An investigation has found the NSW Rural Fire Service failed to pass on crucial information to the crew of a Large Air Tanker before it crashed near Cooma during the Black Summer bushfires.
Three US crew members died in the crash on January 23, 2020, during efforts to put out the Good Good fire.
An investigation by the Australian Transport Safety Bureau (ATSB) has now found that on the morning of the crash, the RFS had asked two tankers to drop fire retardant on fires in the Snowy Mountains area.
The first plane, a Boeing 737, dropped retardant on a fire at Adaminaby but then left the scene after determining the conditions were unsafe.
They advised all aircraft should stop operating in the area.
However, this information was not also passed on by the RFS to the crew of the C-130.
When the C-130 arrived at the fire, the crew also found the circumstances were too dangerous, and instead travelled to a different fire, which was burning nearby at Peak View.
The investigation found the weather conditions they encountered there were similar at that fireground, where the aircraft was "very likely subjected to hazardous environmental conditions", which included a rapid gust of wind and increased tailwind.
The tanker then likely stalled, before crashing, the investigation concluded.
The investigators also found that a smaller aircraft, used to go ahead of tankers to assess the fire, had rejected the particular tasking due to safety concerns.
Their assessment was also not passed on by the RFS to the tanker crew.
ATSB Chief Commissioner Angus Mitchell said the crew did not have all the information they needed before the crash.
"It was still a situation where they were operating with partial knowledge and not the full picture, which is something that we have recommended in the future — having a far more robust system where all that information is able to be collected and disseminated to those that need it."
Investigation finds RFS did not notify crew of risks
The investigators also found that Coulson Aviation — the operator of the American tanker — had inadequate safety risk management processes and that the RFS failed to notify the tanker of some of the environmental risks.
"Coulson Aviation's safety risk management processes did not adequately manage the risks associated with Large Air Tanker operations, in that there were no operational risk assessments conducted or a risk register maintained," Mr Mitchell said in a statement.
The investigation also found "the operator did not provide a pre-flight risk assessment tool for their firefighting Large Air Tanker crews" and that "Coulson Aviation did not include a windshear recovery procedure in their C-130 Airplane Flight Manual".
In addition to a failure to adequately manage risks from the operator, the investigation found the NSW RFS had limited policies for Large Air Tankers, and no procedures for deployment without aerial supervision.
"The RFS also did not have a policy or procedures in place to manage task rejections, nor to communicate this information internally or to other pilots working in the same area of operation," the report stated.
"The responsibility for the safety of aerial firefighting operations has to be shared between the tasking agency and the aircraft operator," Mr Mitchell said.
Mr Mitchell said there was a combination of information that needed to be passed on from the NSW Rural Fire Service to the firefighters.
"We think it's not one single piece of advice, it's the totality of the information there," he said.
"That the conditions at this fireground were the same as at Adaminaby … where they had rejected the tasking due to those conditions, and equally that the other large fire tanker had departed the fireground and was not going to return."
He said they had recommended that in future, the RFS ensured it passed on all safety information, and also that it consider a policy of cancelling flights over an area if many pilots have deemed it unsafe.
Mr Mitchell extended his condolences to the families of those who lost their lives while fighting the fires in Australia.
"All three were far from home helping to defend lives and property, during the worst fire season in Australia on record," he said.
RFS defends decisions made on day of crash
The investigation noted Coulson Aviation had taken "proactive safety actions" in response to the incident, and that the RFS had committed to a review of RFS aviation doctrine and to conducting research to identify best practice on task rejection and aerial supervision policies.
NSW RFS Commissioner Rob Rogers said the crew had encountered an "inherently dangerous environment" on the day of the crash, and that was reflected in the report.
"The report obviously reflects the difficult period we had in that [2019 to 2020] fire season where we lost firefighters and obviously air crew like this," he said.
"These firefighting aircraft operate in really difficult climates, so they're something that you wouldn't send another aircraft – like a commercial plane – to normally because they're in really gusty, windy, very hot temperatures, [with a] lot of turbulence."
He said that on the day of the crash, the crew had made the same assessment of the first fire they attended as the other crews who had earlier flown in the area — that it was an unsafe environment.
"What I would point out is, while that's true what the ATSB report said, it also is true that that's not the fire that the aircraft crashed on," he said.
"They went to the fire, where they didn't have all the information, the pilot assessed it and said it was too dangerous, so they didn't bomb on that fire.
"They then were sent to a different fire — that's the fire they crashed on."
He defended the decisions of the RFS on the day.
"The pilot's are the ones that make the decisions, they look at the fire grounds, they make a decision whether it's safe to do something," he said.
But he said they would be implementing the recommendations set out by the ATSB "to try and make that operating environment as safe as we can".
"I agree that it's helpful to make sure that information is passed on, but just because a smaller aircraft can't fly on a fire does not there follow that the bigger aircraft can't," he said.
"They've been doing so for years, operating at different parameters, and they'll continue to do that.
"But, as the report recommends, to make sure that everybody's aware of anybody that's refused or not able to fly over a particular fire, to make sure they're all aware, and we'll obviously comply with that."
