO and RXB2 conferred and began to make a final decision concerning if, when, and where to burn. Additional parameters were checked against possible fog predictions, and ultimately the two selected Unit 1459, an 800-acre burn block located just three miles west of the Airey Work Center. In an interview after the incident, RXB2 stated, “This was an excellent choice for the day.”

4 75,717 acres is the average for 2005-2014. The least number of acres burned was in 2006 with 14,564 acres and the most number of acres was in 2009 with 114,804 acres burned. 5 On average, there are 40 days annually with conditions suitable for prescribed burning.

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Figure 3: Burn Unit 1459. The red shaded area is part of the unit but was left out the March 30 burn operation. Cross-hatched sections indicate private land. Briefing location is indicated by the green dot. Ground ignitions began in the northeast corner and progressed west and south along the dozer lines and then along the road system/unit boundary.

Activities to implement the burn began with the DFMO and RXB2 scanning and distributing a burn map to resources. Smoke permits were obtained from the state, and email and phone notifications were made to appropriate parties (e.g., smoke-sensitive targets; 9-1-1 responders; county and congressional offices; media, etc.). Because portions of the Tuxachanie Trail (a popular hiking trail) were within the burn unit, personnel from the Airey Work Center posted signage with the burn information at trailheads, and the trail was posted as closed at its intersection with the 415A and 415B roads. Over the phone, at 0830 the De Soto District Ranger gave the authorization to burn.

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Figure 4: This photo shows looking west along the 415A road. Unit 1459 (burned) is on the left and the unburned unit is on the right for fuels reference.

Soon after, a local television reporter contacted RXB2 to request an interview and access to the site for a story he was preparing on prescribed fire. He agreed to meet at the briefing location at the corner of Martha Redman Road and the 415A Road just before 10 a.m. The March 30, 2015 workday also began like many others for the crew of helicopter N50KH (N50KH), a Bell 206L-1 helicopter. At 0730 the helicopter manager, Plastic Sphere Dispenser6 (PSD) operator, and firing boss (FIRB) arrived at the district office to hear conversations about the development of the day’s plan. They took part in a general briefing and obtained weather information from the dispatch center located at the district office. The helicopter manager and PSD operator then headed over to the Wiggins airport, and FIRB followed soon after. At the airport the three of them met with the pilot and readied the aircraft for flight, pulling off tie-downs, performing a pre-flight inspection, and conducting load calculations for the first flight, which was planned to survey (recon) the previous day’s burn. The crew reviewed the burn plan and the unit objectives; held a safety briefing; covered the weather for the day; and confirmed tactical plans and assignments. At 0940 the pilot, PSD operator, and

6 The plastic sphere dispenser (PSD) is installed in the passenger compartment of a helicopter and dispenses plastic spheres out the door opening of the aircraft. The plastic spheres contain potassium permanganate and are injected with ethylene glycol (antifreeze) by the PSD operator before being discharged. A chemical reaction between the potassium permanganate and ethylene glycol causes the sphere to ignite approximately 20 to 30 seconds after injection. An operator controls the PSD from the back seat of the aircraft. A firing boss oversees firing operations from the front seat.

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FIRB departed the Wiggins airport in N50KH to check the previous day’s burn and ultimately reported to RXB2 that one burning snag had some potential. They then proceeded to recon7 Unit 1459. The recon was the aerial ignition crew’s “operational briefing,” during which they got a feel for the unit’s size, shape, and orientation; wind direction; and safety considerations, such as the possible presence of campers, hunters, or hikers. They flew the unit boundaries, marking them on their iPads. At 1048, after boundaries were marked, N50KH returned to the Wiggins airport.

Figure 5: “Black-lining” the road in preparation for the helicopter to igniting the interior of the unit.

Upon their return to the Wiggins airport, the helicopter manager went over the load calculations8 for the upcoming ignition operations, including 2.5 hours of fuel and three bags of balls (approximately 6,000 balls or approximately 60 pounds), and determined the manifested weight to be under the helicopter’s allowable weight for the day’s conditions.9 Following a general briefing and a “go/no-go checklist;” everyone involved supported the planned mission.

7 Abbreviation for reconnaissance. To examine a fire area to obtain information about current and probable fire behavior and other related fire-suppression information. 8 Computing a load calculation prior to any helicopter flight is a standard procedure. 9 The manifest for the flight was calculated to be 630 lbs., and the calculated allowable payload (Load Calculation) was 748 lbs. for this flight.

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The PSD operator bench-tested the PSD machine and then installed it onto the right side of the helicopter at the back of the main crew cabin. The helicopter manager helped to ensure proper installation. Weather was read over the forest radios and as the crew listened, they also checked the weather forecasts on their iPhones. With all this finished, they had a relaxed lunch and waited for the unit to be prepared for aerial ignitions. The morning’s activities were very typical of burn-day operations. Ground Operations The ground-operations briefing was conducted at approximately 1000 at the junction of the 415A Road and the Martha Redmond Road. Resources on scene consisted of seven crewmembers, type 6 and 7 engines, (the type 7 was RXB2’s pickup with a tank on the back) and a dozer. A John Deere wheeled tractor and trailer with a water tank arrived after ignitions began. The briefing covered burn-plan details, including incident-within-incident roles and procedures. The local news reporter filmed the briefing and interviewed RXB2 about the prescribed burn.

Figure 6: Looking south at briefing location (after the burn) at the intersection of 415A Road and the Martha Redmond Road.

Shortly after 1000, the crew lit a test fire and monitored it for approximately 20 minutes. At 1030 RXB2 determined the test fire was meeting the planned objectives. This information was communicated to dispatch, and burning operations began. The dozer was staged just south of the briefing spot. Ignitions began at the intersection of the northern unit boundary (dozer line) and the 415B Road; it progressed west along the 415B and private land boundary and back onto 415B Road, commensurate with the west-southwest wind. RXB2 came across three hikers at the

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intersection of the 415A Road and the Tuxachanie hiking trail and told them they had time to continue east and cross through the burn unit. He then radioed the firefighter on the 415B Road to make sure the hikers had arrived on the other side of the burn unit. RXB2 drove around to the 415B Road and made a sweep through the area and did not see the hikers, but one of the crewmembers on the 415B Road confirmed seeing hikers who matched the description outside of the burn unit, heading east on the trail. Crewmembers working along the northern unit boundary reported a spot fire outside the line; the dozer responded quickly, and the spot was contained. The dozer remained in the northeast corner of the burn after the spot fire was controlled. At about 1130 the DFMO arrived on the burn and checked in with RXB2 and was updated on the prescribed burn’s status. He joined the firing crew and began burning from the hiking trail south along the 415B Road and ultimately tied into the 415A Road. He noted a snag burning in this area. RXB2 and the DFMO discussed winds and whether to do any further burning west along the 415A Road. They decided to work the 415A Road in coordination with the aerial ignition because they did not want to encapsulate the helicopter operations in smoke. RXB2 began checking with the crew to determine whether there was enough depth on the blacklines10 to begin aerial ignition. Firefighters communicated that a few small sections needed more time. Once RXB2 was satisfied with the security of the blacklines, he texted FIRB at the helibase, “Ready.” FIRB replied, “On my way.” Aerial Operations

Figure 7: N50KH is shown with doors removed and Pilot and PSD operator positions visible.

10 Blackline - Pre-burning of fuels adjacent to a control line before igniting a prescribed burn. Blacklining is usually done in heavy fuels adjacent to a control line during periods of low fire danger to reduce heat on holding crews and lessen chances for spotting across control lines.

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Back at the Wiggins helibase, lunch was wrapping up and radio traffic on the cellular-based lync phones11 began to pick up; at around 1320 the request came in the form of a text from RXB2 to FIRB, “Ready.” The pilot and FIRB got into the front of the helicopter, the pilot on the right side and FIRB on the left. The PSD operator climbed into the back right side of the helicopter and sat facing forward, straddling the PSD machine with his right leg outside the helicopter. Both front and rear right doors had been removed. The PSD operator clipped the gunner strap12 around his waist, ensured it was properly tethered to the hard point on the floor between the two forward facing, rear seats, and put on his seatbelt. Lastly he donned his flight gloves and flight helmet and gave the helicopter manager a “thumbs up.” As the helicopter manager made his way out in front of the helicopter so that he was in full view of the pilot, the engine began to start up. He heard the whine of the fans turning and the “tick, tick, tick” of the igniters firing, which was usually followed by the sound of the fuel igniting and the jet engine noise that signals a successful engine start, but not this time. The compressor kept turning and igniters ticking; it was a failed engine start. Failed starts, while not a common occurrence, do happen periodically. The helicopter manager reported he sees three or four a year. The helicopter manager trusted the pilot, who in addition to accumulating 6,471 total hours of flight hours, (about 6,300 hours of which were in the same make and model as N50KH) was also a mechanic for the contractor and served as the contractor’s director of maintenance from 2010 through 2013. The pilot was on his second day as the relief pilot and routinely took over in two-day rotations to relieve the primary pilot. When the engine failed to catch, the pilot seemed calm; he shut everything down, and after everything stopped moving, waited a little over 10 seconds and restarted the engine, this time without incident. With the engine now idling normally, the crew did a communications check, and at 1333 N50KH departed Wiggins airport in route to Unit 1459. FIRB radioed dispatch, “Pilot +2 in the air with two and half hours of fuel and PSD on board.” Dispatch confirmed, adding that automated flight following (AFF) was active.13 Within minutes N50KH was over Unit 1459. The PSD operator was readying the machine and felt comfortable with the situation. He had worked in Mississippi for all but two of the last 13 years, during which time he had worked extensively with RXB2, the DFMO, and others and regarded them as a close-knit and highly professional group. He respected the pilot as well, having flown with him more than 20 times over the past two years. At 1341, N50KH was over the unit and transitioned from flight following with dispatch to communication and flight following with the burn personnel on a tactical radio channel, thus establishing direct communication with the burn incident. RXB2 asked FIRB to check the hiking trail again during his recon. N50KH flew the

11 A system put into place before Hurricane Katrina hit the area that was the only means of communication after the hurricane for some time. The district keeps a cache of lync phones in reserve in case another storm takes out the repeater system. A few phones are kept active and are used as a parallel system to the radio repeater system. 12 A single strap, clipped at the front and attached via a tether to a hard-point in the helicopter, is worn as a required secondary restraint system for PSD operations. The PSD operator was still wearing the strap with carabineer attached when he was found on the road after the crash. 13 Automated Flight Following (AFF): AFF is a system that automatically transmits the location, altitude, course, and speed of an aircraft through commercial satellite segments. This information is provided in near real time to dispatchers, aviation managers, and other system users. It is updated in 2-minute intervals. Source: http://www.ntsb.gov/news/events/Documents/Roth.pdf

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boundaries once again to ensure their understanding of the boundaries were consistent with the ground personnel and confirmed there was no one on the hiking trail. As N50KH began aerial ignitions, FIRB instructed the PSD operator to set the PSD machine to 4 low, meaning that all four chutes were open, but the machine was on the slow dispensing setting. It was left this way for the duration of the operation. FIRB used the standard commands14 when communicating to the PSD operator, going through the sequence each pass they made. N50KH began ignitions in the northeast corner of the unit, reinforcing sections of the private-property boundary on the east side of the burn from north to south and working northwest to southeast lines west into the wind. This pattern helped reduce smoke exposure, favor an unobstructed view of the burn, and enable more precise control of fire behavior. FIRB then moved to reinforcing and straightening from the northern unit boundary, south to the 415A Road. Later both RXB2 and the DFMO recalled, “FIRB was dressing it all up, getting it in line, cleaning it up; this wasn’t uncommon for him. FIRB took pride in what he did and keeping everyone lined out.” FIRB began to direct passes from north to south within the burn unit, backing the fire to the west. Later the PSD operator observed, “Everything was going well, like we expected. (That) comes from working so long together.” The DFMO was continuing with ground ignition on the south side of the fire, progressing west just ahead of the helicopter. RXB2 called crewmembers about the snag on the corner, and two responded and cut it down. The helicopter made approximately 12 passes from north to south, and by that point, had been over the fire for about an hour.

14 From: Interagency Aerial Ignitions Guide, PMS 501. 2015. Page III-8 1. FIRB communicates to operator, “Prepare to fire; activate machine.” 2. Operator actions: a. Activate machine. b. Operator communicates to FIRB, “Ready to fire.” 3. FIRB communicates to operator to “Start firing/Number of chutes or machine speed” (in this case 4 slow). 4. Operator replies, “Firing/Number of chutes or machine speed.” 5. Operator monitors machine operation and refills hopper as needed. Operator observes spheres after they have made contact with the ground to confirm ignition. 6. When appropriate, FIRB communicates, “Prepare to stop firing.” 7. Operator places hand on controls and communicates, “Ready to stop.” 8. FIRB gives the order “Stop firing.” 9. Operator closes chutes and responds, “Firing stopped.” 10. Operator observes last sphere clear of the PSD and relays, “Machine cleared.” 11. FIRB gives order to operator to “secure machine” or “prepare to fire.”

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Just after 1433 the helicopter made what appeared to be its final pass along the fire’s west flank. RXB2 was in his truck heading north along the 415A Road and saw the helicopter just inside the unit, paralleling the road and heading south. The DFMO watched the helicopter complete its pass and make a turn to the east (back into the burn). The DFMO speculated this was done in order to stay within the burn perimeter while the PSD chute was clearing. The DFMO noted that the “helicopter sounded completely normal.”15

Figure 8: The map outlines burn Unit 1459 and the accident site. Black circles indicate AFF position indicators at 2 minute intervals. Purple lines connect locations sequentially. Green dot is original briefing location for reference.

15 Per automated flight following (AFF) time stamp of 1433.

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Helicopter N50KH Loses Power and Crashes Five to ten seconds later, on N50KH the PSD operator recalled they “were flying along 25-to-30 feet above the highest tree…things were going really well,” and they were nearly through the first bag of balls when he heard two alarm warning buzzers go off simultaneously or nearly so,16 followed immediately by the pilot stating, “We lost power,” and FIRB saying, “We’re going in; we’re going in.” Simultaneously, while standing at the SW corner of the burn on the 415A road, the DFMO heard a hiss “like a high-pressure hose blowing off a tank” and wondered what the sound was. The PSD operator swung his right leg over the PSD machine and back inside the helicopter, just as he had practiced in his head when he envisioned this scenario. He didn’t want his leg broken or trapped under the helicopter if it were to roll on its side. As he tightened his lap belt and pushed his back against the seat, hands on his knees in the crash position, he felt the helicopter tip backwards and to the right slightly. The PSD operator believed the pilot initiated this position purposefully, possibly as part of an autorotation.17 The descent through the tree canopy was not violent, and the helicopter slipped through the trees tail first. The impact with the ground was “abrupt.” The PSD operator felt the lap belt catch him; the impact knocked the wind out of him. Seconds after hearing the hissing sound, the DFMO heard what “sounded like metal hitting trees,” and he knew that the helicopter had gone down. At the same time, a crewmember on the east side of the fire along line C heard “Boom…boom,” and asked another crewmember, “What was that?” Shortly after, the crewmembers saw “thick black smoke” to the southwest.

Figure 9: Area of helicopter crash. Trees show little sign of damage. One tree with missing top is circled.

16From NTSB Factual report (2016): “The audio files from the helicopter's aural warning system were played for the surviving crew member during a follow-up telephone conversation. The crew member recognized both alarms and arranged them in the following sequence: the sustained alarm immediately followed by the fast pulse alarm. According to the manufacturer, the sustained alarm corresponds with the low rpm horn and the fast pulse alarm is an engine out indication; however, the pulsed tone will sometimes follow the steady tone when a power loss occurs.” 17 The PSD operator credits the pilot’s actions with saving his life.

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The PSD operator remembers the helicopter coming to rest more or less upright,18 and it was quiet. The PSD operator could hear breathing over the intercom system and “crackling” as the balls they had just dropped began to establish fire. He thought to himself, “I’m still alive!” He unbuckled the lap belt and unhooked the gunner strap’s tether from the helicopter, then reached forward to jostle the pilot, yelling at the pilot and FIRB, “We gotta get outta here.” He exited the helicopter from the right side and once on the ground, moved towards the front of the aircraft. He yelled again, “We gotta go,” calling each by name while realizing they were unconscious and that he wouldn’t be able to move them with his injuries.19 As it was, he was having difficulty breathing and standing up. He now heard the roar of the fire that had grown from small individual spots of fire to a wall of flames surrounding them; he knew it was time to move. He turned and faced the wall of flames and thought, “I just survived a helicopter crash; I am going to live.” He recounted, “I started walking, through the wall of flames 10-to-15 feet thick, then all the glowing ashes on the other side and residual heat…hands over my face and screaming into my hands and saying, ‘Don’t fall, don’t fall’…everything was glowing and I just kept going…I could feel myself burning…the watchband melting on my wrist.” The PSD operator walked approximately 900 feet in a westerly direction to reach the 415A road and the western edge of the burn unit sometime between 1448 and 1451. Response to the Incident-within-an-incident Immediate Response Activities Upon hearing the helicopter go down, the DFMO ordered the dozer operator to “Get the dozer! Quick!” in hopes that the helicopter was still in the green portion of the burn unit and they could cut the burn off before it reached the helicopter. Both the DFMO and RXB2 attempted to make radio contact with the helicopter. At 1436, RXB2 called dispatch on the lync phone20 and informed them that there was a possible “incident with the helicopter” and they had lost radio contact with the helicopter. The DFMO called RXB2 on TAC 1 and asked him to call dispatch and start the emergency medical services (EMS) response. The DFMO also announced on TAC 1 that there was an incident-within-an-incident and that he would be the incident commander (IC) and RXB2 would continue as the burn boss. The DFMO made contact with dispatch declaring “emergency traffic only,” not wanting to sound panicked but trying to express the severity of the situation. Hearing this, the two ground crewmembers wanted to head in the direction of the noise they heard through the brush, but the fire was “too intense,” so they moved to the 415B Road and headed south towards the DFMO. Dispatch contacted RXB2 to inform him that at 1440 the automated flight following (AFF) was still active and providing a location. RXB2 questioned dispatch about which format the coordinates were in, and dispatch didn’t know. RXB2 figured it out and plugged in the coordinates. He then called DFMO and said, “The coordinates show it’s right here!” Dispatch

18 The NTSB, however, concluded that the helicopter came to rest on its left side. 19 Helicopter crash impact injuries: Fractures of two cervical and two lumbar vertebrae, left ocular and left side ribs; intestinal and hernia tears. From: DeSoto Aviation Incident – March 30, 2015; Personal Protection Equipment (PPE) Report. 20 A system put into place before Hurricane Katrina hit the area that was the only means of communication after the hurricane for some time. The district keeps a cache of lync phones in reserve in case another storm takes out the repeater system. A few phones are kept active and are used as a parallel system to the radio repeater system.

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indicated that the AFF locator went from blue (active) to red (stationary) and at 1448 lost contact. RXB2 tried to search for the helicopter using a two-track road to the north, but the fire was “too intense.” RXB2 called dispatch to request helicopter 25 for a search. Multiple Rescue Efforts The DFMO, still at the south end of the unit, made multiple attempts to get to where he thought the helicopter was. “I was doing everything I could to tear in there, but balls were coming together,21 and I kept hitting a wall of flames. I considered running through the flames, but I needed to make sure there were no other incidents, and eventually I came back out to the road.”

Figure 10. Map indicating location of crash site, briefing location (green dot), where initial attempts were made to access the crash site (red arrows), and ultimately where the PSD operator was found on the road (orange triangle).

The dozer operator arrived with the dozer and attempted to push a road through the hardwood brush near the DFMO but was called back as the DFMO realized he “didn’t want him to get hemmed in.” By this time, this corner of the burn was heavily engulfed in flames. After hearing the radio traffic indicating something had happened, crewmembers began to gather at the southwest corner of the burn. The DFMO felt the need to “get up the road,” so he drove north along the west side of the burn on the 415A Road. One crewmember, certified as wilderness

21 The PSD machine drops ping-pong ball-like balls filled with a powder. Just before leaving the machine (and the helicopter) they are injected with a liquid, which after about a 20-40 second delay produce a vigorous flame for a minute or two. The phrase “balls coming together,” suggests the balls that were dropped ignited fires that were now growing in size and starting to merge.

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first responder (WFR), began running after the DFMO’s truck with a medical kit, and wanting additional people and supplies for what he may find, called back to another crewmember to “get the truck.” Soon the DFMO found the PSD operator lying on the road. The PSD operator recalled telling the DFMO, “I am going to live.” The WFR, now in the truck with the other crewmember, arrived at the PSD operator’s location just after the DFMO got there. The WFR made an initial assessment of the PSD operator, noting that he was in a lot of pain but talking and therefore breathing. The WFR made the decision to leave the other crewmember with the PSD operator while he helped with the search for the helicopter where there might be more serious injuries. The crewmember caring for the PSD operator removed one of his boots, opened his shirt, and tried to make him comfortable. According to accounts from the first-responder caregivers, the PSD operator kept repeating, “I had to get out. It was too hot. I had to get out.” He also indicated that the ship “just lost power.”

Figure 11: Location where PSD operator was found on right hand side of road. Beginning of a dozer line into the crash site can be seen in extreme right of photograph.

A three-person search crew prepared to enter the prescribed burn area from the location where the PSD operator was found on the road and where heavy residual heat and smoke remained. The DFMO asked if they were okay with going in and instructed them to stick together and not become another incident. The DFMO indicated that the decision to not join the search was difficult, especially in light of his personal relationship with those on the helicopter, but it was in

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part because of the personal connection that he felt it was necessary for him to remain as IC and maintain appropriate situational awareness and perspective. He later stated to the three, “I’m glad you went in but sorry you had to.” The DFMO instructed the dispatchers to request additional staff in dispatch to help manage the incident. Dispatch subsequently brought in a part-time dispatcher who was working the front desk at the time of the accident. At 1502, dispatch made a series of calls to Harrison County 9-1- 1, the sheriff’s office, Forest Service law enforcement, and the air ambulance. At the same time, helicopter 25 was over the fire and flew a grid pattern in search of N50KH. At one point, the helicopter manager onboard helicopter 25 caught a glimpse of N50KH and believed he saw the rotor all in one piece, and the fire was on and around N50KH. The crashed helicopter seemed to be upright. At about the same time, RXB2 found a spot fire at the end of the 415A Road and sprayed it out with a Type 7 engine to keep it from becoming an additional problem.

Figure 12: Dozer line looking from helicopter crash site towards 415a road. Suggests approximate distance and direction of PSD operator’s route through the burn to the road.

The three-person search team proceeded into the burned area, followed by the dozer. The team struggled with the heavy residual smoke, noting, “It was so stinking hot in there.” At times they were unable to maintain visual contact with each other through the thick smoke and had to use audio cues to determine their position relative to one another. The search team soon located the helicopter and radioed, “Have eyes on the helicopter; this is a recovery mission, not a rescue.”

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Once this message was transmitted, helicopter 25 left the scene and arrived back at Wiggins at 1519. At the crash site, the search team requested a fire extinguisher in an effort to preserve remaining evidence, and one was taken off the dozer. They sprayed the helicopter crew compartment, engine, and interior but were unable to extinguish the burning helicopter. The dozer continued to improve the road into the crash site. The search team did a narrow sweep (gridded out) around the crash site looking for other survivors because it wasn’t absolutely clear whether two bodies were still in the helicopter. Nothing was found in the sweep made 900 yards east of the PSD operator’s position.

Figure 13: Location where PSD operator was treated along 415a road. Hand line cannot be seen directly but unburned vegetation suggests its efficacy.

Returning from the spot fire, RXB2 and a crewmember driving the engine built a short handline to cut off the fire from where the PSD operator was being treated. The crewmember from the engine then began helping care for the PSD operator. To remove the PSD operator’s second boot, they had to cut through the melted laces. Those working with the patient could tell he was burned but noted “his Nomex had held up good” (see PPE Report, Appendix G). They continued to talk to him and comfort him as best they could. One crewmember asked the WFR to return to the road to help with care. The search team returned to the road after they determined their efforts to extinguish the fire on the engine block were futile and because they recognized the smoke hazards from the burning helicopter. The DFMO asked the search team to go back in and perform a wider sweep around the crash site to make absolutely sure there was not another survivor and to secure potential evidence that may remain. The search team then made a wider sweep of the area around the crash site without finding anything. When they returned to the crash site they encountered the DFMO, who indicated he “had to see for himself” how many bodies remained in the helicopter because he was in contact with family of the unaccounted-for Forest Service employee. Family members had just heard of the helicopter accident on the news and wanted accurate information on their loved one. The DFMO surveyed the still-burning helicopter and

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ultimately was able to call and confirm their loved one was among the deceased. On the way back to the road, the search team started to encounter emergency responders walking along the dozer line to the crash site. External Emergency Response Activities As more emergency responders arrived on scene, the engine crewmembers, including the WFR, were repeatedly unsuccessful in finding a more highly qualified medical responder to care for the PSD operator. The first police and volunteer fire departments on scene were not medically trained and did not take over patient care. This situation felt “crushing” to the crewmembers because they were limited in how much they could do for the PSD operator, who was in a lot of pain and obviously seriously injured. The WFR recalls “blanking” as he shifted from thinking he was going to be able to transfer care to realizing he would have to remain in charge. He was at the limit of his training and ability, but there was no one more qualified to take over. There was some confusion between the emergency responders and the agency burn resources. Crewmembers helped emergency responders in trying to extinguish the helicopter. Later, emergency responders instructed those same burn crewmembers to “put out the fire!” The request referred to the fire backing to the road on the east side of the burn adjacent to the first responders’ vehicles but well away from the accident site. This direction put the crewmembers in the awkward position of having to refuse and suggest they go through the burn’s chain of command.

Figure 14: Air ambulance attempting to land.

A little over an hour after N50KH went down, an air ambulance helicopter arrived over the scene and reconned a site identified by RXB2 to land but didn’t attempt to land there. RXB2 assumed it was because there was a section near the site that wasn’t burned out but didn’t know for sure because he wasn’t in direct communication with the air ambulance.22 Next, the air ambulance attempted to land at the south end of the burn unit that several crewmembers thought was “way too tight.” The crewmember closest to this site got frustrated that he couldn’t talk directly

22 The De Soto Ranger District later learned from the air ambulance company that dust possibly causing a “brown- out” was the pilot’s concern.

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with the air ambulance helicopter to call it off.23 Ultimately, the air ambulance landed at a turnout along the Martha Redmond Road about a mile east of the burn. Emergency responders continued to arrive “in waves” and at times blocked access along the 415A Road. When the ground ambulance arrived, a crewmember on the road had to find emergency responders in order to get them to move their vehicles so that the ambulance could reach the PSD operator. As the PSD operator was transferred to the ambulance for transport, the crewmembers caring for him were worried about the level of care the ambulance responders provided. It was frustrating to watch the paramedics lift the PSD operator “onto the stretcher by his belt” and then secure the straps tightly along his badly burned legs. The PSD operator was transported by ground to the waiting air ambulance and at 1614 lifted off, in route to University of Southern Alabama Hospital in Mobile, Alabama.

Figure 15: Map indicating location of crash site, and locations that the air ambulance attempted to land and where the PSD operator was found on the road (orange triangle).

23 During the after-action review (AAR) with the responding agencies, the De Soto Ranger District learned that that even though those on scene may be comfortable communicating with and directing helicopters, it is not best to do so. That action would have only confused the pilot. In this case, emergency response personnel on scene talk with that pilot and helicopter on almost a daily basis and are much more experienced with its capabilities. They were in constant communication with the helicopter during this event.

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Figure 16: Ground ambulance transports the PSD Operator to the awaiting air ambulance.

Figure 17: EMS personnel load the PSD Operator onto the air ambulance. Ensuing Burn Management An employee from the neighboring wildlife refuge called the DFMO during the emergency response and asked if he’d like that staff to take over his burn. The DFMO responded yes, and the US Fish and Wildlife Service crew headed over to relieve them. The Acting Deputy Forest Supervisor also sent personnel from the neighboring unit to allow the DFMO to transition out of the IC role.

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Aviation Technical Team’s Findings

These findings are the result of the Aviation Technical Team’s thorough review of the aviation aspects of this incident. They provide critical factual information on which the Learning Review (LR) and its associated Safety Action Plan (SAP) is based. Contract Finding 1: Helicopter N50KH was operating under an Exclusive Use Contract to the US Forest Service 1.1 Reference: Helicopter Contract

Finding 2: Aircraft was properly inspected and approved by the Forest Service for the contract 2.1 Reference: Aircraft Data Card

Finding 3: Company Part 133 Certificate and Rotor Craft Load Combination Flight Manual complete 3.1 Reference: Review of Part 133 Certificate

Finding 4: Company Part 135 Certificate and Operations Specifications complete 4.1 Reference: Review of Part 135 Certificate

Finding 5: Company Part 137 Certificate complete 5.1 Reference: Review of Part 137 Certificate

Finding 6: Vertical Reference Flight Training Endorsement could not be located 6.1 Reference: Validated by letter from OAS Director of East Region Office

Finding 7: HAZMAT notification complete IAW contract 7.1 Reference: Review of HAZMAT notification

Finding 8: FAA released Fuel Trailer back to the company before U.S. Forest Service investigation team could review fuel sample logs (per contract). FAA Investigator reviewed fuel samples taken from fuel truck; no discrepancies noted 8.1 Reference: FAO statement; verbal statement from FAA ASI at close-out meeting with NTSB

Finding 9: Interagency Contract Pilot records incomplete 9.1 Reference: Validated by letter from OAS Director of East Region Office Management Finding 10: 2012 version of IAIG was most current version of Guide during the planning and implementation stages of this project (2015 IAIG was not available until May 2015) 10.1 Reference: 2012 IAIG and 2015 IAIG

Finding 11: IAIG specifies maximum recommended helicopter speed should not exceed 50 mph (43 knots) during ignition operations 11.1 Reference: 2012 IAIG

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Finding 12: IAIG states, Slow the aircraft speed to the planned application speed when the firing operations are in progress” 12.1 Reference: 2012 IAIG

Finding 13: IAIG states, “Operations require helicopter flight below 500 feet above ground level (AGL)” 13.1 Reference: 2012 IAIG

Finding 14: IAIG recommends operational flight altitude of 300’ AGL 14.1 Reference: 2012 IAIG

Finding 15: 300’ AGL recommendation in IAIG was traced back to 1979 Premo Mark II Sphere Dispenser Operations Guide and is not directly tied to a risk assessment or flight manual 15.1 Reference: 1979 Premo Mark II Guide

Finding 16: IAIG states, “Hovering out of ground effect (HOGE) is the typical flight profile” 16.1 Reference: 2012 IAIG

Finding 17: PASP provided justification for flight below 500’AGL 17.1 Reference: PASP

Finding 18: PASP and mission were approved by appropriate Line Officer 18.1 Reference: PASP Aircraft Finding 19: Company complied with required Aircraft Power Checks in accordance with the Forest Service contract 19.1 Reference: Copy of Power trend

Finding 20: Helicopter was issued an airworthiness certificate on November 10, 1980 20.1 Reference: NTSB Form 6120

Finding 21: 100-hour inspection completed on accident aircraft and engine on March 11, 2015 at ACTT 11,597.5 21.1 Reference: NTSB Form 6120; Maintenance records review

Finding 22: Aircraft Engine was an Allison 250-C30P 22.1 Reference: NTSB Form 6120

Finding 23: Engine TSO of 1861.4 at time of the accident 23.1 Reference: Maintenance records review

Finding 24: Engine TSI of 11936.6 at time of the accident 24.1 Reference: Maintenance records review

Finding 25: Aircraft total time was determined to be 11602.3 hours at time of the accident 25.1 Reference: Maintenance records review

Finding 26: Engine total time was determined to be 12109.1 hours at time of the accident

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26.1 Reference: Maintenance records review

Finding 27: Power check trends showed a +19 trend 27.1 Reference: Power Trend Chart

Finding 28: Based on 206L3 power chart, HIP calculated power check +17 for the conditions during last check 28.1 Reference: NHSP post-accident calculations

Finding 29: Aircraft was within allowable weight and balance 29.1 Reference: Load Calculation & Manifest, HIP review of Pilot/AC records

Finding 30: Helicopter N50KH experienced a failed start prior to accident mission 30.1 Reference: HMGB/PLDO/NTSB statements

Finding 31: Aircraft’s most recent maintenance records were destroyed when aircraft was consumed by ground fire 31.1 Reference: AMI records review (see ADDITIONAL ACTIONS section for immediate action taken)

Finding 32: Aircraft certification CAR 6. 32.1 Reference: Aircraft Airworthiness Certificate Aircraft Damage Finding 33: Helicopter upper deck section, including main rotor, transmission, and collective/cyclic hydraulic servos, remained attached to the fuselage and sustained fire damage; cockpit and cabin were destroyed by fire with the exception of the center window frame and portions of the instrument panel 33.1 Reference: Photographic evidence; NTSB Report

Finding 34: Aircraft crash did not result in ground fire 34.1 Reference: PLDO statement

Finding 35: The collective control was found in the cockpit area with the throttle mechanism exposed and in the idle position; cyclic and collective control continuity from the cockpit to the hydraulic servos could not be attained due to fire damage 35.1 Reference: NTSB Report; photographic evidence; on site examination

Finding 36: Hand rotation of main drive shaft confirmed presence of drive continuity through main transmission to main rotor blades 36.1 Reference: NTSB Report; on site examination

Finding 37: High skid landing gear was separated from the fuselage and located a few feet aft of main wreckage 37.1 Reference: NTSB Report; photographic evidence; on-site examination

Finding 38: Both main rotor blades were attached to main rotor hub: Blade A (white blade) was slightly bent opposite the direction of rotation and Blade B (red blade) displayed two 45-degree chord-wise bends; Tip piece of Blade B was located about 20 feet

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northeast of main wreckage; both blades sustained significant fire damage from the advancing ground fire 38.1 Reference: NTSB Report; photographic evidence; on-site examination

Finding 39: Both main rotor pitch change links exhibited signs of overload separation; white blade separated at swaged end and red blade link separated about mid-span 39.1 Reference: NTSB Report; on-site examination

Finding 40: Tail rotor drive sections rotated freely by hand through respective hanger bearings and flexible Thomas couplings 40.1 Reference: NTSB Report; on-site examination

Finding 41: Continuity of tail rotor drive system showed no indications of spline drive wear on tail rotor spline shaft coupling at the freewheeling unit. Main drive shaft did not exhibit any resistance when moved forward and aft from tail rotor through the gearbox to the steel tail rotor drive shaft that was mounted to freewheeling unit on engine gearbox 41.1 Reference: NTSB Report; on-site examination

Finding 42: Aircraft cockpit/cabin found positioned on its left side 42.1 Reference: NTSB Report; on-site examination Engine

Please refer to the NTSB report24 and reference NTSB Accident Number ERA15FA173 in the Aviation Reports Section.25 Pilot Finding 43: Pilot was the relief pilot, on second duty day 43.1 Reference: Company interview

Finding 44: No indication of pilot fatigue 44.1 Reference: HMGB statement, Pilot Flight & Duty Log

Finding 45: Pilot was within flight and duty limitations 45.1 Reference: Pilot Flight & Duty Log

Finding 46: Pilot was wearing appropriate PPE 46.1 Reference: HMGB statement

Finding 47: Pilot held a current Second Class Medical Certificate 47.1 Reference: Medical Certificate

Finding 48: Pilot had approx. 6471 hrs. of total flight time 48.1 Reference: NTSB Report

24 Go to http://ntsb.gov. 25 Go to http://ntsb.gov/_layouts/ntsb.aviation/index.aspx.

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Finding 49: Pilot had approx. 6300 hours in A/C Make and Model 49.1 Reference: NTSB Report

Finding 50: Pilot’s last PSD operation occurred January 2015 50.1 Reference: Helibase Logs

Finding 51: Pilot was company’s Director of Operations 51.1 Reference: FAR 135 Company Ops Specs

Finding 52: Pilot was properly carded by OAS for Aerial Ignition -PSD missions; Card expiration date would have been April 30, 2015 52.1 Reference: Pilot Data Card

Finding 53: Pilot held A&P Mechanic certification 53.1 Reference: Copy of A&P certificate; FAA records

Finding 54: Pilot signed Go/No-Go checklist as required by Aerial Ignition Guide 54.1 Reference: Go/No-Go Checklist

Finding 55: Pilot was fatally injured (seated in front right seat) 55.1 Reference: NTSB Report Crew Finding 56: FIRB was wearing appropriate PPE 56.1 Reference: HMGB statement

Finding 57: FIRB was qualified for the position and had been qualified for at least 14 years 57.1 Reference: IQCS records

Finding 58: FIRB performed the pre-mission briefing 58.1 Reference: HMGB statement

Finding 59: FIRB obtained PLDO qualification in 1998 59.1 Reference: IQCS records

Finding 60: FIRB was fatally injured (seated in front left seat) 60.1 Reference: NTSB Report

Finding 61: PLDO had current red card for position of PLDO 61.1 Reference: IQCS records

Finding 62: PLDO has been qualified in the position since 2001 62.1 Reference: IQCS records

Finding 63: PLDO met 3-year performance requirement for currency 63.1 Reference: 2012 IAIG

Finding 64: Annual Refresher training for PLDO not documented 64.1 Reference: IQCS

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Finding 65: PLDO was wearing appropriate PPE for mission 65.1 Reference: HMGB statement

Finding 66: PLDO was wearing a seat belt and the required secondary restraint (gunner’s strap with tether) and had to free himself from both to egress the aircraft 66.1 Reference: PLDO statement; IAIG 2012

Finding 67: PLDO was seriously injured (sitting in rear right, forward facing seat) 67.1 Reference: NTSB Report

Finding 68: PLDO sustained additional burn injuries while walking through ground fire to find help 68.1 Reference: PLDO statement, MTDC Report

Finding 69: PLDO received second and third degree burn injuries on an estimated 13 to 22 percent of his body during his escape to the road 69.1 Reference: PLDO statement; MTDC PPE Report

Finding 70: PLDO’s PPE was “clean and serviceable before the incident” 70.1 Reference: PLDO statement; MTDC PPE Report

Finding 71: HMGB completed the manifest for the mission IAW agency requirements 71.1 Reference: HMGB statement; Manifest Weather Finding 72: A Pre-Mission/Weather Briefing was conducted prior to the flight 72.1 Reference: HMGB statement

Finding 73: Environment was unstable from the surface through 8,000 feet MSL, a sounding wind profile revealed the presence of low level wind shear between the surface and 1,000 feet MSL, with several layers of clear air turbulence from the surface through 10,000 feet. 73.1 Reference: NTSB Report

Finding 74: Local weather conditions did not pose a risk to the safety of the mission 74.1 Reference: Prescribed Burn crew statements; RAWS Weather readings; GPT weather report Emergency Response Finding 75: The Aircraft Mishap Response Plan was enacted by De Soto Dispatch 75.1 Reference: Dispatch Logs; Prescribed Fire crew statements

Finding 76: A second helicopter was launched to assist with location of wreckage 76.1 Reference: Dispatch Logs; Prescribed Fire Crew statements

Finding 77: Rx Burn Personnel responded immediately to report of incident within an incident 77.1 Reference: District FMO interview; Dispatch Logs

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Finding 78: RX Burn crew located helicopter approximately 20 minutes after suspected time of the accident 78.1 Reference: Dispatch Logs

Finding 79: RX Burn Personnel attempted to put out burning A/C with an extinguisher from a nearby dozer 79.1 Reference: Prescribed Fire Crew statements

Finding 80: Air Ambulance requested at 1500 and arrived on scene at 1554 but could not land at location 80.1 Reference: Dispatch Logs; 911 Logs

Finding 81: Air Ambulance landed to retrieve survivor at approx. 1557 from alternate landing location; 1 hour 18 minutes after accident occurred 81.1 Reference: Dispatch Logs; 911 Logs Mission Operations Finding 82: The Burn Plan was approved 82.1 Reference: Burn Plan

Finding 83: A Project Aviation Safety Plan was completed and approved for Aerial Ignition Operations for the Forest 83.1 Reference: PASP

Finding 84: Fire Shelters were onboard the aircraft and located in the cargo compartment 84.1 Reference: On-scene examination; HMGB statement

Finding 85: Flight Following was conducted through Dispatch 85.1 Reference: AFF; Dispatch logs

Finding 86: Risk Assessment template used for the PASP was not updated to reflect template found in current IHOG and 2012 IAIG (current at time of accident); Risk management matrix utilized was not current (used of matrix from 2004 IAIG); JHA not current (dated 1/26/14) 86.1 Reference: Job Risk Assessment in PASP; IHOG; 2012 IAIG

Finding 87: A Pre-Mission/Weather Briefing was conducted with the crew outlining mission events, requirements, and procedures prior to the flight 87.1 Reference: HMGB; Prescribed Fire Burn Boss statements

Finding 88: The required PSD Air Operations/Safety Go/No-Go Checklist was completed and signed by the PSD Operator, Pilot, Burn Boss and Helicopter Manager on day of accident 88.1 Reference: Go/No-Go checklist

Finding 89: Helitack Crew, Firing Boss and Burn Boss briefed the day’s missions and reviewed the burn plan which included completing the Prescribed Fire Go/No-Go checklist 89.1 Reference: HMGB Interview

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Finding 90: Plastic Sphere Dispenser was bench tested then installed in the aircraft following the installation procedures for a Bell 206 helicopter (IAIG Chapter III, pg. III-9) 90.1 Reference: HMGB interview

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Part II – Conditions that Supported Decisions and Actions Introduction As was mentioned in the introduction, the decision to burn Unit 1459 utilizing a helicopter is a major focus of this learning review (LR). Decisions and actions after that had little influence on the outcome. In fact, the NTSB’s probable cause statement concluded that, a “loss of engine power for reasons that could not be determined during the post-accident investigation due to post accident fire damage” (National Transportation Safety Board, 2016). The LR team assumes that burning Unit 1459 utilizing N50KH was perceived at the time as an acceptable risk because the decision was made to commit air and ground resources to implementing the burn. In the following section we will articulate the pertinent conditions that influenced that perception. The conditions are generally grouped into four focal areas: conditions relating to the value of the resource to be managed; the influence of prescribed fire targets; the selection of Unit 1459 and implementation of the burn; and risk management. Value of the Resources To understand the influence of the value of the resources we manage one needs to look no further than the Forest Service Mission Statement. The mission of the Forest Service is to sustain the health, diversity, and productivity of the Nation’s forests and grasslands to meet the needs of present and future generations. The mission of the Forest Service is guided by the fundamental principle of providing the greatest amount of good for the greatest amount of people in the long run and is characterized by the slogan: Caring for the Land and Serving People. We exist as an Agency to “sustain” the natural resources valued by the people we serve. Throughout the many fire dependent ecosystems we manage, sustaining those valued resources involves the use of prescribed fire. The need for prescribed fire treatment can and often does exceed the capacity to treat, depending upon a number of conditions. This potential shortfall necessitates the prioritization of the work to be done. The more valued some aspect of the ecosystem is in combination with the potential for that value to be degraded (risk to the value), the greater need there is to manage for it. In this way it is the values for which we manage that drive prioritization. The De Soto Ranger District developed a plan for prioritization of burn units based on four desired fire-return-interval classifications. These classifications range from “low” to “very high” and are based on desired fire-return-interval and management values. The high-value/high- return interval units are prioritized in the highest classification, and Unit 1459 was one such unit (see figure 11 on the next page; Unit 1459 is in the “Magenta” category even though it may look purple in the picture). As evidence of this classification, Unit 1459 has been burned at least 11 times in the past 35 years.26 The following section describes the values influencing the prioritization of treatment of Unit 1459.

26 Source: Personal communication with the district AFMO. Burned in: 2015, 2013, 2011, 2008, 2005, 2003, 1995, 1993, 1989, 1983, and 1980. “Our records are a little sketchy in the 80s and 90s, and we don’t have records past 1980.”

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Figure 18: Map depicting De Soto Ranger District prescribed-fire return-interval goals.

In 2014 the NF in MS revised its Land and Resource Management Plan (LRMP), which replaced the previous (1985) version. Throughout this section we rely heavily on the revised LRMP, as it is essentially a statement of what is valued on the NF in MS and identifies a plan for how best to manage for those values. The revision resulted from a multi-year planning process and collaboration with the public and other agencies, groups, and interested parties. The revised LRMP looks at the current state, desired state, and strategy for achieving the desired state on the 1.2 million acres “of diverse natural resources and valued public lands” administered by the NF in MS (LRMP, 2014, p. 1). In addition to the typical values driving land management such as

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timber, Wilderness, recreation, watershed health, etc., there is an “…emphasis on restoring native ecological systems and improving threatened and endangered species habitat as the primary focus of the revised plan” (LRMP, 2014, p. 7). The revision recognizes an aggressive prescribed fire program as “…an important tool for recreating historic fire regimes and reducing the risk of catastrophic fires” (emphasis added; LRMP, 2014, p. 143). The LRMP stresses that “…restoring fire regimes that favor desirable native ecosystems and improves or maintains habitats for threatened and endangered species is a high resource management priority” (emphasis added; LRMP, 2014, p. 144). Reduce Risk of Catastrophic Fire and Re-creation of Historic Fire Regimes Prescribed fire is part of a national strategy to “effectively reduce hazardous fuel loads and restore fire adapted ecosystems across the National Forest System” (USDA Forest Service Fire & Aviation Management, 2015). With a growing season that lasts from early March to mid- November,27 the NF in MS is an ideal climate for prodigious vegetative growth that if left undisturbed even for a short time will develop dense understory growth resulting in high fuel loadings. Fire occurring under these hazardous fuel conditions has the potential to be uncharacteristically intense, significantly altering vegetative composition, increasing mature tree mortality, and posing a threat to adjacent lands (LRMP, 2014, p. 35). The De Soto Ranger District, like other districts on the forest, is a highly fragmented patchwork of federal and non-federal land. Unit 1459 abuts private land on one whole side of the unit and partially surrounds a private inholding on another side. In recognition, the burn plan for Unit 1459 states as the first resource objective to “[r]educe hazardous fuel loading in order to protect National Forest and adjacent private lands from wildfires.”28 Rapid accumulation of uncharacteristically heavy fuel loads readily translates into an increased risk to adjacent lands and the local public. Re-creating historic fire regimes on the NF in MS and on the De Soto Ranger District with return intervals ranging from one-to-three years in the coastal ecosystems and one-to-six years in the more upland communities improves the system’s resilience as a whole. The relatively short fire- return intervals allow fire “to operate as close as possible to its historic, ecological role,” maintaining open woodlands with sparse mid-stories and understories dominated by grasses and forbs (LRMP, 2014, p. 35). Because of the prodigious vegetative growth rates, even a slight departure from the historic fire-return intervals significantly decreases ecosystem resilience and increases the difficulty of reintroducing fire. Burning Unit 1459 every one-to-two years supports the restoration and maintenance of fuels reduction and historic fire regimes. Restoration of Native Ecosystems While restoration of the full diversity of native ecosystems drives forest management on the NF in MS, the restoration of the Upland Longleaf Pine and Woodland (LLP) ecosystem is a national regional, forest, and district priority. The De Soto Ranger District is “one of 16 range-wide significant landscapes identified as a high priority for longleaf pine restoration” by the America’s Longleaf organization29 (National Forests in Mississippi, 2010). And the Nature Conservancy’s

27 Based on probability of freeze. Source: http://msucares.com/lawn/garden/vegetables/planting/map.html and http://msucares.com/crops/cotton/freeze.html. 28 Prescribed Fire Plan: Unit 1459. 29 Organization’s Web site: http://www.americaslongleaf.org

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East Gulf Coast Ecological Plan identifies the De Soto Ranger District “as a stage 1 priority site for ecosystem restoration based on high biodiversity, the high urgency of threat, some level of ecological intactness, and the potential of partnering to achieve conservation objectives” (National Forests in Mississippi, 2010). The LRMP (p. 12) states as an objective that the De Soto Ranger District is to restore and maintain most30 of its area as LLP. The Unit 1459 burn plan states that one of its objectives is to “…promote the fire dependent longleaf pine ecosystem…” These priorities are aligned with a broad agency and public interest in the restoration of these unique systems, valuing them “…as among the most species-rich terrestrial ecosystems in the temperate zone.” And unfortunately, these are “…among the most critically endangered ecosystems in the United States, now occupying < three percent of their original extent” (Brockway, Outcalt, Tomczak, & Johnson, 2005). Restoration of LLP is inextricably linked to the restoration of historic fire regimes mentioned above. Maintenance of both the LLP plantations and naturally occurring stands dominating Unit 1459 requires frequent (every one-to-two years) growing season burns to reduce woody vegetation in the understory and promote native herbaceous vegetation (LRMP, 2014, p. 44). Sites like Unit 1459 are very productive, and they change rapidly, quickly developing mid-story layers in the absence of frequent fire. Because of a very dense mid-story and a shrub-dominated understory, these sites can quickly accumulate potentially hazardous quantities of fuel” (Brockway et al., 2005, p. 21). As a result, missing even one prescribed fire rotation can degrade LLP ecosystem resilience and make reintroduction of fire more challenging.

The unit contains all but a small portion of the Little Florida Botanical Area.31 These botanical areas are generally good representatives of native ecological systems. The designation directs management efforts to “restore, maintain, and protect the unique botanical characteristics…” for which it has been designated to represent. In the case of Unit 1459, “…xeric sandhill community with longleaf pine forest, saw palmetto, and other characteristic species…” The Botanical Area designation adds yet another layer of emphasis to the value of restoring LLP ecosystems by maintaining the historic fire regime. Create Appropriate Habitat for Fire-dependent and Threatened and Endangered Species Forest Service Manual 2670.3 (2005) directs the agency to “[p]lace top priority on conservation and recovery of endangered, threatened, and proposed species and their habitats.” The 2014 LRMP (p. 29) supports this in stating, “Throughout the plan, threatened and endangered species protection and habitat enhancement are a priority.” The burn plan for Unit 1459 is aligned as well, stating as one of its objectives to “maintain and enhance threatened and endangered species habitat…” Unit 1459 supports threatened, endangered, and rare species. It is recognized as suitable habitat for the threatened gopher tortoise (Gopherus polyphemus) (see figure 19) and supports

30 74 percent. 31 Little Florida Botanical Area (De Soto Ranger District, De Soto National Forest, 121 acres): Little Florida contains the most extensive and highest quality xeric sandhill community with longleaf pine forest, saw palmetto, and other characteristic species remaining in Mississippi. Several plant species such as scarlet basil and littleleaf milkpea reach the western limits of their range at this site. The sand ridge is surrounded by more typical mesic longleaf forest and several drainages. This botanical area is a new designation established by this plan.

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well over 100 gopher tortoise burrows. It supports the endangered Louisiana quillwort (Isoetes louisianensis) (see figure 20) that has been documented on the unit. Unit 1459 contains a rare herbaceous seepage bogs and flats ecosystem where rare carnivorous pitcher plants are found.

Figure 19: Threatened Gopher tortoise (Gopherus polyphemus)32 and Figure 20: Endangered Louisiana quillwort (Isoetes louisianensis).33

Management for the gopher tortoise requires a fire-return interval of one-to-three years, as does the herbaceous seepage bogs and flats ecosystem. The Louisiana quillwort is an aquatic plant that requires the improvement of “…stream habitat, stream channel habitat, and watershed” (LRMP, 2014, p. 60). These realities necessitate the maintenance of a frequent, low- intensity fire regime, which is reflected in the frequency Unit 1459 is burned. Deviation from this quickly reduces system resilience. In the case of the gopher tortoise, “fire favors growth and reproduction of herbaceous gopher tortoise forage by maintaining an open-canopy structure, reducing woody plants and litter, and exposing mineral soil” (Innes, 2009). The “development of dense understory and mid-story oaks degrades habitat for gopher tortoises” (Innes, 2009). The Forest Service, in collaboration with the public it serves, has assigned a great deal of value to attributes of the ecosystems found on the NF in MS and on the De Soto Ranger District. These include the proximity of non-federal land; recreation; native LLP ecosystems; threatened, endangered, and rare species; and unique botanical characteristics. Unit 1459 was assigned the highest priority classification because of the increased risk to these valued attributes with even short lapses in treatment. These values were influential to the perception of those deciding to commit resources to burn Unit 1459.

32 Threatened Gopher tortoise (Gopherus polyphemus) Source: http://www.fs.fed.us/database/feis/animals/reptile/gopo/GOPO.pdf. 33 Endangered Louisiana quillwort (Isoetes louisianensis). Source: https://www.mnh.si.edu/exhibits/losing_paradise/IsoetesLouisianensis.html.

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Prescribed Fire-acre Targets The previous section illustrates how the espoused resource values influenced perceptions. However, these overt values are not the only ones with the potential to influence perception. The extent of influence annual fuels treatment acreage targets had on perception has been a persistent question throughout this LR process. The LR team asked the question early in the process, and the focus groups involved in the sensemaking phase also mentioned it. The participants interviewed by the LR team were insistent that they did not feel pressure to burn from the presence of, or the need to accomplish, annual targets. This appears inconsistent with the reliance on targets and accomplishments to determine success at the national level and the zeal with which this data is collected and maintained at the regional level, which is tied to funding at the forest and district levels. These numbers also contribute to national recognition of Region 8, the NF in MS, and the De Soto Ranger District in fuels treatment accomplishments and serve to highlight the importance of these prescribed fire programs. The following section attempts to explore the potential for these numbers to influence decisions regarding Unit 1459. Targets, Objectives, and Accomplishments Nationally, the fuels treatment program is tasked to “effectively reduce hazardous fuel loads and restore fire adapted ecosystems across the National Forest System (NFS)” (USDA Forest Service Fire and Aviation Management, 2015). In support of this task, the National Fire Use and Fuels Management Program sets annual targets. For 2015, the target was 2,145,000 acres. This includes all fuels reduction treatments, including non-merchantable vegetative thinning and prescribed burning.34 Failure to meet these targets “could result in the eventual loss of investment, damage to agency credibility over time, and compromising meeting stated objectives of effectively mitigating wildfire risk and restoring forest ecosystems” (USDA Forest Service Fire and Aviation Management, 2015).

In support of the 2015 national target, Region 8 established a fuels treatment35 target of 964,000 acres. Since 2009 Region 8 has accounted for an average of 53 percent of the national targeted fuels-treatment acres and is one of a few regions to consistently meet or exceed proposed annual targets. For prescribed fire specifically, Region 8 has contributed an overwhelming majority of the acres towards the national accomplishment, averaging 71 percent of the contribution over the past 10 years (see figure 12). Significantly, in 2012 Region 8 chose to stop setting specific prescribed fire targets for each of the forests in pursuit of the region-wide target because of the potential for those numbers to become conditions that inappropriately influence management decisions.

34 From “Completing the Job” of Hazardous Fuels Management & Forest Restoration.” A FAM Briefing Paper dated April 21, 2015. 35 Prescribed fire, mechanical treatment, herbicide, biological, etc. Source: (USDA Forest Service Fire and Aviation Management, 2015).

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Figure 21: Region 8 contribution to the national prescribed fire acres treated over the past 10 years.

In the absence of regionally prescribed targets, the NF in MS and associated districts decide upon their targets at the annual Burn Boss/Fire Management Officer meeting based on predicted capacity to implement needed treatment. Forest and district level documents cite a variety of factors such as weather, budget, available staff, policy changes, and smoke management as conditions that influence the determination of this capacity (LRMP, 2014, p. 71; Prioritization for De Soto Ranger District). But they do not call these numbers “targets;” rather they determine a reasonable range and call it high and low objectives for the year. Since 2010 the NF in MS has accomplished an average of 86 percent of the proposed objective with 84 percent for the De Soto Ranger District. For 2015, the NF in MS set a low objective of 137,000 acres and a high objective of 218,000 acres. The De Soto Ranger District set its low objective at 60,000 acres and high objective at 90,000 acres. Interestingly, the percent-accomplished figure is based off of the high objective, which begs the question, why have a low objective at all? The number of acres being phrased as an objective rather than target appears to reflect an organizational sensitivity to the pressures that targets can potentially exert. Despite this change in language there are still artifacts at the local level indicating that “targets” have some influence. The following quote from the 2015 Plastic Sphere Dispenser Aviation Safety Plan’s project description section states, “The De Soto Ranger District has an ongoing Aerial Ignition program for the purpose of safely and efficiently accomplishing prescribed fire targets”(emphasis added) (Boykin, 2015). In its 2010 proposal for inclusion into the Collaborative Forest Landscape Restoration Program (CFLRP) (National Forests in Mississippi, 2010) the De Soto Ranger District asked for matching funds averaging $2.3 million per year (2010-2019) to support the “acceleration” of ecosystem restoration, including the following: “maintaining existing longleaf ecosystems in good condition; re-establishing longleaf pine forests; and improving acres classified as ‘longleaf pine forest type’ through return of fire regimes and restoration of native understory plant communities.” The proposal suggests that with the addition of the CFLRP and other leveraged funding, 100,000 acres of treatment can be completed per year. The proposal further indicates

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that “Success will be measured by acres restored, acres of longleaf pine re-established, acres maintained, acres protected…” Since the De Soto Ranger District began receiving funding in 2012, it has fallen short of the proposed targets36 due to “unusually wet weather” and delayed funding allocations. Despite this situation, funding from the CFLRP has remained relatively consistent, albeit slightly below what was proposed. Despite linking the number of acres treated to potential funding, all of the participants we interviewed insisted that there was no pressure to meet targets or objectives. If they are not pressured to meet the targets/objectives, it appears neither are they held to them. As evidence of this, the 2014 revised LRMP for the NF in MS set a forest-wide objective for the next decade of between 180,000 and 250,000 (average is 220,000) acres of prescribed fire treatment annually and an objective of 84,000 acres for the De Soto Ranger District annually, but it qualifies these objectives with the following: Increases in the number of acres burned may be possible with favorable weather conditions, additional agency capacity, or opportunities for joint efforts with State programs. When these opportunities occur, our strategy is to take advantage of these occasions to accelerate37 ecosystem restoration and make improvements toward desired conditions (LRMP, 201, p. 71).

Figure 22: This graph shows De Soto burn acreage and targets since 2010.

The targets/objectives are based on anticipated conditions and capacity and are assumed to be less than what is needed, so if they can do more they will. “We always burn as much as we safely can, no more. We’ve never felt any pressure to produce targets…on the other hand, when conditions allowed, we greatly exceeded the target.”38 Nationally there is pressure to meet treatment targets, but Region 8, the NF in MS, and the De Soto Ranger District all make significant contributions to the fuels reduction program and consistently meet or exceed targets. In their words, “[t]he Southern Region has a proven track

36 Prescribed fire acres burned: In 2012: 50,612 acres. In 2013: 82, 929. And in 2014: 84,474. 37 This “accelerate” language is directly from the CFLRP reports. Demonstrating the importance of that program on land management planning. 38 Personal communication with De Soto AFMO.

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record for delivering a very efficient program of work with high integrity for producing results” (National Forests in Mississippi, 2011). The influence of having such a successful program is likely present but difficult to estimate. The decision at the regional level not to set targets for the forests may indicate a recognition that just the presence of these numbers, regardless of their meaning, are recognized as having the potential to pressure fire managers. The forest’s decision to use objective ranges instead of specific targets further supports the idea that numbers, especially single numbers, may inappropriately influence decision-making. Tying funding to the accomplishment of acres likely has influence although less so in the short-term as was demonstrated above. If the acres burned each year on the De Soto Ranger District become chronically deficient, CFLRP and associated leveraged funding may be affected, but as of yet there is no evidence of this. At the field level the intent is to use every chance to burn in an efficient manner, regardless of targets or objectives. With a nine-month growing season, impacts of missed treatment opportunities are readily apparent in the rapid accumulation of hazardous fuels, increasing risk to resource values. Getting behind is significant, especially considering the substantial investment of time and resources devoted to moving these lands into a more resilient state. Targets, objectives, and accomplishments are used because they are easily understood and communicable surrogates for the complex suit of conditions that exist on the ground. Because of this, it is likely these numbers have greater value for those further from the field and that their influence over decision-making at the field level is limited. It Is a Successful Burn Program, So It Must Be Valuable The prescribed burning program on the De Soto Ranger District is very successful. It is a major part of the region’s “very efficient program of work with high integrity for producing results.” Because of its success it attracts funding and committed personnel. As a result, efficiencies are leveraged, and capacity is increased. The question can be asked, is the De Soto Ranger District doing more prescribed fire because it can or is the activity meeting a real need? While government does have examples of units growing beyond their usefulness just to support the existence of the unit, the De Soto Ranger District burn program is not one. It is clear from the values articulated above and the pace of vegetative growth that the burn program’s capacity is in line with treatment needs. Still the pride in being a part of a high functioning unit will influence perception of values and that was likely at play here, but whether this influence had any detrimental effects on decision-making is inconclusive. Selection of Unit 1459 With an understanding of why the treatment of Unit 1459 was valued, this section will focus on those conditions that influenced the decision to burn Unit 1459 on March 30, 2015. This decision was the result of viewing the priority units to be treated against the organizational and environmental conditions on that day. When RXB2 and the DFMO arrived at work, the wind was out of the southwest and predicted to be predominantly west/southwesterly for the remainder of the day. The forecasts placed the temperature and relative humidity (RH) within regional and forest standard limits.39 They could burn, and they were going to have a westerly wind.

39 Prescribed Fire Plan: Unit 1459 Element 7 Section B.

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Of the many conditions influencing the choice of units, smoke impacts are among the most important. Smoke impacts to roads, community gatherings (e.g., church services), and to area residents sensitive to smoke can be significant given the relative proximity of all these things to the burn unit. In addition, a condition called “superfog” forms when smoke is entrapped locally and combines with water vapor to produce zero visibility smoke/fog” (Achtemeier, 2002). This condition can seriously affect traffic flow and safety on roads. A predicted westerly wind negated many potential units from consideration, but Unit 1459 was less than one mile to the east of State Highway 49. To burn this unit without driving smoke over the highway, a westerly wind was necessary. Beyond this point the prioritization and ultimate selection among the remaining options was a complex suite of conditions, involving years since last treatment; availability and location of personnel and equipment; availability of aerial resources; the number and size of prior burns still in monitor status, etc. The same values that led to the prioritization of Unit 1459 played a similar role in its ultimate selection. Here managers are, in theory, finding the most valuable unit with the greatest chance for successful treatment given the conditions that exist. On March 30, 2015, Unit 1459 was that unit. Implementation The decision to take this burn plan off the shelf and commit resources to it, including aviation, was one of a number of decisions and many factors, which led to the unintended outcome. Any operation involving fire involves some level of risk to implementation personnel, but it must be remembered that a decision resulting in the absence of fire may also involve a level of (higher) risk to personnel in the future. While it has been important to understand the conditions leading to the prioritization and selection of Unit 1459, it is critical to understand the conditions influencing the decision to expose personnel to hazards in pursuit of the values considered in the previous sections. The burn overhead team and many burn crew members had significant experience with the area and with this unit. RXB2 reported that he had burned this unit 10 or more times in his career. When a group of prescribed fire operators and program managers were convened to review the incident narrative and relevant documentation (Unit 1459 Burn Plan, Project Aviation Safety Plan, LRMP, etc.), they concluded that the decision and risk management processes were within agency standards and accepted professional practice. Through these processes hazards were mitigated, but risk remained for the air and ground crew. Utilizing N50KH The primary purpose for utilizing helicopters for aerial ignition in this region is to mitigate the exposure of ground resources to the hazards of hand-lighting units. For Unit 1459, like most units on the De Soto Ranger District, a combination of the vegetation, terrain, and fire behavior make hand-lighting units inefficient and hazardous. Flame lengths of greater than four feet combined with difficult walking conditions raise a red flag for a burn boss concerning firefighter safety. Plants such as palmetto (Serenoa repens), gallberry (Llex spp.), ti-ti (Cyrilla racemiflora), and smilax (Smilax spp.) when combined with needles from longleaf, slash, and Loblolly pines can create flame lengths in excess of 10 feet with as little as a two-to-three year accumulation of dead material. These species are also very difficult to traverse. Smilax vines can ensnare firefighters and drip torches and stop them in their tracks. This area also still has some large

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dead fuel concentrations as a result of Hurricane Katrina. In these areas people working in the woods may encounter downed timber that can stop heavy equipment from forward progress. Another walking hazard is the terrain. In addition to xeric and mesic sites, Unit 1459 has bottomland hardwoods along riparian areas and un-drained flatwoods containing pitcher plant bogs. These very wet features can be extremely difficult to traverse. This hazard is mitigated for nearly all40 the units burned on the De Soto Ranger District by keeping ignition personnel on or close to established control lines, which are typically dozer lines or roads. From these control lines they can light the unit’s exterior and easily access slop-overs and spot fires quickly if needed. While this risk is mitigated for the ground personnel, there is still a need to light the interior of the unit so the risk is transferred to the aviation personnel in a helicopter. This is important enough that it bears repeating. The risk is not truly mitigated; it is not gone from the system; rather it is transferred to the people in the helicopter. Efficiency As was stated above, Region 8 sees itself as having “a proven track record for delivering a very efficient program of work with high integrity for producing results” (emphasis added; National Forests in Mississippi, 2010). And “In many cases aerial ignition is considered the most efficient means of conducting a prescribed burn” (Boykin, 2015). The influence of aviation efficiency is likely significant. Simply put, the NF in MS or the De Soto Ranger District would not be able to treat the number of acres they do without the use of helicopters. It would take a lot more time to hand-light these units using a lot more people working at higher risk in the difficult interior of the burn. This, in combination with any pressure to meet targets and the palpable pressure to not fall behind the prodigious growing conditions, may very well have influenced perception. Control When utilizing aerial ignition the burn boss or firing boss can readily see the entire landscape being treated. From this position a qualified burn boss or firing boss can manage the intensity of the prescribed burn more effectively. The aerial ignition crew can watch changes in fire behavior on the ground and react accordingly by increasing or decreasing the spacing between ignition lines and ignition spheres. When ignition strips are run by ground crews that are traversing rough terrain with heavy fuel loads, oftentimes the strips can become too wide or too narrow, which can result in increased fire behavior. This situation not only endangers firefighters on the ground but may also damage the resources they are trying to manage. Limited terrain features and thick vegetation significantly reduce the efficacy of ground-based lookouts. Lookouts Limited terrain features and thick vegetation significantly reduce the efficacy of ground-based lookouts. Effective lookouts typically have to constantly move around the unit to maintain appropriate situational awareness. Aerial platforms are highly effective lookouts in this terrain and fuel type. They can provide real-time fire behavior updates and are also the primary detection method for spot fires during a prescribed burn. With the helicopter in the air, spot

40 80 percent according to an estimate from DFMO.

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fires are detected quickly and resources can be directed to manage them before they become well established, thus helping maintain control while reducing risk to ground personnel. Smoke Management Managing smoke is critical when conducting prescribed burns; typically smoke production is ideally limited to the afternoon period when smoke dispersion is at its peak and smoke can disperse in the prescribed direction under optimal conditions. Because smoke dispersion wanes during the early evening, ignition planning aims to have all ignitions completed prior to this time with only residual smoke remaining. This timing minimizes smoke settling onto transportation corridors or other sensitive areas in the evening. Aerial ignition expedites this process. More acres can be burned quickly; smoke can move up and away from the unit; and residual nighttime smoke can be limited. With Highway 49 just two miles to the west of the burn, getting the smoke up and out was important to a successful burn within Unit 1459. Risk Management Process Risk management is such a pervasive concept in our culture that it warrants consideration. Viewing strategic and operational environments through our current risk management lens influences perception. Agency leadership along with the wildland fire community has been promoting risk management as the appropriate paradigm for managing wildland fire (Stonesifer, Calkin, Thompson, & Kaiden, 2014). The 2015 Interagency Standards for Fire and Fire Aviation Operations manual contains foundational doctrine to guide the risk management process. The first doctrinal statement is as follows: 1. No resource or facility is worth the loss of human life; however, the wildland fire suppression environment is complex and possesses inherent hazards that can, even with reasonable mitigation, result in harm to fire fighters engaged in fire suppression operations. In recognition of this fact, we are committed to the aggressive management of risk (pp. 05-02). Risk management is defined as “the process whereby management decisions are made and actions taken concerning control of hazards and acceptance of remaining risk” (Federal Fire and Aviation Task Group, pp. 07-02). The control of hazards is a combination of hazard identification and hazard mitigation. The Control of Hazard The risk management processes the Forest Service and the greater wildland fire profession apply are highly influential to decisions and actions. They help establish accepted practices and norms and themselves are a manifestation of the community’s values and beliefs. The LR team used a focus group of peers with extensive prescribed burning backgrounds to assess whether the De Soto Ranger District’s risk management processes were within agency policy and accepted professional practice. After a thorough review of risk management documents and other artifacts,41 the focus group concluded that the risk management processes the De Soto Ranger District followed were within agency standards and accepted professional practice. In addition to the focus group the Aviation Technical Team (ATT) conducted a thorough analysis of

41 Documents that were reviewed include the following: National Environmental Policy Act (NEPA) documentation; the burn plan for Unit 1459 and others; complexity analysis, job hazard analysis (JHA), and the project aviation safety plan. The LR team also provided a narrative account and the local television station’s video footage of the briefing.

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the Agency processes the District used to inform the decision to conduct prescribed fire using aerial ignition. The table below (figure 23) summarizes their analysis. Activity Agency Policy, Protocols, Practices or Comments Procedures (and Reference) Project Planning De Soto Forest Land/Resource All documents required by (not including Management Plan (L/RMP) (RX Fire policy were in order and NEPA) Planning Guide, FSM 1920) signed by appropriate Fire Management Plan (FSM 5140). personnel. Modelling for fire effects and smoke The planning phases of this dispersion (National Forests in Mississippi project were in compliance GMR). with policy. Burn Plan (FSM 5140). PASP (IAIG, IHOG, FSM 5711.1). JHA (IAIG). Job Risk Analysis (IAIG). Mishap Response Plan (IHOG, NWCG PMS503, NAMSP). Communications Plan (PASP). Organization Chart (PASP). Aerial Ignition Pre-Plan Checklist (PASP). Pre-mission Go/No-Go checklist (PASP) Pre-mission briefs are Weather Report/Spot Weather Forecast tailored to cover site- (PASP – JHA & JRA; Burn Plan). specific conditions, Recon of units (in-flight brief – FIRB, PLDO, assignments, weather, Pilot) (IAIG, De Soto District Protocol). objectives, and anything Install and Bench Test of PSD Machine by critical to the success of PLDO IAIG). the mission for that day. Install of PSD QA checked by HMGB and The Pre-mission brief Pilot (IAIG). outline provide in the IAIG Pre-mission briefing discussing the risk is a guide for what to assessment and mitigations to include discuss, as the items Aviation Life Support Equipment (ALSE), suggested are not always emergency procedures, HOGE power relevant to every situation. required, and weight and balance, etc. The “accessibility of fire Communications – frequencies (IAIG) shelters” is not well- Pre-mission brief – weather, unit defined in policy. Many objectives, burn plan, communications, times the fires shelters will confirmed assignments (IAIG, Go/No-Go be placed in the cargo checklist) compartment so they are Fire shelters for all occupants must be on not “loose” inside the board and accessible. cockpit. Mission Use of Qualified Personnel (FIRB, PLDO) – Mission implementation Implementation (IHOG, IAIG) guidance is found primarily Aircraft carded (IHOG, IAIG) in the IHOG and IAIG. Pilot Carded (IHPPTS, IAIG) Most of the requirements Aircraft Pre-flight (FAR: 14 CFR 91.103) for fire extinguishers and

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Activity Agency Policy, Protocols, Practices or Comments Procedures (and Reference) Communications check – frequencies, crash rescue apply to the radio function (IAIG, PASP) helibase/helispot, which in Dry run of unit boundaries (to orient prior this case was located at the to burn - IAIG) Wiggins Airport. Provide crash rescue and evacuation The aircraft flight profile equipment at helibase/helispot (reference for the mission is IHOG). prescribed in the IAIG. See A 40-B:C rated fire extinguisher (reference Appendix 2, Mission IHOG) will be available on site. Analysis, for further The maximum, recommended helicopter discussion. speed should not exceed 50 mph during ignition operations. Slow the aircraft speed to the planned application speed when the firing operations are in progress. The recommended operational flight altitude is 300’ AGL. The PLDO shall wear an approved restraint in the helicopter, complete with approved tether and attached to an approved hard point during firing. Figure 23. Agency Procedures and Requirements for Project Planning and Implementation.

Decision making related to the aerial ignition mission was informed by numerous agency requirements and processes. Guidance for planning a PSD mission is provided in FSM 5700, the IHOG, and the IAIG. Each of these documents shapes the perception of safe operational boundaries for the mission within agency accepted practices. Information contained in manuals, handbooks, and guides identify what personnel are supposed to do (task), how they should be trained to do it (skills and competencies), and what equipment they need to use. Procedures that are followed during the planning process provide reinforcement and confidence that the mission is well planned and can be executed within a level of acceptable risk. Normalizing Risk Normalization of risk is a concept we are using to describe a tendency for individuals and organizations to incrementally accept greater amounts of risk in pursuit of efficacy and productivity. On the De Soto Ranger District and elsewhere, helicopter use is perceived as both highly effective and safer for ground personnel, so the question is whether additional risk was incrementally accepted in pursuit of higher levels of productivity. The concept of risk normalization is rooted in work by Dekker where he describes financial organizations drifting into failure by taking “small steps that increased risk, which took the organization away from previously accepted norms…to achieve local gains” (2013). The concept also draws from social psychology and the study of unconscious bias. Kahneman (2013) and others have demonstrated the surprising power of biases to influence perception of risk at both strategic and tactical scales. The process of normalizing risk is incremental and is a result of individuals and organizations adapting within complex systems, where adaptation is not merely beneficial but

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essential to success. When adaptations provide greater efficiency/productivity without causing harm (even though more risk may be accepted), the “successful” adaptation becomes the new normal from which people accept a little more risk. Over time without mediation, these adaptations will drift towards extracting ever-greater productivity out of finite resources, sometimes accepting incrementally greater risk as a trade-off. The regular use of helicopters for aerial ignition on the De Soto Ranger District is a very likely place to find this tendency at work; there are clear efficiencies and risk transference when helicopters are used and the rate of catastrophic failure is relatively low. Mediating this tendency requires reflection and deliberation, and determining whether and how much these practices were applied is difficult to assess after-the-fact because assessment requires a level of self-reflection that is obscured by the outcome. Judging by the processes, records, and interviews it appears the De Soto Ranger District—like many units—is superficially reflective and attempts to be deliberate in decision-making but falls easily into a pattern of productivity, especially in the midst of the burn season. Normalizing the “Low and Slow” Flight Profile Under the auspices of a safety management system, the safety activities are controlled by safety checks that are typically derived from risk assessment and mitigation processes. By accepting the limitations of the technology currently used, unintentionally we are also accepting a certain level of risk associated with that technology. Policy and procedures for PSD operations are centered on the capabilities and limitations of the PSD machine, rather than the safety of flight (see Figure 15). The PSD technology is at least 40+ years old, and there have been improvements in the equipment (PSD) to increase its reliability over time, but none of the improvements have been designed to increase the safety of the aircraft flight profile. The design improvements to the PSD machine were directly related to known issues that were well documented resulting in an engineering fix by the manufacturers of the PSD.

Figure 23: The influence of organizational processes on the mission.

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In the diagram above, it is clear how organizational processes influenced the acceptance of risk. As a result, risk assessments did not consider the flight profile, as it was already determined that low/slow was necessary in order to accomplish the work. The fact that the recommendations for airspeed and altitude were heavily influenced by the capability of the PSD likely influenced a gradual decay over time of the options and decision space for the pilot to maintain optimal combinations of airspeed and altitude. The fact that this is a successful tool available for conducting prescribed burn operations, sets the stage to “justify” its use, rather than to prompt the agency to look at better options or technology. The acknowledgement of these flight conditions (figure 15) in agency guides likely affects the deliberate acceptance of a “low and slow” profile as necessary for the accomplishment of the mission. A low/slow flight profile makes sense because it is suggested within written procedure. Over a period of time (4+ decades), confidence and acceptability of the flight parameters strengthens with each successful mission, along with a slight departure from the awareness of the hazards associated with the flight profiles. This is a demonstration of how the production goals creep into mission planning to dominate the protection goals without recognition of such. In this case, all required policy was followed (see figure 14) and personnel were conducting their work within the operational norms set up by agency policy and culture. This agency employs a highly competent workforce who understands that some missions pose a higher level of risk in order to accomplish the objectives. This workforce is also very confident in the equipment and in their abilities to carry out those missions. The Forest Service culture understands that risk cannot be completely eliminated and some risk (residual risk) must be assumed in all prescribed fire missions. Acknowledging this technology’s influence on the parameters of our flight profile is crucial. This insight provides compelling motives to question our assumptions about what is possible and acceptable. While options for moving away from the low-and-slow profile may begin with technological innovations to increase flight safety, the conversation must not end there. We must also explore questions that go beyond technological fixes to address our expectations of the desired outcomes. Can we accept a wider range of prescribed fire efficacy in exchange for a higher/faster flight profile regardless of technological innovation? The Acceptance of Remaining Risk Forest Service leadership directs that management decisions should be evaluated by balancing the likelihood of success of an activity and avoided natural and developed resource loss achieved by those activities against the type and amount of firefighter exposure to hazards (Stonesifer et al., 2014, p. 2; Tidwell, 2015). Despite this direction there exists considerable uncertainty in assessing the likelihood of treatment activities to be successful, the avoided losses to values, and the type and amount of exposure personnel face (Stonesifer et al., 2014). There have been recent attempts to meaningfully quantify the type and amount of exposure for both ground and aviation resources, (Stonesifer et al., 2014; Calkin, Phipps, Holmes, Rieck, & Thompson, 2011). In fact, from these studies one can determine a low resolution (general) statistical likelihood of a helicopter accident based on the 10-year average for helicopter accidents in the Forest Service and average number of flight hours per burn season on the district. The numbers indicate the De Soto Ranger District should expect a helicopter accident

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every 85 burning seasons; a fatal accident every 181 seasons; and a fatality every 60 seasons.42 These figures illustrate that while the risk is low, it is not zero; there remains risk. The same quantitative measure is not available for objectively measuring the avoided loss (reduction of risk) to the resource value. This report illustrates the substantial value placed on the resources contained within Unit 1459. These values are only tangentially represented by the commitment of millions of dollars annually43 to the restoration and maintenance of resources on the De Soto Ranger District alone. Qualitative judgments of value such as “highly valued,” “management priority,” and “primary focus” indicate value but are highly subjective. Beyond the values specific to Unit 1459 is the value in contributing to treatment targets, objectives, and accomplishments for the forest, region, and nation. An argument could be made that there was an inaccurate perception of the risks or the values or that condition(s) were distorting the perception of what was necessary and acceptable. Unfortunately any assessment of this is conjecture because objective evaluation remains elusive and may be unknowable. Through an aggressive risk management process that was judged to be within the bounds of accepted professional practice and agency standards, risk was mitigated and transferred, but risk still remained. The remaining risks varied significantly from minor to fatal and defied quantitative estimation in all but the aviation-accident rate, which only allowed for a very crude representation of risk probability. Conclusion The DFMO and RXB2 in charge when this incident happened possessed 60 years of combined experience during which they had accomplished roughly one million acres of burning in this fuel type. Everything these individuals did the morning before the accident was routine: getting to work and analyzing the day’s tasks, weather, predicted smoke impacts, prescription, resources, and so forth. Through these activities, they decided on burning Unit 1459. The above conditions influencing decisions and actions do not represent a complete list but are a thorough examination of the complex suite of environmental and organizational conditions influencing perception of the values and risks. Understanding the influence of these conditions is powerful because while this event might be unique in time and space, the conditions that influenced perceptions, decisions, and actions are not. In the next section we will attempt to make sense of these conditions through a combination of the focus groups’ feedback and relevant academic theory.

42 Assumptions: 260 flight hours/season (from personal communication with regional aviation personnel. Number averaged from past year’s contractor records), 4.54 accidents/100,000 flight hours, 2.12 fatality accidents/100,000 flight hours and 6.36 fatalities per 100,000 flight hours. These accident rates are for all helicopter use throughout the Forest Service, both fire and non-fire. (USDA Forest Service, 2013). 43 Agency budget allocations, CLFRP, and associated leveraged funds.

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Part III – Sensemaking Introduction After an extensive review of the decision to burn Unit 1459 and the conditions influencing the decision, we argue that the risk management and decision making processes employed by the De Soto were within Agency standards and accepted professional practice. Therefore, to make sense of this incident we must look beyond adherence to a process and to the process itself. Doing so should allow for novel perspectives and dialogue around adjustments to the current systems to improve risk management processes and structure, ones that include the recognition of conditions such as normalization of risk, the pressure to maintain an efficient program and meet targets/objectives, the subjective and uncertain nature of risk to personnel and resource values, etc. Viewing this event through some relevant academic theories may uncover ways of learning that include adjustments to the system and enable us as individuals and the organization to question assumptions, routines, and scripts and recognize the importance of cultivating effective relationships. These new ways of learning may be exponentially more valuable. Central to these new ways of learning are concepts derived from complexity science relating to organizations that exhibit characteristics of Complex Adaptive Systems (CAS). These systems not only contain uncertainty; they are characterized by uncertainty, meaning it is an identifying trait of the system and is irreducible. Uncertainty in our wildland fire and Forest Service system cannot be eliminated.

If we could always predict what the system would deliver, we could confidently rely on our routine behavior and traditional risk management processes to achieve desired results, but because CAS are characterized by uncertainty, routines and processes give us a false sense of security. Instead we must constantly reflect on whether our current assumptions, routines, and scripts are valid in the current context. Reflection helps us learn about the system anew, as it is now. This level of reflection and inquiry is a social act (Schein, 2013) and depends on effective relationships because “it is the quality of the interrelationships—not simply the quality of each element—that gives a system its resilience” (McDaniel, Jordan, Thomas, & Lanham, 2015). In this section we explore key aspects of the De Soto aviation incident that surfaced during the focus groups through the lens of relevant academic theories to access new ways to approach learning in our organization: learning that emphasizes the presence of irreducible uncertainty inherent within our system of work, the necessity of challenging routines and assumptions about how work is done, the power of genuine curiosity, effective relationships, and individual and organizational reflection. Irreducible Uncertainty There are aspects of our work environment that are definite and knowable, such as the number of resources on a fire, the chain of command, etc., but there are also many aspects of the environment we do not and cannot know, regardless of how much information we could gather. Importantly, much of this uncertainty is associated with predicting future events and conditions, and again it is not a matter of just getting more information because some things will never be able to be predicted or known. Uncertainty has multiple forms and origins. Broadly speaking, there are two general types of uncertainty. There is environmental uncertainty, such as the

Page 51 of 89 De Soto Aviation Incident Learning Review – Accident behavior of wind at a local level—climate forecasting falls into this type. Because of the number of variables and their unpredictable interactions, it is unknowable and therefore uncertain. There is also subjective uncertainty—such as the uncertainty surrounding a new professional or personal partnership. Again because of the number and interdependencies of the variables, the outcome is unknowable, but in this case the variables involve subjective valuation and perception. The current risk management processes mitigate known hazards to reduce overall risk and by- in-large do not account for these uncertainties, or if they do, treat them as the same as known risk. Additionally, our risk management processes fail to account for the complexity and resultant uncertainty when considering multiple-risk situations. It is very difficult to look at the intersection of risk situations, so we typically treat them one at a time in a linear fashion. For example, the risk of flying a helicopter is separated from the risk of igniting the burn. Of course, in the actual situation, the two interact in a non-linear fashion—they in fact intersect. For simplicity and manageability our current risk management process doesn’t differentiate between subjective and environmental uncertainty and treats risk situations as independent variables, or at best as simply additive. As a result, the discussion of interdependent risk situations are separated in time and space, and the unknowability of the situations are left out of the risk management process. This is a systemic/organizational challenge, not readily perceived at the unit level. It is therefore something that needs to be addressed first at the strategic level. Challenging Routines and Assumptions Operating in a CAS requires a continuously improved capacity to understand risk and uncertainty in the system in which the Forest Service operates, including questioning assumptions about how and why things are done the way they are (routines, scripts, etc.). The current risk mitigation process has evolved, whether intentionally or unintentionally, into an efficient routine of checking boxes, following lists, and adhering to scripted routines (Heaton, 2015). These routines do reduce risk by recognizing and mitigating common and known hazards. However, our scripts and routines constrain our ability to

Page 52 of 89 De Soto Aviation Incident Learning Review – Accident recognize and react to uncertainty in the system and question the assumptions underpinning the accepted routines and habits. Once things get routine, it is difficult to make sense of them as dangerous (McDaniel R. J., 2015). Joe’s question is indicative of the questions we need to ask about all of our routines. Reviewing this LR brought out previously unasked questions regarding routine assumptions and routines. What if this question was globally asked prior to taking action on any situation? Our current approach seems to assume that each fire is the same. Individually we recognize that each fire is different from the next; however, our entrenched routines and scripts provide a sense of comfort and control (Heaton, 2015). Questioning the assumptions and routines beyond what the current risk management process enables is critical to improving our capability to incorporate the high levels of uncertainty characteristic of CAS into our decision-making. The above example is what questioning assumptions and routines looks like; the question is how to provoke this kind of curiosity more broadly in our organization. Genuine Curiosity At some point during each focus group session, as exemplified by Joe’s conversation, the question was asked whether the use of a helicopter to burn Unit 1459 resulted from a deliberate decision or a default reaction based on the availability and comfort with helicopters. Determining whether it was a deliberate or default decision is problematic. On the one hand, it is impossible to objectively evaluate and on the other, cognitive (decision-making) science tells us that any decision we make is neither wholly deliberate nor default (intuitive); all decisions fall in the fuzzy space between these two extremes. In addition, research strongly indicates that when we make repetitive decisions, such as whether to use aerial ignition support for prescribed burning operations, over time similar scenarios produce fewer deliberate and more intuitive decisions (Kahneman, 2013, p. 62) (Zajonc, 2001). While evaluating how deliberate a decision was after-the-fact is problematic, recognizing its influence on decision-making beforehand is of great value. This is the power of Joe’s dialogue with his fire staff; it establishes an expectation for deliberate decision-making that challenges what is normally done, regardless of how often these decisions get made. Deliberate decision-making requires genuine curiosity. If we believe we already know the outcome there is no need for inquiry and the routine response that has worked in the past will do just fine. As this incident illustrates, many aspects of normal operations are not certain and we must direct attention to developing ways to constantly question the assumptions that underpin our routines and to be genuinely curious. Need for Conversation Genuine curiosity can be an outcome of deliberate conversations. Deliberate conversations can also trigger socially distributed cognition, which enhances sensemaking, learning, and improvising. Having conversations that challenge the accepted procedures and practices need to become the norm.

Page 53 of 89 De Soto Aviation Incident Learning Review – Accident Conversations that are used to identify uncertainties in the system are also needed. It should never be assumed that there are no uncertainties. The very dynamics of CAS assures us that there will be uncertainties. In the recognition of the existence of uncertainty, there is the recognition of the need to converse about it; if all aspects of the environment were ultimately knowable we could assume that once a path was set based on that knowing it could be left unchecked and unchanged and still provide expected results, but the existence of uncertainty necessitates the constant interaction, conversation, and renegotiation in order to foster expected outcomes. The most important part of Joe’s conversation is not that it happened but that it set the stage for it to happen again and again. Therefore, a key strategy for navigating the uncertainties in a complex adaptive system is to develop good relationships and use these to engage in sensemaking, learning, and improvising. These relationships are the foundations for fostering vital conversations that could go a long way in improving already robust sensemaking capacity that exists on the De Soto and elsewhere and reduce the individualistic behavior that surrounds activities in the wildland fire organization as a whole. Individual and Organizational Reflection Normalizing risk is a normal human quality—when we are exposed to repeated risk. Doing so requires a reduction or absence of reflection or reflection that is superficial. Because the normalizing process happens in a series of adaptations, all seemingly beneficial, effective reflection must extend beyond what is currently seen as accepted or normal work. Deeper reflection that questions key underlying values, beliefs, and assumptions may be necessary to catch the slow and incremental drift. Accessing the level of reflection necessary to counter the effects of risk normalization requires a capacity for self-insight that questions what is accepted as normal. Defining what normal is exists both as an individual act and a social one. As was suggested above in reference to acceptable risk, individual perceptions of risk or what constitutes normal work vary considerably, but in addition there exists an evolving set of “basic assumptions that a given group has invented, discovered, or developed” (Schein, Coming to a New Awareness of Organizational Culture, 1984) to maintain the group’s coherence and respond to the external environment. These basic assumptions are the foundation of an organization’s culture. So while individual reflection is warranted–even encouraged—social- cultural reflection is necessary to mediate cultural normalization of risk, and that requires effective interrelationships among individuals.

Page 54 of 89 De Soto Aviation Incident Learning Review – Accident As a Forest Service and wildland fire culture we have (and continue to) normalized the use of helicopters. They are efficient, and the rate of catastrophic failure is relatively low. The challenge is to find ways to, individually and through our relationships, question the assumptions that support what is considered normal operations. The difficulty of this challenge cannot be understated. The norms established by the culture have solved problems; it’s what makes us “successful;” we are getting the job done. Questioning assumptions means questioning what makes us successful, and that is not often well received. Again this is why the strength of relationships is so vitally important. Because of the uncertainty surrounding the effect of any given interaction or relationship, it is important to cultivate our ability to effectively interact and maintain relationships that enable us to reflect on what we culturally accept as normal. Effective Relationships In his 2015 Letter of Intent for Fire Management, the Chief of the USDA Forest Service (Chief) provided eight “fundamental principles we continue to embrace for success.” Five of the eight relate to safety and/or risk management and two in particular are helpful in framing the concept of acceptable risk. Principle number three states, “We assess, analyze, communicate, and share risk before, during, and after incidents.” Principle number four states, “We do not accept unnecessary risk or transfer it to our partners or future generations” (Tidwell, 2015). Together these principles communicate leadership’s intent to the field that risk is to be understood, communicated, and shared within the community of stakeholders. Our past experience with risk management has demonstrated an inability to objectively measure or quantify risk. This has been a stumbling block. Our most current model of risk management is the identification of known hazards and the development of “mitigations,” which are designed to reduce exposure. Once mitigations are created, there is a sense of relief, which generally leads to an acceptance of the remaining risk, often without additional inquiry or questioning. This is not to suggest that we are callus risk takers; more likely is that our organizational culture and our system, as designed, does not provide or support ways to communicate risk valuation and it may be that because of the uncertainty that characterizes our operational environment, the measure of risk may be unknowable. The most important aspect of meeting the Chief’s intent may not be the measurement of risk but instead the development of organizational and cultural support for the recognition and communication of uncertainty, where uncertainty is the recognition that we may not be able to measure or know all the risks in any given situation. What is most important in the assessment of whether to accept the remaining risk is NOT the decision but the relationships that enable the discussion to happen continually as perception and the environment change, understanding that uncertainty will never allow an objective measure of risk.

Page 55 of 89 De Soto Aviation Incident Learning Review – Accident Take, for example, a conversation between an agency administrator and a unit leader or a crew boss and a sawyer. Because of their individual propensities for taking risk, perception of reward, accident potential, and sense of severity (Adams, 1995) and the inherent uncertainty in the environment, their individual perceptions of the hazards, risks, and values will never perfectly align. Successful risk management must therefore be redefined to focus on the relationships that work to align divergent perceptions of risk and value with the understanding that objective measure and absolute alignment are likely unknowable and unachievable. Our culture and our leadership focus on the outcome of risk management (level of acceptable risk) whereas CAS theory and others focus on the process of sensemaking (McDaniel, Jordan, Thomas, & Lanham, 2015) and the relationships that encourage the constant renegotiation of what is acceptable. A shift in the language of leadership’s intent could reflect this new way of learning from “We only accept necessary risk…” to “We cultivate relationships that encourage the constant renegotiation of success.” Conclusion This Learning Review revealed limitations in how the wildland fire community as a whole learns, makes sense of our environment, and improvises in the face of uncertainty. These revelations, while inspired by the De Soto aviation incident, are not isolated to the De Soto. In fact, the De Soto Ranger District and the NF in MS have committed considerable time and resources in support of effective relationships and sensemaking. However, it is the opinion of the LR team that the wildland fire community, including the De Soto, need to integrate uncertainty into the evolution of our risk management paradigm. A new risk management paradigm enables individuals and the organization to engage in deliberative inquiry and reflection to challenge cultural routines and assumptions, all of which is dependent upon the cultivation of effective relationships. Cultivating effective relationships underpins all other means of aligning our risk management paradigm with the complexity of our system. Success in such systems requires adaptation and improvisation to novel circumstances. Effective relationships provide access to reservoirs of adaptive capacity through an ability to constantly re-assess and renegotiate the system, our position in it, and what success looks like. Renegotiating the balance of values at risk with the risk to personnel is just one outcome of working within effective relationships, and in our operational environment where this balance is elusive, subjective, and constantly changing, this process provides a meaningful solution to meeting agency leadership’s intention to only accept necessary risk. Therefore, effective relationships must be central to any attempt at fostering new ways of understanding risk management.

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The Safety Action Plan represents the integration of the Learning Review Team’s sensemaking effort, the Aviation Technical Team’s review of the incident and from information gained from the lessons learned from those directly involved (Appendix B). This section represents the formal recommendations to the Agency. Deliberate Discussions that Challenge the Norm Responsible Due Date Topic Party Rocky Learning Life First Initiative Mountain products from The Life First Initiative did not exist when the De Soto Research this effort incident happened, nor did it during a major portion of Station (RMRS) should be the time the De Soto Learning Review was being written, Innovation and ready by July but when the sensemaking from the LR and the intent of Organizational 15, 2017. the Life First Initiative are compared, striking similarities Learning (IOL) emerge. Research, The Life First initiative’s artifacts such as Stop, Think, Development, Talk…Then Act focus on the conversation and have & Application captured the same ideas of deliberative inquiry, (RD&A). uncertainty, dialogue, risk, and relationships the LR has brought forward and have done so in very simple and actionable ways that appear to be having a desirable impact. The action recommended for the De Soto LR is to keep moving forward with the Life First Initiative, specifically:

 Review positive outcomes/normal work to capture how Life First is being implemented in the field. o These reviews should be compiled, made sense of as a whole, and made readily available to the field, thus ensuring the conversation between leadership and the field is sustained. Fire and Convene De Soto Sensemaking Session Aviation meeting by Because of the focus on dialogue, the LR team in Management January 28, coordination with the National Fire Use and Fuels (FAM); IOL 2017. Management office wishes to bring together members RD&A. Have RT-300 of the fire use and prescribed fire communities to Refresher discuss the implications of the De Soto incident, the LR, Module ready and the Life First Initiative as they relate to fire used to for review by meet management objectives and prescribed fire. The March 3, sensemaking from this gathering can be used to produce 2017. content for the RT-300 (Burnboss Refresher).

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Administrative Response to Unplanned Events Responsible Due Date Topic Party FAM. Region 8 Job Revision of the Agency Administrator’s Guide to Critical Aid reviewed Incident Management and vetted for The Agency Administrator’s Guide to Critical Incident national Management needs to be modified so that it can guide adoption by agency administrators through the stressful minutes, March 15, hours, and days immediately following a tragic event. 2017. Concise quick reference material organized in a logical and meaningful way to provide relevant information at the appropriate times is needed. Region 8 has developed the R8 Unplanned Event Job Aid, which should be used as a template for national adoption. Planning and Pre-Season Preparedness Discussions with Emergency Response Partners Responsible Due Date Topic Party FAM, Incorporate into Encourage the incorporation of Emergency Responder appropriate Partners in Emergency Response Planning and Pre- planning guides Season Preparedness Discussions. and checklists The De Soto RD recognized the importance of by June 30, including local emergency response and life flight 2017. operations into planning, pre-season readiness discussions, and scenario-based training. Inclusion enables the identification of many common challenges that occur when involving these resources on an incident-within-an-incident (such as communication, ICS protocol, etc.). The LR team recommends the incorporation of emergency response partners in pre-season emergency response preparedness planning and training scenarios.

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Aircraft Performance and Mission Profile Responsible Due Date Topic Party FAM. Convene meeting Working Group to Explore New Aerial Ignition by February 28, Technology 2017. Assemble a working group to explore technology to improve aerial ignition devices, equipment, and/or delivery systems to enhance mission safety. The intent of this Safety Action Item is to look for short- term improvements to the current system of aerial ignition. Evaluate equipment including but not limited to mounting devices and personal protective equipment. Assess the survivability of crash positions when PSD machine is installed in the aircraft. FAM, in Convene a New Technology to Accomplish Aerial Ignition partnership working group by Join the following groups to explore new technology with January 17, 2017. to accomplish aerial ignition: Leadership, Operations, Unmanned Initial report of Research and Development, and Safety. The intent Aircraft working group of this Safety Action Item is a long-term exploration Systems (UAS) intent and of aerial ignitions systems beyond what is currently Steering direction to be used/available. Committee and completed by Missoula September 2017. Technology and Development Center (MTDC). FAM. Begin by January Aircraft Features 31, 2017. Working Assemble a working group to explore options for group improved aircraft features that enhance crash recommendations worthiness, performance, etc. Evaluate contracting for contract for new aircraft engine technology such as FADEC. guidance to be completed by September 15, 2017. FAM. Distribute Hover Out of Ground Effect Power Check technical/safety Incorporate a Hover Out of Ground Effect (HOGE) bulletin by power check requirement from the Interagency November 30, Helicopter Pilot Practical Test Standards (IHPPTS) 2016. Update into the Interagency Helicopter Operations Guide IHOG by April 30, (IHOG). 2017.

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Responsible Due Date Topic Party FAM. Begin by January Explore Altitude and Airspeed Combinations for 31, 2017. PSD Missions Assemble a group of subject-matter experts to explore appropriate and effective altitude/airspeed combinations during PSD operations. The group must challenge accepted practices and traditional fixes such as those proposed in the 2005 Sabine helicopter incident report (see appendix F). a. Replace current language in the Interagency Aerial Ignition Guide (IAIG) to redefine mission parameters and foster a culture that continually seeks to achieve a safer mission profile. Complete by September 1, 2017. b. Include a flight safety component to the IAIG or Interagency Helicopter Operations Guide (IHOG) that provides consideration to safe operating airspeed and altitude combinations for aerial ignition operations or other missions conducted within or near the shaded portion of the HV curve. Complete by November 15, 2017.

Aircraft Crew Safety Equipment Responsible Due Date Topic Party FAM; Begin by March Fire Shelter Access Acquisition 31, 2017. Assemble a working group to explore options to make Management Complete by fire shelters within the aircraft cabin wearable. (AQM); and December 31, MTDC. 2017.

Aerial Ignition Mission Preparation Responsible Due Date Topic Party FAM. Convene Aerial Ignition Risk Assessment meeting by Update and implement the aerial ignition strategic risk December 31, assessment. (Reference the Programmatic Risk 2016. Assessment and Quality Assurance Evaluation for Aerial Complete by Ignition Using the Plastic Sphere Dispenser, Final Report, June 30, 2017. April 5, 2010.)

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Responsible Due Date Topic Party FAM. Begin by Streamline Risk Management Process January 31, Integrate existing risk management tools to create a 2017. streamlined risk management process. Complete by July 31, 2017.

Aviation Record Keeping Responsible Due Date Topic Party FAM; AQM. Begin by Fuel Truck October 31, Because the FAA released the fuel truck back to the 2016. Complete company before the Forest Service investigation team by December could review fuel sample logs (per contract), review 31, 2016. the National Master Contract Specifications for helicopter use (Section C-18, Mishaps, Paragraph C, Wreckage Preservation) to ensure the fuel truck is specified as “aircraft equipment.” Aircraft Incident Response Responsible Due Date Topic Party FAM; MTDC; Complete by Real-Time Aircraft Tracking and AQM. September 30, Assemble a working group to explore real-time options 2017. for aircraft flight tracking systems. Develop recommendations for change (or not) to Agency standards for Flight Following. FAM. Report due by Robust Emergency Response June 30, 2017. Develop a needs assessment based on our current capacity and desired appropriate capacity for basic aircraft crash rescue response.

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McDaniel, R., Jordan, M., Thomas, J., & Lanham, H. (2015). Organizational Adapation to Discontinuity. Unpublished. National Forests in Mississippi. (2010, April). Collaborative Forest Landscape Restoration Program (CFLRP): PROPOSAL. Retrieved July 10, 2015, from De Soto RD CFLRP Landscape Restoration Page: http://www.fs.fed.us/restoration/documents/cflrp/2011Proposals/Region8/NF Mississippi/DeSotoRangerDistrictCFLRPProposalFY2011.docx National Forests of Mississippi. (2014). Land and resource Management Plan. Jackson: USDA FOrest Service, National Forests of Mississippi. National Transportation Safety Board. (2016). Factual Report: ERA15FA173. Washington, DC: NTSB. Retrieved from http://dms.ntsb.gov/pubdms/search/hitlist.cfm?docketID=58669&CurrentPage= 1&EndRow=15&StartRow=1&order=1&sort=0&TXTSEARCHT= National Transportation Safety Board. (2016). Statement of Probable Cause: ERA15FA173. Washington, DC: NTSB. Retrieved 06 23, 2016, from http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150330X73700 &key=1&queryId=ac3c8bb9-d75f-4966-8936- 4e021f69354b&pgno=1&pgsize=100 National Transportation Safety Board. (2016). Statement of Probable Cause: ERA15FA173. Washington, DC: NTSB. Retrieved June 23, 2016, from http://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20150330X73700 &key=1&queryId=ac3c8bb9-d75f-4966-8936- 4e021f69354b&pgno=1&pgsize=100 National Wildfire Coordinating Group. (2012, July 25). Interagency Aerial Ignition Guide PMS 501. Boise, ID: Technology Branch, National Interagency Aviation Group, National Interagency Fire Center. Retrieved from Technology Branch, National Interaagecy Aviation Comittee, National Interagency Fire Center. National Wildfire Coordinating Group. (2013). Interagency Helicopter Operations Guide. Boise, ID: Equiptment and Techniology Branch, National Interagrncy Aviation Committee, National Interagency Fire Center . National Wildfire Coordinating Group. (2014). Interagency Prescribed Fire Planning and Implementation Procedures Guide PMS 484. Boise, ID: NWCG Fuels Management Committee, National Interagency Fire Center. National Wildfire Coordinating Group. (2015). Interagency Aerial Ignition GuideNation. Boise, ID: Technology Branch, National Interagency Aviation Group, National Interagency Fire Center. Schein, E. H. (1984). Coming to a New Awareness of Organizational Culture. Sloan Management Review, 25(2), 3-16. Schein, E. H. (2013). Humble Inquiry: The Art of Asking Instead of Telling. San Francisco: Barrett-Koehler Publishers. Stonesifer, C. S., Calkin, D. E., Thompson, M. P., & and Kaiden, J. D. (2014). Developing an Aviation Exposure Index to Inform Risk-Based Fire Management Decisions. Journal of Forestry, 1-10.

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Tidwell, T. (2015). Chief's Letter of Intent - 2015 Fire Management. Washington Office. Washington, DC: USDA Forest Service Washington Office. USDA Forest Service. (2005). Forest Service Manual 2670.3 - Policy 2670.31 - Threatened and Endangered Species. USDA, Forest Service. USDA Forest Service. USDA Forest Service. (2013). US Forest Service Aviation Safety Management Systems. Retrieved July 9, 2015, from USDA Forest Service Fire & Avaition Management: http://www.fs.fed.us/fire/av_safety/assurance/fy_safety_reports/FY2013_Sum mary.pdf USDA Forest Service Fire & Aviation Management. (2015). Completing the Job” of Hazardous Fuels Management & Forest Restoration. Boise: Fire Use and Fuels Management Program. Zajonc, R. B. (2001). Mere Exposure: A Gateway to the Subliminal. Current Directions in Social Science, 224-228.

Acknowledgements Learning Review Team Coordinated Response Protocol (CRP) Team Leader – Heather Provencio Learning Review (LR) Team Lead – Matt Carroll Regional Prescribed Fire Subject Matter Expert – Jon Wallace CRP/LR Process Coach – Ivan Pupulidy Writer/Editor – Gwen Ernst-Ulrich Review Participants Special thanks to the NF in MS De Soto Ranger District and affiliated units and numerous focus group members throughout the Forest Service.

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Appendices Appendix A – March 30, 2015 Unit 1459 Area Map

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Appendix B –Lessons Learned from Those Involved

The LR team worked closely with the De Soto Ranger District and NF in MS to develop this section. The voice of those directly involved and affected by this incident are evident and important. Their first-hand knowledge of the incident and the context of the locale were vital to clarity and utility of this section. The information in this section does not represent the formal recommendations of this Learning Review. Rather it should be interpreted as a communication between those directly involved and the wider fire, fuels, and aviation communities about the lessons they took away from this incident and actions they have proposed. Some of the items in this section have been highlighted in the Safety Action Plan (SAP), which does represent the formal recommendations of the Learning Review and/or are described in more detail in the Aircraft Safety Investigation Report (SIR). B.1 - Preparing for the Prescribed Burning Season and the Unexpected District Preparation In preparation for the prescribed burning season, the De Soto District Ranger and DFMO had recently reviewed and updated the “Agency Administrator’s Guide to Critical Incident Management,” which includes good information and things to think about before anything happens.  Each unit should ensure key individuals review and update this document annually.  Guide information should be updated to better account for social media and almost instantaneous news coverage to help people at least have these potential challenges on their radar.  While the document was useful after the incident, those involved in this incident did not find the “during” part helpful because everything was happening at a pace that required quick, almost reflex-like decisions. Additionally, some of these actions may be happening through local law enforcement or the fire chief and thus outside of Forest Service control. That being said, reading the guide ahead of time could help recall information in the guide to support decisions.  The Agency Administrator’s Guide to Critical Incident Management needs to be modified so that it can guide agency administrators through the stressful minutes, hours, and days immediately following a tragic event. Concise quick reference material organized in a logical and meaningful way to provide relevant information at the appropriate times is needed. Guide information should account for social media and almost instantaneous news coverage to help people have these potential challenges on their radar.  Region 8 has developed the R8 Unplanned Event Job Aid. (This recommendation was brought forward to the Safety Action Plan) First Response Plans, Contingency Plans, Project Aviation Safety Plans, Aviation Risk Assessments, Helibase Plans, Job Hazard Analysis, Go/No-Go Checklists, and any other plans are all useful prior to a crash and for those involved away from the accident scene. Every aviation accident will have different circumstances that a plan cannot cover. Also, those on-scene may all react differently than expected when a truly horrific accident occurs. The following preparation may help.

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 A one-page reminder/check list/contingency plan can be added to the regular incident organizer or fire report, so all ICs have immediate access to a quick emergency reference.  All emergency-response training helps. In particular, the “L” courses utilize unusual and unfamiliar scenarios to stress students and develop reactions and instincts.  Local 9-1-1 office representatives could make a presentation at a firefighter refresher or district safety meeting. The presentation could include a list of information that will be needed and how the 9-1-1 office uses it along with 9-1-1 dispatch procedures.  During the annual district safety meeting, presenters could explain a simple and standard way to communicate coordinates and emphasize that in the event of an emergency, radio frequencies and phone lines should be clear other than emergency traffic.  Various people on the unit should write aviation mishap response plans and Project Aviation Safety Plans. Thinking about an aviation accident, visualizing it on a specific burn unit, and then writing the response plan will lock it into memory better than just reading it or hearing about it at a briefing.  Many different individuals should prepare burn plans or at least the incident-within-the- incident contingency plan. It is best to make the response plan for each burn unit a little different rather than one response plan that is simply inserted into every burn plan. For example, units should have landing zones for that burn unit already located, including coordinates. This will help people become familiar with emergency procedures and retain many of the steps involved. There may be no time to look at a plan during the emergency. A scenario or sand-table-type practice may be very useful. During a Forest Leadership Team meeting in 2014, the NF in MS forest leadership team (FLT) conducted a sand-table exercise where the situation involved a helicopter going down during a prescribed fire (see Appendix B). The scenario and after-action review (AAR) lasted only about two hours, but it allowed the participants to be better able to adequately manage the situation when it actually occurred.  Fire Staff and FMOs could “lead up” and encourage FLTs to conduct a scenario such as this. Dispatch Preparation Some vital information can be obtained ahead of time to prepare for emergencies. On the De Soto Ranger District, an in-briefing checklist is being developed for all detailed dispatchers that includes emergency procedures.  Dispatch should have on file emergency contact numbers for all local employees, including detailers and seasonals.  Flight crews most often inform dispatch of the “number of souls on board” or “pilot plus two,” etc. Depending on how dispatch and the helibase are situated, it could be important for dispatch to already know the names of individuals on each flight to save time in emergencies. A phone call prior to each flight is probably most appropriate. Each day that burns take place, the briefing should include “in-case-of-emergency” information. On burn days, the De Soto dispatch center now proceeds as follows:

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 Dispatch uses a cover sheet for the Interagency Aviation Mishap Response Guide. The cover sheet summarizes, in one short page, what must be done in dispatch immediately following any serious accident. The guide can be used for follow-up actions.  Either the DFMO or RXB2 briefs dispatchers on anything unique concerning emergency procedures for each burn unit. Dispatch will have a copy of the contingency plan from the burn plan for each day’s burn unit.

Dispatch was utilizing the NWCG check list44 for aviation accidents to guide its response.  While the guide did provide useful information, it was perceived as lengthy and confusing. One dispatcher commented, “It was like reading a book!” and suggested that it be simplified to accommodate the stressful and time-critical nature of these rare events. B.2 - Dispatch Staffing The dispatch office covering burn operations on unit 1459 is currently based out of the district office in Wiggins, Mississippi. At the time of the incident, the staff included one dispatcher who was filling in and relatively new to dispatch operations but very familiar with prescribed fire, aviation, and the local area where the accident occurred. An administrative support specialist and a military liaison that handle dispatch duties when needed were also at the office when the helicopter went down. Collectively these two possessed nearly a decade of dispatch experience.  District employees agree that having individuals in dispatch with local experience and a strong connection to the employees and community during this time proved to be invaluable. The De Soto Ranger District dispatcher position has not been permanently filled since February 2014, and for two years prior to that the employee had often been out on sick leave. The NF in MS is analyzing alternatives for a transition from a fourth-tier to a three-tier dispatch system that involves a proposed move to a centralized dispatch office in Jackson, Mississippi. The De Soto dispatcher permanent position remains unfilled pending the potential dispatch location change.  Most people interviewed expressed concern about leaving “a critical position vacant for that long” on a district with an active and complex prescribed burn and wildfire program. All district employees along with local cooperators and government agencies, including the adjacent ranger district, have expressed concern about the transition to a centralized dispatch office in Jackson, Mississippi.  Moving to a centralized dispatch “would take folks away from ‘the ground’ and that local knowledge of place names and understanding of the landscape.” An example of this was the initial uncertainty about in which county the incident took place because the Stone-Harrison county line bisects unit 1459 nearly in half north to south. This is significant because it determines which county has 9-1-1 and emergency-response jurisdiction. Once the final AFF location was given to the county 9-1-1 dispatchers, they

44 See National Wildland Fire Coordinating Group publication number 503 at http://www.doi.gov/aviation/upload/IAMRGC_PMS503.pdf.

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were able to work it out. The concern is that a centralized dispatch will lose crucial adaptive capacity imbedded in the local knowledge and critical relationships.  In addition to being within eight counties, the De Soto Ranger District contains Camp Shelby under a 117,000-acre military special use permit, which requires close coordination with Range Control due to restricted air space, memoranda of understanding, and areas of potential unexploded ordnance. A trained local dispatcher also has ongoing relationships with local emergency response personnel for the different counties, Camp Shelby, and other coordinating agencies that are useful in determining appropriate emergency contacts. B.3 - Locating the Accident One point of confusion emerged regarding the last-position coordinates AFF recorded before N50KH experienced the power loss that brought about the crash. After receiving the coordinates from dispatch, RXB2 attempted to clarify whether the coordinates were in degree, minutes, seconds (DMS) or degrees, minutes, decimal minutes (DMD). Although typically AFF is displayed as DMD, cooperators, law enforcement, military operations, and others along with systems such as Wildland Fire Decision Support System (WFDSS) and the Fire Statistics System (FIRESTAT) require or prefer different formats, making uniformity unachievable. Both De Soto dispatch computers have a coordinate convertor on the desktop. However, when RXB2 inquired about the format, dispatch was initially unable to discern which it was, and by the time dispatch called back with the correct format, RXB2 had already inferred the format based on the digit number and arrangement and had adjusted his GPS accordingly. (This topic is presented in finding 78 and in the Safety Action Plan)  Even though the dispatchers were experienced in using AFF, a permanent dispatcher who uses the system daily may have responded faster with accurate coordinates. The initial confusion became even more frustrating as dispatchers and RXB2 came to realize that, besides the last-known coordinates being awkward to obtain from AFF, those coordinates were found to be nowhere near the crash site, and the AFF icon for N50KH did not indicate a “lost signal” for some 18 minutes after the crash had occurred.  Technology exists that can track helicopter movements, up to the second and in real time. Aerial ignition should not be done without a tracking system in place that will allow both dispatch and ground crews to know exactly where a downed aircraft is located. The De Soto Ranger District is currently researching the following:  I-Pads and/or I-phones for tracking.  Law enforcement tracking systems.  Military tracking systems. B.4 - Helicopter Equipment  Helicopter contracts require fire shelters to be on board. The De Soto aviation people have always carried the shelters in the external compartment behind the cockpit. In this crash, that compartment was inaccessible. Fire shelters should be carried in the cockpit in a very convenient location for each occupant. (This topic is presented in Finding 84 and in the Safety Action Plan)

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B.5 - Burn Plans and Crash Rescue Responders will not likely know exactly where a downed aircraft is located. In this situation, the De Soto Ranger District was working on a relatively small burn (800 acres) with a nine-person crew scattered around the burn unit. Only one person heard the crash. The flight crew had no time for a radio distress call. On a larger burn, the only indication of a mishap may be that the ship does not respond to a 15-minute check-in. Locating a lost helicopter in a 2,000 acre burn unit could take hours, and AFF is virtually useless. (This topic is presented in findings 75,76,77,78 and 79 and in the Safety Action Plan)  Ideally, burn plans should have an “incident-within-an-incident” contingency plan that includes the following:  Location of the nearest available aircraft to help with the search.  Ground search-party organization.  Plans to use dozers or whatever means necessary to immediately cut the burn off, in case the ship went down just outside of the area already on fire.  Nearest landing-zone locations, including coordinates.  A crash kit and the correct fire extinguisher and hazmat and breathing apparatus should be readily available to ground burn personnel should they need to enter the burn and extinguish a vehicle fire. B.6 - Notification of Next of Kin/Media In urban forests, media use scanners to monitor law enforcement, ambulance, and fire traffic. Once a 9-1-1 call goes out, it will be reported on the news. With cell phones and social media, family members will almost immediately know what has happened. Next of Kin The District Ranger was out of town when the accident happened. A colleague who had worked closely with the deceased FIRB for years and knew his wife and family well immediately assumed the position of family liaison. Atypically, the contracted helicopter company had representatives on site at the time of the accident. Those employees immediately became family liaisons for the deceased pilot’s family.  Those involved in this incident agree that the person with the closest connection to the family who is able to emotionally handle the task should be asked to assume the family liaison role, regardless of qualifications or position on the organization chart. Other Staff and Family When Forest Service employees and families poured into the dispatch office soon after the accident, those working on the emergency found their presence distracting while realizing at the same time those people’s need for information did not stem from idle or morbid curiosity. In the best of situations, these visitors would be given proper attention by folks not handling the unfolding emergency.  Ideally, someone who is not busy with dispatch activities or working with the next of kin and who has leadership qualifications and skills should assume command. That person

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may have to make some tough decisions in a delicate way, and such an individual may not always be available. Media In small communities, Forest Service employees typically have close relationships with local media. Following each other on social media and exchanging emails, texts, and calls on a regular basis builds those close relationships that then cause consternation in the tension between protecting next-of-kin privacy and ensuring media can do their jobs. It has been proven that if the best information source is not forthcoming, misinformation is more likely to be shared through the media. That being said, those handling the emergency response chose not to speak to media at all as the incident unfolded. The De Soto Ranger District has a tight-knit relationship with the Wiggins community, and when the crash happened, local media reached out to every person they knew for information. The DFMO wasn’t prepared for the huge response that occurred immediately after the 9-1-1 call. He had practiced procedures—or at least knew clearly what they were—for informing next of kin, but word got out before he could follow any of that. Many of the first responders (law enforcement, fire department, coroner, etc.) were required by their agency to immediately document the names of those involved. The DFMO reluctantly gave that information to several people after verifying their identity. No names were released until all family members were notified and all agencies involved agreed that it was okay to release names.  In hindsight, those handling the incident believe they needed a public information officer in charge immediately to handle all of that chaos. That person would be listed high on a call checklist. The family liaison in this incident continues to struggle over how to handle persistent media who seem oblivious to the need to protect the privacy of grieving relatives.  He hopes the district can make it a practice to review protocol for these situations at both the annual fire refresher and at an in-house safety meeting. He also believes it is important to engage cooperating agency leads in these discussions and recognizes that outlining protocol does not offer fail-safe assurance that everything will be handled perfectly. He said, “We know that in our line of work things don’t always work by the book, but if we have a good understanding of protocol and a good foundation to work from when things do happen, things pop into our minds so we can make adjustments…when it comes to handling next of kin issues, although we need to know protocol, things are going to happen according to who we are as individuals.”  The District Ranger and family liaison have remained in close contact with the local Forest Service employee’s family since the incident and believe that is a vital component to the incident response.  District fire and aviation employees have also remained in close contact with the pilot’s family.

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B.7 - The Emergency Response At 1457 the Harrison County emergency dispatch center received a call from the Wiggins dispatch office reporting an incident with a helicopter. The Harrison County sheriff’s office dispatched officers, fire personnel, and medical units to the scene. The units responding were a mix of full-time paid Harrison County officers, volunteer firefighters, and a contracted private (AMR) emergency medical response and transportation. The responders’ primary mission was to extinguish the helicopter and provide search-and-rescue help if needed along with medical care and transportation for the injured. According to the agency personnel interviewed, the emergency medical response needed improvement in three main areas: command and control; patient care; and air-ambulance communication. Since the AAR conducted on August 26, 2015, the NF in MS has resolved its questions concerning these topics. The sections below articulate the concerns so as to inform other units about similar topics that could be proactively addressed prior to an emergency. Command and Control As noted in the narrative above there were times when the number and arrangement of personal vehicles blocked movement along the 415A Road. Related to this were concerns about chain of command and which entity was responsible for what aspect of the accident response. A specific instance was given in which an emergency responder asked one of the agency crewmembers to suppress the fire as it backed to the road where the emergency responders’ personal vehicles were parked. Another crewmember commented, “We need to understand the authority we have to control the scene.” During the LR information collection phase, agency personnel noted, “We have made some attempts to meet with emergency responders to sort out these issues, but maybe we should think about making this happen.” The NF in MS ultimately followed through on the intention and now is planning to facilitate an annual cooperators’ meeting. Patient Care With the larger number of emergency responders showing up at the scene, those agency crewmembers caring for the PSD operator made multiple attempts to transfer care to a higher qualified individual but were repeatedly disappointed that none of the initial emergency responders were better qualified. When the paramedics arrived, the crewmembers again expressed deep concern for the level of care provided and regretted not stepping in to intervene. One said, “Then to pick him up the way they did…I should have taken over when the paramedics didn’t do their job properly.” However, during the AAR, the crewmembers learned that the paramedics made a calculated decision to immediately prepare the PSD operator for intubation due to a quickly swelling airway. That information changed the early responders’ perspective concerning the paramedics’ treatment actions. Air Ambulance According to those interviewed, the air ambulance made multiple attempts to land at different spots near the fire. RXB2 gave coordinates for a preferred landing zone on the west side of the burn unit to Wiggins dispatch, which they passed on to Harrison County dispatch. The air ambulance attempted to land and then aborted. The helicopter then moved and attempted to land at what ground personnel deemed as a very tight spot on the south end of the burn unit.

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When the ship was very close to the ground, this landing too was aborted. In both of these aborted attempts, Forest Service ground personnel were unable to talk directly to the helicopter, and no communication was ever established. The air ambulance ultimately landed at a turnout on the Martha Redmond Road southeast of the burn unit, and the PSD operator was transported by ground to that location and transferred for the flight to Mobile, Alabama. Ground personnel shared a frustration with the inability to communicate with the air ambulance directly. As a result, two suggestions emerged, and Forest Service personnel later understood the rational for limiting ground contact with the helicopter.  Continue to work with external responding units to ensure communication protocols and channels are known, appropriate and utilized. There is a need to collect and communicate Best Practices for working with external responding units, especially Air Ambulance units.  During the AAR with the responding agencies, the De Soto Ranger District learned that that even though those on scene may be comfortable communicating with and directing helicopters, it is not always best to do so. That action would have only confused the pilot. In this case, emergency personnel on scene talk with that pilot and helicopter on almost a daily basis and are much more experienced with its capabilities. They were in constant communication with the helicopter during this event. B.8 - Medical Certification Of the nine personnel on the ground during ignition operations on unit 1459, one was qualified at the wilderness first responder (WFR)[1] level, and three were trained and certified first responders (now called emergency medical responders).[2] Others on the burn had been trained in the past to various levels, but qualifications had lapsed. Most had received basic first aid and CPR training during their annual refresher training. Those who took part in the medical response for the PSD operator expressed considerable unease and uncertainty with the lack of national EMS Direction.45 This is not a new issue and the Forest Service has initiated an effort to address it. Early in 2015, before this accident, the Forest Service completed an EMS Safety Impact Analysis to identify key EMS vulnerabilities and potential Agency mitigations. In November 2015, an EMS Implementation Working Group was chartered to explore options and provide risk-based implementation recommendations to provide access to the appropriate level of EMS to employees. The objective is to increase the chances of survival and rapid recovery of employees who become seriously ill or injured during the performance of work.

[1] Wilderness First Responders are individuals who are trained to respond to emergency situations in remote settings. [2] A certified first responder (also called an emergency medical responder) is a person who is trained and certified in providing pre-hospital care for medical emergencies. These individuals are not as highly trained as a paramedic.

45 Since this incident, the De Soto Ranger District has scheduled an emergency medical responder training to take place in November. Additionally, one district person is currently in Emergency Medical Technician (EMT) training.

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B.9 - Immediate Incident-within-an-Incident (IWI) Response  One of the first actions should be to identify leadership roles: the IC for the accident and the burn boss or IC for the wildfire.  The IC for the aviation mishap should consider immediately assigning group supervisors or liaisons for the following:  The downed aircraft search.  Survivor care, medivac, life flight, landing-zone location, medical liaison.  Scene security/law enforcement liaison.  Fire/fire department liaison.  Traffic and staging areas.  For fatality incidents, after all the immediate response is handled, order the following:  Nearby resources to take over the prescribed burn or fire.  Nearby resources to take over the incident-within-the-incident.  An incident management team (IMT) to help handle the aftermath. It is helpful if a more local IMT can be brought in (i.e., team members that affected employees know).  Within a few days of a serious accident, a forest should have contacts in place for legal counsel for all employees involved. B.10 - Afterward On August 26, 2015, the DFMO, RXB2, and a NF in MS supervisor’s office fire staff representative met with most of the responders or their representatives, for an after-action review (AAR) concerning the response to the crash. This meeting proved to be extremely valuable for both future cooperation and for understanding the events of March 30. After much discussion, the conclusion was reached that command and control of all components of the accident response was appropriate and well executed. One of the first responders on scene was the County Assistant Fire Chief (CAFC). The CAFC immediately located the DFMO (IC) for a briefing and then assumed command. As other resources (Air Force fire department, coroner, etc.) arrived, the CAFC coordinated all efforts. The only improvement in communications noted was that the transfer of command could have been more formally stated. District personnel later said, “As firefighters and incident commanders, our normal operations, experience, and training lead us to believe we should be in command. However, in this instance, we were the incident and were much better off to allow others to take control.”

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Appendix C – Sequence of Events

*All times approximate and are CDT. **Times annotated with “XX” indicate the correct hour but not exact minute; was able to be accurately determined based on information obtained. Recon of Units – Pre-burn Mission Time Description of Event Source 0940 KH – Pilot + 2 for recon Dispatch Logs 0946 KH – recon of units Dispatch Logs 1022 KH – [radio check in] recon Dispatch Logs over unit 1025 KH – recon [of additional units] Dispatch Logs 1034 KH – [illegible] looking at Dispatch Logs smoke 1041 KH – Inbound Wiggins Dispatch Logs 1048 KH – [land] at Wiggins Dispatch Logs

Table Information Comments: Decision making related to the aerial ignition mission was informed by numerous agency requirements and processes. Guidance for planning a PSD mission is provided in FSM 5700, the IHOG, and the IAIG. Each of these documents shapes the perception of safe operational boundaries for the mission within agency accepted practices. Information contained in manuals, handbooks, and guides identify what personnel are supposed to do (task), how they should be trained to do it (skills and competencies), and what equipment they need to use. Procedures that are followed during the planning process provide reinforcement and confidence that the mission is well planned and can be executed within a level of acceptable risk. Mission Prep Time Description of Event Source XXXX FIRB performed permission HMGB statement briefing XXXX PSD bench tested by PLDO and HMGB statement installed on Helicopter 50KH

Table Information Comments: When confirmed the burn unit is ready for aerial ignition, the PLDO prepares the PSD machine, the pilot conducts another pre-flight, and a pre-mission brief is conducted including the spot weather forecast and the go/no-go checklist. Mission Time Description of Event Source 13XX Pilot experiences failed start* HMGB/PLDO of helicopter statement 13XX Normal start of helicopter HMGB/PLDO upon restart statements 1333 KH – Pilot +2 [FIRB & PLDO] AFF & Dispatch Logs with machine onboard depart for burn operations

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Time Description of Event Source 1334 KH – in air, 8-10 mi. out Dispatch Logs 1340 KH – [switching to] TAC 1 on Dispatch Logs RX 1454 [beginning burn operations]

Table Information Comments: HMGB was present at the time of the failed start. Pilot allowed a brief cool-down and initiated a successful start. *Type of failed start unknown. Accident Sequence Time Description of Event Source Between Witnesses report sound that RX Burn Crew 1433- resembled an air hose being Witness statements 1436 unplugged from a high pressure tank, and others reported hearing a loud “bang” only a few seconds prior to the time the accident was believed to occur (prescribed burn crew witness statements) 1436 Possible incident with the Dispatch Log helicopter 1440 Aircraft not responding to Dispatch Log radio calls, but showing on AFF; Incident within an Incident Commander designated at scene 1444 RXB requests to have RX Burn Crew Helicopter 25GH without statements/Dispatch machine [PSD] respond [to Logs assist with location of KH] 1448 AFF signal lost; [initiate] Dispatch Logs aviation mishap response [protocols] Between Survivor [PLDO] located RXB statement 1448 & walking on Martha Redmond 1451 Road, and is given medical attention by crew

Table Information Comments: From the time the RXB first suspected an incident with the helicopter at 1436 CDT, to the time the survivor was located was 14 minutes or less; the survivor received immediate medical attention from the crew on site who possessed advanced training in medical response. Emergency Response Time Description of Event Source 1451 RXB calls 911 on cell 911 Logs

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Time Description of Event Source 145X RX Burn Crew (3 people) RX crew statements initiate search for wreckage 1456 Dispatch calls Houston ATC to Dispatch Log ask about location of 50KH 145X Line crew locates wreckage RX crew statements 1500 Dispatch (Wiggins) requests air 911 Logs/Dispatch ambulance Logs 1502 911 Dispatch notifies Life Flight 911 Dispatch Logs 1504 A/C confirmed crashed in area 911 Logs of Martha Redmond Road per FS contact 1505 Last known coordinates 911 Logs provided 1506 RXB provides directions to site 911 Logs to emergency crews 1511 RXB reports from scene- 1 Dispatch Logs seriously injured, 2 fatal; initiate contact with Forest Supervisor; and clear channel 1515 Dispatch announces to clear Dispatch Logs radio traffic [for emergency] 1519 25GH lands at Wiggins Dispatch Logs 1521 18 min. ETA for Life Flight 911 Logs 1523 Martha Redmond Road closed 911 Logs for incident response 1524 Spoke with FAA 911 Logs 1527 Emergency responders tending 911 Logs to survivor 1534 RX burn personnel contacted Dispatch Logs Dispatch to inquire about notifications [IAW] accident flow chart 1537 Life Flight inbound 911 Logs 1551 [RX Burn Crew] requesting to 911 Logs suppress fire around downed helicopter 1554 Life Flight on scene Dispatch Logs 1557 Life Flight unable to land at 911 Logs location—flew to alternate location

Table Information Comments: 911 was contacted approximately 14 minutes after the crash by cell phone. Local Medical response was on scene just a little over an hour after the accident. The search crew located the wreckage approximately 20 minutes after the accident occurred, despite the fact that they had been unable to get into the area due to the active fire. Emergency

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Air Medical services were requested by Dispatch at 1500, and the air ambulance arrived on scene about 1 hour and 20 minutes after the accident occurred (about 57 minutes after they were called). Post-accident Notifications Time Description of Event Source 1726 Called FAA Dispatch Logs 1826 NTSB ETA 3/31 between 0800- Dispatch Logs 0900hrs 1829 Scene will be secured 911 Logs overnight

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Appendix D – Sand-table Exercise – NF in MS FLT (2014)

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Appendix E – De Soto Aviation PPE Report De Soto Aviation Incident – March 30, 2015 Personal Protection Equipment (PPE) Report This report is based on personal interviews with involved personnel and inspection of the personal protection equipment (PPE). Burn Injuries  All burn injuries were sustained during the escape from the helicopter to the road. 1. Second and third degree burn injuries are estimated to be between 13 and 22 percent of body surface area.

 Areas include: Right palm, back of left hand, right forearm, left and right elbows, front of left and right legs from top of socks to top of knees, calves, face cheeks, and ears. 2. Helicopter crash impact Injuries:

 Fractures of two cervical and two lumbar vertebrae, left ocular and left side ribs.  Intestinal and hernia tears. PPE Requirements Interagency Helicopter Operations Guide (IHOG) – February 2013 Chart 9-1: Requirements for Personal Protective Equipment – Flight Missions General

 Fire Resistant Clothing (long sleeved shirt and pants or flight suit)  Fire Resistant and/or Leather Gloves  Approved Aviator Flight Helmet  All-leather Boots  Hearing Protection FR Pants

 Trouser, Army Combat Uniform, Flame Resistant  Cloth: 65% FR Rayon, 25% Para Aramid and 10% Nylon  Condition: Char (dark brown/black color) is present mostly on the pants below the knees front and back. Char is also present on the upper leg areas as well as the rear mostly on material edges of pockets and flaps. There is a 4-inch tear on the lower rear of the left leg.

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Figure 1. Front and rear views of the helicopter survivor crash victim’s pants.

FR Shirt No label – appears to be early version Forest Service Specification – 5100-91  Cloth: 95% Meta-Aramid, 5% Para-Aramid  Condition: Dye sublimation (tan/light brown color) and char (dark brown color) are most prevalent on the abdomen, lower back, lower arms and elbow areas.

Figure 2. Front and rear views of the helicopter survivor crash victim’s shirt.

Gloves Flyer’s, summer. MIL-G-81188B, Type GSIFRP2  Condition: Palm leather and Nomex cloth are shrunk in the wrist area.

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Figure 3. View of the helicopter survivor crash victim’s gloves.

Discussion The PSD operator experienced very high levels of both convective and radiant heat throughout his escape. The highest levels occurred when he ran through the flame front; he held his breath during that time. Even though the shirt shows very high temperature exposure to the abdomen, lower back and arms, PSD operator did not receive any burn injuries under his cotton t-shirt. The cloth tear on the lower left leg most likely occurred during the PSD operator’s escape. The clothing appears to have been clean and serviceable before the incident. Item conditions and corresponding temperatures Item Condition Corresponding Temperature Vegetative Fire (typical) 1600-1800 F FR Rayon Cloth (pants) – Char 970 F Meta-Aramid Cloth(shirt) – Char 825 F Nylon Webbing and Material – Melt 500 F Meta-Aramid Cloth (shirt) – Dye Sublimation 425 F Leather – Shrinks 10% 350 F Human Skin – 2nd Degree Blister 130 F

__/s/ Tony Petrilli______November 16, 2015______Tony Petrilli Date Fire Equipment Specialist US Forest Service

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Appendix F – Sabine Aviation Incident NTSB Report Excerpt Sabine Incident Reference (see page 62, table 1) Excerpt from Sabine National Forest Aviation Incident (March 10, 2005) SECTION I. RECOMMENDATIONS FROM PAST, SIMILAR ACCIDENTS Sabine National Forest, March 10, 2005 – PSD Operation. NTSB Accident Identifier: DFW05FA086 on the NTSB Web site.46 The following information from this report is re-visited to demonstrate similar accident circumstances and to highlight recommendations from an accident that occurred 10 years previous. The purpose is to demonstrate that the mission profile and mission risk was identified but also minimally addressed. Note: This is an agency-wide issue and not specific to the De Soto Ranger District (NFs in Mississippi). Accident Brief: During PSD Operations on the Sabine National Forest, a Bell 206B-3 helicopter sustained substantial damage when it impacted heavily wooded terrain near Shelbyville, Texas. The pilot and two Forest Service crewmembers sustained fatal injuries. As with the De Soto Helicopter Accident, this accident report also noted that the PSD operation was conducted within established policy, and personnel (pilot and crewmembers) were experienced and qualified for the mission. Significant Findings and Recommendations included the following:

Significant Finding 8. Aerial ignition operations and associated risk assessment are minimally addressed in the burn plan and aviation management safety plan for the Forest.

 Burn Plan and Forest Aviation Management Safety Plan.

Recommendations Preliminary Recommendations Recommendation #1 Include in FS agency policy, relative to pilot approval (carding), a requirement that agency pilot inspectors review/verify pilot time for those pilots that have never been approved by the agency (Initial approvals). Subsequent approvals would not require this review for total time. Recommendation #2 Require the installation and use of Automated Flight Following (AFF) equipment in all mission (not point to point) helicopters utilized by the agency.

46 Go to the NTSB Web site at http://www.ntsb.gov/Pages/default.aspx.

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Recommendation #3 Include a requirement in the Interagency Aerial Ignition Guide pre-mission briefing that addresses PSD flight profile “watch out” situations including but not limited to loss of tail rotor effectiveness (LTE), Settling with Power, etc. Recommendation #4 Require pilots being evaluated for an Initial approval for PSD Operations demonstrate to the Inspector Pilot their skill in low level, low airspeed maneuvering in a simulated PSD flight. Recommendation #3 has been added to the Go/No Go checklist contained in the IAIG under Pilot/Aircraft: “Discuss flight profile, watch out situations including loss of tail rotor authority, settling with power, downwind turns, etc.” It is not clear to what extent these parameters are being discussed prior to engaging in individual aerial ignition operations. This could be further researched in the field.

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Appendix G – Aviation Acronyms

A/C - aircraft A&P Mechanic - Airframe and Powerplant Mechanic ACTT - Aircraft Total Time AD - Airworthiness Directive ADM - Aeronautical Decision Making AFF - Automated Flight Following AGL - Above Ground Level ALARP - As Low as Reasonably Practicable AMD - Aviation Management Directorate AQM - Acquisition Management ASI - Air Safety Investigator ATV - All Terrain Vehicles BC-ASMS - Branch Chief, Aviation Safety Management Systems CAR - Civil Air Regulations CDT - Central Daylight Time CO - Contracting Officer COR - Contracting Officer Representative CRM - Crew Resource Management CWN - Call When Needed ERP - Emergency Response Plan ETOPS - Extended Operations EU - Exclusive Use FAA - Federal Aviation Administration FAM - Fire and Aviation Management FAO - Forest Aviation Officer FAR - Federal Aviation Regulations FIRB - Firing Boss FMO - Fire Management Officer

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FS - Forest Service GMR - General Management Review GOM - General Operating Manual GPS - Global Positioning System HAZMAT - Hazardous Material HECM - Helicopter Crew Member HIP - Helicopter Inspector Pilot HMGB - Helicopter Manager HOGE - Hover Out of Ground Effect HOS - Helicopter Operations Specialist HVC - Height Velocity Curve IAIG - Interagency Aerial Ignition Guide IAW - In Accordance With ICA - Instructions for Continued Airworthiness ICAO - International Civil Aviation Organization IIP – Initial Impact Point IQCS - Incident Qualifications and Certification System IHOG - Interagency Helicopter Operations Guide IHPPTS – Interagency Helicopter Pilot Practical Test Standards JHA - Job Hazard Analysis JRA - Job Risk Analysis LTE - Loss of Tail-Rotor Effectiveness MTRs - Military Training Routes MSL - Mean Sea Level MTDC – Missoula Technology and Development Center NHSP - National Helicopter Standardization Pilot NIFC - National Interagency Fire Center NOAA - National Oceanographic and Atmospheric Administration NOTAM - Notice to Airmen NTSB - National Transportation Safety Board

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OAS - Office of Aviation Services ORM - Operational Risk Management OSHA - Occupational Safety and Health PASP - Project Aviation Safety Plan PHI - Petroleum Helicopters International PIC - Pilot in Command POH - Pilot Operating Handbook PLDO - Plastic Sphere Dispenser Operator PPE - Personal Protective Equipment PSD - Plastic Sphere Dispenser QA - Quality Assurance RA - Risk Assessment RAO - Regional Aviation Officer RASM - Regional Aviation Safety Manager RAWS - Remote Automated Weather Station RM - Risk Management RFI - Request for Information RFM - Rotorcraft Flight Manual ROC - Record of Conversation ROSS - Resource Ordering and Status System Rx - Prescribed (as in Prescribed Burn) RXB1/2 - Prescribed Fire Boss SAR - Search and Rescue SB - Service Bulletin SRACOW - Strategic Risk Assessment Close Out Working Group STC - Supplemental Type Certificate SME – Subject-Matter Expert SMS - Safety Management Systems SOP - Standard Operating Procedure SU - Special Use

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TSI - Time Since Install TSO - Time Since Overhaul USFS - United States Forest Service UTC - Coordinated Universal Time UTV – Utility Vehicle VFR - Visual Flight Rules VHF - Very High Frequency

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