United States Department of Agriculture 

Forest Service 

FY 2004 

Aviation Safety Summary 

Prepared by the 

National Aviation Safety Center 

Boise, ID 
1

Table of Contents 

Executive Summary 2 

Aircraft Program Administration 3 

Aviation Safety Accomplishments 4 

Statistical Summary 5 

USFS Owned Aircraft Statistics 14 

Fixed-Wing Statistics 16 

Airtanker Statistics 18 

Helicopter Statistics 20 

SafeCom Summary 22 

Accident Summary 29 

NOTE: Formulas used: Industry standard “per 100,000 hours flown” 

Accident Rate = Number of accidents divided by the number of hours flown times 100,000. 

Fatal Accident Rate = Number of fatal accidents divided by the number of hours flown 

times 100,000. 

Fatality Rate = Number of fatalities divided by the number of hours flown times 100,000. 

Departure Accident Rate = Number of accidents divided by the number of departures 

times 100,000
2

Executive Summary

Systems Safety – Re-defining a Core Value

Safety, as a stand-alone principle is ambiguous and subject to wide interpretation. We 

have identified a means to focus on systems safety as a corporate safety culture, which 

includes interagency cooperation in key risk management arenas, realizing the true core 

of the Aviation Safety program. The National Aviation Safety Center (NASC) is 

dedicated to the support of the Forest Service aviation program needs with safety 

information, lessons learned, risk management tools, safety training, accident 

prevention, all focused on our ultimate goal of eliminating mishaps. 

What is the culture of systems safety? 

System; A group of interrelated processes which are a composite of people, 

procedures, materials, tools, equipment, facilities, and software operating in a specific 

environment to perform a specific task or achieve a specific purpose, support, or 

mission requirement for an air carrier. 

System Safety; The application of special technical and managerial skills to identify, 

analyze, assess and control hazards and risks associated with a complete system. 

System safety is applied throughout a system's entire lifecycle to achieve an acceptable 

level of risk within the constraints of operational effectiveness, time, and cost. 

System Approach; The structured, safety-driven means by which the USFS will certify 

and survey elements that are designed to interact predictably within the USFS system 

and sub-systems form the foundation of this management strategy. 

What is a sub-system? Training program is a sub-system by which the USFS ensures 

personnel are trained to perform assigned duties in accordance with the USFS 

approved training program. (this is an example of a sub-system) 

Safety Attributes; The authority, responsibility, procedures, controls, process and 

measurements, and interfaces that the USFS has designed into its systems. 

“As a world-class leader in natural resources management, the Forest Service has a 

responsibility to protect its most valuable resource – our personnel. The success of our 

mission depends upon how effectively we incorporate safety and health into our culture 

and our daily behavior.” 

We invite you to study the FY 2004 Accident Review and to benefit from the lessons 

learned. For more about the USDA Forest Service Aviation Safety program, visit the 

NASC website at www.fs.fed.us/fire/aviation_safety. 

R.G. “Ron” Hanks 

National Aviation Safety and Training Manager 
3

Aircraft Program Administration 

Approximately 160 employees at the Washington Office and Regional levels administer 

the Forest Service aviation program. The national staff is located in Washington D.C. 

and at the National Aviation Safety 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 850 to 900 aircraft. These include 

government owned, chartered, leased, and contractor operated aircraft. The Forest 

Service owns approximately 250 aircraft and operates 38 aircraft (36 fixed-wing and 2 

helicopters.) Over 200 Forest Service owned aircraft are operated by numerous states 

under the Federal Excess Personal Property (FEPP) program. Approximately 600 

helicopters and fixed wing aircraft of various makes and models were chartered, leased 

or contracted in FY 2004. The aircraft are inspected and “carded” for government use 

by interagency inspectors, and are flown and maintained by the contractors.
4

Aviation Safety Accomplishments 

We continue to look for ways to improve aviation safety. The USFS Aviation Safety 

Council unanimously agreed to adopt the System Safety and begin implementation in 

2005. Accomplishments achieved in aviation safety in FY 2004 included: 

Safety Initiatives:

• Airspace Steering Committee 

• MOA – Pilot Training for low level /mountain flying; APHIS 

• Safety Alerts (8) 

• Technical Alert (1) 

• Airwards (3 issues) 

• Contracted for Hot, High, Heavy accident history and trend analysis 

• Airtanker Modernization Standards participation 

• Coordinated Dropped Loads accident history and trend analysis 

• M-18 Dromader SEAT Safety Stand-down 

• SEAT field review team 

• SAFECOM database combined with DOI 

• Office efficiency improvement project; conference area/resource library/work 

center 

• Added a new metric (Sorties per 100K hours) to annual report 

• Coordinated investigation teams on 5 accidents 

• RASM lead assignments in areas of expertise 

• Support and mentor Automated Flight Following project 

Policy/Procedure Recommendations

• Draft 5720 manual final 

• 5709.16 Requirement for risk assessment 

• 5709.16 Requirement for pilot training standards 

• Contract requirement for FAR Part 27 helicopters (Type 3) 

• Changes to FS SEAT contracts to improve performance planning 

Training Programs:

• Transferred funding to R-5 Training Center 

• Coordinated/funded project with DOI for Interagency Aviation Training program 

o On-line computer based training/ contracted course development 

o ACE classroom training held at 2 locations 

• Coordinated/Funded project with BLM for SEAT pilot training 

• Contracted for professional curriculum development 

• Coordinated USFS ACE instructor assignments, preparation 

• Presented FS Aviation Safety Review at four training courses 
5

Statistical Summary

The accident rate for fiscal year 2004 is 8.0 which is above the 15 year average of 6.29. 

We experienced 5 accidents and 9 “Incidents with Potential” (IWP). Unfortunately, we 

did not make it through the year without any fatalities. There were four fatalities, one 

helicopter and three fixed-wing. The USFS flew 62,472 hours, which is 15,292 hours 

less than the 15 year average. 

 

The Forest Service utilizes aircraft mainly for fire suppression. The primary mission of 

USDA Forest Service Aviation is to support the ground firefighter through a variety of 

means, including, but not limited to: 

9 Aerial delivery of firefighters by parachute, rappel line, or on site landing 

9 Air tactical command and control 

9 Firefighter transport 

9 Surveillance, reconnaissance, and intelligence gathering 

9 Infrared mapping 

9 Aerial delivery of fire retardant and water 

Aircraft are also used for a wide variety of other missions, including administration, 

research, forest rehabilitation, forest health, law enforcement, aerial photography, and 

infrared surveillance. 
6

USFS Aircraft Accident Rates 1987 to 2004 

FY 2004 Accident Statistics 

Aircraft Type Hours 

Number of 

Accidents 

Accident 

Rate 

Number of 

Fatal 

Accidents 

Fatal 

Accident 

 Rate 

Number 

of 

Fatalities 

Fatality 

Rate 

Fixed-Wing 22,713 2 8.8 1 4.4 3 13.2 

Helicopter 29,885 2 6.69 1 3.34 1 3.34 

Airtanker 1,535 0 0 0 0 0 0 

* SEAT 1,006 1 99.4 0 0 0 0 

USFS Owned 7,333 0 0 0 0 0 0 

Total 62,472 5 8.0 2 3.2 4 6.4 

The actual hours flown in FY 2004 are below the fifteen-year average of 77,764. 

Analysis of the data shows a decrease (-15,292) in total number of hours flown. 

*SEAT – flight hours for SEAT aircraft on USFS lands were obtained from the DOI, 

Aviation Management Directorate. This is the first year this information has been 

obtained. The reason the SEAT accident rate is so high is due to the low number of 

flight hours. 

9.15

7.36

6.11

11.67

8.42

1.74

9.2

1.58

4.69

11.91

3.12

7.86 8

2.71

4.21

6.26

3.31

1.06

2.61 3.02

8.15

2.29

5.1

10.5 10.62

5.39 4.31

6.97

3.58

0

2

4

6

8

10

12

14

1987 1989 1991 1993 1995 1997 1999 2001 2003 2005

accident rate

Accident Rate Departure Accident Rate Linear (Accident Rate)
7

77,764

62,472

0

20,000

40,000

60,000

80,000

Average Actual

Average vs Actual Hours Flown for FY 2004

FY04 Flight Hour Percentages 

36.4%

47.8%

2.5% 11.7%

1.6%

Fixed-Wing Helicopter

Airtanker USFS Owned

SEAT
8

Comparison of Averages FY 1990-2004 

 15 Year Average Actual Comparison 

Hours flown 77,764 62,472 -15,292 

Number of Accidents 4.87 5 +.13 

Number of Fatalities 1.47 4 +2.53 

Accident Rate 6.29 8.13 +1.84 

15-Year Flight Hour Statistics 

Flight Hours: 

Fiscal Year Fixed Wing Helicopter Airtanker SEAT USFS Owned Total 

2004 22,713 29,885 1,535 1,006 7,333 62,472

2003 32,704 50,662 5,082 7,607 96,055

2002 33,011 54,427 8,573 13,052 109,063

2001 26,580 39,497 7,832 11,241 85,150

2000 34,976 53,145 10,616 12,749 111,486

1999 21,873 25,174 6,069 10,019 63,135

1998 32,416 24,423 3,685 9,055 69,579

1997 16,753 16,295 2,801 7,608 43,457

1996 31,919 36,307 8,407 11,648 88,281

1995 23,406 20,031 4,154 9,883 57,474

1994 44,995 49,200 10,100 14,405 118,700

1993 19,824 12,026 1,947 9,037 42,834

1992 28,793 27,973 5,147 9,847 71,760

1991 27,056 26,032 2,782 9,610 65,480

1990 39,389 27,309 4,446 10,396 81,540

15-year totals 436,408 492,386 83,176 153,490 1,166,466

Averages 29,094 32,826 5,545 10,233 77,764

0

2

4

6

8

Number of Accidents Number of Fatalities Accident Rate

Average vs Actual for FY 2004

Average Actual
9

Accident Rates by Flight Hours Vs. Departure 

15 Year Average of Flight Hour Percentages

1990-2004

44%

33%

8% 15%

Fixed-Wing Helicopter Airtanker USFS Owned

15 Year Average Accident Rate

Percentages 1990-2004

10%

33%

41%

16%

Fixed-Wing Helicopter Airtanker USFS Owned

10 Year Average Departure Accident Rate

Percentages 1995-2004

15%

29%

19%

37%

Fixed-Wing Helicopter Airtanker USFS Owned
10

 Total Accident Rates 

Year 

Total 

Number of 

Accidents 

Total 

Accident 

Rate 

Fixed-Wing 

Accident 

Rate 

Helicopter 

Accident 

Rate 

Airtanker 

Accident 

Rate 

USFS Owned 

Accident 

Rate 

2004 5 8.0 8.8 6.69 0.00 0.00 

2003 3 3.12 3.05 3.94 0.00 0.00 

2002 13 11.91 3.02 14.69 23.32 15.32 

2001 4 4.69 3.76 5.06 0.00 0.00 

2000 4 3.58 2.85 3.76 0.00 7.84 

1999 1 1.58 0.00 3.97 0.00 0.00 

1998 3 4.31 3.08 4.09 27.14 0.00 

1997 4 9.20 0.00 24.55 0.00 0.00 

1996 5 5.66 0.00 11.02 0.00 8.59 

1995 1 1.74 0.00 0.00 24.07 10.12 

1994 10 8.42 2.22 14.23 9.90 6.94 

1993 5 11.67 15.13 8.31 51.34 0.00 

1992 5 6.97 0.00 14.29 19.43 0.00 

1991 4 6.11 0.00 7.86 0.00 20.81 

1990 6 7.36 0.00 18.31 22.49 0.00 

15-year 

Average 4.87 6.29 2.79 9.39 11.85 4.64 

Total Fatal Accident and Fatality Rates 

Year Fatal 

Accidents

Fatal Accident 

Rate 

Number of 

Fatalities 

Fatality 

Rate 

2004 2 3.2 4 6.4 

2003 1 3.12 2 1.04 

2002 3 2.75 5 4.58 

2001 0 0.00 0 0.00 

2000 1 0.89 2 1.79 

1999 0 0.00 0 0.00 

1998 2 2.87 4 5.75 

1997 1 4.60 2 4.60 

1996 0 0.00 0 0.00 

1995 2 1.74 3 5.22 

1994 4 2.53 6 5.05 

1993 2 4.67 6 14.01 

1992 1 1.39 2 2.79 

1991 2 3.05 2 3.05 

1990 1 1.22 2 2.45 

15-year Average 1.47 2.13 2.67 3.78 
11

10-Year Departure Data 

Number of Departures by Year and Aircraft Type 

Number of Departures: 

Fiscal 

Year 

Fixed 

Wing Helicopter Airtanker

USFS 

Owned Total 

2004 29,391 58,851 4,399 5,258 97,899 

2003 39,643 74,133 11,463 5,545 130,784 

2002 42,581 87,387 20,553 8,932 159,453 

2001 34,427 70,503 19,382 8,015 132,327 

2000 40,541 81,034 22,856 8,353 152,784 

1999 27,594 43,559 15,348 7,571 94,072 

1998 28,941 44,322 10,214 7,014 90,491 

1997 21,558 27,729 8,793 5,776 63,856 

1996 33,100 58,814 18,037 8,616 118,567 

1995 25,751 29,727 10,075 8,134 73,687 

1994 40,614 58,482 16,995 10,981 127,072 

10-year 

totals 323,527 576,059 141,120 73,214 1,113,920 

Averages 32,353 57,606 14,112 7,321 111,392 

Departure Accident Rate 

Year 

Total 

Number of 

Accidents 

Total 

Departure 

Rate 

Fixed-Wing 

Departure 

Rate 

Helicopter 

Departure 

Rate 

Airtanker 

Departure 

Rate 

USFS Owned 

Departure 

Rate 

2004 5 5.1 6.8 3.4 0 0 

2003 3 2.29 2.52 2.69 0 0 

2002 13 8.15 2.34 9.15 9.73 22.39 

2001 4 3.02 5.8 2.83 0 0 

2000 4 2.61 2.46 2.46 0 11.97 

1999 1 1.06 0 2.29 0 0 

1998 3 3.31 3.45 2.25 9.79 0 

1997 4 6.26 0 14.42 0 0 

1996 5 4.21 0 6.8 0 11.6 

1995 2 2.71 0 0 9.92 12.29 

10-Year 

Average 4.4 3.87 2.34 4.62 2.94 5.82 

Departure Accident Rate is the number of accidents divided by the number of departures times 

100,000. 
12

Departure Accident Rate

by Aircraft Type

0

5

10

15

20

25

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Fixed-Wing Helicopter Airtanker USFS Owned Total
13

 Forest Service Aircraft 

Accident Statistics in 5-Year Increments 

Observations 

The total number of accidents in 5-year increments shows a steady decline, until the last 

period. The total number of fatalities in 5-year increments shows a major decline in the 

80’s from the 70’s. 

67

85

60

45

34 32

26

17

25

43.4

0

10

20

30

40

50

60

70

80

90

1961-1965

1966-1970

1971-1975

1976-1980

1981-1985

1986-1990

1991-1995

1996-2000

1999-2003

1961-2003 Average

Total Number of Accidents for all aircraft

(5-Year Increments for 40-Years) 

35

30

40

19

15

11

19

8 9

20.6

0

5

10

15

20

25

30

35

40

1961-1965

1966-1970

1971-1975

1976-1980

1981-1985

1986-1990

1991-1995

1996-2000

1999-2003

1961-2003 Average

Total Number of Fatalities for all aircraft

(5-Year Increments for 40-Years)
14

USFS Owned Aircraft 

Forest Service owned aircraft accounted for nearly 12 percent of the total hours flown in 

FY 2004; the fifteen-year average is 15 percent. Accident rates have steadily declined 

until FY02 when we experienced two accidents. There have not been any fatalities for 

the past nine years 

USFS Owned 15-Year Statistics 

Fiscal 

Year 

Hours 

Flown Accidents Accident Rate 

Fatal 

Accidents 

Fatal 

Accident 

Rate 

Fatalities Fatality 

Rate 

2004 7,333 0 0.00 0 0.00 0 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 

1999 10,019 0 0.00 0 0.00 0 0.00 

1998 9,055 0 0.00 0 0.00 0 0.00 

1997 7,608 0 0.00 0 0.00 0 0.00 

1996 11,648 1 8.59 0 0.00 0 0.00 

1995 9,883 1 10.12 1 10.12 1 10.12 

1994 14,405 1 6.94 0 0.00 0 0.00 

1993 9,037 0 0.00 0 0.00 0 0.00 

1992 9,847 0 0.00 0 0.00 0 0.00 

1991 9,610 2 20.81 1 10.41 1 10.41 

1990 10,396 0 0.00 0 0.00 0 0.00 

Total 153,490 8 2 2 

Average 10,233 .53 4.46 0.13 1.37 0.13 1.37 
15

USFS Owned Aircraft Accident Rates 1989 to 2004 

0

2000

4000

6000

8000

10000

12000

14000

16000

1989199019911992199319941995199619971998199920002001200220032004

USFS Owned Hours Flown and 

Number of Departures

Hours Flown Departures

10.17

0 0

10.12

8.59

0 0 0 00

12.29 11.6

0000

11.97

0

22.39

0 0

20.81

0

0

7.84

6.94

15.32

0

5

10

15

20

25

1989 1991 1993 1995 1997 1999 2001 2003 2005

accident rate

Accident Rate Departure Accident Rate Linear (Accident Rate)
16

Fixed-Wing (Contract) 

Fixed-Wing aircraft accounted for 36 percent of the total hours flown in FY 2004; the fifteenyear average is 44 percent. There were 22,713 hours flown in FY 2004, which is below the 

fifteen-year average of 29,094. 

Fixed-Wing 15-Year Statistics 

Fiscal 

Year 

Hours 

Flown Accidents Accident 

Rate 

Fatal 

Accidents

Fatal 

Accident 

Rate 

Fatalities Fatality 

Rate 

2004 22,713 2 8.80 1 4.40 3 13.2 

2003 32,704 1 3.06 0 0.00 0 0.00 

2002 33,011 1 3.03 0 0.00 0 0.00 

2001 26,580 1 3.76 0 0.00 0 0.00 

2000 34,976 1 2.86 1 2.86 2 5.72 

1999 21,873 0 0.00 0 0.00 0 0.00 

1998 32,416 1 3.08 0 0.00 0 0.00 

1997 16,753 0 0.00 0 0.00 0 0.00 

1996 31,919 0 0.00 0 0.00 0 0.00 

1995 23,406 0 0.00 0 0.00 0 0.00 

1994 44,995 1 2.22 0 0.00 0 0.00 

1993 19,824 3 15.13 1 5.04 4 20.18 

1992 28,793 0 0.00 0 0.00 0 0.00 

1991 27,056 0 0.00 0 0.00 0 0.00 

1990 39,389 0 0.00 0 0.00 0 0.00 

Total 436,408 11 3 9 

Average 29,094 0.73 2.80 0.2 0.82 0.06 2.61 
17

Fixed-Wing (Contract) Aircraft Accident Rates 

1989 to 2004 

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

1989199019911992199319941995199619971998199920002001200220032004

Fixed-Wing Hours Flown and 

Number of Departures

Hours Flown Departures

2.9

0

15.13

000 0

3.76

3.06

8.8

5.88

000

3.45

0

2.46

5.8

2.34 2.52

6.8

0 0

3.08

2.86

2.22

3.03

0

2

4

6

8

10

12

14

16

1989 1991 1993 1995 1997 1999 2001 2003 2005

accident rate

Accident Rate Departure Accident Rate Linear (Accident Rate)
18

Airtankers 

Airtankers accounted for 2.5 percent of the total hours flown in FY 2004; which is well 

below the fifteen-year average of 8%. 

Airtanker 15-Year Statistics 

Fiscal 

Year 

Hours 

Flown Accidents Accident 

Rate 

Fatal 

Accidents 

Fatal 

Accident 

Rate 

Fatalities Fatality 

Rate 

2004 1535 0 0.00 0 0.00 0 0.00 

2003 5,082 0 0.00 0 0.00 0 0.00 

2002 8,573 2 23.33 2 23.33 5 58.32 

2001 7,832 0 0.00 0 0.00 0 0.00 

2000 10,616 0 0.00 0 0.00 0 0.00 

1999 6,069 0 0.00 0 0.00 0 0.00 

1998 3,685 1 27.14 1 27.14 2 54.27 

1997 2,801 0 0.00 0 0.00 0 0.00 

1996 8,407 0 0.00 0 0.00 0 0.00 

1995 4,154 1 24.07 1 24.07 2 48.15 

1994 10,100 1 9.90 1 9.90 2 19.80 

1993 1,947 1 51.36 1 51.36 2 102.72 

1992 5,147 1 19.43 1 19.43 2 38.86 

1991 2,782 0 0.00 0 0.00 0 0.00 

1990 4,446 1 22.49 1 22.49 2 44.98 

Total 83,176 8 8 17 

Average 5,545 0.53 11.85 0.53 11.85 1.13 24.47 
19

Airtanker Accident Rates 1989 to 2004 

0

5000

10000

15000

20000

25000

1989199019911992199319941995199619971998199920002001200220032004

Airtankers Hours Flown and

Number of Departures

Hours Flown Departures

18.74 19.43

51.36

24.07

00 0 0 00

5.88

9.92

0 0

9.79

000

9.73

0 0

0

22.49 27.14

0

9.9

23.33

0

10

20

30

40

50

60

1989 1991 1993 1995 1997 1999 2001 2003 2005

accident rate

Accident Rate Departure Accident Rate Linear (Accident Rate)
20

Helicopters 

Helicopters accounted for the largest percent of the total hours flown in FY 2004. They 

flew 48 percent of the total hours flown in FY 2004. The 15-year average is 33 percent. 

The average number of accidents is three; we experienced 2 in FY 2004. 

Helicopter 15-Year Statistics 

Fiscal 

Year 

Hours 

Flown Accidents Accident Rate 

Fatal 

Accidents

Fatal 

Accident 

Rates 

Fatalities Fatality Rate

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 

1999 25,174 1 3.97 0 0.00 0 0.00 

1998 24,423 1 4.09 1 4.09 2 8.19 

1997 16,295 4 24.55 1 6.14 2 12.27 

1996 36,307 4 11.02 0 0.00 0 0.00 

1995 20,031 0 0.00 0 0.00 0 0.00 

1994 49,200 7 14.23 3 6.10 4 8.13 

1993 12,026 1 8.32 0 0.00 0 0.00 

1992 27,973 4 14.30 0 0.00 0 0.00 

1991 26,032 2 7.68 1 3.84 1 3.84 

1990 27,309 5 18.31 0 0.00 0 0.00 

Total 492,386 45 9 13 

Average 32,826 3 9.37 0.60 1.82 0.87 2.77 
21

Helicopter Accident Rates 1989 to 2004 

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

1989199019911992199319941995199619971998199920002001200220032004

Helicopters Hours Flown and 

Number of Departures

Hours Flown Departures

19.42

14.3

8.32

0

11.02

24.55

3.97

5.06

3.95

6.69

11.96

0

6.8

14.42

2.25 2.29 2.46 2.83

9.15

2.69 3.4

7.68

18.31

4.09

3.76

14.23

14.7

0

5

10

15

20

25

30

1989 1991 1993 1995 1997 1999 2001 2003 2005

accident rate

Accident Rate Departure Accident Rate Linear (Accident Rate)
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. 

In 2004 the Forest Service and DOI Aviation Management Directorate combined 

SAFECOM databases. There were a total of 906 SAFECOM’s submitted to the 

Interagency SAFECOM internet database of which 20 were duplicates, leaving a total of 

883. These include all DOI bureaus, States, Military and unknown. 

The following charts trend the Forest Service SAFECOM data submitted to the 

Interagency SAFECOM Internet database at http://www.safecom.gov/. The average 

number of Forest Service SAFECOM’s submitted is 665 per year. In FY 2004 the 

number of Forest Service SAFECOM’s submitted was significantly lower at 506, of 

which 12 were duplicates, giving us a total of 494. 

The five most reported SAFECOM’s were engine, communications, policy deviation, 

dropped load and intrusion. In an analysis of the past five years policy deviation had 

dropped off the top five last year, but was the second highest in FY04. These same top 

five SAFECOM’s have been consistent issues through the past 5 years. 

Yearly Forest Service SAFECOM Totals 

YEAR Number of SAFECOM’s 

2004 494 

2003 887 

2002 962 

2001 773 

2000 949 

1999 640 

1998 546 

1997 366 

1996 633 

1995 402 

Total 6652 

10 YR Average 665 
23

Forest Service FY 2004 SAFECOM’s by Aircraft Type 

Aircraft Type 

 

Aircraft Type Number Percent of all SAFECOM’s

Fixed Wing 95 19% 

Helicopter 326 67% 

Airtanker 12 2% 

SEAT 19 4% 

USFS Owned 30 6% 

Other 12 2% 

Total 494 100% 

Percent of SafeCom's by Aircraft Type

19%

67%

2% 6%2% 4%

Fixed-Wing Helicopter

Airtanker USFS Owned

Other SEAT
24

Forest Service FY 2004 SAFECOM’s by Category 

With the combining of the FS and DOI SAFECOM databases came some additional 

changes. There were three new main categories added and several more sub 

categories. The numbers of SAFECOM’s by category will be more than the total 

number of SAFECOM’s reported as each SAFECOM can now have more than one 

category assigned to it. 

The total number of SAFECOM’s reported in the Interagency SAFECOM database 

was 903, of which 20 were duplicates and not included in these statistics leaving a 

total of 883 SAFECOM’s. There were 494 Forest Service, 330 DOI, 55 State, 1 

Military and 3 Other SAFECOM’s.

SAFECOM’s by Category 

 

Category Number Percent of all SAFECOM’s 

Accident 5 1% 

Airspace 46 9% 

Hazard 147 28% 

Incident 46 18% 

Maintenance 221 43% 

Management 3 1% 

Mishap Prevention 2 0% 

Total 520 100% 

Percent of SafeCom's by Category

9%

28%

0% 18%

43%

1% 1%

Accident Airspace

Hazard Mishap Prevention

Incident Maintenance

Management
25

Percent of Airspace SAFECOM's

26%

4%

55%

4%

2% 7% 2%

Conflict Congestion

Intrusion Near Mid-Air

Other Procedures

Route Deviation

Forest Service FY 2004 Airspace 

SAFECOM’s by sub-category 

Airspace SAFECOM’s by sub-category 

 

Category Number Percent of all SAFECOM’s 

Conflict 12 26% 

Congestion 2 4% 

Intrusion 25 55% 

Near Mid-Air 2 4% 

Other 1 2% 

Procedures 3 7% 

Route Deviation 1 2% 

Total 46 100% 
26

Forest Service FY 2004 

Hazard SAFECOM’s by sub-category 

6

1

3

30

14

8

6

4

10

10

1

9

9

7

5

1

23

0 5 10 15 20 25 30 35

Communications

Commo (Frequency congestion)

Commo (Frequency mgt)

Commo (Ground radios/repeaters)

Commo (Verbal)

Commo (Written)

Flight Equipment

Flight Following

Fuel

Ground Equipment

Instructions

Oth

Pilo

er

t Action

Policy Deviation

Preflight Action

Unqualified Personnel

Weather
27

Forest Service FY 2004 Incident 

SAFECOM’s by sub-category 

Category Number 

Aircraft Damage 16 

Bird Strike 3 

Dragged Load 4 

Dragged Load (Human Factor) 7 

Dropped Load 11 

Dropped Load (Human Factor) 10 

Dropped Load (Mechanical) 5 

Gear Up Landing 2 

Ground Damage 1 

Injury 3 

Other 15 

Precautionary Landing 7 

Precautionary Landing (Crew) 1 

Precautionary Landing (Mechanical) 6 

Rotor Strike (Main) 3 

Rotor Strike (Tail) 1 

Security 1 

Total 46 

17%

3%

11%

1% 27%

3%

16%

15%

4% 1%

2%

Aircraft Damage Bird Strike Dragged Load

Dropped Load Gear Up Landing Ground Damage

Injury Other Precautionary Landing

Rotor Strike Security
28

0 5 10 15 20 25 30 35 40 45 50

Airframe

Avionics

Cargo Hook

Caution Light 

Chip Light

Electrical

Engine

Flaps

Flight Controls

Fuel 

Gear Box

Hydraulic

Instrument

Landing Gear

Mission Equipment

Oil 

Other

Propeller

Rotor (main)

Rotor (tail)

Transmission

Warning Light

Forest Service FY 2004 Maintenance 

SAFECOM’s by sub-category 
29

Forest Service FY 2004 Management 

SAFECOM’s by sub-category 

Category Number 

External 2 

Internal 1 

Total 3 

Forest Service FY 2004 Mishap Prevention 

SAFECOM’s by sub-category 

There were two SAFECOM’s submitted that were categorized as Mishap Prevention 

and personnel involved in both of the situations received AIRWARDS. 

Category Number 

Kudos 2 

Total 2 
30

SAFECOM’s by Region

The chart below shows the number of Forest Service SAFECOM’s by region 

reported in FY 2004.

Percent of Safecoms by Region

R-3

18%

R-4

9%

R-5

26%

R-8

7%

R-10

7%

R-9

3%

R-6

22%

WO

0% R-2

2%

NEA

0%

R-1

6%

0

50

100

150

R-1 R-2 R-3 R-4 R-5 R-6 R-8 R-9 R-10 NEA WO
31

FY 2004 SAFECOM’s by Aircraft Type and Region 

Region FixedWing Helicopter Airtanker SEAT USFS 

Owned 

N/A Total 

Region 1 5 21 0 2 4 0 32 

Region 2 3 6 0 0 2 0 11 

Region 3 14 53 2 9 8 1 87 

Region 4 7 27 2 1 8 1 46 

Region 5 22 87 4 2 3 5 123 

Region 6 18 80 3 4 1 4 111 

Region 8 8 27 0 1 2 0 36 

Region 9 2 9 0 0 1 0 13 

Region 10 15 16 0 0 1 1 33 

NEA 1 0 0 0 0 0 1 

WO 0 0 1 0 0 0 1 

Total 95 326 12 19 30 12 494 

FY 2004 SAFECOM’s by Category and Region

Region Accident Airspace Hazard Incident Maint. Mgt. Mishap Prevent Total

1 1 1 15 6 20 0 0 43 

2 0 0 3 5 4 0 0 12 

3 0 10 33 20 33 1 0 97 

4 0 1 23 9 14 0 1 48 

5 0 15 28 17 63 2 0 125 

6 3 14 24 20 49 0 1 111 

8 1 4 2 10 19 0 0 36 

9 0 0 8 4 1 0 0 13 

10 0 1 10 5 17 0 0 33 

NEA 0 0 0 0 1 0 0 1 

WO 0 0 1 0 0 0 0 1 

Total 5 46 147 96 221 3 2 520 
32

2004 Accident Review 

Human actions are cited as causal factors in the majority of aircraft accidents and 

incidents. 

Over the past 40 years, more than 80% of accidents and incidents may have been 

preventable through the proper application of Human Factors principles and a change in 

Aviation Safety Culture. 

The Forest Service experienced five accidents in the 2004 fiscal year. All of the 

accidents involved human error. There were four fatalities and two serious injuries. 

Human error has been implicated in 70-80% of all civil and military accidents. Yet, most 

accident reporting systems are not designed around any theoretical framework of 

human error. As a result, most accident databases are not conductive to a traditional 

human error analysis, making the identification of intervention strategies onerous. What 

is required is a general human error framework around which new investigative 

methods can be designed and existing accident databases restructured. Indeed, a 

comprehensive human factors analysis and classification system (HFACS) has recently 

been developed to meet those needs. Specifically, the HFACS framework has been 

used within the military, commercial, and general aviation sectors to systematically 

examine underlying human casual factors and to improve aviation accident 

investigations. The Forest Service is currently in the process of developing a HFACS 

database which we will enter the checklists that our investigators have been completing 

over the past few years, as well as going back through our other accident reports and 

gathering and entering the data. 

NTSB 831.13 Flow and dissemination of accident or incident information. 

(b)...Parties to the investigation may relay to their respective organizations information 

necessary for purposes of prevention or remedial action. 

...However, no (release of) information... without prior consultation and approval of the 

NTSB. 

Avoid discussion of “Probable Cause”, unless determined and published by the NTSB 

For accident prevention purposes only. 
33

In Memory of:

Patrick Mike Ward

Ken Good

Davita Bryant

Jim Long
34

Region 6, Regional Air Group 

NTSB Identification: SEA04LA029. 

Accident occurred Monday, December 22, 2003 in Missoula, MT 

Aircraft: Beech 58P, registration: N181AM 

Injuries: 1 Minor, 1 Uninjured. 

The aircraft departed Redmond, OR transporting two passengers to Missoula, MT. 

After dropping off the passengers in Missoula, the mission was then changed to pilot 

training for the return flight from Missoula to Redmond. 

Shortly after take off during night instrument meteorological conditions the flying pilot 

reported that he made a right turn from runway heading at about 400 to 500 feet above 

ground level to intercept the outbound radial from the VOR to accomplish the departure 

procedure. 

The second pilot, who had no previous flight time in this make and model aircraft and 

was the flying pilot, 
35

During the turn, a "thump" was felt and the right bank angle increased 

from about 25 degrees to 45 degrees. While the second pilot was 

attempting to correct from the increased bank angle, the aircraft at some 

point, entered a descent. 

Direction of Landing
36

Just before ground impact to open terrain about one mile south of the 

runway, the pilot-in-command took control of the aircraft to level the 

wings. 

The aircraft skipped across the open terrain for several hundred yards 

before coming to rest on its belly. The aircraft was consumed by fire 

shortly thereafter. 

Mishap Site 12/23/2003

Empennage, looking in direction of landing
37

Neither pilot could explain the loss of altitude as both believed they 

were in a continuous climb during the event as airspeed and pitch 

attitude remained constant. Neither pilot could recall if they scanned 

the vertical speed indicator or altimeter to verify if they were indicating 

a climb or descent. 

Fire Damage

Condition of Engines and Props
38

During the post accident inspection of the aircraft, no evidence of a 

mechanical failure or malfunction was found and no evidence of an in 

flight collision with an object was noted. At the time of the accident, low 

freezing fog and visibility was reported. 

Trim Settings

Obstacles
39

NTSB Probable Cause: The second pilot's failure to maintain terrain 

clearance while maneuvering after takeoff. Proper climb rate not 

verified by the flight crew, fog, freezing fog, dark night conditions and 

inadequate supervision by the pilot-in-command were factors. 

Accident Review Board Action Items 

3⁄4 Perform a review of R6 standards and practices for pilot training to 

ensure adequacy, compliance with national standards (where 

applicable), and implementation. Correct identified deficiencies. 

3⁄4 Request an outside resource (i.e. GSA-ICAP) to evaluate the R6 

aviation management and flight operations program. 

3⁄4 Re-emphasize the importance of aviation site reviews nationally. 

Develop an aviation site review schedule for all regions and provide 

this information to the Directors of FAM and RAO’s. 

3⁄4 Rewrite national policy in the FSH 5709.16 to require a formal risk 

assessment process and go-no-go decision-making prior to each 

fixed wing flight. 

3⁄4 Standardize pilot training and proficiency through a centralized, 

national-level process and establish and maintain a database for 

record keeping. 

3⁄4 Rewrite policy in FSH 5709.16 to establish IFR takeoff minimums 

for visibility, ceiling, icing conditions, and safe return to the airport of 

departure in case of emergency. 
40

Region 8, LBJ National Grasslands 

NTSB Identification: FTW04TA075. 

Accident occurred Wednesday, February 18, 2004 in Decatur, TX 

Aircraft: Bell 206B, registration: N16MV 

Injuries: 1 Minor. 

The helicopter was providing aerial ignition and external load (water bucket) 

supporting a prescribed burn. The helicopter utilized both a Plastic Sphere 

Dispenser and a 108-gallon Bambi Bucket. 

During lift off from soft uneven terrain, the rear portion of the helicopter's right 

main skid came in contact with the ground resulting in a dynamic rollover. The 

pilot reported that the terrain he departed from was "clumpy and lumpy with ruts 

of grass approximately 1 to 2 feet in height." 

As he started to lift the helicopter off the ground, he made a slow ascent rate. 

When the skids were about 1 foot above the ground, he said, "the helicopter 

stopped for a split second as if something had caught some portion of the right 

side of the helicopter and the helicopter began a slight lateral roll to the right." 
41

The pilot further reported that he recognized the problem too late as he 

applied full left cyclic and lowered the collective after the helicopter 

exceeded the critical angle of bank into the low skid to a point where 

the situation was unrecoverable, and it rolled 90 degrees to the right. 

No mechanical deficiencies with the engine or airframe were noted 
42

The Rotorcraft Flying Handbook (FAA-H-8083-21), page 11-7, described 

dynamic rollover as, "the pivoting around a skid or landing gear wheel of 

a helicopter causing it to reach its critical rollover angle. Beyond this 

point, main rotor thrust continues the roll and recovery is impossible." 
43

NTSB Probable Cause: The pilot's failure to maintain control of the 

helicopter during liftoff after encountering dynamic rollover. A 

contributing factor was the rough and uneven terrain. 

Accident Review Board Action Items 

3⁄4 The agency should establish minimum Training, evaluation and 

certification for entry-level helicopter pilots performing aviation 

natural resource missions including external load missions 

3⁄4 The agency should re-assess the role of and need for a 

Marshaller/Parking Tender under the various missions. (This 

recommendation is currently being addressed by the agency, and is 

expected to be finalized in 2005) 

3⁄4 With a significant number of dynamic rollover events occurring on 

flatland terrain, we recommend the Agency review the data for 

dynamic rollover events, determine if there is a cause and effect 

situation, and recommend actions be taken as needed. 
44

Region 6, Malheur National Forest 

NTSB Identification: SEA04TA147. 

Accident occurred Monday, July 26, 2004 in Burns, OR 

Aircraft: WSK PZL Mielec M-18A, registration: N495WP 

Injuries: 1 Uninjured. 

The aircraft was delivering retardant to the Tenant fire approximately 

20 miles northwest of Burns, OR. 

The pilot was attempting to climb following a fire retardant drop. When 

he moved the throttle forward, the engine did not respond. The 

airplane started loosing altitude, and the pilot performed a forced 

landing to an open plateau. During the landing, the throttle would not 

retard all the way. 

In order to land the airplane, the pilot turned the fuel selector to the off 

position. During the landing roll, the left wing impacted a fence pole 

bending ribs and wrinkling the aileron. Post accident examination 

revealed that the bolt normally connecting the throttle linkage clevis to 

the throttle arm was missing. 
45

The investigating team examined a sister aircraft from the same 

provider. They found that a nylon lock nut had been installed on the 

clevis bolt, and it was loose enough to be removed without the aid of 

any tools. 

Bent ribs and wrinkled aileron 

Nylon and/or fiber nuts are 

highly susceptible to wear 
46

The industry standard, found in FAA Advisory Circular AC43.13-1B, chapter 

7, section 4, paragraph 7-64, states that nylon locking nuts should not be 

used with rotating components or assemblies. It further states that nylon 

and/or fiber nuts are highly susceptible to wear from repetitive use and from 

high heat applications. 
47

NTSB Probable Cause: The improper installation of the throttle 

linkage clevis to the throttle control arm by unknown maintenance 

personnel. Contributing factors were the nylon lock nut separating from 

its' bolt, which permitted the throttle cable to disconnect from the 

throttle control arm, and the fence post. 

Accident Review Board Action Items 

3⁄4 Re-inspect aircraft operated by vendor. 

3⁄4 Establish contractual requirements for maintenance of SEAT aircraft 

equivalent to other interagency fire aircraft. 

3⁄4 Conduct a risk analysis and develop mitigation measures for Forest Service 

use of SEAT’s. 

3⁄4 Establish an interagency working group to conduct an operational analysis of 

SEAT’s and develop use standards. 

3⁄4 Establish policy based on the risk and operational uses analyses. 
48

Region 6, Okanogan & Wenatchee National Forests 

NTSB Identification: SEA04TA158

Accident occurred Wednesday, August 11, 2004 in Leavenworth, WA 

Aircraft: Bell 205A1, registration: N205XP 

Injuries: 1 Fatal. 

The aircraft was delivering supplies to smokejumpers in the Alpine Lakes Wilderness, 

approximately 20 miles northwest of Leavenworth, WA via a 150 foot longline. 

Visual meteorological conditions prevailed. The flight departed from the USFS 

Leavenworth helibase (Fromme Field) approximately 0955. 

The helicopter was destroyed and the pilot was fatally injured when it impacted heavily 

wooded, mountainous terrain. Prior to the impact, the helicopter's tail rotor struck a tree 

and aircraft control was lost while maneuvering to deliver an external load. 

The helicopter was carrying a dual sling load on a long line. The pilot put the first load 

down without incident. He set the second load down, but then lifted it again, moved a 

short distance, and set it down again. 

Both loads were then unhooked from the longline by a ground crewman. One load was 

re-hooked to the longline to go to another fire. The pilot was given the thumbs up that 

the load was re-hooked and the crewman was clear of the aircraft. 
49

The helicopter then started to ascend, and at that time, the helicopter's tail 

rotor contacted a dead snag. When the tail rotor contacted the snag, the 

helicopter was about 150 feet above the ground. 

Rotor strike on the 

Aerial view of drop zone

Snag that tail rotor hit

Drop 

Zone 
50

The helicopter began to spin, the main rotor blades struck other trees, and the 

helicopter fell to the ground. 

Crash site looking east

Broken tail boom
51

A post-crash fire erupted, which consumed the fuselage of the helicopter.
52

NTSB Probable Cause: NTSB has not yet determined the probable 

cause. 

Accident Review Board Action Items 

3⁄4 Revise the IHOG Longline Procedures and Forest Service Operations and 

Safety Procedures Guide for Helicopter Pilots to state: In areas of sloping 

terrain or with obstacles rising to one or more sides of the cargo 

pickup/delivery area, or dip site, pilot shall maintain rotor clearance from all 

obstacles equivalent to the IHOG Chart 8-1 landing area safety circle 

requirements. When specified clearance cannot be maintained, the mission 

shall be declined by the pilot until hazards are removed, additional line can be 

added or a better location can be identified. 

3⁄4 Implement nationally a longline training and certification process for 

firefighters assigned to direct operations at helicopter drop zones. 

3⁄4 Include the following in the national and regional longline training: 

1. Tree height measurement 

2. Hazard recognition 

3. Positive air to ground communication requirements Incorporate tree height 

estimation training in all longline operations training (triangulation or use of 

clinometers). 

3⁄4 Reevaluate the use of drop zone markers in light of the hazard of target 

fixation. 
53

Region 1, Flathead National Forest and 

Washington Office, Rocky Mountain Research Station 

NTSB Identification: SEA04GA192 

Accident occurred Monday, September 20, 2004 in Essex, MT 

Aircraft: Cessna U206G, registration: N206SM 

Injuries: 3 Fatal, 2 Serious. 

The aircraft departed Glacier Park International airport in Kalispell, MT transporting 

four USFS passengers to Shafer Meadows, MT, a USFS back country airstrip to 

perform a annual vegetation analysis and communications maintenance. 

The aircraft departed Kalispell , MT on September 20, 2004, at approximately 1530 

mountain daylight time the aircraft impacted mountainous terrain while 

maneuvering about 6 nautical miles northwest of Essex, Montana. The pilot and 

two USFS employees were killed, and the other two USFS employees sustained 

serious injuries. 

Visual meteorological conditions prevailed for the airplane's departure at 1500 from 

Glacier Park International Airport in Kalispell. An FAA flight plan was not filed; 

however, the airplane was receiving flight following services from the USFS. 

The flight was originally scheduled to depart at 1300. The scheduled departure 

was delayed from 1300 to 1500 due to weather conditions. 

Not actual accident aircraft 
54

The planned route of flight was to follow Highway 2 from Glacier Airport to a point 

about 3 miles south of the town of Essex, where the highway and the Middle Fork 

of the Flathead River separate. At this point, the flight was to leave the highway 

and follow the Middle Fork drainage to Schafer. 

View looking north down Tunnel Creek 

Engine Prop 
55

The last contact Glacier Tower had with the airplane was at 1508, when the pilot 

reported that he was through "the canyon" (Badrock Canyon approximately 8 miles 

northeast of Glacier Airport) and switching to "backcountry frequency" (USFS 

dispatch). Examination of radar data confirmed that at 1508, the airplane was 

exiting Badrock Canyon heading northeast. Radar contact with the airplane was 

lost at this time due to mountainous terrain. 

Approximate first ground contact 

Looking northwest at accident site
56

From Badrock Canyon, the airplane's planned route proceeded along Highway 2, 

which follows a large bend in the Middle Fork of the Flathead, heading first 

northeast, then east, and finally southeast towards Essex. At 1515, the airplane 

checked in with USFS dispatch, and the pilot reported his position as "Essex, 

inbound for Schafer." This was the last radio communication received from the 

airplane. 

Right wing tip 

Engine cowling cowl flap

The right cargo door located on left side of wreckage 

Looking southeast from first point of impact 
57

When the airplane did not check in with USFS dispatch as expected at 1530, a 

search was initiated. The wreckage of the airplane was spotted by ground 

searchers about 1345 on September 21, 2004. Search and rescue personnel 

reached the accident site via helicopter about 1510. The Deputy Coroner for 

Flathead County inspected the scene and announced that all five occupants were 

fatally injured. The ground search was suspended. Approximately 1430 on 

September 22, 2004, two survivors walked out of the Tunnel Creek drainage. 

The airplane impacted rugged mountainous terrain near the head of the Tunnel 

Creek drainage of the Flathead Range at a Global Positioning System (GPS) 

location of 48 degrees 19.011 minutes North, 113 degrees 44.166 minutes West, 

and an elevation of 6,604 feet. The airplane came to rest in a sparsely wooded, 

rocky area on an upslope of 30 to 45 degrees. All major components of the 

airplane were accounted for in the main wreckage area. The debris path measured 

approximately 80 feet in length along a magnetic bearing of 165 degrees. 

The fuselage with both wings attached came to rest inverted, and the empennage, 

which remained attached to the fuselage by control cables came to rest upright. 

The engine had separated from the firewall, and the propeller had separated from 

the engine crankshaft. All flight controls remained attached to their respective 

attach points, and control continuity was verified from the control surfaces to the 

cockpit controls. The cockpit, cabin and the inboard sections of both wings were 

destroyed by fire. All three propeller blades were bent and twisted, the blade tips 

were broken off, and the blade leading edges were gouged and scraped. 
58

NTSB Probable Cause: NTSB has not yet determined the probable 

cause. 

Accident Review Board Recommendations 

3⁄4 Review and modify as needed, current Forest Service requirements for 

backcountry pilot experience and approvals for appropriate requirements 

including a standard definition for “typical terrain.” 

3⁄4 Re-evaluate appropriate personal protective equipment (PPE) requirements for 

fixed wing backcountry flight operations. 

3⁄4 Place managerial emphasis on the full implementation as planned of the 

Automated Flight Following (AFF) program. Until this is fully implemented, 

latitude, longitude and heading reports should be required for check-in on all 

GPS equipped aircraft. 

Burned out engine compartment