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July 10, 2024 · Air Tractor AT-802A · N10122

Helena, MT

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
July 10, 2024
Injury Outcomes
1 injury (1 fatality)
Location
Helena, MT
Aircraft
Air Tractor AT-802A (2013)
Tail Number
N10122
Operator
Aero Spray
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
WPR24FA238

The pilot of the single-engine air tanker flew as part of a group of four airplanes and was in the No. 2 position. The group departed from their home airport in support of aerial firefighting efforts and arrived at the destination 1 hour and 44 minutes later. Once they arrived on scene, near the wildfire, they flew to a nearby lake to begin the water scooping portion of the mission; the accident occurred during the first scoop sequence. Witnesses on the lake and in their homes reported that the lead airplane successfully completed its scoop and lifted off from the lake. The float-equipped accident airplane was beginning to scoop when witnesses observed the airplane “moving unsteadily” before the left wing dipped into the water, the right wing rose into the air, the airplane veered left and subsequently impacted the rock face. During the initial water scoop, the lead pilot transmitted an instruction to abort the scoop due to a tailwind. As the lead airplane climbed away from the lake, the accident airplane had descended toward the water. The pilot did not acknowledge the abort instruction, and the airplane began to drift to the left. A review of the airplane’s SpiderTrack flight tracking data showed that during the final 1,447 ft of the water scoop, the airplane drifted about 10° left while on the water. The lead airplane’s flight data showed that the accident airplane’s drift to the left, away from the middle of the waterway and toward the shoreline and rock face, occurred simultaneously with the lead airplane’s turn to the left. The pilot did not take any evasive action to avoid the rock face. According to the operator, this was the accident pilot’s first fire season. The pilot’s training history showed that during tactical flying, the pilot at times lost situational awareness, which led to a regression in fundamental flying skills and freezing at the flight controls. Given these documented deficiencies, the pilot likely experienced a similar degradation in performance during the accident sequence. Postaccident examination of the wreckage revealed no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Toxicology results indicated a low level of cetirizine in the pilot’s postmortem femoral blood; with the low level found, the pilot was not likely to have experienced any significant impairment effects at the time of the accident. Additionally, a very low level measured concentration of morphine was identified in the pilot’s urine. The positive toxicology result is nonspecific and may have been found after opioid drug use or poppy seed consumption. Given the low level detected, it is unlikely that the pilot was impaired by the effects of morphine at the time of the accident.

NTSB Probable Cause

The pilot’s loss of situational awareness during the water scoop due to task overload while operating in a multi-airplane tactical firefighting environment, which resulted in the pilot’s failure to maintain directional control and the airplane’s collision with terrain.

Full Narrative

HISTORY OF FLIGHTOn July 10, 2024, about 1210 mountain daylight time, an Air Tractor AT-802A (Fire Boss) airplane, N10122, was substantially damaged when it was involved in an accident near Helena, Montana. The pilot was fatally injured. The airplane was operated as public use aircraft for the purpose of firefighting. The operator reported dispatching four of their single-engine air tankers to Helena for the United States Forest Service in support of aerial firefighting efforts for the Horse Gulch Fire. The flight of four departed Coeur d’Alene Airport – Pappy Boyington Field (COE), Coeur d'Alene, Idaho, about 1 hour and 44 minutes before the accident, and flew directly to Hauser Lake, where they began scooping water from the lake. The accident airplane was flying in the No. 2 position. During its first water scoop, witnesses on the lake and the pilots of the two airplanes flying behind the accident airplane saw the airplane make a turn to the left. The airplane subsequently impacted a vertical rock face bordering the southern shoreline of the lake, fell into the water, and sank. According to the lead pilot, after the lead airplane’s scoops deployed, he recognized a slight tailwind and aborted the scoop. He transmitted instructions for the remaining airplanes to abort the scoop sequence. The pilots of the Nos. 3 and 4 airplanes acknowledged the transmission; however, the accident pilot did not. The lead pilot repeated the abort instruction specifically to the accident pilot but received no response. The accident airplane was equipped with a SpiderTrack flight tracking system. Downloaded data (figure 1) showed that after departing COE, the airplane turned to a southeasterly heading and ascended to an altitude of about 9,400 ft mean sea level (msl). The airplane continued on a southeasterly heading, at altitudes between 9,275 ft and 9,575 ft msl, until it began a descent at 1146. The group of four airplanes flew over Hauser Lake and completed several turns before they made a descending right turn from the east side of the lake. The accident airplane descended to the lake’s surface, on a track of about 279° magnetic, and traveled about 4,233 ft across the water. The airplane then made a left turn to a heading of 269° and traveled about 1,447 ft until the data ended in the area of the accident site. Figure 1: SpiderTrack Image of Flight Track (Courtesy of Operator) Witnesses on the lake and in their homes had been watching a group of airplanes fly overhead and scoop water from the lake. One witness reported that the first airplane scooped water and took off again. The second airplane touched down but did not take off again. The airplane was “moving unsteadily from side to side” and appeared to be ” out of control.“ The witness believed that the left wing hit the water, which changed the airplane’s direction of travel where it collided with a rock face. Another witness reported that the accident airplane descended to the water and was moving unsteadily from side to side before it took off. The witness recalled the airplane in a right-wing-high attitude before the airplane impacted the rock face. The pilot of the No. 3 airplane reported that after the accident airplane touched down, it gradually drifted left and did not appear to change direction before it impacted the shoreline. PERSONNEL INFORMATIONThe pilot’s hire date with Dauntless Air was January 10, 2024. According to the operator, this was the pilot’s first fire season. According to information provided by the operator, as of April 6, 2024, the pilot performed 122 scoops while in training. She had amassed 25.2 hours of flight time during training and an additional 42.8 hours of ferry flight time relocating airplanes. The operator stated that the pilot’s total Fire Boss experience before the accident included 150 total scoops and about 96.4 hours of flight time. The following information about the pilot’s training was provided by a representative of Dauntless Air: Figure 2: Pilot's training record dates provided by Dauntless Air. The operator’s Chief Pilot/Director of Operations stated that he had flown with the pilot on at least 4 flights and noted that she had been lagging behind the rest of her class but was showing improvement. He added that instructors had identified her as lagging behind the rest of the class in the tactical environment, specifically in situational awareness and formation flight operations with four aircraft. Additionally, he reported that one instructor flagged her as not ready for tactical or for a check ride. However, the pilot gained more experience, including numerous ferry flights, practicing formation, and a mock check ride prior to conducting a final check ride. A former Dauntless Air flight instructor reported that he had flown with the accident pilot 10 different times, of which 4 times were during initial training. He stated that during one of the early flights, he noticed that the accident pilot lost situational awareness on the return flight back to the airport. He believed that the accident pilot may have experienced similar situational awareness issues while conducting ferry flights when she ferried an aircraft. The flight instructor added that when the accident pilot was tasked with more than one item, she would get overwhelmed easily. The flight instructor also recalled that in one case, the accident pilot “just kind of froze on the controls, when joining up on an airplane” and he had to take control of the airplane from her, which startled her. AIRCRAFT INFORMATIONThe airplane was equipped with a Wipaire 10000 Series Amphibious Water Scooping Float System. A review of the airplane’s logbooks revealed that an annual inspection had been completed on March 9, 2024, with an airframe total time of 1,785.2 hours. METEOROLOGICAL INFORMATIONA witness on the lake, about 300 yards from the accident site, reported water conditions as choppy, but not “white capping.’’ AIRPORT INFORMATIONThe airplane was equipped with a Wipaire 10000 Series Amphibious Water Scooping Float System. A review of the airplane’s logbooks revealed that an annual inspection had been completed on March 9, 2024, with an airframe total time of 1,785.2 hours. WRECKAGE AND IMPACT INFORMATIONAccident Site The airplane impacted a vertical rock face along the shoreline of Hauser Lake and came to rest upright, submerged about 20 ft from the rock face. The debris field was contained in the area immediately below the impact with the vertical rock face. All major structural components of the airplane, engine, and propeller assembly were located at the accident site. The only components not located were the outboard segment of the left aileron, including the counterweight, and a segment of left elevator, including the left elevator counterweight. The fuselage came to rest upright on a magnetic heading of about 225°. Both floats had separated from the landing gear and were located together downstream from the main wreckage. Examination of the airplane after its recovery from the water revealed that the wings, tail sections, and engine remained attached to the fuselage. Flight control continuity was established from the cockpit to all flight controls. The cockpit remained intact. The emergency jettison handle was in the stowed and locked position. Postaccident investigation established flight control continuity from the cockpit to the respective flight control surfaces. The engine remained attached to the airframe at its engine mount. The propeller assembly had separated from the engine. The flaps were extended to 30°, the fully extended position. Both floats had separated from the airframe, the right float sustained minimal damage, and the scoop was deployed about 1/8 inch below the main keel. The left float sustained minimal damage with the scoop deployed about 1/4 inch below the main keel. The scoops were functionally tested with no discrepancies noted. Two of the five propeller blades separated from the hub, with one of those propeller blades not recovered. The propeller blades showed varying degrees of rotation/S-bending, nicks and gouges, and chordwise scratching. Two blades were bent toward the cambered side, and one blade was bent toward the face side. The recovered propeller blade that separated from the hub was mostly straight with visible nicks and gouges. According to the propeller manufacturer, the impact signatures indicated that the propeller was rotating at a high rpm under high engine power and was producing thrust at the time of impact. Postaccident examination of the airplane revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. ADDITIONAL INFORMATIONThe FAA Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25C) identifies, in part, the following operational pitfalls: Peer pressure: Poor decision - making may be based upon an emotional response to peers, rather than evaluating a situation objectively. Getting behind the aircraft - This pitfall can be caused by allowing events or the situation to control pilot actions. A constant state of surprise at what happens next may be exhibited when the pilot is getting behind the aircraft. Loss of positional or situational awareness - In extreme cases, when a pilot gets behind the aircraft, a loss of positional or situational awareness may result. The pilot may not know the aircraft’s geographical location or may be unable to recognize deteriorating circumstances. MEDICAL AND PATHOLOGICAL INFORMATIONThe Lewis and Clark County Medical Examiner performed the pilot’s autopsy. According to the autopsy report, the cause of death was drowning, and the manner of death was accident. Toxicology testing performed by FAA Forensic Sciences Laboratory detected morphine in the pilot’s urine at 3 ng/mL. Cetirizine was detected in the pilot’s femoral blood. Cetirizine was also detected in the pilot’s urine at 126 ng/mL. Morphine is an opioid drug that may be used to treat pain. Morphine also may be a metabolite of other drugs that were not detected in this case (heroin, which is an illicit opioid drug, and codeine, which is a medication that may be used to treat pain, cough, or diarrhea). Additionally, morphine may sometimes be detected in urine after poppy seed consumption. The FAA instructs aviation medical examiners not to issue medical certificates to pilots who use opioid drugs regularly, although medical certificates may be issued in cases of occasional opioid use for time-limited conditions that are nonrecurrent or recurrent and resolved (and not otherwise disqualifying). Regardless, the FAA states that a pilot should not fly after using an opioid drug until adequate time has elapsed for the drug to be eliminated from circulation. Cetirizine is a second-generation antihistamine medication that is available over the counter and is commonly used to treat allergy symptoms. Cetirizine often carries a warning that users may experience drowsiness and should be careful when driving a motor vehicle or operating machinery. Data on sedation and psychomotor impairment from cetirizine are mixed, with some studies finding some sedating and impairing effects. The FAA states that pilots should wait 48 hours after using cetirizine before flying, to allow time for the drug to be cleared from circulation. In living people, typical therapeutic levels of cetirizine in plasma are about 100 ng/mL to 600 ng/mL.

Flight

Event TypeAccident
Event Time12:10 MDT
Nearest AirportHelena Rgnl (8nm ENE)
Flight Plan FiledCvfr
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftAir Tractor AT-802A
Tail NumberN10122
Aircraft CategoryAir
DamageSubstantial
OperatorAero Spray
Engines1
Engine TypeTurboprop
Engine DetailsPratt And Whitney - Canada · PT6A-67F · Turboprop · 1600
Seats2

People & Injuries

Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 45 · Second Class · Fatal

Conditions

ConditionsVMC
LightDaylight
Wind50° @ 5 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point48 F
Altimeter30.05 inHg
Observation Time11:53
Weather SourceWFAC

Appendix: Source Data