Zero Accidents Attributable to Forest Service This Year
The following information relates to Vendors with Forest Service contracts
For the purpose of lessons learned.
Changes in Investigations
and Reporting
Public Use Vs Civil – Operational Control
Determined by NTSB
Time lines will be longer, Causal Factors
determined by NTSB
Information Sharing 49 CFR Ch VIII 813.13
(b)
• NTSB states that “Parties to the investigation
may relay to their respective organizations
information necessary for purposes of
prevention or remedial action. However, no
information concerning the accident or
incident may be released to any person not a
party representative to the investigation
before initial release by the Safety Board
without prior consultation and approval.
The NTSB has not finalized or determined
probable cause for all of the accidents at
this time.
This is preliminary information, subject to
change, and may contain errors. Any errors
will be corrected when the final report has
been completed.
The information is for accident prevention
purposes only.
 On
January 17, 2012, the Forest Service
officially attained the Gold Standard
Status among Federal Aviation Operators
for meeting best aviation safety
practices.
 Analysis of this event resulted in the
following lessons learned:
 First
time in the history of FS aviation
organization, we experienced a zero
accident year in 2011.
 Accident
s determined charged to unit in
“Operational Control” by NTSB
 Dedicated
Employees working over the
past five years to develop and implement
Safety Management Systems.
 Focus on risk assessment and safety
assurance.
 Contract requirements for the operators
to adopt SMS based safety programs.
 Oversight that assures high quality
standards.
Bell 205 A
Kern County California
Tehachapi, California
September 4, 2011
Injuries: None
Forest Service Exclusive use contracted aircraft
Aircraft was supporting Kern County firefighting
efforts on the Canyon Fire (Non-FS Operation)
On Sept 4, 2011, at approximately 1445 hours,
N205WW (H 522), a Bell 205A, sustained
substantial damage when the pilot attempted to
execute an emergency landing due to an in-flight
malfunction. The downwind landing was hard,
spreading the skids and causing significant
damage.
9
 Air
attack was over the fire and providing
aerial supervision
 The
mission was to provide structure
protection and spot fire suppression
approximately 3 miles South of Mountain
Valley airport (L94)
 Another
type 2 and a type 1 helitanker
were also operating in the immediate
area under control of Kern County Fire.
 H-522
was operating with a Bambi Bucket
hooked directly to the cargo hook.
 The
aircraft was on approach for a water
drop.
 With
the aircraft at 100 feet AGL and 10
KTS over the drop spot, the pilot heard a
low RPM horn, and then noticed an
illuminated caution light.
 He
jettisoned the load and executed a left
pedal turn to exit the canyon and move
away from the fire.
12
 The
pilot checked his
Rotor/Engine RPM
gauge and noticed
the needles were
split, with rotor rpm
at the 4-5 o’clock
position and engine
rpm at 6 o’clock.
13
 The
pilot interpreted
indications to be the
result of a governor
failure.
 The
pilot spotted and
maneuvered toward
an area suitable for
an emergency
landing.
 The
pilot commenced manual governor
procedures.
 As he pulled collective, he felt rotor RPM
decrease and noticed the gauge
indicating 90% NR.
 At approximately 200-300’ and losing
both altitude and rotor RPM, he lowered
the collective, establishing an
autorotation into the LZ.
15
Location of
Jettisoned
Bambi Bucket
Accident Landing Zone
 Damage
:
• Landing skids
• minor damage to
sheet metal around
the landing skid
cross tube mounts
• Damage to aft tail
boom section.
 Tail
stinger was bent
upward
 Greenhouse
plexiglass section over the
left side pilot cockpit
broken.
RH tail boom near tail skid
 Chin
bubble
mounted mirror bar
bent and lower wire
cutter assembly was
partially separated
 Lower
rotating
beacon was
separated.
Bent mirror bar and lower wire cutter
 Pilot
in Command has total PIC time 8785 hours and 915 hours time in model.
 Completed
Emergency Procedure
Training on 5/10/11.
 Pilot
who landed in accident LZ after
accident occurred, needed 46 lbs torque
(max 52 lbs) to land, indicating strong tail
wind.
20
 Pilot
had 400 ft to troubleshoot and select
proper course of action.
 Once
determined, pilot followed
procedure for failed governor yet failed
to adequately restore rotor RPM.
 Tear-down
revealed a failure in the
Engine N2 Tachometer Generator shaft
(Engine RPM indicator system).
21
 Pilot
Jettisoned load when situation got bad.
 Pilot
diagnosed situation, developed a plan
and stuck to it.
 Altitude
limited time for pilot to
troubleshoot problem.
A
hard landing in an open area is better
than uncontrolled crash in trees.
Eurocopter AS 350-BA
N230 CH
Juneau, Alaska
September 26, 2011
Injuries: None
 Aircraft
landing on Ridge to pick up 2 Forest
Sciences Lab personnel working on a
weather station nearby.
 Helicopter
manager on-board.
 NTSB
has categorized the accident as a part
135 operation, not public use.
 Same
aircraft/crew landed in accident LZ
approx 3 hours prior to drop off scientists.
 About
1230, the aircraft landed on top of
ridge at an elevation of about 3100 ft.
 Pilot
locked collective and set engine to
flight idle for 2 minute cool-down.

About 30 to 90 seconds into cool-down,
pilot noted vegetation down-slope and to
his right being buffeted by wind.





A strong gust of wind lifted the helicopter about
5 feet and rolled it onto its left side.
When motion stopped, the pilot secured the
engine and both crew exited the right side door.
The manager called dispatch and a helicopter
was sent to pick up the crew and passengers.
The crew was taken to hospital for medical
evaluation and released.
 The
mission
utilized a Project
Aviation Safety
Plan.
 Pilot
landed N/NE
into perceived
prevailing wind.
 There
was a forecast for prevailing wind
shift from S to N and associated
turbulence the hour before and during
the accident.
 Recorded gusts in the area at 22 mph
from the East.
 LZ was along a ridge line with steeply
sloping terrain dropping off toward the
East.
 The
LZ was south
of considerably
higher rugged
terrain.
Incidents With Potential
 PSD
operations in support of the
Horseshoe 2 incident, burning out fuels
around a mobile repeater site.
 The
crew consisted of the pilot, burn
boss, and the PSD operator/helicopter
manager.
 After
lighting the area around the
repeater site, the flight moved to check
an area where ground crews were going
to burn out around several structures.
 The
flight was on scene about 35
minutes before heading back towards
the repeater site to evaluate the
progress of the burnout.
 Smoke
was becoming worse and the
crew decided to fly under the smoke
column.
 The
pilot descended to about 125 – 150 ft
AGL and 40 knots.
 Due
to degraded visibility the pilot
turned back, slowing the aircraft and
making a right 180 degree turn.
 The
aircraft encountered an un-contolled
right yaw while making the turn in the
drainage along Forest Service Road 42.

The aircraft encountered three 360 degree
spins before the pilot was able to arrest the
yaw rate, 50 ft above the tree-line.
winds
Helicopter
path
 The
crew concluded that everyone was
ok and that there were no mechanical
problems and everyone agreed to
continue flying.
 After
about15 or 20 minutes, the crew felt
that winds and turbulence was starting to
exceed their comfort level and the flight
returned to the heli-base.


The pilot was highly
qualified in type
aircraft and has
participated in
teaching High Altitude
Flying.
Helicopter was
operating in the
vicinity of the FS 42
road under the
influence of right
quartering tail wind .
 Aircraft
was operating in Mountainous
terrain at approximately 5000 ft MSL.
 Winds were 20 to 30 knots. Temp: 96 F
 Aircraft was heavy but within satisfactory
limits.
 Aircraft flying as slow airspeed
 After PSD operations, the crew continued
operating as a reconnaissance platform.
 FAA
advisory circular
90-95
 USFS
IASA (safety
alert) 11-03
 PSD
crew exposed
needlessly in recon
mission.
 The
Bell 407 is not normally recognized for
LTE.
 The
pilot never stopped flying the aircraft and
had a backup plan.
 Even
though left turns are preferred for
maneuvering at low airspeed and high weight,
conditions will not always be conducive to
provide that option.
 If
a right turn is your best direction,
compensate by increasing airspeed and or
altitude prior to making the right turn.
June 15, 2011
T-885
Pike/San Isabel National Forest
Region 2, Fremont County Airport
Canon City, Colorado
 Structure
protection, dropping fire retardant
on Duckett fire.
 Aircraft had been operating out of Fremont
County airport from 0911 – 1145.
 The aircraft was under a DOI National OnCall contract.
 Aircraft repositioned to Buena Vista airport
due to shortage of retardant at Fremont
County.
 Aircraft had made last drop and was
returning to Fremont County to standby.
 Winds
150 v 210 (AWOS)
 Temperature: 92F (AWOS)
 Density Altitude 8800’ (AWOS)
 Wind
Event- Pilot entered the Fremont
County Airport area around 1316, winds
developed to 21 mph with gusts to 40 at
around the same time.
 The
pilot) to received the current weather
information 12 miles out.
 The
pilot approached the airport from the
Northwest to enter a downwind to runway
11.
 On
final approach, the pilot noticed a large
“dust devil” or “thermal” crossing the
runway and decided to abort the landing
attempt and continue heading down runway
11.
 The
 The
pilot decided to land on Runway 17.
pilot flew a high observation pass of
the runway to check wind conditions and
continued to land on runway 17.
 The
pilot entered a
left traffic pattern for
runway 17 and, after
crossing runway
threshold, he
encountered a “wind
shear”, causing the
aircraft to suddenly
drop approximately
80 to 100 feet.
N
11
17
29
 The
pilot increased power and touched
down about 200’ beyond the approach end
of the runway.
 On
rollout, and, just after crossing taxiway
A1, he encountered a left wind shear
forcing the aircraft to the right.
 He
applied rudder, brake and power for
additional directional control.
 He
applied full take
off power. as the
aircraft drifted right,
departing the runway
in a banked left turn.
 The
left leading edge
of the wing contacted
a runway marker.
 The
impact broke off
the marker and
damaged the leading
edge, lower wing
skin, left aileron and
contacted the left
lower trailing edge
wing tip.
 The
pilot
continued into the
air, setting up for
a landing on
runway 29, landing
uneventfully, he
taxied back to the
airtanker base.
June 24, 2011
Heli-Tanker 719
Coronado National Forest
Region 3, Sierra Vista Arizona
 The
aircraft was a CH54, N719HT on a
National Exclusive Use Contract.
 They
were assisting crews with water
drops on the Monument fire.
 The
aircraft was coming in for a second
drop on a specific tree.
 Smoke
conditions made the drop area
difficult to find.

The aircraft made a 30 knot down canyon
approach for a split drop at 200 feet
(AGL) and around 100 feet above the tree
top.
 Immediately
after the
drop, the crew heard
a loud “bang” and
noticed the right side
chin bubble broken.
 The
PIC jettisoned
the remainder of the
load and returned to
the helibase
 Snorkel
hose length was measured at 18 feet
8 inches.
 The
snorkel pump housing impacted both
left main landing gear outboard tire and
right side chin bubble.
A
witness in the vicinity of the water drop
saw the snorkel hose swinging “violently”
and stated the hose seemed much more
flexible than others he had seen.
 Alignment
inputs on
final approach to the
drop may have
created /amplified
swinging of the
snorkel .
 Two
variety of hoses,
some pilots thought
the “white” variety of
hose to be “noodley”.
 The
potential of the
snorkel hose
impacting other parts
of the aircraft,
including the main
rotor system, exists.
Bottom edge of chin bubble
May 14 – June 12, 2011
Multiple Aircraft
Region 3, Large Fires



During a 4 week period from May through June,
2011, large fire activity was occurring along the
Arizona and New Mexico border with extensive
use of Air-tankers, Heli-tankers, helicopters and
coordination aircraft.
Received four reports of airspace conflicts
indicating conditions that could lead to a mid-air
collision.
One un-reported conflict was discovered during
research into one of the reported incidents.
 Horseshoe
2 Fire, a Type-1 heli-tanker and
Type-2 helicopter with long-line had a near
miss with approximately 700 ft separation.
• Air attack distracted and overloaded while working
•
•
•
•
an evacuation of spike camps.
Mission changed since AM brief.
Helicopters not aware of each others presence.
No HELCO.
One aircraft transitioning N-S while other was E-W,
creating intersection.
 Horseshoe
2 fire – Two conflicts in one
day, Heli-tankers and type-2 Helo
supporting ground firefighters.
 Heli-tanker encountered conflict with a
Lead setting up a tanker drop.
 Later that afternoon, Heli-tanker came out
of smoke and saw an un-announced ASM
making dry runs through the area he was
working.
 Large
numbers of aircraft working the
area with ASM and Lead aircraft.
 HELCOs not used.
 Emergent missions, with little or no brief
with other aircraft.
 Long ATGS transition radio traffic.
 Radio traffic extremely heavy, air crew
were turning down certain frequencies
and not hearing warning calls.
 Wallow
Fire – Helicopters working out of
the Springerville heli-base entering FTA
without establishing radio contact.
 Traffic
conflicts were occurring between
these helicopters and air-tankers / lead
planes.
 Heli-base
was just outside and North of
the Fire Traffic Area (FTA).
 Helicopters
were supporting fire activity
South of the FTA, direct flight most
expedient route.
 Insufficient
time to contact ATGS.
 Area
Command was being transported
from one town in the southern part of a
large FTA to a town just inside the
Northern boundary of the same FTA.
 The FTA was divided into 3 zones with a
different Air attack for each zone.
 Area command aircraft had near miss
with Air Attack in the second zone they
were entering enroute to destination.



Area Command aircraft
took off from Reserve
and had radio contact
with zone 2 air attack.
Zone 1 air attack was
being relieved and its
relief was reconning the
area before pass-down.
Zone 1 aircraft was unaware the Area
Command aircraft was
entering their zone.
60 nm
Show Low
Zone 1
Zone 2
Reserve
Fire Traffic Area Willow
 High
traffic encountered with both Rotor
and Fixed wing.
 Incidents occurred during the afternoon.
 Morning missions briefed in controlled
environments with little distraction.
 Afternoon, emergent missions develop that
miss the opportunity for crews to get clear
and complete information.
 Radio traffic was generally heavy.
 Transition radio conversations were tying
up air to air frequency.
 Transition
is a particularly vulnerable
period until the coordination rhythm is
restored.
 Critical radio calls not received and position
calls were sometimes not made.
 Aircraft experiencing incidents involved at
least one aircraft that was not in radio
communication with the other and was
unaware of its location.
 Helicopter water operations and fixed wing
tanker drops are still set up without “fences”
to ensure separation.
 Air
Attack crews were experiencing high
workloads resulting in reduced attention to
the helicopter coordination.
 FTA procedural discipline begins to
breakdown as radio traffic becomes intense.
 When the FTA is close to a base, aircraft are
inside the 7 mile area as soon as they are
airborne.
 Teams interviewed agreed there was a need
for a HELCO when air operations got
complex.
 On
March 09, 2012 the NTSB released it’s
Probable Cause and Contributing Factor
for this 3 fatality accident (Pilot and 2 FHP
employees were only soles on board)
 The aircraft was heading towards William
T. Piper Memorial Airport, near Lock
Haven, PA when the engine failed within
5 miles of the airport.
 Probable
Cause: The total loss of engine
power resulting from the fatigue failure of
the engine's number 2 cylinder exhaust
valve. The fatigue failure was due to valve
guide wear that led to excessive
clearance between the valve and valve
guide.
 Contributing
Factor: Contributing to the
accident was the contract operator’s lack
of compliance with its own maintenance
procedures, which, if followed, would
have prevented the accident.