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 Page 1 of 89 De Soto Aviation Incident Learning Review – Accident 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