2011
Pacific Northwest
Region
PNWCG Analysis
Task Order 1010-05, Aviation Accident Summary Report
Pacific Northwest Region
PNWCG Report
Aviation Working Team (AWT)
Last 10 Years 1
1/27/2011
To: Chair, Aviation Working Team
October 13, 2010
Subject: Task Order 1010-05, Aviation Accident Summary Report
The PNWCG Steering Committee tasks the AWT to develop an aviation accident
trend report representing the past 10 years. The steering committee is interested in
reviewing the trends to see if any actions could be taken in the PNW to further
support any national efforts to help reduce aviation accidents.
The steering committee assumes the AWT would use current national data to create
the report for accidents in the PNW. No additional collection of data is expected,
but the summary report should represent accidents from the PNW and from all
member agencies of PNWCG. The key to this Task Order is for the AWT to help
the Steering Committee better understand aviation accident trends so we can better
support efforts to help reduce them.
Due Date: Jan 2011.
If you have questions, please contact your SC liaison Joe Shramek (360) 902-1317).
Sincerely,
/s/ Ken Snell
Ken Snell
Chair
Pacific Northwest Region
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Last 10 Years 2
Trend Data
Accident. An occurrence associated with the operation of an aircraft that takes place between
the time any person boards the aircraft with the intention of flight and all such persons have
disembarked, and in which any person suffers death or serious injury, or in which the aircraft
receives substantial damage (Title 49 of the Code of Federal Regulations (49 CFR) § 830.2,
Definitions).
Incident. An occurrence other than an accident, associated with the operation of an aircraft,
which affects or could affect the safety of operations (49 CFR § 830.2, Definitions).
Incidents-With-Potential (IWP). Term used by the Forest Service (FS) and the Department
of Interior (DOI) which represent aircraft mishaps that narrowly avoided being declared an
“accident” by the National Transportation Safety Board (NTSB) and in which the circumstances
indicate significant potential for substantial damage or serious injury.
As a starting point we will discuss aviation usage over the last 10 years in the
Pacific Northwest; General Aviation (GA) data, FS data and DOI data in an effort
to discover similarities. The Federal Aviation Administration (FAA) defines the
GA accident rate as a numerical value of accidents “per 100,000 flight hours”
using the following equation.
(Accident Rate = Number of accidents / divided by the total hours flown X times 100,000)
The FAA, USFS, and DOI use the accident rate to more accurately pinpoint
safety concerns or trends indicating potential safety concerns.
GA aircraft average 20.46 million flight hours per year in the US, with an average
of 1,500 accidents per year. Currently the GA accident rate is 7.2 per 100,000
flight hours.
General Aviation Accidents for the Last 10 Years
Total Oregon Accidents:
416 Aviation Accidents
78 Accidents were Fatal
Also 223 Incidents were Reported to the FAA in Oregon
Total Washington Accidents:
605 Aviation Accidents
98 Accidents were Fatal
Also 378 Incidents were Reported to the FAA in Washington
Total Pacific Northwest General Aviation Accidents:
1,021 Aviation Accidents
176 Accidents were Fatal
Also 601 Incidents were reported to the FAA
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The following statement taken from the Annual Review of the U.S. General
Aviation Accident Data provided by the NTSB which gives an insight into factors
the NTSB thinks affect all aviation accidents. In recent years both FS and DOI
aviation accident prevention efforts have been directed toward this same area.
Approximately 80% of general aviation accidents are directly related to some
form or combination of human factors. These run the gamut of external
organizational influences, inadequate supervision, personnel factors (such
as self imposed stress), to individual acts such as, skill based errors,
misperception errors, judgment and decision-making errors, etc.
FY10 was a relatively slow fire season which normally results in an overall
reduction in flight hours for both FS and DOI. However, the DOI flight hours
increased from 72,007 in FY09 to 73,143 in FY10. This increase can be
attributed to the wide range of non-fire aviation missions conducted by all DOI
bureaus and agencies. The DOI accident rate is currently 5.47.
The slow fire season resulted in FS flight hours which dropped from 57,534 hours
in FY09 to 44,833 flight hours in FY10. The FS accident rate is currently 4.46.
Below are the listings of FS and DOI accidents and IWP’s for the past 10 years in
the Pacific Northwest. As the data was reviewed an effort was made to discover
the NTSB human contributing factors listed above in each accident and incident.
This became a difficult task given the age of some of the accident reports.
Contributing factors are hidden within the accident and incident discription and
the processes used in accident investigation at the time were not designed to
explore this subject. For example, many accidents and incidents are classified
as “Pilot Error”. In these reports there is little discussion probing the pilot’s state
of mind to clarify what may have caused the pilot to make the error; so
understanding the human contributing factors is not possible. Even when an
aircraft part fails there is usually a human contributing factor which led to that
failure. In a perfict world, knowing what contributed to the accident or incident
will aid in establishing a focused effort toward accident prevention.
The author took the liberty of interpreting the accident and incident data and
added clarification of probable human contributing factors where possible. These
contributing factors are listed in “red” within the comment section of each
accident or incident.
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Accident Data
Accident Contributing Factors:
E = external organizational influences
I = inadequate supervision
S = skill based errors
J&D = judgment and decision-making errors
M = Mechanical Failure
Forest Service
Date
Location
Injuries
6/30/2008
Bend, OR
1 – Minor
1 – Serious
Burns, OR
7/07/2007
1 – None
Aircraft
Type
Airplane –
Single
Engine
SEAT
Comments
Fire Recon – Engine Failure
M, S, J&D
Single Engine Air Tanker (SEAT)
Engine stopped running
8/11/2004
7/26/2004
Leavenworth,
WA
1 – Fatal
Burns, OR
1 – Minor
Helicopter
M, E
205 A++ Fire Long-Line Mission
Tail rotor strike
SEAT
E, I, J&D
Fire Drop – Throttle linkage broke and
engine RPM would not respond
12/22/2003
8/16/2001
Missoula, MT
Ukiah, OR
1 – Minor
1 – Serious
1 – Minor
Airplane –
Twin Engine
SEAT
M
Lead-plane Training Mission
Crashed in bad weather at airport
E, I, S, J&D
Airport - An inadequate recovery from a
bounced landing and directional control was
not maintained during landing
S, J&D
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PNWCG Report
Last 10 Years 5
Department of Interior
Date
Location
Injuries
Aircraft
Type
Comments
1/17/2010
Corvallis, OR
2 – Fatal
Airplane –
Single
Engine
Waterfowl Survey/Repositioning Flight
– deteriorating weather conditions contributed
7/21/2007
Omak, WA
1- None
Helicopter
to controlled flight into terrain
E, S, J&D
Fire Water Drop (Bucket) – tail rotor strike
to the water’s surface caused torsional
overload failure of the rotor drive shaft
7/25/2003
Keller, WA
1 – Fatal
Helicopter
E, I, J&D
Fire Water Drop (Bucket) – material
failure due to corrosion fatigue within the rotor
system led to the loss of all four rotor blades in
flight.
6/25/2002
4/11/2002
Mt. Rainier
Natl Park, WA
3 – None
Richland, WA
4 – None
Helicopter
M
Search and Rescue – pilot not properly
carded, poor mission planning, risk
management and failure to comply with policy
Helicopter
WA
E, I, S, J&D
Aerial Animal Capture – gunner net
damaged rotor blade upon deployment
S, J&D
E = external organizational influences
J&D = judgment and decision-making
errors
M = Mechanical Failure
I = inadequate supervision
S = skill based errors
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
FS
DOI
E
Pacific Northwest Region
I
S
PNWCG Report
J&D
M
Last 10 Years 6
E = external organizational influences
I = inadequate supervision
S = skill based errors
J&D = judgment and decision-making errors
M = Mechanical Failure
INCIDENTS WITH POTENTIAL
Date
8/10/2009
Region/
Forest
ORRRF
FS
Persons on Aircraft
Aircraft
Type
1 – No Injuries Helicopter
Comments
Windshield broke
(Rogue River-Siskiyou National
Forest)
8/01/2009
ORUPF
1 – No Injuries
Helicopter
M
Rotor Strike –Tree
(Umpqua National Forest)
7/31/2009
ORUPF
1 – No Injuries
Helicopter
E, J&D
Main rotor contacted rotor hub
(Umpqua National Forest)
9/26/2006
WAOWF
1 – No Injuries
Helicopter
S, J&D
Rotor Strike – Tree
(Okanogan/Wenatchee National
Forest)
7/29/2005
ORMAF
1 – No Injuries
SEAT
E, S, J&D
Engine failure
(Malheur National Forest)
7/18/2004
WAOWF
2 – No Injuries
Helicopter
M
Rotor strike – Tree
(Okanogan/Wenatchee National
Forest)
8/12/2003
WAOWF
1 – No Injuries
Helicopter
J&D
Hydraulic Failure
(Okanogan/Wenatchee National
Forest)
7/08/2002
ORFMF
1 – No Injuries
SEAT
M
Wing – tree strike
(Fremont National Forest)
7/25/2001
ORMAF
9 – No Injuries
Helicopter
E, I, J&D
Engine failure
(Malheur National Forest)
M
Pacific Northwest Region
PNWCG Report
Last 10 Years 7
DOI INCIDENTS WITH POTENTIAL
Date
8/19/2010
8/20/2010
7/08/2008
8/22/2006
6/30/2004
Location
Prineville,
OR
Madras, OR
Portland,
OR
Persons on
Aircraft
1 - No Injuries
Aircraft
Type
Helicopter
Comments
Fire Water Drop (Bucket) – longline
entangled in power line after quick release by
pilot to avoid in-flight collision
2 - No Injuries
3 - No Injuries
Airplane Multi-engine
Helicopter
E
Fire Air Attack – poor fuel management led
to in-flight fuel starvation
E, J&D
Wildlife Survey – unnecessary risk taking by
pilot choosing to fly between two Interstate 5
bridge towers
Fields
Guard
Station, OR
1 - No Injuries
Omak, WA
1 - No Injuries
Helicopter
I, J&D
Engine Start-Up – two nuts had come off the
drive shaft coupling causing hesitations in the
tail rotor
Helicopter
M
Fire Water Drop (Bucket) – struck power
line in flight
6/25/2004
Vale, OR
1 - No Injuries
Helicopter
J&D
Fire Water Drop (Bucket) – engine fire
resulting from loss of airflow due to excessive
left yaw by the pilot
S
E = external organizational influences
I = inadequate supervision
S = skill based errors
J&D = judgment and decision-making errors
M = Mechanical Failure
Conclusion
Close examination reveals contributing human factors in almost every accident
and incident. We are reminded that even our best employees make mistakes.
Our challenge is to design a safety system where we anticipate human failure.
To achieve this, both FS and DOI are implementing a fully integrated Safety
Management System (SMS) into their aviation programs. SMS integrates
modern safety risk management and safety assurance concepts into every
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Last 10 Years 8
system within an organization. SMS emphasizes safety management as a
fundamental operational process to be considered in the same manner as other
aspects of operations management.
This systematic approach to aviation safety is supported by the FAA and is
based on the International Civil Aviation Organization (ICAO) efforts to reduce
accidents and incidents worldwide involving large air carriers. For SMS to be
successful within the FS and DOI there must be personal commitment and
involvement of every leader and every employee in our organization. We are
ultimately seeking a change in our “Safety Culture” which will take time.
Fred Manuele made this statement in his book On the Practice of Safety; “An
organization’s culture consists of its values, beliefs, legends, rituals, mission
goals, performance measures, and sense of responsibility to its employees,
customers, and the community.” So the Human Aspect is the Safety Culture of
an organization!
In order to find the answer for why “Approximately 80% of general aviation
accidents are directly related to some form or combination of human factors” we
must be willing to explore what makes people react under various circumstances.
This requires a change in how accidents and incidents are viewed within our
safety cultures. The graph on page 6 clearly shows that judgment and decisionmaking errors contribute to most DOI/FS accidents followed closely by external
organizational influences.
Recommendation
Not shown in this report is the National FY10 accident data for six fixed
wing accidents. Five of those accidents occurred during non-fire missions
and resulted in the deaths of nine people. To reduce our accident rate we
need to implement processes and procedures that will provide better
oversight to DOI/FS aviation operations and encourage improved judgment
and decision-making. Concerted efforts must be made to provide training
and tools to aviation managers and field personnel to reduce the effects of
external organizational influences. The AWT requests the support from
PNWCG in implementing additional standardized training and oversight
requirements for non-fire light fixed wing missions in the PNW.
Pacific Northwest Region
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Last 10 Years 9