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Amphibious Scoopers LOC-W (Loss of control in Water)

A Fireboss losing control during a scooping run in Portugal

If you got here, you probably started with this Linkedin post showing a Fireboss LOC-W (Loss of control in water).

If not, it could be good to go back there to fully understand the context.

But what happens during this Fireboss incident?

Please try to think to yourself what happened there.

Then compare with my findings below.

It is a good exercise to know where you are.

Mandatory reporting

Unfortunately, there is no official information on this event as it remains an unreported event, so take this as my personal opinion based on my previous experience with the type and the fact I was working there when it happened.

According to EASA regulations, occurrences that may represent a significant risk to aviation safety should be mandatorily reported. We don’t need to damage an aircraft or injure a person but just think of the worst-case scenario to report.

Basic knowledge but important to remember.

Safety culture, or lack of it.

The safety culture of an organization tends to be shaped by the worst behavior we are willing to tolerate,

It is entirely down to us and the organizations we work for to choose one path or the other.

Report in an open manner, or keep it quiet truing not to rock the boat too much.

The regulations are clear about it:

Furthermore, following ICAO Annex 13, #GPIAAF, #ANAC and #EASA should investigate and identify the causes of these events, formulate recommendations, and implement measures to prevent their continuation.

Unfortunately, it does not always happen as we will see in this article.

Then we cry those gone and put them as heroes blaming the inherent risks of the activity.

And back again to the starting point.

Over, and over.

I have seen it so many times…

Frustrating.

When we ignore a Very-High-Risk problem, it remains Very-High-Risk and perpetuates the threat until we get the slap of a fatality.

Deciphering the LOC-W incident

To the point.

It seems there is a lot going on in a short period of time, right?

From hindsight, in this specific LOC-W event I see the following:

  1. A too short distance between the 2 aircraft to safely perform a tandem scoop (one after the other).
  2. The narrow river does not allow for side-by-side scooping, as it is only about 180m.
  3. Number 2 hits the wake turbulence of number 1, drops the right wing, and hits the water with the right float first at a too-high speed.
  4. The drag of the right float in combination with a too-nose down position makes the aircraft violently veer right, jumping uncontrollably over the waves created by number 1.
  5. The pilot goes into full reverse rejecting the scoop run, and becoming a test pilot under unexplored circumstances (non-described procedure in the aircraft manual nor operator SOP)
  6. The test worked well and barely touched the shore and rocks present. The aircraft passes by a narrow corridor between the shore and a rock 20-30m from the shore almost touching it with left wingtip.

 

When all of that happens, we are flipping a coin.

Luckily, the pilot got on the winning side and left the plane with a bit more white hair and not in a coffin. The organization and insurance company walked away unscathed, instead of having to replace a 4 Million asset.

It is important we understand that the actual outcome of an incident differs from the worst-case scenario, and we should always think of the worst consequences we could have experienced.

That is the mentality we should aim for.

Don´t rely on luck.

Tha bag tends to empty before the bag of experience fills up.

Worst-case scenario

This other video shows a well-known classic scene of the Beaver crashing while illustrating the other side of the coin we face when we lose control in the water.

This is the worst-case scenario.

Or close (the pilot survived).

We see a plane turning upside down violently, a pilot forced to egress from cold water after a serious impact, and an aircraft probably damaged beyond repair.

Life-threatening circumstances.

Similar to the ones we have just shown, there are other 14 LOC-W Fireboss events registered with serious consequences, in addition to the other 14 incorrect landing gear configuration events, during the past 2 decades.

Statistics – Own source

How do I know this?

All accidents are public.

The problem we encounter is, that in most cases, investigation boards do not connect accidents within the same organization, fail to link accidents within the same country, and rarely correlate events with a common root cause internationally. In other occasions, specific “vox populi” incidents are hidden or not deemed necessary to investigate when the worst-case scenario would have been fatal.

That is the reason why I am to gather all the available information together for the brands I fly, in a common format, and in a common language.

The goal is to create a database that, in turn, serves to summarize, analyze, and apply data and information in order to prevent future events and identify potential trends.

This is a cornerstone for any organization thinking of operating a Fireboss.

The statistics shown above and the image below serve as an example.

A teaser of the work done.

 

More than 100 slides to fully understand this type during the 45 safety events studied

The method used involves gathering and expanding available information, connecting root causes when appropriate, and, if needed, making safety recommendations from a pilot/instructor perspective. The study analyses every year since 2003, identifying and classifying hazards into a common hazard log. At the end of every year there is a yearly report including statistics. Events are classified and measured against previous year statistics in the search of new trends, and the number of events versus 100.000 flight hrs, which is a common standard in aviation.

It is available to those pilots and organizations keen on taking their safety to the next level, without experiencing the same accidents.

The right ones.

It is listed as part of the services available for organizations under the aerial firefighting mentor program

www.aerialfirefightingmentor.com/offerings

 

Competitive Behaviour – An ignored organizational factor

In addition, I am aware of other contributing factors I would like to share as a teaser of our findings.

To start with, during the LOC-W Fireboss video, I should say the two aircraft were competing against a pair of Canadairs CL-215s also supporting that wildland fire.

The policy of the organization while trying to prove and expand the Fireboss concept and discard the previous paradigm (old CL-215 piston), was to scoop wherever they were scooping, and provide faster turnarounds.

A not addressed and ignored organizational factor.

Busy upper managers trying to portray how good and robust their systems are to get more contracts, instead of actually finding out what is going down there, stabilizing the operation, and figuring out how to fix the latent issues that are putting the lives of their front liners at risk.

And what was happening down there on that specific case?

From my perspective, the trailing pilot (a very skillful and experienced one that I have flown quite a bit with) was struggling to keep up with the pace of his leader, and was cutting the corner and shortening the distance of the formation until eventually he got into the wake turbulence and lost control.

In a short pattern from scooping to fire, as was the case,  if the leader does not feel like waiting, there is not much to do to remain as a pair or group, other than scooping close, which could be dangerous in narrow rivers as we saw.

There is another accident investigated by Canadian TSB, highlighting competitive behavior as one of the causes in another Fireboss LOC-W event, this time wrecking the aircraft.

Here is the link to the report

A must read I would say.

Well done TSB of Canada for making us safer pilots by learning in advance from others’ experiences without needing to go through them (An expensive way to operate, costing lives and millions replacing assets)

But this is not over yet:

Poor leadership and questionable mentoring – A latent organizational factor

In previous years, there were two other accidents in Portugal, involving the same formation leader, which turned out to be, the Accountable Manager, which also held NP roles as Flight Ops Manager, Crew Training Manager and had placed a Safety Manager from the airlines, friend of him, who was as proficient in Aerial Firefighting as I can be speaking Russian.

So that in the real scenario, there was a quadruplicity of positions, something totally against EASA trends, which searches for plurality in complex operators to avoid this sort of issue. It is an anachronistic and inadvisable from the point of view of modern safety, regardless of whether such regulations apply in Portugal which regulates many of the aspects nationally.

This is one of the organizational factors laying at the root cause of the events, that would go unnoticed when investigation boards don´t do their jobs right.

In the aftermath, two more Fireboss wrecked after losing control in the water, not to do with specific pilots or the design of the aircraft, but to do with organizational factors.

Two more accidents potentially connected to the one we just saw that perhaps we could have avoided if we knew.

Now you know.

Again, pilots were over-stressed beyond their sills trying to keep up with a pushy leader, more experienced than them.

On the first one we see the result of heavy interaction with the water when you start bouncing out of control at 16000 Lbs with an aircraft only designed to touch the water at 11500 Lbs:

Luckily, he made it to the runway and did not need to egress. That could have been a different story.

The report on this accident is here:

EC-LGT i006748

Shame the authorities did not deem it necessary to continue the investigation. Did not travel to the scene, and only issued an information notice.

Surely there is a lot we could learn if they get deep down to the root courses at organizational levels as the Canadian TSB did with a very similar event.

It is important we learn from accidents

The Canadian Operator who held a record of 4 serious Fireboss accidents in 13 months, has significantly improved their operations safety record with the Fireboss fleet, after fixing some of the issues an external safety-minded organization as Canadian TSB, had spotted.

Check the following article from Aero Assurance to understand, how a good investigation could alter (for good), the Safety Management approach and structure of a specific organization.

Here is the second accident that correlates with the LOC-W we started the article with.

Inexperienced pilot on the brand, poor planning of side-by-side scooping not taking into account wake turbulence and wind drift, no previous formation training, and a pushy leader taking pilots beyond their current level of skills.

Full report here:

EC-JLB i006278

A last note and potentially contributing factor is that the two pilots were senior pilots relatively new to the Fireboss on their way to 70, with well-known physical struggles to keep up with the demanding efforts of a fast pace on the Fireboss.

If you hire senior retired pilots, treat them like senior pilots.

Otherwise, rethink your recruiting policy as they do with fighter pilots.

The maximum age for becoming a fighter pilot varies by country and by branch of military service. In the United States, for example, the maximum age for joining the Air Force as a commissioned officer and serving as a fighter pilot is typically around 35 years old.

There is a reason why they retire from the frontline at a reasonably young age.

The reason is safety and physical constraints.

Aerial Firefighting with amphibious scoopers is demanding. Can get as real as 1 drop every 3 minutes, and it feels like a proper workout for the body and the mind.

Fixed Wing Underwater Egress Training( FWUET)

Regarding Fixed Wing Underwater Egress Training( FWUET) let´s highlight once again the importance of being current in this sort of training.

Unfortunately, there are a significant number of Fireboss pilots who have never undergone this training and may be at risk in the event that their aircraft flips over.

Considering there have been at least 14 incidents involving incorrect landing gear configuration for this particular model, we should not underestimate the risk our pilots face if they have not been provided adequate training for the circumstances and statistics they face.

Here is a link to the last landing gear event a few months ago:

I personally know quite a few pilots in Portugal and Spain who, in case of an accident in the water, will be facing this scenario for the first time, without undergoing any previous training.

Far from ideal.

We should act calmly, from muscle memory as this video shows.

There are different types of mockups. Find one that replicates your cockpit and that simulates the event as really as possible. For a fixed-wing aircraft, it is more realistic to simulate a forward flip, than a side flip as it would happen with helicopters.

 

Something else we should train for is remaining calm while facing a stressor.

And ice-cold water is! Many of the remote mountain lakes we operate from have very cold water even in summer.

Make sure you are able to stay calm, breathe and think properly.

During this exercise, the water was ice cold and we had to reply to some questions accurately to be able to swim away.

 

You don´t want to find out what your survival skills look like when you actually need to fight for your life!

Chose your partners wisely

🙏🏻 Before taking the leap, make sure you understand what you’re getting into.

  • Don’t put your life in someone else’s hands without knowing what you are getting into.
  • Measure safety performance against an external, unbiased benchmark.
  • In addition to joining forces with organizations with acceptable standards, set your own, unnegotiable safety standards.
  • Take responsibility for your safety and the safety of your organization.
  • Enjoy the journey, feeling accompanied.
  • Be in control of your career or organization.

Be careful when selecting partners.

☠️ Failure to perform due diligence could put lives at risk, as well as your organization’s reputation and viability.

🔚 There are no replacements for life.

Don’t carry the weight of being a silent party during catastrophic accidents.

🎯 Join us on our zero fatalities mission!

 

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2 thoughts on “Amphibious Scoopers LOC-W (Loss of control in Water)”

  1. Riguroso análisis sobre manejo y gestión del riesgo de mi amigo y compañero Éder Navacerrada.
    Como siempre, Éder está muchos pasos por delante de los demás. Con una capacidad única de ver la operación de forma global y con la adecuada perspectiva. Un trabajo de investigación sorprendente que una vez más nos brinda a los demás para que intentemos entenderlo, aplicarlo y divulgarlo.
    Recomiendo abrir los enlaces que ilustran sus razonamientos ya que ayudan a entender el rigor con el que conecta los diferentes elementos que forman parte de esta compleja operación.

    Muchas gracias Éder. Le pones mucho esfuerzo y talento. A ver si vamos aprendiendo los demás…

    A deep and clever analysis of risk management from my friend Éder Navacerrada.
    As usual, Éder is many steps ahead of the rest of us. He has a unique vision of the big picture and uses to put everything in the proper perspective. This is another research job that he brings to us to try to make us understand, apply and spread.

    I highly recommend following the links in this article to illustrate his conclusions by connecting the different elements involved in this complex Flight Operation.

    Thank you Éder. You put a huge effort into this. Very much appreciated.

    Reply

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