U.S. Forest Service
FY 2009
Aviation Safety Summary
Table of Contents
Executive Summary
3
Aviation Safety Accomplishments
5
Statistical Summary
7
USFS Owned and/or Operated Statistics
14
Fixed-Wing Statistics
16
Airtanker Statistics
18
Helicopter Statistics
21
SAFECOM Summary
23
Mishap Summary
33
NOTE: Formulas used: Industry standard “per 100,000 hours flown”
Accident Rate = Number of accidents divided by the number of hours flown
multiplied by 100,000.
Fatal Accident Rate = Number of fatal accidents divided by the number of
hours flown multiplied by 100,000.
Fatality Rate = Number of fatalities divided by the number of hours flown
multiplied by 100,000.
This report is available on-line at: http://www.fs.fed.us/fire/av_safety/
fy_safety_reports/index.html
2
Executive Summary
In FY 2009 the U.S. Forest Service experienced a below average mishap rate, however,
the attainment of zero aviation accident/incident occurrence is our ultimate goal.
The Forest Service Aviation Risk Management program is based on the philosophy that
all aircraft mishaps are preventable and that mishap prevention is an inherent function
of management.
Risk Management Program Objective:
The objectives of Aviation Risk Management and Training Systems are in keeping with
the most modern approaches to the safe management of complex systems. The Forest
Service incorporates Safety Management Systems (SMS) in it’s aviation program.
Safety Management Systems achieve high standards of efficiency and effectiveness
within the four primary components which include:
Policy is management commitment, responsibility and accountability for the program and the appointment of key safety personnel. Forest Service manuals are being revised using principle centered management for guidance of aviation operations.
 Risk Management identifies hazards and applies risk assessment and mitigation
processes.
 Assurance is the process of monitoring controls that also includes aviation accident
prevention, review and analysis of historical data, accident investigation, error
analysis, and corrective action plans.
 Promotion includes training for pilots, crews, managers, support personnel and endusers. Other communications, awards and lessons learned help to maintain safety
awareness.

Interagency Cooperation to Reduce Aviation Mishaps
Success in aviation safety is a result of coordinated efforts with cooperators and vendors
who provide approximately 90% of all Forest Service aviation services.
 The Forest Service is the leading federal agency working with the FAA on implementing Safety Management Systems that target a reduction in the number of accidents experienced by aircraft vendors that service our natural resource missions.
 Interagency Aviation Program Risk Assessments have been completed for fire suppression operation of Airtankers, SEATS, Aerial Supervision, and Helicopters and
for FS aviation operations in Infra-Red, Forest Health Protection and the Rocky
Mountain Research Station programs.
 A Strategic Risk Assessment was completed on the Type I Helicopter Program.
Contracts were awarded to complete Strategic Risk Assessments on the Rappel and
Aerial Supervision programs in 2010.
3
Executive Summary
Mishap Trends:
The Branch of Aviation Risk Management monitors safety data, hazard reports and mishaps in its effort to identify hazardous trends. The Aviation Accident Database supports
accident trend analysis, and the identification of Human Factors issues. The SAFECOM
system is a proactive method that monitors and corrects safety issues and shares lessons
learned on a daily basis.

All three of the Forest Service aviation related accidents in 2009 occurred on firefighting activities, including an airtanker ferry flight, helicopter water drop and rappel proficiency mission.

There were four Incidents With Potential (IWP) all of which were also supporting fire
suppression activities (3 helicopter and 1 airtanker).

The FS had 441 SAFECOM reports; as a leading indicator of incidents and hazards
this is 32% below the average of 699 reports.

There were a total of 74 incidents and 120 hazards reported in the SAFECOM system
for 2009.

The current accident rate of 5.21 is slightly below the average of 5.89; however, over
the past ten years the trend line is on a slight increase (pg 8).

The current fatality rate is 6.95, which is above the 10-year average of 4.45.

Forest Service Owned and/or Operated aircraft (O/O) have not had an accident in 6
years, the last accident occurred in December of 2003. There have not been any fatalities in O/O aircraft for 14 years.

Fixed wing contract operations have generally remained the same for the past ten
years with an average of one accident a year, however, there were no accidents in
2009.

Airtankers accounted for 7.8% of the flight hours in 2009 and 33.3% of the accidents.

Airtankers accounted for 8% of the flight hours over the last 10 years and 14% of all
the accidents.

Helicopters accounted for 46% of the flight hours in 2009 and 66.6% of the accidents.

Helicopters accounted for 47.9% of the flight hours over the past 10 years and 59% of
all the accidents.

The number of reported helicopter dropped (11) and dragged (19) loads accounted for
41% of the incident reports in 2009 compared to 54% in 2008 and 42% in 2007.
4
Aviation Safety Accomplishments
Accomplishments achieved in aviation safety in FY 2009 include the following:
Safety Promotion:
Published 4 Interagency Aviation Safety Alerts
Published 2 Interagency Technical Bulletins
Published 3 Interagency Aviation Lessons Learned
Published 8 Interagency Accident Prevention Bulletins
Produced 2 FS Safety Alerts
Produced 4 Monthly SAFECOM Summaries
Produced one Interagency Airward Newsletter
SAFECOM Working Group launched online SAFECOM Survey
SAFECOM Working Group added function to upload picture and pdf files to SAFECOM
SAFECOM Working Group produced SAFECOM Training Module
Redesigned Forest Service Aviation Safety web pages to reflect Safety Management System
philosophy
Developed Aviation Safety Management System web pages with the Wildland Fire Lessons
Learned Center
Coordinated investigations on 3 Forest Service accidents, and 4 incidents with potential
Promoted Safety Management Systems (SMS) with BLM and AMD
Updated program risk assessments for Infrared, Rope Assisted Deployment System
(RADS), and Emergency Human Extraction Longline (EHELL)
Contracted and completed Strategic Risk Assessment for Type I Helicopters
Initiated Strategic Risk Assessment for Rappel program
Policy/Procedure Recommendations
Assisted in fire and aviation policy rewrite implementing Doctrine
Completed 5720 doctrinal rewrite
Produced draft Safety Management Systems Guide
Assisted with contract modifications to include safety criteria
Assisted with contract evaluation to assess safety criteria
Incorporated ARB action items into training programs and aviation contracts
Assisted in revision review of Interagency guides including Redbook, IHOG, Rappel guide,
etc.
Produced the Interagency Risk Assessment Workbook
5
Aviation Safety Accomplishments
Training
Training is managed through a system of resources including basic Interagency aviation
courses, university level education, and NWCG sanctioned skills based training for all FS
aviation users.
 The FS sponsored an FAA Safety Management Systems (SMS) course for all FS aviation personnel and as well as interagency partners. (85 attendees)
 Sponsored 27 scholarships each for six System Safety Leadership and Aviation Management (SSLAM) modules through UC Davis
 To date 49 Forest Service personnel have completed the SSLAM Certificate Program,
which also meets the requirement for issuance of the ICAP Federaql Aviation Safety
Officer Certificate
 Interagency Aviation Training (IAT): Forest Service employees completed 12,457 online courses, 1,627 classroom courses and 817 courses at an ACE conference for a total
of 14,901 courses
 Coordinated/funded projects with DOI for Interagency Aviation Training (IAT) program, including on-line computer based training and contracted course development
 One Aviation Centered & Education (ACE) training session was held in Boise
 Interagency Aviation Training (IAT) provided 74 “A courses” including 25 online
courses with the remainder being classroom instruction of basic safety courses to over
9,600 FS employees to date
 Assisted R-3 in coordinating an IAT week long training session in Albuquerque.
 Assisted FHP in presenting two IAT week long training sessions in Portland, OR and
Salt Fork, OH.
 Coordinated USFS ACE instructor assignments.
 Presented Controlled Flight into Terrain (CFIT) course for NAFA and SSLAM
 Presented A-200 Aviation Mishap Reviews at several Helicopter Crewmember, Helicopter Manager and Helibase Manager Courses
 Conducted three IAT instructor classes qualifying 10 new FS Instructors
6
Statistical Summary
The USFS flew 57,536 hours in FY 2009 which is well below the 10-year average of
83,105. There were 3 accidents and 4 “Incidents With Potential” (IWP). The accident
rate for FY 2009 is 5.21, which is slightly below the 10-year average of 5.89. Unfortunately
there were 4 fatalities, 3 involved in the airtanker accident and one rappel accident.
The primary mission of Forest Service Aviation is to support the natural resource programs
through a variety of means, including, but not limited to:












Aerial delivery of firefighters by parachute, rappel rope, or on site landing
Air tactical command and control
Surveillance, reconnaissance, and intelligence gathering
Infrared detection & mapping
Aerial delivery of fire retardant and water
Passenger transport for firefighting and resource missions
Administrative flights
Research
Forest rehabilitation
Forest Health Protection (aerial surveys, application and photography)
Law enforcement
Aerial photography
Approximately 180 employees at the Washington Office, Regional Offices and Forest levels administer the Forest Service aviation program. The national staff is located in Washington D.C. and at the National Interagency Fire Center in Boise, Idaho. The vast majority of aviation personnel are located at nine regional operations centers around the United
States, providing day-to-day operational oversight and program guidance.
The Forest Service annually operates approximately 650 aircraft. These include government owned and leased, but mostly contracted aircraft. The Forest Service owns and operates 27 aircraft (24 fixed-wing and 3 helicopters) and leases/operates 13 aerial supervision
fixed wing aircraft.
Several state agencies and county municipalities operate aircraft under the Federal Excess
Personal Property (FEPP) program which is managed by the Forest Service. These aircraft
are not included in these statistics or mishap data.
7
Statistical Summary
USFS Aircraft Accident Rates 1999 to 2008
USFS Aircraft Accident Rates 2000-2009
14
11.91
accident rate
12
10
8.17
8
8
6
4
5.21
4.96
3.58
4.46
4.69
4.07
3.12
2
0
20
09
08
07
06
20
20
20
05
04
03
20
20
20
02
01
00
20
20
20
Accident Rate
Trendline
FY 2009 Accident Statistics
Aircraft Type
Hours
Number of
Accidents
Accident
Rate
Number of
Fatalities
Fatality
Rate
Fixed-Wing
18,576
0
0
0
0
Helicopter
26,439
2
7.56
1
3.78
3,684
1
27.14
3
81.43
781
0
0
0
0
8,056
0
0
0
0
57,536
3
5.21
4
6.95
Large Airtanker
(LGAT)
*Single Engine Airtanker (SEAT)
USFS Owned and/or
Operated (USFS O/O)
Total
*SEAT – flight hours for SEAT aircraft on USFS lands were obtained from the DOI,
Aviation Management Directorate
8
Statistical Summary
FY 2009 Flight Hour Percentages
6.4%
14.0%
46.0%
Fixed-Wing
1.4%
32.3%
Helicopter
LGAT
USFS O/O
SEAT
10 Year Average of Flight Hour Percentages
2000-2009
7.0%
10.6%
1.0%
47.9%
33.5%
Fixed-Wing
Helicopter
LGAT
9
USFS O/O
SEAT
Statistical Summary
Average vs Actual Hours Flown for FY 2009
100,000
83,105
80,000
57,536
60,000
40,000
20,000
0
Average
Actual
Comparison of Average vs 2009
10 Year Average
2009
Comparison
83,105
57,536
-25,569
Number of Accidents
4.9
3
-1.9
Number of Fatalities
3.7
4
.3
Accident Rate
5.89
5.21
-.68
Fatality Rate
4.45
6.95
2.5
Hours flown
Average vs Actual for FY 2009
Average
7
Actual
6
5
4
5.89
4.9
6.95
5.21
3.7
3
Number of Accidents
Accident Rate
10
4
Number of Fatalities
4.45
3
2
1
Fatality Rate
0
Statistical Summary
10-Year Flight Hour Statistics
Fiscal
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
10-year
Totals
Averages
Fixed
Wing Helicopter
18,576
26,439
23,600
35,512
29,631
41,571
34,564
39,735
22,521
28,362
22,713
29,885
32,704
50,662
33,011
54,427
26,580
39,497
34,976
53,145
LGAT
3,684
5,010
5,641
6,659
3,682
1,535
5,082
8,573
7,832
10,616
SEAT
781
1,318
628
1,792
674
1,006
765
451
282
750
USFS
O/O
8,056
8,187
8,122
6,898
5,185
7,333
7,607
13,052
11,241
12,749
Total
57,536
73,627
85,593
89,648
60,424
62,472
96,055
109,063
85,150
111,486
278,876
399,235
58,314
8,447
88,430
831,054
27,888
39,924
5,831
845
8,843
83,105
10-Year Accident Rates
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
10-year
Average
# of
Total All
Accidents Aircraft
FixedHelicopter LGAT
Wing
3
3
7
4
3
5
3
13
4
4
5.21
4.07
8.17
4.46
4.96
8.0
3.12
11.91
4.69
3.58
0.00
4.23
3.37
2.89
4.44
4.4
3.05
3.02
3.76
2.85
7.56
5.63
9.62
7.55
7.05
6.69
3.94
14.69
5.06
3.76
27.14
0.00
0.00
0.00
0.00
0.00
0.00
23.32
0.00
0.00
4.9
5.89
3.32
7.26
5.14
SEAT
USFS
O/O
0.00
0.00
0.00
0.00
318.47 0.00
0.00
0.00
0.0
0.00
99.4 13.693
0.00
0.00
0.00
15.32
354.6
0.00
0.00
7.84
47.35
4.52
Accident Rate = Number of accidents divided by the number of hours flown multiplied by 100,000.
11
Statistical Summary
10-Year Fatal Accident and Fatality Rates
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
10-year
Average
Fatal
Accidents
2
1
1
2
1
2
1
3
0
1
Fatal
Number of
Accident Rate Fatalities
3.47
4
1.35
9
1.16
1
2.23
6
1.65
3
3.2
4
1.04
2
2.75
6
0.00
0
0.89
2
1.4
1.68
3.7
Fatality
Rate
6.95
12.22
1.16
6.69
4.96
6.4
2.08
5.50
0.00
1.79
4.45
Fatal Accident Rate = Number of fatal accidents divided by the number of hours flown
multiplied by 100,000.
Fatality Rate = Number of fatalities divided by the number of hours flown multiplied
by 100,000.
12
Statistical Summary
Forest Service Aircraft
Accident Statistics in 5-Year Increments
The total number of accidents in 5-year increments shows a steady decline, until the 20012005 period. The total number of fatalities in 5-year increments shows a major decline in
the 80’s from the 70’s; however, since 2001 the number of fatalities has begun to rise. With
the adoption of Safety Management Systems, particularly new risk management processes
and quality assurance programs we anticipate a decrease in the number of accidents and fatalities in the future.
90
80
70
60
50
40
30
20
10
0
85
Total Number of Accidents for all aircraft
(5-Year Increments)
67
60
45
41.1
34
32
28
26
17
17
e
ag
er
Av
8
00
-2
61
19
10
20
600
*2
5
00
-2
01
20
0
00
-2
96
19
5
99
-1
91
19
0
99
-1
86
19
5
98
-1
81
19
0
98
-1
76
19
5
97
-1
71
19
0
97
-1
66
19
5
96
-1
61
19
Total Number of Fatalities for all aircraft
(5-Year Increments)
40
40
35
35
30
30
25
20
15
19
20
19
21.2
15
15
11
8
10
5
0
e
ag
er
Av
8
00
-2
61
19
10
20
600
*2
5
00
-2
01
20
0
00
-2
96
19
5
99
-1
91
19
0
99
-1
86
19
5
98
-1
81
19
0
98
-1
76
19
5
97
-1
71
19
0
97
-1
66
19
5
96
-1
61
19
13
USFS Owned and/or Operated Aircraft
This section of statistics include the 27 Forest Service owned fleet aircraft and 13 leased/
Forest Service operated aerial supervision aircraft. The Forest Service owned aircraft accounted for 5,326 flight hours and the 13 leased aerial supervision aircraft flew 2,730
hours. This was 14% of the total flight hours, which is well above the average of 10.6 percent. There have not been any accidents since FY 2004 (December 2003) and no fatal accidents for fourteen years in USFS owned aircraft.
USFS Owned and/or Operated 10-Year Statistics
Fatal
# of
Accident Fatal
Fatality
Accident Fatalities
Accidents Rate Accidents
Rate
Rate
Fiscal
Year
Hours
Flown
2009
8,056
0
0.00
0
0.00
0
0.00
2008
8,187
0
0.00
0
0.00
0
0.00
2007
8,122
0
0.00
0
0.00
0
0.00
2006
6,898
0
0.00
0
0.00
0
0.00
2005
2004
5,185
7,333
0
1
0.00
13.63
0
0
0.00
0.00
0
0
0.00
0.00
2003
7,607
0
0.00
0
0.00
0
0.00
2002
13,052
2
15.32
0
0.00
0
0.00
2001
11,241
0
0.00
0
0.00
0
0.00
2000
12,749
1
7.84
0
0.00
0
0.00
Total
88,430
4
Average
8,843
0.4
0
4.52
14
0
0
0.00
0
0.00
USFS Owned and/or Operated Aircraft
USFS Owned & Operated Hours Flown
14000
12000
10000
8000
6000
4000
2000
Hours Flown
Trendline
0
20
20
20
20
20
20
20
20
20
20
09
08
07
06
05
04
03
02
01
00
USFS Owned & Operated Accident Rates
18
15.32
16
13.63
accident rate
14
12
10
7.84
8
6
Accident Rate
Trendline
4
0
0
0
0
0
07
20
08
20
09
20
0
06
20
0
05
20
2
0
04
20
03
20
02
20
01
20
00
20
15
Fixed-Wing Aircraft (contract)
Fixed-Wing contract aircraft accounted for 32.3% of the total hours flown in FY 2009; the
10-year average is 33.5 percent. There were 18,576 hours flown in FY 2009, which is well
below the 10-year average of 27,888. This was the first year contract fixed-wing aircraft did
not have an accident in the past 10 years.
Fixed-Wing 10-Year Statistics
Fiscal
Year
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Total
Average
Fatal
Accident
Fatal
Fatality
Accidents
Accident Fatalities
Rate
Accidents
Rate
Rate
18,576
0
0.00
0
0.00
0
0.00
23,600
1
4.23
0
0.00
0
0.00
29,631
1
3.37
0
0.00
0
0.00
34,564
1
2.89
0
0.00
0
0.00
22,521
1
4.44
0
0.00
0
0.00
22,713
1
4.40
1
4.40
3
13.2
32,704
1
3.06
0
0.00
0
0.00
33,011
1
3.03
0
0.00
0
0.00
26,580
1
3.76
0
0.00
0
0.00
34,976
1
2.86
1
2.86
2
5.72
278,876
9
2
5
27,888
0.9
3.22
0.2
0.71
0.5
1.79
Hours
Flown
16
1
Fixed-Wing Aircraft (contract)
Fixed-Wing Hours Flown
40000
35000
30000
25000
20000
15000
10000
5000
Hours Flown
Trendline
0
20
00
20
20
01
20
02
20
03
04
20
05
20
06
20
07
20
08
20
09
Fixed-Wing Accident Rates
5
4.4
4.5
accident rate
4.23
3.76
4
3.37
3.5
3
4.44
3.03
2.86
3.06
2.89
2.5
2
1.5
1
0.5
Accident Rate
Trendline
0
0
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
17
Airtankers (contract)
Large Airtankers accounted for 6.4% of the total hours flown in FY 2009; which is slightly
below the 10-year average of 7%. There was one large airtanker accident with 3 fatalities.
The accident occurred in April while enroute to New Mexico from Montana, see page 34
for more information. There were no SEAT accidents under Forest Service operational
control.
All Airtanker 10-Year Statistics
Fiscal
Year
Hours
Flown
Accidents
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Total
4,465
6,328
6,269
8,451
4,356
2,541
5,847
9,024
8,114
11,366
66,761
1
0
2
0
0
1
0
2
1
0
7
Average
6,676
0.7
Fatal
Accident
Fatal
Fatality
Accident Fatalities
Rate
Accidents
Rate
Rate
22.39
1
22.39
3
67.18
0.0
0
0.00
0
0.00
31.9
0
0.00
0
0.00
0.00
0
0.00
0
0.00
0.00
0
0.00
0
0.00
39.35
0
0.00
0
0.00
0.00
0
0.00
0
0.00
22.16
2
22.16
5
58.32
12.32
0
0.00
0
0.00
0.00
0
0.00
0
0.00
3
8
10.48
18
0.3
4.49
0.8
11.98
Airtankers (contract)
Large Airtanker 10-Year Statistics
Fiscal
Year
Hours
Flown
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Total
3,684
5,010
5,641
6,659
3,682
1,535
5,082
8,573
7,832
10,616
58,314
Average
5,831
Fatal
Accident
Fatal
Accidents
Accident Fatalities
Rate
Accidents
Rate
1
27.14
1
27.14
3
0
0.00
0
0.00
0
0
0.00
0
0.00
0
0
0.00
0
0.00
0
0
0.00
0
0.00
0
0
0.00
0
0.00
0
0
0.00
0
0.00
0
2
23.33
2
23.33
5
0
0.00
0
0.00
0
0
0.00
0
0.00
0
3
3
8
0.3
5.14
0.3
5.14
0.8
Fatality
Rate
81.43
0.00
0.00
0.00
0.00
0.00
0.00
58.32
0.00
0.00
13.71
Single Engine Airtanker 10-Year Statistics
Fiscal
Year
Hours
Flown
Accidents
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Total
781
1,318
628
1,792
674
1,006
765
451
282
750
8,447
0
0
2
0
0
1
0
0
1
0
4
Average
845
0.4
Fatal
Accident
Fatal
Accident Fatalities
Rate
Accidents
Rate
0.00
0
0.00
0
0.00
0
0.00
0
318.47
0
0.00
0
0.0
0
0.00
0
0.0
0
0.00
0
99.4
0
0.00
0
0.0
0
0.00
0
0.0
0
0.00
0
354.6
0
0.00
0
0.0
0
0.00
0
0
0
47.35
19
0
0.00
0
Fatality
Rate
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
Airtankers (contract)
Airtanker Hours Flown
12000
LGAT
SEAT
ALL AT's
Trendline LGAT
Trendline SEAT
10000
8000
6000
4000
2000
0
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
Airtanker Accident Rates
400
All AT's
LGAT
SEAT
Trendline All AT's
354.6
350
318.47
accident rate
300
250
200
150
100
99.4
50
12.32
0
0
0
0
22.16
23.33
0
39.35
0
31.9
0
0
0
0
0
0
0
0
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
20
0
0
22.39
27.14
Helicopters (contract)
Helicopters accounted for 46% of the flight hours in FY 2009, which is below the 10-year
average of 47.9%. There were 2 helicopter accidents, a Type I helicopter and fatal rappel
accident, see pages 35 & 36 for more information. There have been a minimum of 2 helicopter accidents yearly for the past 10 years and at least one fatal accident for the past 8
years.
Helicopter 10-Year Statistics
Fatal
Accident
Fatal
Accident Fatalities
Rate
Accidents
Rate
7.56
1
3.78
1
Fiscal
Year
Hours
Flown
Accidents
2009
26,439
2
2008
35,512
2
5.63
1
2.81
9
25.34
2007
41,571
4
9.62
1
2.40
1
2.40
2006
39,735
3
7.55
2
5.03
6
15.01
2005
28,362
2
7.05
1
3.52
3
10.57
2004
29,885
2
6.69
1
3.34
1
3.34
2003
50,662
2
3.95
1
1.97
2
3.95
2002
54,427
8
14.70
1
1.84
1
1.84
2001
39,497
2
5.06
0
0.00
0
0.00
2000
53,145
2
3.76
0
0.00
0
0.00
Total
Average
399,235
39,923
29
2.9
7.26
9
0.9
2.25
24
2.4
6.01
21
Fatality
Rate
3.78
Helicopters (contract)
Helicopter Hours Flown
60000
50000
40000
30000
20000
10000
Hours Flown
Trendline
0
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
Helicopter Accident Rates
16
14.7
14
accident rate
12
9.62
10
8
6.69
6
7.05
7.56
7.55
5.63
5.06
3.95
3.76
4
2
Accident Rate
Trendline
0
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
20
00
20
22
SAFECOM Summary
The SAFECOM system satisfies Federal Aviation Regulations requirements for incident
reporting, but more importantly, it provides management and front line supervisors with
near real time trend information. Armed with data on emerging safety and effectiveness
challenges, operators and management can take appropriate actions before a mishap occurs.
There were a total of 830 SAFECOMs (441 Forest Service, 287 DOI, 98 State and 4
Other/Unknown) submitted to the Interagency SAFECOM database.
The following charts trend the Forest Service SAFECOM data submitted to the Interagency SAFECOM database online at http://www.safecom.gov/. In FY 2009 there were
441 Forest Service SAFECOMs submitted, which is well below the 10-year average of 699.
The most reported SAFECOMs in FY 2009 were communications (49), engine (43), electrical (42), pilot action (24), instrument (21), dragged load (19), and chip light (19). In an
analysis of the past five years, all but pilot action, instrument and dragged loads were in the
top reported. We saw a decrease in the number of dropped loads, precautionary landings
and policy deviation SAFECOMs in 2009.
Yearly Forest Service SAFECOM Totals
YEAR
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Total
Number of SAFECOM’s
441
594
620
753
516
494
887
962
773
949
6,989
10 YR Average
699
23
SAFECOM Summary
2009 SAFECOMs by Aircraft
Aircraft Type
Number
Fixed Wing
Helicopter
Airtanker
N/A
SEAT
USFS Owned/Operated
Total
11
281
50
15
0
37
441
SAFECOMs by Aircraft Type for 10 Years
600
500
400
300
200
100
0
Fixed-Wing
2009
2008
Helicopter
2007
2006
Airtanker
2005
24
2004
USFS Owned
2003
2002
SEAT
2001
2000
SAFECOM Summary
SAFECOMs by Category
The numbers of SAFECOMs by category will be more that the total number of SAFECOMs
reported as each SAFECOM may have more than one category assigned to it. For example
a good portion of the Maintenance SAFECOMs also have Incidents or Hazards associated
with them.
2009 Percent of SAFECOMs by Category
2.5% 0.4%
5.4%
24.9%
1.7%
49.7%
15.4%
Accident
Hazard
Incident
Management
Airspace
Mishap Prevention
Maintenance
10-Year Average Percent of SAFECOMs by Category
0.4% 0.3%
9.9%
26.7%
45.0%
0.5%
17.2%
25
SAFECOM Summary
Airspace SAFECOMs by sub-category
There were a total of 26 Airspace SAFECOMs reported this year, significantly below the 10year average of 75. The most notable difference is number of intrusions, there were only 7 reported this year and the 10-year average is 41.
2009 Percent of Airspace SAFECOMs
3.4%
24.1%
17.2%
13.8%
6.9%
10.3%
24.1%
Conflict
Near Mid-Air
Route Deviation
Congestion
Other
Intrusion
Procedures
10-Year Average Percent of Airspace SAFECOMs
2.7%
1.1%
9.6%
8.1%
18.1%
6.0%
54.4%
26
SAFECOM Summary
Hazard SAFECOMs by sub-category
Communication issues are the most reported hazard, accounting for almost half of the
Hazard SAFECOMs. Frequency management and verbal communications accounted
for several of the communication SAFECOMs. Below are charts indicating the top 5
Hazard SAFECOMs reported and the total number of Hazard SAFECOMs reported
for the last 10-years.
2009 Top 5 Hazards reported
50
49
45
40
35
30
25
24
20
15
16
10
12
9
5
0
Communications
Flight Following
Pilot Action
Policy Deviation
Preflight Action
Total number of Hazards reported by year
300
283
275
250
245
248
235
200
193
150
100
120
144
139
137
50
0
2009
2008
2007
2006
2005
27
2004
2003
2002
2001
2000
SAFECOM Summary
Incident SAFECOMs by sub-category
The number of Dragged loads were most reported in this category this year. Precautionary
Landing and Dropped Loads are generally the most reported. Below are the top 5 Incident
SAFECOMs reported in 2009 and the total number of Incident SAFECOMs reported for
the last 10-years.
2009 Top 5 Incidents reported
20
18
19
16
14
14
12
10
11
8
8
6
5
4
2
0
Aircraft Damage
Dragged Load
Dropped Load
Injury
Precautionary
Landing
Total number of Incidents reported by year
250
200
202
150
127
100
50
161
156
155
125
111
95
95
2005
2004
74
0
2009
2008
2007
2006
28
2003
2002
2001
2000
SAFECOM Summary
Maintenance SAFECOMs by sub-category
Almost half of the SAFECOMs reported had maintenance related deficiencies. Engine
maintenance discrepancies continue to be the most reported. In 2004 we added a subcategory under engine to capture more severe engine events (failures & shutdowns)
which included six last year. Below are the top 5 Maintenance SAFECOMs reported in
2009 and the total number of maintenance SAFECOMs reported for the last 10-years.
2009 Top 5 Maintenance deficiencies reported
50
49
45
40
42
35
30
25
20
21
19
15
15
10
5
0
Chip Light
Electrical
Engine
Instrum ent
Fuel
Total number of Maintenance deficiencies reported by year
500
450
400
350
334
300
419
360
337
250
200
479
453
299
264
239
220
150
100
50
0
2009
2008
2007
2006
2005
29
2004
2003
2002
2001
2000
SAFECOM Summary
Forest Service Mishap Prevention
This was a new category added in 2004 to attempt to capture the good things that individuals are doing for mishap prevention. We have a lot more work to do promoting the
SAFECOM System for reporting the good things that folks are doing.
14
12
10
8
6
4
2
0
2009
2008
2007
2006
2005
2004
Forest Service Management
SAFECOM’s by sub-category
Management was a new category added in 2004 as well with the intent of capturing management issues internally and externally.
12
10
8
6
4
2
0
External
2009
2008
Internal
2007
30
2006
2005
2004
SAFECOM Summary
FY 2009 SAFECOMs by Region
Percent of SAFECOMs by Region
R-8
7%
R-9
1%
R-10
3%
WO R-1
1% 4%
R-2
4%
R-3
15%
R-6
25%
R-4
10%
R-5
30%
FY 2009 SAFECOMs by Aircraft Type and Region
Region
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 8
Region 9
Region 10
NEA
WO
Total
FixedWing
6
1
9
3
15
17
3
1
7
0
1
63
Helicopter
Airtanker
SEAT
4
11
29
32
93
75
26
2
8
0
1
281
2
2
16
2
19
7
1
0
0
0
1
50
0
0
0
0
0
0
0
0
0
0
0
0
31
USFS
Owned
3
3
12
5
3
8
1
0
0
0
0
35
N/A
Total
1
1
0
2
5
2
1
0
0
0
3
15
16
18
66
44
132
109
32
3
15
0
6
441
SAFECOM Summary
SAFECOMs by Region
The numbers of SAFECOM’s by category are more than the total number of SAFECOMs
reported as each SAFECOM can have more than one category assigned to it.
FY 2009 SAFECOMs by Category and Region
Region
Accident
Airspace
Hazard
Incident
Maint
.
Mgt.
Mishap
Prevention
Total
R-1
R-2
R-3
R-4
R-5
R-6
R-8
R-9
R-10
NEA
WO
Total
0
0
0
0
2
0
0
0
0
0
0
2
0
0
5
3
11
6
1
0
0
0
0
26
6
7
12
13
47
15
13
1
4
0
2
120
3
1
5
17
19
23
5
0
1
0
0
74
9
11
46
10
63
74
12
2
10
0
2
239
0
0
1
0
3
5
1
0
1
0
1
12
0
2
0
0
2
1
1
1
0
0
1
8
18
21
69
43
147
124
33
4
16
0
6
481
32
Mishap Summary
USFS Accidents
Date
4/25/2009
Region/Forest
USFS/STATE
Aircraft Type
Lockheed P2V
Tail #
N442NA
Mission
Ferry
7/17/2009
R-5, Six Rivers NF
Sikorsky SH-3H
N613CK
7/21/2009
R-5, Six Rivers NF
Bell 212
N212HP
Water Drop, Fixed
Tank
Rappel Proficiency
The following are the NTSB Reports for the accidents. All of the reports are the preliminary reports which are subject to change, and may contain errors. Any errors in
these reports will be corrected on the NTSB web-site when the final reports are completed. Links are provided to the NTSB reports where updated information may be
posted after the completion of this report.
33
Mishap Summary - Accidents
NTSB Identification: WPR09GA216
14 CFR Public Use
Accident occurred Saturday, April 25, 2009 in Stockton, UT
Aircraft: LOCKHEED P2V-7, registration: N442NA
Injuries: 3 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in
this report will be corrected when the final report has been completed.
On April 25, 2009, about 1005 mountain
daylight time, a Lockheed P2V-7 Neptune, N442NA, impacted the terrain
about one and one-half miles north of
Stockton, Utah. The two airline transport
pilots and their passenger were killed in
the accident sequence, and the airplane,
which was owned by Neptune Aviation
Services, and under the operational control of the United States Forest Service,
was destroyed by the impact. The 14
Code of Federal Regulations Part 91 Public Use repositioning flight, which departed Missoula, Montana, about two
hours prior to the accident, was en route
to Alamogordo, New Mexico. At that time of the accident, the airplane was flying in an
area of low ceilings and restricted visibility. No flight plan had been filed.
According to two individuals who were
near the crash site, the airplane could be
heard proceeding in a southeasterly direction, and although to them it sounded
low, it could not be seen because of the
low clouds. In a matter of seconds after
the airplane passed their location, they
heard what sounded like the airplane impacting the terrain.
The wreckage was eventually located
about 250 feet below the top of a ridge on
the eastern side of Stockton Pass. The
point of initial impact was located about 5,630 feet above sea level, on the northwestern
slope of the ridge.
34
Mishap Summary - Accidents
NTSB Identification: WPR09TA353
14 CFR Public Use
Accident occurred Friday, July 17, 2009 in Willow Creek, CA
Aircraft: Croman SH-3H, registration: N613CK
Injuries: 1 Serious, 1 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in
this report will be corrected when the final report has been completed.
On July 17, 2009, about 1530 Pacific daylight time, a Croman SH-3H, N613CK,
collided with a tank near Willow Creek,
California. The United States Forest Service (USFS) was operating the public-use
helicopter under the provisions of 14 Code
of Federal Regulations (CFR) Part 133.
The commercial rated first pilot sustained
serious injuries, and the commercial rated
second pilot sustained minor injuries. The
helicopter rolled over and sustained substantial damage to the main rotor blades,
fuselage, and tail rotor. The local public-use flight departed Willow Creek about 1430 on
a firefighting mission. Visual meteorological conditions prevailed, and no flight plan had
been filed.
The operator reported that the pilots
were getting water out of a tank, and
had made several circuits. During this
liftoff, the helicopter experienced a
“droop condition.” Witnesses indicated
that the helicopter then collided with
the tank. The helicopter banked until
the main rotor blades contacted the
ground. The left main landing gear
sheared off, and the helicopter rolled
over. The pilots were able to extricate
themselves from the helicopter. The
first pilot was taken to a hospital for
overnight observation.
35
Mishap Summary - Accidents
NTSB Identification: WPR09TA356
14 CFR Public Use
Accident occurred Tuesday, July 21, 2009 in Willow Creek, CA
Aircraft: BELL 212, registration: N212HP
Injuries: 1 Fatal, 5 Uninjured.
This is preliminary information, subject to change, and may contain errors. Any errors in
this report will be corrected when the final report has been completed.
On July 21, 2009, at 1010 Pacific daylight time, a helitack firefighter was killed during an unarrested descent from a Bell 212 helicopter, N212HP, near Willow Creek, California. The
airline transport pilot, spotter and 3 remaining rappellers were not injured. The helicopter
was being operated under contract to the United States Forest Service by Heli-1 Corporation,
Reno, Nevada, as a visual flight rules (VFR) public use flight under Title 14, Code of Federal
Regulations (CFR) Part 91, when the accident occurred. Visual meteorological conditions
prevailed for the local flight. The flight originated from a helibase at Willow Creek at 1004;
no flight plan was filed for the training flight.
A representative from the US forest Service reported that the rappeller was positioned on the
skid when the accident occurred. The helicopter was in a stabilized hover at 200-feet above
ground level (AGL).
The helicopter was not damaged and no mechanical malfunction or failure was reported.
Not actual accident aircraft
36
Mishap Summary - Incidents With Potential
USFS Incidents with Potential
Date
Region/Forest
Aircraft Type
Tail #
Mission
7/31/2009
R-6, Umpqua NF
Kaman 1200
N312KA
Water Drop
8/1/2009
R-6, Umpqua NF
Kaman 1200
N134WC
Water Drop
8/10/2009
R-6, Rogue River/
Siskiyou NF
Cal Fire
MD-600
N60BK
Ferry
Lockheed P2V
N443NA
Retardant
Drop
9/12/2009
KAMAX Rotor Damage, Umpqua NF, July 31, 2009
The helicopter was completing the 12th drop
in his assigned area; which was a side-hill/uphill drop. The afternoon winds were up-slope
making the water drops even more difficult
for the KMAX due to the quartering tailwind.
The pilot elected to continue with the drops
despite the tailwind. As the water was released, thus unloading the helicopter rotor
system and requiring a reduction in power,
the helicopter made an un-commanded turn
into the wind. The pilot reacted to the uncommanded turn by immediately applying full pedal accompanied by sharp cyclic control inputs resulting in a cross controlling condition. The cross control inputs combined
with the low power setting and low airspeed resulted in the right hand 2 rotor blades contacting the opposite rotor hub.
37
Mishap Summary - Incidents With Potential
KMAX Rotor Blade Strike, Umpqua NF, August 1, 2009
The KMAX arrived at the Williams Creek
Helibase to begin work on the Williams
Creek Fire. The Air Attack (ATGS) assigned to the fire would request helicopter
support when visibility allowed for bucket
work. Due to the winds, smoke and fire
behavior helicopter activity was limited to
the late afternoon hours. At 1610, the
KMAX was dispatched to perform water
bucket support.
The dip site had been established on the
Umpqua River next to Highway 138. Dip
site monitors were in place however they
did not have positive contact with the helicopters. This dip site was being used by the
KMAX and 2 Boeing BV-107’s, all bucket aircraft utilizing varying lengths of longlines.
The incident dip site had been in use for 3 days prior to the incident.
The KMAX was using a 150 foot long line
and had been into the dip site at least 12
times totaling approximately 1 hour of flight
time. On this dip the pilot noticed that the
bucket did not fill completely due to the
depth of the river at his selected dip point.
The pilot repositioned the helicopter rearward to a deeper location in the river in an
effort to fill the bucket completely. In doing
so the pilot failed to notice a tree to the right
rear of the helicopter; the rotor blades contacted tree limbs. Upon noticing debris in
the air and settling on the water at the dip
point the pilot realized his blades had contacted a tree. He then emptied the bucket, told Air Attack of the incident and preceded to
the nearest possible landing area to inspect the rotor blades for damage.
The KMAX performance charts used in the interagency load calculation process are part
of a FAA approved revision specific to interagency requirements to reflect a minimum
specification engine. This revision was interpreted incorrectly by the pilot resulting in an
erroneous load calculation. The pilot used pressure altitude instead of density altitude on
figure S1-8 (Power Required OGE Hover 104% Nr) resulting in an incorrect entry in line
7b of the load calculation (approximately 400 lbs more than allowed). The load calculation was not a factor in this incident.
38
Mishap Summary - Incidents With Potential
MD-600 Windshield Damage, Rogue River/Siskiyou NF, August 10, 2009
The Helicopter was on a Call When Need (CWN) contract administered from the Pacific
Northwest Regional Office in Redmond, Oregon. This helicopter is fairly new with only
1727 hours of flight time logged at the time of the incident.
While arriving at the helibase the right front windshield shattered into pieces and those pieces blew
inside the aircraft with great force. At the time the
helicopter was in a slight flair preparing to land at
the airport and was traveling at an approximate
airspeed of 100 knots. The pilot heard a loud bang
as the right side windscreen imploded. The pilot’s
first reaction was to check his aircraft instruments
and see if the helicopter was operating properly.
Upon seeing the proper instrument indications, the
pilot’s next reaction was to secure the right front seat cushion, which had come loose due
to rotor wash in the cockpit. As the pilot secured the seat cushion he landed the helicopter
on the end of the runway to ensure there were no other problems; satisfied the pilot air taxied the helicopter along the airstrip to his parking area at the helibase.
After the helicopter was shut down and notifications were made the aircraft was searched
for damage from top to bottom, inside and out. The shattered plexiglass scared and cut
much of the right side interior, even scars in the backseat area. The pilot was flying from
the left side with the left side door off and stopped many of the larger pieces of plexiglass
from exiting the aircraft through his door. No other damage was found on the outside of
the helicopter or the rotor blades. The aircraft was being operated within the Aircraft
Flight Manual parameters and this was not the reason the plexiglass windshield failed.
The pieces of the windshield were assembled in their approximate locations and examined
for impact damage or any revealing evidence that would explain the windshield failure. It
was discovered that the bottom edge of the windshield had no glue residue on it as would
have been the case if it had been properly glued into position at the time the aircraft was
manufactured. Once the windshield was examined the aircraft windshield frame was examined confirming the absence of glue. Additionally, stress cracks were discovered along
the bottom of the aircraft windshield frame indicating movement where there should have
been none.
The Fact Finding Team concluded that the plexiglass was not properly secured in position
when the helicopter was manufactured; this allowed slight movement of the bottom of the
plexiglass, which over time stressed the plexiglass to the point of failure. The MD repair
manual confirmed that the windshield should have been glued all the way around when
installed. We were very lucky that no one was sitting in the right front seat of this aircraft!
39
Mishap Summary - Incidents With Potential
P2V, T-43 Fresno Tanker Base, Cal Fire Retardant Drop, September 12, 2009
After the takeoff roll was completed and aircraft became airborne the crew noticed that it
took a slightly different amount of normal trim to maintain straight and level otherwise all
indications were normal
Two of the company mechanics were returning to the base and going through the gate to
the tanker base. The mechanic driving was working the buttons on the touch pad and did
not notice T-43 taking off. The mechanic riding was watching T-43 take off and he witnessed a flash about 8 feet in diameter just before aircraft rotation. He described it as a
“split second flash, it was gone just as quick as it came”. The tower did not report seeing
anything nor did anyone else on the ramp. This led the mechanic to wonder what he had
seen and thought it must have been nothing. This particular mechanic had also been sick
recently and was not feeling very well. He had asked multiple people if they had seen what
he had, no one did so that is as far as he took it.
When the aircraft returned from the fire the cowling was displaced and looked as if it had
come unlatched in flight.
The crew chief notified Maintenance Control and a company investigation team was assembled and dispatched to the aircraft. The team consisted of Neptune Aviations Director
of Flight, Director of Maintenance, Ground Safety, and Jet shop manager. The RASM was
initially notified of the event, but not to the severity of the explosion and cowling damage.
The RASM and WO were not notified for several days of the severity after the event. The
company had already changed out the engine and had it shipped back to their base before
the agency could investigate. A SAFECOM was never submitted
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Mishap Summary - Incidents With Potential
Below are findings from the company investigation.
 Upon initial examination the Jet shop manager noticed a hairline crack in the aft portion
of the jet fuel control unit (FCU). See picture below.
 The Company Investigation Team placed the jet throttle lever to the Stand by position.
Fuel began leaking immediately from the cracked location.
 What happened was when the aircraft taxied out as per the run-up checklist the jet throt-
tle was placed in stand by and fuel would have began to leak inside of the jet cowling as it
would continue to leak after the jet was running. The jet would have and did run as normal the crew would have not known.
 As the aircraft began their take-off roll the fuel and fumes would have been moved back
towards the hot section area when it would have lit off as an explosion this would have
blown the cowlings open and this would also have been the flash that the mechanic witnessed. The jet ran normally so the crew would have had no indication of trouble. Had it
not been just a flash explosion but a continuous fire the jet fire light and warning tone
would have came on alerting the crew.
 The company completed a onetime inspection of all aircrafts jet fuel controls and have
found no other defects.
 Upon further examination they found that there are several different styles of the rear
cover on the fuel controls some “beefier” than others.
 The company has changed our preflight inspection to include putting the jet fuel control
to the standby position and pressurizing the fuel system to check for leaks.
 The company will also be installing the “beefier” style rear cover on all fuel controls that
are installed on their aircraft.
 The company will also be coming up with a way to communicate with the flight crews
from the ground and train personnel on these procedures.
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