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Learnings from the death of an Aerial Firefighter
The GPIAAF (Portuguese Aviation Investigation Board) has just issued a final report concerning the tragic accident that claimed the life of our colleague, André Serra, during a Fireboss accident in 2022.
Following GPIAAF’s initial assessment of the event as a LOC-I (Loss of Control-Inflight), we promptly disseminated informative resources within the aerial firefighting pilot community.
These materials were intended to enhance safety measures for the remainder of the 2022 season.
Once the investigation is over and we have access to a final report, we can learn from its findings, recommendations, and conclusions to prevent similar tragedies from happening again.
The report stands out for its extensive and professional nature, making it a valuable resource for learning and improving safety standards. The investigators demonstrated an admirable commitment to getting as deep as they could into the causes with the tools and information they had.
The report uncovered some critical points worth discussing and learning from, especially when it comes to hardware.
For instance, it shed light on the unsafe practice of using tie-wraps to secure the door, a matter we’ve highlighted in the past back in 2020
The application of these tie wraps restricts the door opening, either by the normal or emergency system, forcing the pilot to slide the tie wrap away before choosing to open the door using either the normal or emergency opening systems.
Tie-wraps use (from an article dated 2020):
There are some operators I’m familiar with who display a shocking level of ignorance and indifference when it comes to safety. In cases where the pilot door inadvertently opens during flight, often due to factors like vibration, excessive speed during drops, or a subpar locking mechanism, their response is far from responsible. Instead of addressing the issue by reaching out to the manufacturer or proposing an improved and approved design, they resort to a rather crude solution. This involves securing the door with a plastic tie wrap looped around the opening handle. This makeshift “quick fix” not only violates safety regulations but is also a matter of shame, both on the part of those who suggest it and on our part as pilots if we accept and overlook such practices.
A few months ago, once reached by the investigation board and thanks to their work, Air Tractor finally came with a Service Letter:
The phrase “in extreme cases, some operators have used cable ties” means to me that the primary dealer and the operators belonging to the same net of organizations, have been supplying newly manufactured planes with cable ties as a standard for the past 10-15 years.
Hard to believe.
Those promoting or allowing this practice lack a safety-minded view, and it is concerning they are supposed to lead the firefighting scene in EU.
Furthermore, there is a lack of compliance control from Air Tractor / Wipaire to their dealers if these practices have been unnoticed or allowed for more than one decade.
Manual VS Auto scooping:
The report also emphasized the different modes of the scooping system (Auto and Manual) and how pilots were instructed to rely on the Manual mode unnecessarily. This manual scooping approach, without a clear rationale, increases the pilot’s workload, diverts attention, and heightens the risk of overfilling, especially for less experienced pilots.
It comes from the old days when the AUTO Mode was not reliable, and even if today the issue has been fixed, it stayed as an inherited paradigm.
Nowadays, the AUTO Mode works well.
Pilots should be familiar with both modes. As with any automatism having a manual backup, we should know how to use both, but during the earlier phases of the pilot’s training and growth, the auto mode would free mental resources to take care of other relevant aspects of the mission. Having a pilot target fixated on hopper quantity during the scooping phase, it’s bad news.
But certain organizations are still stuck in the old ways, in this case, Manual Mode as the only way that works which is not true.
“Here, we have always done it like that”
This attitude is better explained through The Monkey / Stepladder experiment:
Human and Organizational aspects
When it comes to the human and organizational aspects, as much as the report spots relevant points such as the lack of operator procedures with mitigation actions among pilots, after identifying a deviation from normal operations, or how the operator did not have established procedures for appointing and approving the formation’s lead pilot, being at the time of the accident an informal process based on the perception of the flight ops director, we are still missing key aspects and we are barely scratching the surface:
Why was a novice pilot, without specific training to lead an Aerial Firefighting group, assigned to a leadership role, leading another brand-new pilot in a challenging mountainous area? What is at root cause level?
Digging down to root cause levels and straight to the main point, it is the direct consequence of the absence of experienced pilots in critical positions due to unsustainable growth.
This is because of two main factors:
- Pilots who were historically covering that area of Portugal were attending contracts abroad, more specifically in Greece. A wealthier and more promising market.
- The Flight Operations Manager, who was the assigned lead pilot that day, was not there to take care of his newer pilots. A common practice there down to non-operational reasons that go beyond the purpose of this article.
Ultimately, it ends up in an unfortunate reason: money.
If you are scheduled on duty as a pilot while holding a management position, you also get paid the day as a pilot even if there is no flying.
Poor leadership and questionable mentoring – A latent organizational factor
In the article below (Amphibious Scooper LOC-W), as we get into the section on competitive behavior, a disconcerting pattern emerges. The same individual, who was supposed to be the leader instead of André in the latest accident, and hold the Flight Operations Manager (FOM), has been indirectly involved with three additional accidents. In each of these cases, the pilots flying as his wingman under his leadership, found themselves struggling to keep up, ultimately resulting in crashes or narrowly avoiding disaster.
The reports point to all sorts of reasons, but nobody thinks it was the same leader and management putting the individuals under those circumstances
We must learn from accidents – a similar scenario in Canada years ago
These crucial dots (repeating patterns and the same individuals involved) must be connected, not just for the sake of investigation boards but also to offer a valuable safety recommendation to the operator.
Back to our report on the Fireboss fatal accident, it mentions one of those 3 accidents of the same operator occurred in Aguieira, on 03/08/2016, where the same leader was involved.
(Proc.º GPIAAF 09/INCID/2016 (EC-LGT))
Here is the link:
On that notice, the investigation team did not deem it necessary to continue the investigation and were satisfied with the findings of the internal investigation of the operators, blaming the pilot for pushing the wrong buttons. They did not travel to the scene and only issued an information notice. What they did not know is that the pilot who suffered the incident was close to 70 years old and was struggling and pressured to keep up with the same “leader” and manager that keeps appearing in all those accidents
A similar scenario happened in Canada 8 years ago. 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. After another Fireboss fatality, the reports, the recommendations, and the actions taken catalyzed positive change in the organization.
Check the following article from Aero Assurance to understand, how a good investigation could alter (for good), the Safety Management approach and organizational structure of a specific operator.
Had the investigation board in Portugal connected the dots between those three accidents and the numerous other incidents that the organization has experienced over the past decade, particularly focusing on management and organizational factors, it might have led to significant improvements, as it happened to the Canadian Operator years ago, who left that dark period behind and today is a Fireboss safety reference.
These changes could include organizational changes in the nominated persons holding management positions, and better decision-making processes, such as, perhaps, not leaving André alone during the initial stages of his career as an aerial firefighter.
The importance of recognizing these patterns and addressing them cannot be overstated in enhancing safety standards and preventing future accidents.
The pilot involved in the accident, who was leading the team, had supposedly accumulated 159 hours of total flight time on the aircraft, as reported by the operator. The trailing pilot had 86 hours of experience on the Fireboss.
“In bases with more than one aircraft, the company will designate a “Lead Pilot” foreseen in the monthly schedule. The “Lead Pilot” will be the one that the Flight Operations Department considers to have the best characteristics in terms of flight experience and aerial combat against forest fires, age, local knowledge and language level in Portuguese. It also established the minimum requirements to be proposed as a lead pilot:
-130 hours on the AT-802/A;
-80 hours of aerial firefighting;
If he/she meets the minimum requirements, the SOP states that the pilot must also go through a transitional phase as leader in adaptation and as a wingman qualified as a leader, for a minimum period of 5 firefighting flights”.
Still not enough.
Even though, according to the report, the pilot involved in the event did not meet these requirements, if they had been applicable at that time.
A similar case just a few months after:
Regrettably, just a few months later, another operator, part of the same group of companies with a shared board of directors and management, allowed a disturbingly similar situation to unfold in another country.
This time, the circumstances were even worst. A young pilot, newly rated on the Air Tractor 802 and lacking firefighting experience, narrowly escaped a Loss of Control-Inflight (LOC-I) incident but was forced to cut short his career as an aerial firefighter due to the traumatic experience of a near miss.
He found himself in a LOC-I event and was fortunate to survive.
What sets this apart is that he had only accumulated 11 hours of flight time on this particular aircraft type when he was dispatched to a new, highly lucrative contract, driven by business obligations.
Once again, the root causes of this incident included a rushed introduction to demanding tasks, inadequate training, and ineffective management and leadership from the organization.
After this brave pilot dared to speak amd approached the Aerial Firefighting Mentor, we made the event public through this Linkedin post, so we all could learn from it.
Remember that if you are an organization feeling targeted by these posts, imagine what pilots and families of those suffering from negligent acts, are going through.
There is only one way to stay away from the spotlight:
Do the right thing, not the easy thing. No shortcuts when it comes to safety!
Lack of formal Upset Prevention and Recovery Training (UPRT) and training in mountainous areas are a couple of points that would have provided the pilot with more tools to make an informed decision on the turn or prevent the entrance of the spin during the turn.
This has been highlighted several times in several articles.
These gaps in the pilot’s training may have contributed to the tragic outcome, but why were these elements not adequately covered? Why are those not mandatorily required due to the specific nature of the flying we perform, spending a great part of the flight close to the stall and often in mountainous terrain?
The answer is because of the lack of OSD from the manufacturer and the consequent lack of standardized training provided by the different operators
The absence of an Operational Suitability Data (OSD) from the manufacturer, and just a brief Operational Evaluation Guidance Material on the AT802 land version, plus the differences in training levels between AT-802 land and amphibious not been evaluated, means there is no standardization and every operator could train their Fireboss pilots as they think it’s best, sometimes differing from an optimum path.
A Fireboss is a different machine than the land version and its operation is completely different.
OSD covers pilot training, maintenance staff, and simulator qualification; the master minimum equipment list (MMEL); and possibly other areas, depending on the aircraft’s systems.
Pilot qualification is at the heart of OSD. It defines a minimum syllabus for a type rating and training areas of special emphasis.
Not having one with such a demanding aircraft creates a gap for lack of standardization and the consequences we are seeing.
The manufacturer and STC holder have been approached in the past regarding the issues we were going through, aiming to standardize procedures and training during the expected Fireboss growth, as this post details.
Nothing happened and accidents continued to occur, including this fatal event.
Workload and Scheduling:
The report hinted at workload concerns.
According to the investigation, it was not possible to relate the gathered information regarding the week’s workload. This is a murky area where further investigation could uncover vital information.
We have evidence that the operator made changes to the official schedule after the accident, including assignments to different leader pilots the day of the accident (removing the FOM who was originally assigned as the leader) and reducing the workload of the pilot who died in the accident, as he was close to the limit of his duty and flight time allowances. On the initial schedule, the pilot was scheduled for 25 days during July, having only 6 days off duty. This is a lot for anyone, but way too much for a new pilot.
This revelation casts doubt on the reliability of the information provided. If they have proceeded like that with the schedule, why they wouldn´t proceed the same way with the pilot experience or other information provided?
From the Aerial Fire Fighting Mentor and Doxastic Safety blog, we believe this accident does not represent another sacrifice linked to the inherent risks of our profession, as it tends to be put across among the unspecialized public. Instead, it is the tragic loss of a talented and dedicated young pilot who had unwavering trust in the system while the system failed to support him throughout his career.
His life was cut short due to an accident that could have been prevented with more effective management and responsible decision-making. The vast record of accidents of the operator both in Portugal and Spain through their net of operators with different names, provides enough insights to the investigation boards to connect them and dig deeper on serious organizational factors.
André’s passing has left behind a grieving family, including his wife and children.
While André is no longer with us to share his thoughts and experiences as the pilot who survived the LOC-I a few months after him, we stand in his place to express our deepest condolences, remove any potential blame on him, and remember him within the circumstances that led to his accident
May he rest in peace.