A failure to observe altitude restrictions and maintain situational awareness at low altitudes and high speeds are among six factors the Coast Guard says contributed to the fatal crash of a MH-60 Jayhawk helicopter near La Push, Wash., July 7, 2010, according to a final action memo drafted here and released Monday that summarizes the key findings of an administrative investigation into the crash.

“…operation of the helicopter at high speed and low altitude created a situation in which there was little margin for error,” wrote Vice Adm. Sally Brice-O’Hara, Coast Guard vice commandant, in the memo. “And even a momentary lack of attention increased the potential for a mishap.”

The Jayhawk was being transferred to Air Station Sitka, Alaska, from the Aviation Logistics Center in Elizabeth City, N.C., following a six-month overhaul period.  An ALC crew flew the helicopter to Air Station Astoria, Ore., where the Sitka-based crew took custody of the helicopter.

Shortly after departing, the aircraft struck power transmission lines and broke apart in flight, coming to rest in approximately 10 feet of water near the Quillayute River Inlet.  Three of four crewmembers were killed — the copilot survived.

The memo directs 16 actions including a review of existing policy relating to low-level flight, an audit of Coast Guard-maintained power lines and towers to ensure they are adequately marked and a reassessment of existing policy on flying over Coast Guard boats.

The principal purpose of the investigation was to identify and better understand what went wrong and what can be done to prevent future crashes.

“Coast Guard operations are inherently dangerous, whether carrying out a mission or carrying out daily routine operations,” said Brice-O’Hara. “We hope to honor the memory of those lost by learning all we can from this accident to ensure Coast Guardsmen are fully prepared to safely and proficiently conduct operations.”

The memo was posted to the Coast Guard’s FOIA reading room and is accessible by visitinghttp://www.uscg.mil/foia/docs/CG%206017%20FAM.pdf.

HeliHub.com Editor notes -In the summary of the report, it states “Since this mishap, Coast Guard leaders have visited every aviation unit and senior operational commanders to personally discuss ASAAP findings and address the issues of complacency, the need to follow established aviation policy, and the importance of professional execution and adherence to accepted safety procedures.   See also

• Accident report page – 07-Jul-10 6017 Sikorsky MH-60 nr James Island, US-Washington (3F)
• US Coast Guard drops charges against co-pilot crash survivor