United States Department of Agriculture 

Forest Service 

FY 2002 

Aviation Safety Summary 

Prepared by

National Aviation Safety Center 

Boise, ID 
Table of Contents 

Executive Summary 1 

Statistical Summary 2 

USFS Owned Aircraft Statistics 9 

Fixed-Wing Statistics 11 

Airtanker Statistics 13 

Helicopter Statistics 15 

SafeCom Summary 17 

Accident Summary 25 

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

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

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

Fatality Rate = Number of fatalities divided by the number of hours flown.
Executive Summary 

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 take a proactive approach in 

designing projects and activities, and in developing policy and procedure to

ensure personnel safety. 

The Forest Service was unsuccessful with our continuing plight to achieve a zero 

aviation accident rate in 2002. The number of mishaps that occurred in 2002 

exceeds all other accident rates since 1979. Contributing factors such as recordbreaking wildfire occurrence, extended periods of field deployment, greater than 

average numbers of aircraft and a corresponding peak in numbers of flight hours

are recognized as culprits. However, we cannot ignore the need to redouble our

accident prevention efforts and be better prepared for similar occurrences in the 

future. 

In response to the season’s high mishap rate an all-out effort is being made to 

plan a more safe and effective future aviation program. A Blue Ribbon Panel 

was chartered to “identify weaknesses and fail points in the current aviation 

program, focusing on safety, operational effectiveness, costs, sustainability, and 

strategic guidance”. The panel’s findings with regard to aviation safety are 

included in the appendix to this report. 

We are working diligently to improve key direction and safety systems integrity. 

The Aviation Safety Council designed a new Safety Plan. The FSM 5720 has

been revised to incorporate changes in the FS Accident Investigation Guide and 

to recognize our standards for SAFECOM reporting, AIRWARDS and other 

accident prevention efforts. 

Our vision of the corporate culture, teamwork, and interagency cooperation in a 

wide array of key risk management arenas leads to one additional area of focus. 

This spring we unveiled a proposal for the development of a National Aviation 

Safety Center (NASC). That proposal was received with resounding support 

from the regions and we are now underway. The NASC is dedicated to the 

support of aviation program needs with safety information, lessons learned, risk 

management tools, safety training, accident prevention systems, and a 

heightened awareness of safety culture. By providing a cultural safety center we 

hope to raise the mark of achievement and close the gap between current 

performance and the “zero goal” for success. 

We hope you will join us in making 2003 a banner year for aviation safety and the 

NASC. 

1
Statistical Summary 

Fiscal year 2002 was the highest mishap year for the Forest Service Aviation Program 

since 1979. Our accident rate peaked with 13 Accidents and 10 “Incidents With 

Potential”. Sadly, we lost six professional aviators in three accidents and in one 

additional accident had two serious injuries. The USFS flew 109,063 hours (over 30% 

above the annual average) the vast majority of which in support of the wildland fire 

program. 

 

The Forest Service utilizes aircraft for a wide variety of other missions, including routine 

administration, research, forest rehabilitation, law enforcement support, aerial 

photography, infrared surveillance and fire prevention. 

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 Aerial delivery of fire retardant and water 

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 aircraft. These include 

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

Service owns approximately 250 aircraft and operates 44 aircraft (42 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 800 

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

contracted including a vintage fleet of multi-engine airtankers. The aircraft are inspected

and “carded” for government use by interagency inspectors, and are flown and 

maintained by the contractors. 

2
USFS Aircraft Accident History 

9.15

7.36

6.11

11.67

8.42

1.74

9.2

1.58

4.69

11.91

3.58

6.97

4.31 5.39

10.5 10.62

0

2

4

6

8

10

12

14

1987 1989 1991 1993 1995 1997 1999 2001 2003

accident rate

FY 2002 Accident Statistics 

Aircraft Type Hours

Number 

of 

Accidents

Accident 

Rate 

Number 

of Fatal 

Accidents

Fatal 

Accident 

 Rate 

Number 

of 

Fatalities 

Fatality

Rate 

Fixed-Wing 33,011 1 3.02 0 0 0 0

Helicopter 54,427 8 14.69 1 1.83 1 1.83

Airtanker 8,573 2 23.32 2 23.32 5 58.32

USFS Owned 13,052 2 15.32 0 0 0 0 

Total 109,063 13 11.91 3 2.75 5 4.58 

3
The actual hours flown in FY 2002 were above the average number of hours (75,186). 

Analysis of the data shows an increase (+33,877) in total number of hours flown. 

75,186

109,063

0

50,000

100,000

150,000

Projected Actual

Average vs Actual Hours Fown for FY 2002

FY02 Flight Hour Percentages 

30%

50%

8% 12%

Fixed-Wing Helicopter Airtanker USFS Owned

4
0

2

4

6

8

10

12

14

Number of Accidents Number of Fatalities Accident Rate

Average vs Actual for FY 2002 

Average Actual

Comparison of Averages FY1993-2002 

Average Actual Comparison

Hours flown 78,916 109,063 +30,147 

Number of Accidents 5.1 13 +7.9 

Number of Fatalities 1.5 6 +4.5 

Accident Rate 6.46 11.91 +5.45 

5
10-Year Statistics

Flight Hours: 

Fiscal Year Fixed Wing Helicopter Airtanker USFS Owned Total

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

10-year totals 285,753 330,525 64,184 108,697 789,159

Averages 28,575 33,053 6,418 10,870 78,916

10 Year Average Flight Hour Percentages 

1993-2002 

36%

42%

8% 14%

Fixed-Wing Helicopter Airtanker USFS Owned

6
Accident Rates 

Year 

Number 

 of Accidents 

Accident 

Rate 

Fixed-Wing 

Accident Rate 

Helicopter 

Accident Rate 

Airtanker 

Accident Rate 

USFS Owned 

Accident Rate 

2002 13 11.91 3.02 14.69 23.32 15.32

2001 4 4.69 3.76 5.06 0 0

2000 4 3.58 2.85 3.76 0 7.84

1999 1 1.58 0 3.97 0 0

1998 3 4.31 3.08 4.09 27.14 0

1997 4 9.2 0 24.55 0 0

1996 5 5.66 0 11.02 0 8.59

1995 2 1.74 0 0 24.07 10.12

1994 10 8.42 2.22 14.23 9.9 6.94

1993 5 11.67 15.13 8.31 51.36 0

10-year 

Average

5.1 6.46 2.79 9.07 9.34 5.18

Fatal Accident and Fatality Rates

Year Fatal Accidents 

Fatal Accident 

Rate

Number 

of Fatalities Fatality Rate

2002 3 2.75 5 4.58 

2001 0 0 0 0 

2000 1 0.89 2 1.79 

1999 0 0 0 0 

1998 2 2.87 4 5.75 

1997 1 4.6 2 4.6 

1996 0 0 0 0 

1995 2 1.74 3 5.22 

1994 4 2.53 6 5.05 

1993 2 4.67 6 14.01 

10-year 

Average

1.5 1.9 2.8 3.54

7

10 Year Average Accident Rate

Percentages 1993-2002

11%

34%

35%

20%

Fixed-Wing Helicopter Airtanker USFS
Forest Service Aircraft 

Accident Statistics in 5-Year Increments

Observations 

The 1998-2002 5-year increment shows an increase of hours flown over the 

previous 5-year increments. 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

43.44

0

10

20

30

40

50

60

70

80

90

1961-1965

1966-1970

1971-1975

1976-1980

1981-19851986-1990

1991-1995

1996-2000

1998-2002

1961-2002 Average

Total Number of Accidents for all aircraft

(5-Year Increments for 40-Years)

35

30

40

19

15

11

19

8

11

20.88

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

1998-2002

1961-2002 Average

Total Number of Fatalities for all aircraft

(5-Year Increments for 40-Years)

8
USFS Owned Aircraft 

Forest Service owned aircraft accounted for approximately twelve percent of the total 

hours flown in FY 2002; the ten-year average is fourteen percent. Accident rates had 

steadily declined until FY02 and fatality rates continue to decrease. 

USFS Owned 10-Year Statistics 

Fiscal Year 

Hours 

Flown Accidents 

Accident 

Rate

Fatal 

Accidents

Fatal 

Accident Rate Fatalities

Fatality

Rate

2002 13,052 2 15.32 0 0 0 0 

2001 11,241 0 0 0 0 0 0 

2000 12,749 1 7.84 0 0 0 0 

1999 10,019 0 0 0 0 0 0 

1998 9,055 0 0 0 0 0 0 

1997 7,608 0 0 0 0 0 0 

1996 11,648 1 8.58 0 0 0 0 

1995 9,883 1 10.11 1 10.11 1 10.11 

1994 14,405 1 6.94 0 0 0 0 

1993 9,037 0 0 0 0 0 0 

Total 108,697 6 1 1 

Average 10,870 0.6 5.51 0.1 .91 0.1 1.01 

9
USFS Owned 15-Year Statistics in 5-Year Increments

Year Hours Accidents Fatalities Accident Rate Fatality Rate

1998-2002 56,116 2 0 5.34 0 

1996-2000 51,616 2 0 3.87 0 

1991-1995 52,782 4 2 7.58 3.79 

1986-1990 53,466 6 1 11.23 1.87 

Average 53,495 3.5 .75 6.54 1.4 

0

1

2

3

4

5

6

1986-1990 1991-1995 1996-2000 1998-2002

Number of Accidents in 5-Year Increments

0

0.5

1

1.5

2

1986-1990 1991-1995 1996-2000 1998-2002

Number of Fatalities in 5-Year Increments

10
Fixed-Wing (Contract) 

Fixed-Wing aircraft accounted for 30 percent of the total hours flown in FY 2002; the 

ten-year average is 36 percent. There were 33,011 hours flown in FY 2002, which is 

above the ten-year average of 28,575. Both accident and fatality rates have decreased 

over the past 40 years. 

Fixed-Wing 10-Year Statistics 

Fiscal Year 

Hours 

Flown Accidents 

Accident 

Rate

Fatal 

Accidents

Fatal 

Accident Rate Fatalities

Fatality

Rate

2002 33,011 1 3.02 0 0 0 0 

2001 26,580 1 3.76 0 0 0 0 

2000 34,976 1 2.85 1 2.85 2 5.71 

1999 21,873 0 0 0 0 0 0 

1998 32,416 1 3.08 0 0 0 0 

1997 16,753 0 0 0 0 0 0 

1996 31,919 0 0 0 0 0 0 

1995 23,406 0 0 0 0 0 0 

1994 44,995 1 2.22 0 0 0 0 

1993 19,824 3 15.13 1 5.04 4 20.17 

Total 285,753 8 2 6 

Average 28,575 0.8 2.79 0.2 0.69 0.6 2.09 

11
Fixed-Wing 15-Year Statistics in 5-Year Increments

Year Hours Accidents Fatalities Accident Rate Fatality Rate

1998-2002 148,856 4 2 2.68 1.34 

1996-2000 137,937 2 2 1.44 1.44 

1991-1995 144,074 4 4 2.78 2.78 

1986-1990 175,418 3 2 1.71 1.14 

Average 151,571 3.25 2.5 2.14 1.64 

0

5

10

15

20

25

1961-

1965

1966-

1970

1971-

1975

1976-

1980

1981-

1985

1986-

1990

1991-

1995

1996-

2000

1998-

2002

Number of Accidents in 5-Year Increments

0

5

10

15

20

1961-

1965

1966-

1970

1971-

1975

1976-

1980

1981-

1985

1986-

1990

1991-

1995

1996-

2000

1998-

2002

Number of Fatalities in 5-Year Increments

 

12
Airtankers 

Airtankers accounted for eight percent of the total hours flown in FY 2002; which is the 

ten year average. Although they fly the least amount of hours, they have the highest 

accident rate. FY 2002 was the most disastrous year for the airtanker program in recent 

history. 

Airtanker 10-Year Statistics 

Fiscal Year 

Hours 

Flown Accidents 

Accident 

Rate

Fatal 

Accidents

Fatal 

Accident Rate Fatalities

Fatality

Rate

2002 8,573 2 23.32 2 23.32 5 58.32 

2001 7,832 0 0 0 0 0 0 

2000 10,616 0 0 0 0 0 0 

1999 6,069 0 0 0 0 0 0 

1998 3,685 1 27.13 1 27.13 2 54.27 

1997 2,801 0 0 0 0 0 0 

1996 8,407 0 0 0 0 0 0 

1995 4,154 1 24.07 1 24.07 2 48.14 

1994 10,100 1 9.9 1 9.9 2 19.80 

1993 1,947 1 51.36 1 51.36 2 102.72 

Total 64,184 6 6 13 

Average 6,418 0.6 9.34 0.6 9.34 1.3 20.25 

13
Airtanker 15-Year Statistics in 5-Year Increments

Year Hours Accidents Fatalities Accident Rate Fatality Rate

1998-2002 36,775 3 7 8.15 13.59 

1996-2000 31,578 1 2 3.16 6.33 

1991-1995 24,130 4 8 16.58 33.15 

1986-1990 21,529 5 5 23.22 23.22 

Average 28,503 3.25 5 11.40 17.54 

0

5

10

15

20

25

1961-

1965

1966-

1970

1971-

1975

1976-

1980

1981-

1985

1986-

1990

1991-

1995

1996-

2000

1998-

2002

Number of Accidents in 5-Year Increments

0

2

4

6

8

10

12

14

1961-

1965

1966-

1970

1971-

1975

1976-

1980

1981-

1985

1986-

1990

1991-

1995

1996-

2000

1998-

2002

Number of Fatalities in 5-Year Increments

14
Helicopters 

Helicopters accounted for the largest percent of the total hours flown in FY 2002. They 

flew 50 percent of the total hours flown in FY 2002. The 10-year average is 42 percent. 

The number of helicopter accidents in FY 2002 was the highest in recent history as well. 

The average number of accidents is three; we experienced 8 in FY 2002. 

Helicopter 10-Year Statistics 

Fiscal Year 

Hours 

Flown Accidents 

Accident 

Rate

Fatal 

Accidents

Fatal 

Accident Rate Fatalities

Fatality

Rate

2002 54,427 8 14.69 1 1.83 1 1.83 

2001 39,497 2 5.06 0 0 0 0 

2000 53,145 2 3.76 0 0 0 0 

1999 25,174 1 3.97 0 0 0 0 

1998 24,423 1 4.09 1 4.09 2 8.18 

1997 16,295 4 24.54 1 6.13 2 12.27 

1996 36,307 4 11.01 0 0 0 0 

1995 20,031 0 0 0 0 0 0 

1994 49,200 7 14.22 3 6.09 4 8.13 

1993 12,026 1 8.31 0 0 0 0 

Total 330,525 30 6 9 

Average 33,053 3.0 9.07 0.6 1.81 0.9 2.72 

15
Helicopter 15-Year Statistics in 5-Year Increments

Year Hours Accidents Fatalities Accident Rate Fatality Rate

1998-2002 196,666 14 3 7.11 1.01 

1996-2000 155,344 12 4 7.72 2.57 

1991-1995 135,262 14 5 10.35 3.7 

1986-1990 108,854 18 3 16.55 2.76 

Average 149,032 14.50 3.75 9.72 251 

0

10

20

30

40

50

1961-

1965

1966-

1970

1971-

1975

1976-

1980

1981-

1985

1986-

1990

1991-

1995

1996-

2000

1998-

2002

Number of Accidents in 5-Year Increments

0

5

10

15

1961-

1965

1966-

1970

1971-

1975

1976-

1980

1981-

1985

1986-

1990

1991-

1995

1996-

2000

1998-

2002

Number of Fatalities in 5-Year Increments

16
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. The National Safety Office provided monthly safety summaries to the field by

providing hard copy and internet access to vital risk management data. 

These charts trend the SafeCom data posted on the Forest Service Aviation Internet site at 

http://www.fs.fed.us/fire/av_safety/index.html. The average of total numbers of 

submitted SafeCom’s is 613 per year. The FY 2002 number is significantly higher at 

962. The total number of SafeCom’s submitted fluctuates with the total number of hours

flown. 

Again, this year no big surprises, the five most reported SafeCom’s were engine, 

communications, intrustions, electrical and dropped loads. In an analysis of the past five 

years policy deviation was in the top five most reported, which decreased significantly in 

FY 2002. 

FY 2002 SafeCom Information

Aircraft Type Number Percent of all SafeCom’s

Fixed Wing 197 20.5% 

Helicopter 515 53.5%

Airtanker 135 14%

SEAT 13 1.4%

USFS Owned 62 6.4% 

Other 40 4.2%

Total 962 100%

Category Number Percent of all SafeCom’s

Airspace 130 14%

Hazard 290 30%

Incident 147 15%

Maintenance 395 41%

Total 962 100%

17
Top Eleven SafeCom Categories Reported For Five Years 

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Engine

Communications

Intrusion

Policy Deviation

Electrical

Dropped Load

Chip Light

Fuel

Pilot Action

Aircraft Damage

Flight Following

1998 1999 2000 2001 2002

These 11 categories account for 50-60% of Total Safecoms submitted 

Communications SafeCom’s Reported by Mission for 5 years 

0

5

10

15

20

25

30

35

40

45

Air-Attack Airtanker Helicopter Other Helitack Leadplane Passenger Ferry Recon Smokejumper

Retardant Bucket Transport Reposition 

18
Policy Deviation SafeCom’s Reported by Mission for 5 years 

0

5

10

15

20

25

30

35

Fire, Passenger Helicopter Passenger Recon Ferry Air-Attack Airtanker Law 

Transport Bucket Transport Reposition Retardant Enforcement 

Drop Drop 

SafeCom's by Aircraft Type

20%

55%

14%

6% 4% 1%

Fixed-Wing Helicopter Airtanker

USFS Owned Other SEAT

19
SafeCom's by Category

41%

14%

30%

15%

Maintenance Airspace

Hazard Incident

Airspace SafeCom's

20%

3%

64%

5% 4% 4%

Conflict Congestion Intrusion

Near Mid-Air Other Procedures

20
0

10

20

30

40

50

60

70

80

Communicatioons

Flight Equipment

Flight Following

Fuel

Ground Equipment

Instructions

Other

Pilot Action

Policy Deviation

Weather

Hazard SafeCom’s 

18%

6%

26%

1%

2%

37%

10%

Aircraft Damage Dragged Load Dropped Load

Forced Landing Ground Damage Other

Precautionary Landing

Incident SafeCom’s 

21
22

0 20 40 60 80 100 120

Airframe

Avionics

Caution Light

Chip Light

Electrical

Engine

Elevator

Flaps

Flight Controls

Fuel

Gear Box

Hydraulic

Instrument

Landing Gear

Pitot Static

Oil 

Other

Propeller

Rotor (main)

Rotor (tail)

Transmission

Trim

Maintenance SafeComs 
SafeCom’s by Region

Percent of Safecoms by Region

R-1

5%

R-3

16%

R-4

10%

R-5

16%

R-8

10%

R-10

3%

R-9

1%

R-6

18%

WO

2% R-2

19%

0

50

100

150

200

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

USFS Other Agen

The chart below shows the number of SafeComs by region (FS and other agency) 

reported in FY 2001. There were a total of 962 SafeComs reported, 806 were 

USFS and 156 were other agencies. 

cies

23
SafeCom’s by Category and Region 

Region Airspace Hazard Incident Maintenance Total

Region 1 2 12 9 23 46 

Region 2 20 65 26 73 184 

Region 3 31 42 14 65 152 

Region 4 19 27 17 34 97 

Region 5 18 39 19 79 155 

Region 6 21 55 35 66 177 

Region 8 16 22 20 36 94 

Region 9 3 4 0 2 9 

Region 10 0 13 6 12 31 

WO 0 11 1 5 17

Total 130 290 147 395 962

SafeCom’s by Aircraft Type and Region 

Region FixedWing Helicopter Airtanker SEAT USFS

Owned 

N/A Total

Region 1 11 24 5 0 5 1 46 

Region 2 28 100 33 3 11 9 184 

Region 3 43 61 32 4 7 5 152 

Region 4 15 53 14 1 8 6 97 

Region 5 29 99 23 0 2 2 155 

Region 6 32 101 18 4 16 6 177 

Region 8 23 52 10 0 5 4 94 

Region 9 6 1 0 0 2 0 9 

Region 10 16 15 0 0 0 0 31 

WO 4 4 0 1 6 2 17

Total 207 510 135 13 62 35 962

24
2002 Accident Review 

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

incidents. 

The purpose of this class is to present an overview of the various components

which constitute Human Factors and how their failures may have resulted in 

these USFS accidents. 

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 thirteen accidents in the 2002 fiscal year. There 

were 6 fatalities and 3 serious injuries. 

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. 

25
 

 In 

Memory 

 of

Gordon Knight

 Rick Schwartz 

Milt Stollak

Steven Wass

Craig Labare 

Michael Davis

26
Great Gulf Fire, Daniel Boone NF

November 12, 2001 

Bell 407 

Mission: Water Bucket Operations 

Damage: Substantial 

Injuries: One Serious 

Procurement: CWN 

NTSB ID: NYC02TA026

The helicopter was conducting bucket operations when the bucket, which 

was attached to the cargo hook came into contact with the tail rotor of the 

aircraft. 

27
The total length of cable and bucket was 25 feet. The distance from the 

cargo hook to the tail rotor blade was 20 feet 2 inches.

28
Stocking Fire, Francis Marion NF 

December 21, 2001

Bell 206 

Mission: Water Bucket Operations

Damage: Substantial 

Injuries: None 

Procurement: CWN 

NTSB ID: ATL02TA021

29
The pilot was attempting a water-dip when the cable slipped over the toe of the skid. As 

the pilot began a climb from the pond, the helicopter rolled right and collided with the 

water. 

The pilot could not recover from the unbalance caused by the Bambi Bucket cable 

draped over the right skid and the forward acceleration of the aircraft. 

The pilot was wearing a PFD. He exited the aircraft from underwater and escaped 

without injury.

30
Maintenance Test Flight, Boise, ID

January 2, 2002

Beech 58P Baron 

Mission: Maintenance Test Flight 

Damage: Substantial 

Injuries: None 

Procurement: Fleet 

NTSB ID: SEA02FA023

The pilot noticed flames from the engine nacelle just after liftoff. 

He radioed the tower and notified them of the situation and that he was 

landing the aircraft on the departure runway. 

31
The NTSB determined the probable cause(s) of this accident as follows: 

Improper clearance between an alternator wire and a pneumatic line and fuel fumes. 

The alternator wire chafe and arcing were factors.

32
Ferry Flight, Region 8 to Region 1 

April 5, 2002

Douglas DC-3 

Mission: Ferry Flight 

Damage: Substantial 

Injuries: None 

Procurement: Fleet 

NTSB ID: DEN02TA037

33
The Douglas DC-3C, N115Z, was substantially 

damaged when its left 

main landing gear 

collapsed while standing 

at Natrona County 

International Airport. 

The landing gear 

hydraulic pressure was 

high. The pilot asked the 

copilot to cycle the 

landing gear handle to the 

down position in an 

attempt to lower the pressure. The copilot 

inadvertently raised the 

landing gear. 

34
Ocala, NF 

April 9, 2002

Aerospatiale SA 319B 

Mission: Search & rescue 

Damage: Substantial 

Injuries: Two 

Procurement: Exclusive Use 

NTSB ID: MIA02TA082

U.S. Forest Service personnel dispatched the helicopter with inoperative 

brakes for the sole purpose of searching for a possible downed aircraft. 

A USFS employee was on board.

35
The pilot flying was assured that the chief pilot would be standing by 

with chocks upon returning to the helibase. 

Upon landing at the helibase, the aircraft began to roll forward on 

the ramp. The pilot attempted to gain control of the aircraft by lifting 

to a hover when the main rotor struck the tail boom. 

36
Cannon Fire, Humboldt-Toiyabe NF 

June 17, 2002

Lockheed C-130 

Mission: Retardant Drop 

Damage: Destroyed 

Injuries: 3 Fatal 

Procurement: Exclusive 

NTSB ID: LAX02GA201

N130HP broke apart in flight while executing a fire retardant delivery. 

37
During the delivery, the wings separated from the fuselage near the wing 

roots. Subsequently, fire was ignited in the area of the separated wings. 

Preliminary 

findings have 

found several 

cracks in the 

center wing box 

lower skin. 

Specifically, the 

area of the wing 

that separated 

failed in fatigue 

as a result of the 

promulgation of 

the cracks.

38
San Bernardino NF 

June 20, 2002 

Cessna 337 

Mission: Point to Point 

Damage: Destroyed 

Injuries: One Minor 

Procurement: CWN 

NTSB ID: LAX02TA207

N2671S was destroyed by fire after a hard landing to a residential 

road following a loss of engine power to both engines while on 

approach. 

39
Due to a compromise 

of the evidence, the 

cause of the loss of 

power is 

undetermined at this 

time. 

The pilot reported that 

both engines lost total 

power. Unable to reach 

the runway, the pilot 

executed a forced 

landing to a residential 

road. 

40
Big Elk Fire, Arapaho-Roosevelt NF 

July 18, 2002 

Consolidated PB4Y 

Mission: Retardant Drop 

Damage: Destroyed 

Injuries: 2 Fatal 

Procurement: Exclusive Use 

NTSB ID: DEN02GA074

T-123, N7620C, was destroyed when it impacted into mountainous terrain. 

Prior to the impact, the airplane's left wing separated and aircraft control 

was lost.

41
Preliminary findings of the 

wing indicated that the left 

wing, forward spar, lower 

spar cap assembly failed in 

fatigue. 

The copilot of T-161 said 

T-123 was in his base turn 

for the drop when the left 

wing separated from the 

airplane. 

"The aircraft then went into 

a rotation and impacted the 

ground."

42
Big Elk Fire, Arapaho-Roosevelt NF 

July 30, 2002 

Aerospatiale SA-315B 

Mission: Water Bucket Operations

Damage: Substantial 

Injuries: One Fatal 

Procurement: CWN 

NTSB ID: DEN02GA085

43
N3978Y was destroyed 

when it struck terrain. 

Witnesses heard the 

pilot give a warning 

over the radio: 

"Helicopter going 

down." 

Witnesses heard a high-pitched 

whine and saw the main rotor 

blades turning slowly as the 

helicopter descended. 

There was a post impact ground 

fire that was quickly 

extinguished. 

Preliminary findings 

indicate that an engine 

failure may have occurred 

prior to the crash. 

An Aviation Safety Alert 

was published as a result of 

this accident.

44
Beaverhead-Deerlodge NF 

August 24, 2002 

Bell 206L1 

Mission: Water Bucket Operations 

Damage: Substantial 

Injuries: None 

Procurement: Exclusive Use 

NTSB ID: SEA02TA164

N832AH settled into trees, the helicopter was substantially 

damaged. 

It was only after a post-flight walk around that the pilot noticed 

damage to both main rotor blades.

45
The pilot later said he was 

“heli-mopping” when he 

descended into the trees 

with the 50-foot long line. 

During this maneuver, the 

main rotor blades came in 

contact with trees. 

 

Several missions had been 

flown the day of the 

accident and the pilot was 

unsure as to when the 

damage occurred. 

46
Rio Grande NF 

August 26, 2002 

Bell 206L3 

Mission: Initial Attack 

Damage: Destroyed 

Injuries: 1 Serious 

 3 Minor 

Procurement: CWN 

NTSB ID: DEN02TA100

N801HM collided with trees and impacted terrain during landing approach. 

The pilot was seriously injured and three passengers received minor injuries.

47
Witnesses reported the helicopter was approaching to land in gusty wind 

conditions when it started spinning to the right. 

48
San Bernardino NF 

August 30, 2002 

Sikorsky S-55T 

Mission: Water Bucket Operations 

Damage: Substantial 

Injuries: None 

Procurement: CWN 

NTSB ID: LAX02TA267

N747A collided with terrain while attempting a precautionary landing 

in a dry creek bed. 

A hydraulic warning light illuminated and the flight controls became 

stiff.

49
The pilot began an approach, the cyclic moved "hard over," and the pilot 

was unable to regain control before the rotors made contact with a rocky 

shelf. 

A sample of hydraulic 

fluid was taken from 

the reservoir and it 

appeared to be 

severely contaminated. 

The fluid was sent to a 

laboratory for testing.

50
Sample was placed in graduated cylinder and allowed to 

separate. Two phases existed with top phase being 78% and 

bottom (water) phase being 22%. Karl Fischer water analysis 

was performed on the top phase (1.85%). Microbial Growth was 

detected in sample. 

 P.O. Number : PD CC# Client Code :USDAGB 

Sample Date : 09/01/02 Description :1ST SAMPLE, N747A 

TAKEN FROM_HYD RESERVOIR 

PO#91U24186 

Test Performed Result

Water by Karl Fischer, ASTM D6304......18450 ppm 

Microbial Growth, HL-1126 ..................1126-2.0 

Bacteria.....................................................NEGATIVE 

Fungi..........................................................HEAVY 

51
INYO NF 

September 29, 2002

Aerospatiale AS 350 B3

Mission: Point to Point 

Damage: Substantial 

Injuries: None 

Procurement: Exclusive Use 

NTSB ID: LAX02LA299

AS350-B3, N352SA, collided with terrain while engaged in a pre-departure 

hydraulic flight control check. 

52
The collective had been placed in the down and locked position. 

After depressing the hydraulic test switch, the pilot moved the cyclic fore 

and aft to confirm there was remaining pressure. 

53
 The collective's 

locking mechanism 

stud was worn and the 

collective came loose 

during movement of 

the cyclic. 

The collective 

indirectly rose 

and the 

helicopter 

moved forward 

in a nose down 

attitude. 

The main rotor 

struck the 

ground and the 

helicopter made 

two revolutions 

before rolling 

over onto its 

side.

54
Preliminary Findings

The following are Human Factors that have played a significant part in 

contributing to accidents in FY 2002. They are listed here as a source 

for study and application in future project planning and risk

management. 

◊ Sensory/Perceptual Factors: 

▪ Misjudgment of distance, clearance, altitude, speed, etc. 

 ▪ Loss of situational awareness 

▪ Attention failure (e.g., failure to monitor or respond when correct 

information was available) 

 ▪ Unintentional activation of control switch (slip) 

◊ Medical and Physiological 

 ▪ Self-medication (without medical advice or against 

 medical advice) 

 ▪ Cold, flu,or other known illness) 

◊ Knowledge and Skill 

 ▪ Inadequate knowledge of systems, procedures, etc. 

 (knowledge-based errors) 

 ▪ Used improper procedure 

◊ Mission Factors 

▪ Poor communication with other assets (ground, other aircraft, etc.) 

 ▪ Lack or variation of standards 

◊ Personality and Safety Attitude 

▪ Demonstration of excessive motivation to achieve mission 

◊ Judgment and Risk Decision 

▪ Intentional deviation from safe procedure (imprudence) 

▪ Intentional violation of standard operating procedure or 

regulation 

▪ Violation of orders/regulations/SOP 

 ▪ Accepted unnecessary hazard 

 ▪ Noncompliance with prescribed mission profile/parameters 

55
◊ Communication and Crew Coordination 

▪ Inadequate mission plan/brief or preflight 

▪ Inadequate understanding of communication or failure to 

 acknowledge communication 

▪ Inadequate training in communication/crew coordination 

◊ Supervisory and Organizational 

 ▪ Not adhering to rules and regulations 

▪ Failure to provide proper training 

▪ Failure of standards, either poorly written, highly 

interpretable, or conflicting 

▪ Risk outweighs benefit 

 ▪ Inadequate mission briefing/supervision 

▪ Intentional violation of a standard or regulation 

◊ Supervisory and Organizational (cont) 

- Failure to perceive or assess the mission risks correctly, with 

respect to: 

 ▪ Hazards go unseen/unrecognized 

▪ Environmental hazards/operating conditions 

▪ Aircraft and equipment limitations 

◊ Maintenance 

 - Procedures 

 ▪ Not Followed 

 - Records 

 ▪ Discrepancies entered but not deferred or cleared 

 ▪ Entries not recorded or not recorded in correct book(s) 

 - Quality Assurance 

▪ Not used (available)

56
Conclusion

"Human Factors is about people: it is about people in their working and 

living environments, and it is about their relationship with equipment, 

procedures, and the environment. Just as importantly, it is about their 

relationships with other people.... Its two objectives can be seen as safety

and efficiency.'' (ICAO Circular 227) 

What Can You Do? 

If we are to make any major strides in Aviation Safety in the coming years, 

our greatest opportunity is in behavioral changes in our aviation safety 

culture with special emphasis on human error. The expansion of human 

factors awareness presents our aviation community with the single most 

significant opportunity to make aviation both safer and more efficient. 

57
Appendix #1 

Findings of the Blue Ribbon Panel 

Safety: 

The safety record of fixed wing aircraft used in wildland fire management is 

unacceptable. 

The Panel determined that contractor personnel flying large air tankers are subject to a

lower safety standard than government personnel flying federally owned and operated 

lead planes and smoke-jumper aircraft. Further, the level of safety for both contractor and 

government aerial firefighting operations is lower than can be financially justified, and is 

less than expected for any employer concerned about his employees. This disparity in 

safety standards stems from a government contracting process that assumes the 

airworthiness of today’s large air tanker fleet has been assured by the FAA’s type 

certification process. However, responsibility for the continued airworthiness of aircraft 

converted to air tankers is up to the contractors who own and operate the aircraft. 

The panel saw no reports that identified in-flight structural failures or break-ups of 

helicopters. However, in reviewing a document that summarized 36 aviation accidents

related to fire service rotorcraft during the past 10 years, there were many accidents with

similar features. The panel also found that varying airworthiness standards required under 

federal firefighting contracts had an impact in helicopter safety. However, much of the 

helicopter work associated with firefighting is consistent with the helicopter’s original 

mission design. 

The Forest Service owns and operates a fleet of 19 pressurized Beechcraft Baron BE-58P 

aircraft. Although flown in a variety of roles, the Baron’s principal mission is to serve as 

lead plane for large air tankers. Many lead plane missions are flown over mountainous 

terrain during summer months when temperatures are well above those of a standard day. 

Under these conditions, air density is much lower than at sea level, which reduces the 

capability of an aircraft to maintain altitude. In addition, much of the terrain in fire-prone 

regions, particularly in the western United States, is higher than the Baron’s single-engine 

service ceiling, which is the maximum altitude that a multi-engine aircraft can maintain a 

50-foot/minute rate of climb when flying on one engine. The Baron fleet is also 

experiencing a high rate of maintenance problems, raising concerns about the long-term 

sustainability of safe operations. The structural life expectancy for Barons flying the 

firefighting mission also is questionable. It would appear that Baron operations cannot be 

easily limited to missions that can be conducted safely, and there are no other suitable 

aircraft available to assume firefighting functions. 

Damage resistant voice and data recorders on aircraft are essential for effective accident 

investigations. However, no Forest Service or BLM policy requires recorders to be 

installed on either government-owned or contractor-flown aircraft. 

58