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Forest Service
FY 2009
Aviation Safety Summary
Table of Contents
Executive Summary
Statistical Summary
14
Fixed-Wing Statistics
16
Airtanker Statistics
18
Helicopter Statistics
21
SAFECOM Summary
23
Mishap Summary
33
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.
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.
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:
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.
Statistical Summary
14
11.91
accident rate
12
10
8.17
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
Hours
Number of
Accidents
Accident
Rate
Number of
Fatalities
Fatality
Rate
Fixed-Wing
18,576
Helicopter
26,439
7.56
3.78
3,684
27.14
81.43
781
8,056
57,536
5.21
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
Statistical Summary
14.0%
46.0%
Fixed-Wing
1.4%
32.3%
Helicopter
LGAT
USFS O/O
SEAT
10.6%
1.0%
47.9%
33.5%
Fixed-Wing
Helicopter
LGAT
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
2009
Comparison
83,105
57,536
-25,569
Number of Accidents
4.9
-1.9
Number of Fatalities
3.7
.3
Accident Rate
5.89
5.21
-.68
Fatality Rate
4.45
6.95
2.5
Hours flown
Actual
6
5
4
5.89
4.9
6.95
5.21
3.7
3
Number of Accidents
Accident Rate
10
Number of Fatalities
4.45
3
2
1
Fatality Rate
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
# 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 80s from the 70s; 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
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
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
Fiscal
Year
Hours
Flown
2009
8,056
0.00
0.00
0.00
2008
8,187
0.00
0.00
0.00
2007
8,122
0.00
0.00
0.00
2006
6,898
0.00
0.00
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
0.00
0.00
0.00
2002
13,052
15.32
0.00
0.00
2001
11,241
0.00
0.00
0.00
2000
12,749
7.84
0.00
0.00
Total
88,430
Average
8,843
0.4
0
4.52
14
0
0.00
0.00
Hours Flown
Trendline
0
20
20
20
20
20
20
20
20
20
20
09
08
07
06
05
04
03
02
01
00
16
13.63
accident rate
14
12
10
7.84
8
6
Accident Rate
Trendline
4
0
07
20
08
20
09
20
06
20
05
20
2
0
04
20
03
20
02
20
01
20
00
20
15
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
Hours Flown
Trendline
0
20
00
20
20
01
20
02
20
03
04
20
05
20
06
20
07
20
08
20
09
4.4
4.5
accident rate
4.23
3.76
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
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.
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)
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
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
0.00
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
All AT's
LGAT
SEAT
354.6
350
318.47
accident rate
300
250
200
150
100
99.4
50
12.32
0
0
22.16
23.33
0
39.35
0
31.9
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.
Fiscal
Year
Hours
Flown
Accidents
2009
26,439
2008
35,512
5.63
2.81
25.34
2007
41,571
9.62
2.40
2.40
2006
39,735
7.55
5.03
15.01
2005
28,362
7.05
3.52
10.57
2004
29,885
6.69
3.34
3.34
2003
50,662
3.95
1.97
3.95
2002
54,427
14.70
1.84
1.84
2001
39,497
5.06
0.00
0.00
2000
53,145
3.76
0.00
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
16
14.7
14
accident rate
12
9.62
10
8
6.69
7.05
7.56
7.55
5.63
5.06
3.95
3.76
4
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.
Number of SAFECOMs
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
500
400
300
200
100
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.
5.4%
24.9%
1.7%
49.7%
15.4%
Accident
Hazard
Incident
Management
Airspace
Mishap Prevention
Maintenance
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.
24.1%
17.2%
13.8%
6.9%
10.3%
24.1%
Conflict
Near Mid-Air
Route Deviation
Congestion
Other
Intrusion
Procedures
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.
49
45
40
35
30
25
24
20
15
16
10
12
5
0
Communications
Flight Following
Pilot Action
Policy Deviation
Preflight Action
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.
19
16
14
14
12
10
11
4
2
0
Aircraft Damage
Dragged Load
Dropped Load
Injury
Precautionary
Landing
202
150
127
100
50
161
156
155
125
111
95
95
2005
2004
74
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.
49
45
40
42
35
30
25
20
21
19
15
15
10
5
0
Chip Light
Electrical
Engine
Instrum ent
Fuel
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
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%
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 SAFECOMs 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
Sikorsky SH-3H
N613CK
7/21/2009
Bell 212
N212HP
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
35
36
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
MD-600
N60BK
Ferry
Lockheed P2V
N443NA
Retardant
Drop
9/12/2009
37
40
The Company Investigation Team placed the jet throttle lever to the Stand by position.
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.
41