United States Department of Agriculture

Forest Service

FY 2003

Aviation Safety Summary

Prepared by

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 this FY 2003 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 aircraft. These include

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

Service owns approximately 250 aircraft and operates 42 aircraft (40 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.
4

Aviation Safety Accomplishments

After the devastating year in 2002, we were actively looking for ways to improve aviation 

safety in 2003, starting with changing our safety culture. We focused on increased 

training and improving risk management processes.

Accomplishments achieved in aviation safety in 2003 included:

• Implemented the National Aviation Safety Plan

• Revised the FSM 5720

• Produced Aviation Safety Lessons Learned packages and distributed to airtanker 

and helicopter contractors

• Created the National Aviation Safety Center 

• Established the new National Aviation Safety Center website

• Combined SAFECOM system with DOI – Aviation Management

• Increased involvement in Interagency Aviation Training ACE courses and 

steering committee

• Tested and received support for implementation of Automated Flight Following in 

2004

• Created Accident/Incident database

• Generated and distributed eight Safety Alerts 

• Produced and distributed three Safety Summaries during the fire season

• Produced and distributed three Airward News letters

• Proposed National Aerial Firefighting Academy (NAFA) Improvements & MOU for 

joint support with BLM

• Implemented the Fire Traffic Area (FTA) proposal from Region 5 

• Eliminated operations with high-risk airtankers

• Reduced exposure through new direction on airtanker utilization

• Grounded leadplanes and smokejumper aircraft for evaluation of suspected 

safety concerns

• Addressed concerns about operational parameters

• Installed safety equipment (TCAS & AFF)

• Explored methods for helicopter safety enhancements

• Represented USDA at GSA Interagency Committee for Aviation Policy

• Proposed interagency MOU to improve airspace coordination and management 

on wildland fire operations

• Participated in National Safety and Health Council and Fire Operations Safety 

Council meetings 

• Participated in Regional Fire Directors meetings to keep them informed of 

developing aviation safety issues

• Participated in Aviation Management Council and Aviation Operations Oversight 

Team

• Participation in NIFC Fire and Aviation Safety Team
5

Statistical Summary

The accident rate for fiscal year 2003 was less than half of the 15 year average. We 

experienced 3 accidents and 9 “Incidents with Potential” (IWP). Unfortunately, we did 

not make it through the year without any fatalities. The pilot and helicopter manager 

were fatally injured in the helicopter accident involved in the recovery effort for the 

space shuttle Columbia. The USFS flew 96,055 hours, which was 17,431 hours above 

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: 

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

 ̧ Air tactical command and control

 ̧ Firefighter transport

 ̧ Surveillance, reconnaissance, and intelligence gathering

 ̧ 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. 

This year we have added a new metric for analysis of risk. The number of accidents per 

100,000 departures (Departure Accident Rate) has been included as a tool for

comparing the frequency of exposure to risk (number of departures) with the amount of 

time at risk (number of flight hours). This comparison will assist with the recognition of 

hazardous trends and aid in accident prevention efforts. 
6

USFS Aircraft Accident Rates 1987 to 2003

FY 2003 Accident Statistics

Aircraft Type Hours

Number of 

Accidents

Accident 

Rate

Number of 

Fatal 

Accidents

Fatal

Accident

 Rate

Number 

of 

Fatalities

Fatality 

Rate

Fixed-Wing 32,704 1 3.05 0 0 0 0

Helicopter 50,662 2 3.94 1 1.97 2 3.94

Airtanker 5,082 0 0 0 0 0 0

USFS Owned 7,607 0 0 0 0 0 0

Total 96,055 3 3.12 1 1.04 2 2.08

The actual hours flown in FY 2003 were above the fifteen-year average number of 

hours (78,624). Analysis of the data shows an increase (+17,431) in total number of 

hours flown. 

9.15

7.36

6.11

11.67

8.42

1.74

9.2

1.58

4.69

11.91

3.12

7.86

2.71

4.21

6.26

3.31

1.06

2.61 3.02

8.15

2.29

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

78,624

96,055

0

20,000

40,000

60,000

80,000

100,000

Average Actual

Average vs Actual Hours Flown for FY 2003

FY03 Flight Hour Percentages 

34%

53%

5% 8%

Fixed-Wing Helicopter Airtanker USFS Owned
8

Comparison of Averages FY 1989-2003

15 Year Average Actual Comparison

Hours flown 78,624 96,055 +17,431

Number of Accidents 5.07 3 -2.07

Number of Fatalities 2.4 2 -.4

Accident Rate 6.44 3.12 -3.32

15-Year Flight Hour Statistics

Flight Hours:

Fiscal Year Fixed Wing Helicopter Airtanker USFS Owned Total

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

1989 34,450 25,749 5,337 9,829 75,365

15-year totals 448,145 488,250 86,978 155,986 1,179,359

Averages 29,876 32,550 5,799 10,399 78,624

0

1

2

3

4

5

6

7

Number of Accidents Number of Fatalities Accident Rate

Average vs Actual for FY 2003

Average Actual
9

Accident Rates by Flight Hours Vs. Departure

15 Year Average of Flight Hour Percentages

1989-2003

38%

42%

7% 13%

Fixed-Wing Helicopter Airtanker USFS Owned

15 Year Average Accident Rate

Percentages 1989-2003

8%

35%

37%

20%

Fixed-Wing Helicopter Airtanker USFS Owned

10 Year Average Departure Accident Rate

Percentages 1994-2003

11%

29%

18%

42%

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

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

1989 8 10.62 2.90 19.42 18.74 10.17

15-year 

Average 5.07 6.44 2.23 9.83 10.34 5.76

Total Fatal Accident and Fatality Rates

Year Fatal 

Accidents

Fatal Accident 

Rate

Number of 

Fatalities

Fatality 

Rate

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

1989 0 0.00 0 0.00

15-year 

Average 1.33 1.69 2.4 3.05
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

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 334,750 575,690 153,716 78,937 1,143,093

Averages 33,475 57,569 15,372 7,894 114,309

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

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

1994 10 7.86 2.46 11.96 5.88 9.1

10-Year 

Average 4.9 4.28 2.09 5.38 3.25 7.6

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

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

44.88

0

10

20

30

40

50

60

70

80

90

1961-19651966-19701971-19751976-19801981-19851986-19901991-19951996-20001999-2003

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

21.4

0

5

10

15

20

25

30

35

40

1961-19651966-19701971-19751976-19801981-19851986-19901991-19951996-20001999-2003

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 eight percent of the total hours flown in FY 

2003; the fifteen-year average is thirteen percent. Accident rates have steadily declined 

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

the past eight years

USFS Owned 15-Year Statistics

Fiscal 

Year

Hours 

Flown Accidents Accident Rate

Fatal 

Accidents

Fatal 

Accident 

Rate

Fatalities Fatality 

Rate

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

1989 9,829 1 10.17 0 0.00 0 0.00

Total 155,986 9 2 2

Average 10,399 0.6 5.76 0 1.28 0 1.28
15

USFS Owned Aircraft Accident Rates 1989 to 2003

0

2000

4000

6000

8000

10000

12000

14000

16000

198919901991199219931994199519961997199819992000200120022003

USFS Owned Hours Flown and 

Number of Departures

Hours Flown Departures

2.9

0

15.13

0 0 0 0

3.76

3.06 2.46

0 0 0

3.45

0

2.46

5.8

2.34 2.52

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)
16

Fixed-Wing (Contract)

Fixed-Wing aircraft accounted for 34 percent of the total hours flown in FY 2003; the fifteenyear average is 38 percent. There were 32,704 hours flown in FY 2003, which is above the 

fifteen-year average of 29,876.

Fixed-Wing 15-Year Statistics

Fiscal 

Year

Hours 

Flown Accidents Accident Rate

Fatal 

Accidents

Fatal 

Accident 

Rate

Fatalities Fatality 

Rate

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

1989 34,450 1 2.90 0 0.00 0 0.00

Total 448,145 10 2 6

Average 29,876 0.66 2.23 0.13 0.44 0.40 1.33
17

Fixed-Wing (Contract) Aircraft Accident Rates

1989 to 2003

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

198919901991199219931994199519961997199819992000200120022003

Fixed-Wing Hours Flown and 

Number of Departures

Hours Flown Departures

9.15

7.36

6.11

11.67

8.42

1.74

9.2

1.58

4.69

11.91

3.12

7.86

2.71

4.21

6.26

3.31

1.06

2.61 3.02

8.15

2.29

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)
18

Airtankers

Airtankers accounted for five percent of the total hours flown in FY 2003; which is well 

below the fifteen-year average. Although they fly the least number of hours, they have 

the highest accident rate of any aircraft utilized by the USFS. 

Airtanker 15-Year Statistics

Fiscal 

Year

Hours 

Flown Accidents Accident Rate

Fatal 

Accidents

Fatal 

Accident 

Rate

Fatalities Fatality 

Rate

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

1989 5,337 1 18.74 0 0.00 0 0.00

Total 86,978 9 8 17

Average 5,799 0.6 10.34 0.53 9.19 1.13 19.54
19

Airtanker Accident Rates 1989 to 2003

0

5000

10000

15000

20000

25000

198919901991199219931994199519961997199819992000200120022003

Airtankers Hours Flown and

Number of Departures

Hours Flown Departures

18.74 19.43

51.36

24.07

0 0 0 0 0

5.88

9.92

0 0

9.79

0 0 0

9.73

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 2003. They 

flew 53 percent of the total hours flown in FY 2003. The 15-year average is 42 percent. 

The average number of accidents is nearly five; we experienced 2 in FY 2003. 

Helicopter 15-Year Statistics

Fiscal 

Year

Hours 

Flown Accidents Accident Rate

Fatal 

Accidents

Fatal 

Accident 

Rates

Fatalities Fatality Rate

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

1989 25,749 5 19.42 0 0.00 0 0.00

Total 488,250 48 8 12

Average 32,550 3.2 9.83 0.53 1.63 1.20 2.45
21

Helicopter Accident Rates 1989 to 2003

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

198919901991199219931994199519961997199819992000200120022003

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

11.96

0

6.8

14.42

2.25 2.29 2.46 2.83

9.15

2.69

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. The National Aviation Safety Center 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.safecom.gov/ The average of total numbers of submitted SafeCom’s 

is 636 per year. The FY 2003 number is significantly higher at 887. 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, intrusions, 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 2003 SafeCom Information

Aircraft Type Number Percent of all SafeCom’s

Fixed Wing 157 17.7%

Helicopter 552 62.2%

Airtanker 108 12.2%

SEAT 9 1.0%

USFS Owned 29 3.3%

Other 32 3.6%

Total 887 100%

Category Number Percent of all SafeCom’s

Airspace 81 9.1%

Hazard 223 25.1%

Incident 136 15.3%

Maintenance 447 50.4%

Total 887 100%
23

FY '03 Safecoms by Category

51%

9%

25%

15%

Maintenance Airspace Hazard Incident

FY '03 SafeCom's by Aircraft Type

18%

62%

12% 3%4% 1%

Fixed-Wing Helicopter

Airtanker USFS Owned

Other SEAT
24

FY '03 Airspace SafeCom's

22%

52%

6%

7%

12% 1%

Conflict Intrusion Near Mid-Air

Other Procedures Route Deviation

0

10

20

30

40

50

60

CommunicationsFlight Equipment

Flight Following

Fuel

Ground Equipment

Instructions

Other

Pilot Action

Policy Deviation

Weather

FY '03 Hazard SafeCom's
25

FY '03 Incident SafeCom's

18%

13%

1% 36%

2%

22%

8%

Aircraft Damage Dragged Load

Dropped Load Forced Landing

Ground Damage Other
26

0 20 40 60 80 100 120 140

Airframe

Avionics

Caution Light 

Chip Light

Electrical

Engine

Environmental

Flaps

Flight Controls

Fuel 

Gear Box

Hydraulic

Instrument

Landing Gear

Oil 

Other

Propeller

Rotor (main)

Rotor (tail)

Transmission

Trim

Vacuum

Warning Light

FY ’03 Maintenance SafeComs
27

SafeCom’s by Region

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

agency) reported in FY 2003. There were a total of 887 SafeComs reported, 812 

were USFS and 75 were other agencies.

Percent of Safecoms by Region

R-1

27%

R-3

R-4 15%

11%

R-5

13%

R-8

8%

R-2

4%

WO

0%

R-6

18%

R-9

2%

R-10

2%

0

50

100

150

200

250

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

USFS Other Agencies
28

FY ’03 SafeCom’s by Category and Region

Region Airspace Hazard Incident Maintenance Total

Region 1 28 42 34 137 241

Region 2 8 12 2 11 33

Region 3 9 42 20 60 131

Region 4 10 29 13 47 99

Region 5 8 23 21 63 115

Region 6 12 41 34 74 161

Region 8 3 19 8 37 67

Region 9 2 6 3 5 16

Region 10 0 7 1 13 21

WO 1 2 0 0 3

Total 81 223 136 447 887

FY ’03 SafeCom’s by Aircraft Type and Region

Region FixedWingHelicopter Airtanker SEAT USFS 

Owned

N/A Total

Region 1 41 157 28 0 14 1 241

Region 2 12 12 5 1 1 2 33

Region 3 21 82 12 5 2 10 132

Region 4 15 56 17 2 6 3 99

Region 5 16 81 14 0 0 4 115

Region 6 23 98 29 1 2 7 160

Region 8 7 55 0 0 1 4 67

Region 9 10 5 1 0 0 0 16

Region 10 11 7 0 0 2 1 21

WO 2 0 1 0 0 0 3

Total 158 553 107 9 28 32 887
29

2003 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 three accidents in the 2003 fiscal year. Two of the 

accidents were mechanical with only one being human error. There were two fatalities 

and three 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. Although the Forest Service does not have the HFACS in a database 

yet, we have required our accident investigators over the last few years to complete an 

HFACS checklist, which we intend to get put into a database in the near future.

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.
30

In Memory Of

Jules Mier

Charles Krenek
31

Angelina NF, Texas

Gordon Knight

NTSB Identification: FTW03FA118

14 CFR Part 91: General Aviation

Accident occurred Thursday, March 27, 2003 in Broadus, TX

Aircraft: Bell 407, registration: N175PA

Injuries: 2 Fatal, 3 Serious.

Mission

Aerial search and recovery of debris from the 

Space Shuttle Columbia accident, the aircraft 

was under a CWN contract with the USDA, 

Region 3.

The pilot and 1 crewmember were fatally injured 

and 3 crewmembers sustained serious injuries.
32

Visual meteorological 

conditions prevailed.

The helicopter was 

completing its second 

search mission of the day 

while hovering about 125 

feet above the ground.

The surviving passengers 

reported that the helicopter 

lost power and descended 

rapidly into the 80-foot tall 

trees. The helicopter came 

to rest on its right side at the 

base of a 80-foot tree.

After the wreckage was recovered, the engine was removed and set up in a test cell. 

The engine operated normally in the manual mode. During the test cell run, it was 

discovered that the power lever angle (PLA) indicator on the Hydro Mechanical Unit 

(HMU) responded erratically to normal throttle inputs when the engine was operated in 

the electromechanical mode. 
33

Gypsy Moth Project, Narrows, VA.

NTSB Identification: NYC03TA138

14 CFR Part 91: General Aviation

Accident occurred Thursday, June 26, 2003 in Pearisburg, VA

Aircraft: Air Tractor 402A, registration: N4506L

Injuries: 1 Uninjured.

Mission

Aerial application of Pheromone flakes in 

support of the Gypsy Moth slow the spread 

strategy (STS) 

The pilot was in the middle of a run when 

he observed orange flames and black 

smoke emitting from the engine exhausts. 

He feathered the propeller, and set up for 

a forced landing in a nearby open area.
34

The Air Tractor under 

contract to the USDA 

Forest Service, was 

substantially damaged 

during the forced landing

The engine was reported to have a total 

time of 26,775 hours, including 10,708.9 

hours since last overhaul and was retained 

for further examination.

The tear down analysis revealed 

excessive damage to the compressor 

blades and other turbine components

Hole in Burn Can

Turbine blade damage
35

Tucson, AZ, Coronado NF

NTSB Identification: LAX03TA229

14 CFR Part 133: Rotorcraft Ext. Load

Accident occurred Monday, July 07, 2003 in Tucson, AZ

Aircraft: Sikorsky S-64E, registration: N6979R

Injuries: 2 Uninjured.

Mission

The purpose of the flight was 

to provide retardant/water 

drops for suppression of the 

Aspen fire.

The helicopter was equipped 

with a 2,000 gallon fixed tank 

with snorkel hover fill

capability, and configured to 

carry a maximum of three flight 

crewmembers. 
36

Maintenance personnel discovered 

the exhaust tube on the left engine 

was damaged. The helicopter was 

shutdown and examined 

Upon closer inspection, it was 

determined that "all pieces were 

there." Other components of the

helicopter were also examined. All 

4 tail rotor blades sustained 

damage. 

There was a misjudgment of aircraft 

clearance to trees, and loss of pilot 

situational awareness. Both dip site 

personnel and the pilots failed to 

assess unseen hazard of trees at dip 

site.

Suspected Tree Strikes
37

Incidents With Potential

Flathead NF, Wedge Canyon

The Piper Seneca III flying an 

Air Attack Mission over the 

Wedge Canyon Fire began to 

lose power on one engine 

During the trouble-shooting of 

the rough-running engine, the 

pilot realized his fuel gauges 

were showing empty. 

The pilot was able to make a 

successful forced landing into a 

back-country airstrip without

damage to the aircraft. 

The pilot had asked the local FBO to “top off the tanks”, the pilot was told by an employee of 

the FBO that the aircraft had been fueled. The pilot believed the tanks were full but did not 

visually check the fuel in the tanks or monitor fuel gauges. 

The Forest Service experienced 9 Incidents With Potential (IWP) in FY 2003 

which included:

• 1 Rotor Strike (Bell 212) NASA

• 2 Wire Strikes (Bell 206L4) WY-BTF and Bell (206L3) NASA

• 1 Unintended Take Off (AS350B2) WA-WEF

• 1 Wing Damage, landing/go around (Dromander M18A) AZ-TNF

• 1 Near Mid-Air Collision (DC7 & BE58P) 

• 3 Fuel Starvations (Piper Seneca III) MT-FNF, (Cessna 337) ID-BOF & (Cessna

 185) R-10

The following focus on the three fuel starvation IWP’s.
38

Boise NF, Canyon Creek

Tongass NF, Yakutat, AK

The mission of this Cessna 

337F was to fly Air Attack in 

support of the Canyon Creek 

incident in the Boise National 

Forest.

After about 3 hours of flying 

time the aircraft departed the 

Canyon Creek Fire inbound to 

Boise Airport. Approximately 

20 miles from the Boise Airport 

the aircraft had a front engine 

failure. A safe landing was 

made at Boise.

The pilot indicated that the aircraft was refueled at the end of the previous mission day and 

that he visually checked the fuel quantity immediately after fueling was complete. The pilot 

said he checked the fuel gauges before the flight, but upon inspection after the incident, the 

gauges were found to be inaccurate.

The Cessna 185 departed the 

Yakutat airport with three passengers 

to conduct moose telemetry survey.

This pilot serviced the aircraft with all 

the required fuel in one tank. 

The fuel selector switch was placed 

to the left tank during the start up and 

remained there for just over two 

hours until in a tight turn at 1,000 

AGL the aircraft experienced fuel 

starvation and an in flight engine shut 

down (power loss). 

(Not Incident Aircraft)

As the aircraft started to loose altitude, the pilot set up for an emergency landing on a 

gravel bar and proceeded with a restart. The pilot regained powered flight by 

switching tanks and initiating an in flight restart at less than 300 AGL. The pilot 

terminated the mission and returned to base