Investigation Summary
On the day of the accident, extreme weather conditions were present in the Snowy Mountains region, including forecast mountain wave activity and severe turbulence. Despite these conditions, which had led other firefighting aircraft (including a Boeing 737 Large Air Tanker and a lead plane) to cease operations in the area, Bomber 134 was tasked to the Adaminaby fire-ground. Upon arrival, the crew assessed the conditions at Adaminaby as unsuitable and diverted to a secondary tasking at the Good Good fire-ground near Peak View. The ATSB investigation noted that the New South Wales Rural Fire Service (RFS) did not communicate to the crew that other aircraft had rejected the area due to weather, nor did they provide a lead plane for aerial supervision. Witness video captured the aircraft performing a partial retardant drop of approximately 1,200 US gallons (4,500 L) on a heading of 190 degrees at about 200 feet above ground level. Following the drop, the aircraft began a left-hand turn and climb. Data indicated the aircraft climbed for approximately 10 seconds to about 170 feet above the drop height before its performance began to degrade. The aircraft was then observed descending in a left-wing-down attitude. The investigation concluded that a sudden increase in tailwind and low-level wind shear likely reduced the aircraft's airspeed below the stall margin. The crew did not have sufficient time or altitude to jettison the remaining retardant load before impacting the ground, which resulted in a high-energy collision and a post-impact fuel-fed fire.
Final Conclusions
The ATSB released its final report (AO-2020-007) on 29 August 2022. The investigation concluded that the primary cause was a collision with terrain following an aerodynamic stall induced by hazardous environmental conditions. Contributing factors included the lack of a formal RFS policy for managing task rejections and communicating weather-related flight cessations to all crews. Furthermore, Coulson Aviation's risk management processes were found to be inadequate, as they lacked predefined pre-flight risk assessment criteria and did not include wind shear recovery training or detection systems for the C-130 fleet at the time of the accident.
Photographic Evidence (1)
Video Analysis
No video analysis linked for this case file yet.
Airframe & Maintenance
Crew Experience
Captain
Ian McBeth (45). Had completed 994 air tanker drops.
First Officer
Paul Hudson (42). Former US Marine Corps pilot.
Flight Engineer
Rick DeMorgan Jr. (43). Former US Air Force flight engineer.
Systems & Failure Modes
Inertial Switch (CVR)
A switch designed to cut power to the Cockpit Voice Recorder in the event of a crash; in this case, it was found to have likely activated prematurely during a prior flight, leaving the CVR unpowered during the accident flight.
Wind Shear Detection System
The aircraft was not equipped with a wind shear warning system, which the ATSB noted could have provided the crew with earlier recognition of the hazardous conditions.
Emergency Dump System
A system allowing the crew to rapidly jettison the entire retardant load to reduce weight and improve climb performance; it was not activated before impact.
Interesting Facts
- 01The aircraft was a former U.S. Navy EC-130Q manufactured in 1981.
- 02The Cockpit Voice Recorder (CVR) failed to record the accident flight because an inertial switch had likely tripped during a previous landing, cutting power to the unit.
- 03The crew released only a partial load (approx. 1,200 of 4,000 gallons) before the stall occurred.
- 04A Boeing 737 air tanker and a lead plane had previously refused to operate in the same area due to hazardous winds.
- 05The debris trail extended approximately 180 meters linearly from the initial tree strike.
Safety Actions & Advisories
Wind Shear Training
Coulson Aviation incorporated wind shear recovery procedures into their C-130 Flight Manuals and simulator training.
Pre-flight Risk Assessment
Coulson Aviation implemented a mandatory pre-flight risk assessment tool for pilots to complete prior to the first tasking of the day.
RFS Policy Update
The NSW Rural Fire Service established new policies for aerial supervision and procedures for communicating task rejections to other aircraft in the area.
Location
APPROXIMATE POSITION · AIRPORT LEVEL · Coordinates are the estimate published in the entered by an editor. The ring shows the accuracy the record supports, not the point of impact.