United States

Department of Agriculture

United States

Department of the Interior

BEAR AIR

An Interagency Aviation

Safety Flyer

Spring 1999

AVNFS-NIFC-001-99
This United States Department of Agriculture, Forest Service (USDA-FS) sponsored publication is published in

cooperation with United States Department of the Interior (USDI), Office of Aircraft Services (OAS) and Bureau

of Land Management (BLM). The intent of this biannual publication is to communicate aviation safety information. The contents of the publication are not to be used for advertising, publication or promotional purposes. The USDA-FS has developed this information for circulation to its employees, contractors, and cooperating federal and state agencies, and is not responsible for the interpretation or use of this information by anyone

except its own employees. The use of trade, firm, or corporation names in this publication is for the information and convenience of the reader, and does not constitute an endorsement by either agency of any product

or service to the exclusion of others that may be suitable.

The publication is provided to those offices that have requested to be on the mailing list. To add, change or

delete your office address, please submit the information to: USDA-FS Aviation Safety Office, National

Interagency Fire Center, 3833 South Development Avenue, Boise, Idaho 83705.

Editorial submissions may be directed to the following agency representatives:

Bob Martin, USDA-FS 

Larry Mahaffey, USDI-BLM 

Gary Morgan, USDA-FS Region 9
Letters...

BEAR AIR Spring 1999 - 1

Is the National Flight Following

Frequency Working?

Our air resources travel all over the

United States under the total mobility concept. The requirement to maintain contact

while in flight has prompted some concerns

of accessibility of frequencies for aircrews.

The National Flight Following Frequency

(168.650) was established to help solve

this problem. Is it working in the dispatch

centers? Are the pilots able to make contact with dispatch centers or tanker bases?

Some of the problems brought to my attention are:

1) Installing the frequency on mountain

top sites and in dispatch centers;

2) Centers without a dedicated aircraft

dispatcher tend to miss national frequency

calls during initial attack activity, when most

of the aircraft are moving; and 3) calls on

168.650 bleed over from other units.

Since the publication of the USDA/

USDI Aircraft Radio Communication Guide

was discontinued, no “official” source is

available. In 1997, Wildland Firefighter

Frequency Guide was created and printed

by PJ Smith, Salmon/Challis NF, and the

NIFC Incident Communication Support

Unit. It has had limited distribution in part, I

believe, due to the lack of National Aviation

Office support. Charlotte Larson, FS

Aviation Management Office and I agree

that this is an important tool that needs our

facilitation to provide an extra margin of

safety for our aircrews. We are planning to

have the Wildland Frequency Guide available for the 1999, fire season.

Larry Mahaffey

BLM Aviation Safety and Training

Letters...

Table of Contents

Letters . . . . . . . . . . . . . . . . . . . . . . . 1

Washington Office . . . . . . . . . . . . . 2

Aviation Safety Links - WWW . . . 3

Initial Attack Management . . . . . . 4

From the SafeCom Files . . . . . . . . 5

Medications and Flying. . . . . . . . . 7

From the NTSB Files . . . . . . . . . . 10

General Aviation Accidents. . . . . 12

Disorientation is a Killer . . . . . . . 14

Why We Fail to Communicate . . 16

Reporting Safety Events . . . . . . . 18

Esther Lake Fire . . . . . . . . . . . . . . . 19
2 - Spring 1999 BEAR AIR

As I reflect on USDA-FS Aviation in the

’90s, I think of a number of aspects that

have made me particularly proud. However,

there are also a few areas in need of attention by all USFS Aviation leaders, if we’re

to maintain the ability to adequately support

the Forest Service Natural Resource mission. There have also been significant

changes resulting in tremendous improvements to our programs. I am especially

proud of the following accomplishments:

The response of USDA-FS Aviation to the

Florida fire activity from May to July,

where we had as much as 156 tactical aircraft assisting in the effort. The ability of

Region 8 to manage the overload associated with this event was impressive. At

one time, over half the Regional Aviation

Officers were there in a variety of leadership positions. That’s putting the talent

where the needs are!

Implementation of the National Airtanker

Study II (NATS) Airtanker support base

improvement initiative. In ’99 we’ll be

investing over 5 million dollars in planning,

design and construction at 13 airtanker

bases with more to follow in 2000. These

improvements will provide for both safer

and more efficient bases that will host the

aircraft of the future.

The quality work that I see being done by

the Regional Aviation Officers (RAOs) and

Regional Aviation Safety Managers

(RASMs) is impressive. Both groups are

in high gear and are doing a very professional job of staffing out and recommending solutions to various aviation policy and

program management issues through the

efforts of the RAO Council and the RASM

Council. If any employee has questions

regarding the aviation policy process, you

are encouraged to contact your RASM or

RAO.

Interagency cooperation with the USDI

agencies has never been better. We have

worked together to tackle some tough

issues with positive results.

Some conditions have changed USDAFS administrative flying has decreased dramatically in the past decade from a high of

30% of our flight hours to a current level of

about 8%. This has significant impacts on

the proficiency opportunities for our

employee pilots.

The overall increase in productivity of

fire fighting aircraft is one of the quiet successes of the past decade. With the introduction of the C23A (Sherpa) and the

DC3T aircraft, lift capacity for smokejumper

missions increased significantly. The introduction of the C130A and P3A airtankers

into the fleet, brought the retardant capacity

of the average airtanker up by over 10%

with the added plus of increased speed.

The Type I helicopter fleet build up has

been nothing short of impressive. That

capability has grown to about 3 times what

it was in 1990. The Type III helicopter fleet

has successfully integrated faster and more

Washington Office Corner

•

•

•

•
BEAR AIR Spring 1999 - 3

capable aircraft with the Bell 407 and the

A-Star 35OB2. These are a few examples

of cases where aviation is making a greater

contribution to the overall Natural

Resources effort.

There are still concerns that we must

continue to address. One challenge is our

development of professional Aviation leaders and managers. We have transitioned

from a point where all of the Regional

Aviation Officers were or had been pilots, to

a time where about half are pilots. The nonpilot RAOs have brought good management skills, diversity, and agency knowledge to the job. Are we doing all we can as

an agency to develop the leadership and

management talents of our employee pilots

who have the desire to move up?

Another challenge we must address is

our hiring, training, and retention of

employee pilots. I hear a great deal of frustration from the RAOs surrounding the

issues of hiring, training and retention of

our own in-house pilots. There are lots of

things being done and considered, including better pre-hire screening, training evaluation, and changes in organizational structure. Left unresolved, this area could drastically impair our ability to accomplish our

assigned mission.

I am excited about the possibilities for

USFS Aviation in ’99. Lets make the last

year of the millennium a good and safe

one.

Pat Kelly

USDA-FS Email - pjkelly/wo

Internet – pjkelly/wo@fs.fed.us

(202) 205-1505

(202) 205-1272

Aircraft Publications:

Airworthiness Directives and Parts Manufacturer Approvals www.fedworld.gov/faasearch.html

Technical Standard Orders (TSOS) www.faa.gov/avr/air/air100/TSOhome.html

Type Certificate Data Sheets and Specifications www.fedworld.gov/faasearch.html

Information for Pilots:

Advisory Circulars www.faa.gov/abc/ac-chklst/actoc.htm or www.faa.gov/avr/avrhome.htm

Aviation Safety Program Pamphlets www.faa.gov/avr/news/Ppams.htm

Federal Aviation Regulations www.faa.gov/avr/AFS/FARS/

Civil Aeromedical Institute (CAMI) www.cami.jccbi.gov

Miscellaneous Aviation Sites:

Air Safety Home Page www.airsafe.com

International Civil Aviation Organization (ICAO) www.cam.org/~icao

Helicopter Association International www.rotor.com

Aspect One-Human Error and Human Factors www.wcinet.net/~aspect

Associated Airtanker Pilots www.airtanker.com/aap/aap2.htm

Aviation Safety Links on the World Wide Web
4 - Spring 1999 BEAR AIR

Initial Attack 

Management 

System (IAMS)

Larry Mahaffey

BLM Aviation Safety and Training

Several federal agencies began to

study how the USDA-FS Computer Aided

Navigation (CAN) program could be

applied to the BLM Initial Attack

Management System (IAMS) in 1988. The

original IAMS was a computerized system

designed to provide intelligence that helps

managers more effectively dispatch initial

attack forces to incidents. At that time

plans were made to develop a stand-alone

system for use by all agencies.

The name was changed to Computer

Aided Aviation Hazard Information System

(CAHIS) and it was recognized as a part of

IAMS in 1991. CAHIS ran on the BLM network with Lightning Maps and Remote

Automated Weather Stations (RAWS). The

cost of maintaining and operating the system was very expensive, so the program

was discontinued in 1994. The lightning

map and RAWS are now available on the

Internet.

In 1997, I was tasked with getting the

stand alone IAMS system back on line and

out to the field for the 1998 summer season. Jon Skeels and Erin McCormick, from

Region 2; Gary Schmunk and Alex Clarke

from the Alaska Fire Service, Susan

Stillings from National Interagency Fire

Center (NIFC), and I were able to cut CDs,

update the system and get it out to the

field for the 1998 fire season. Later the

system was placed on the Internet allowing

users to down load the IAMS program and

updates. The update site has a guide with

instructions and phone numbers for help.

The Internet addresses are:

www.nifc.blm.gov/pub/iams/iams.html

This site provides the system down load

data (C:\IAMS).

www.nifc.blm.gov/pub/iams.html

All three files must be loaded and placed

into a known file.

1. C:\AIRBASE.EXE, (updated every 28 

days)

2. C:\MILITARY.EXE, (updated every 56 

days)

3. C:\UPDATE98.EXE

IAMS displays a base map of the

United States with several layers including:

the continental U.S. with state boundaries,

roads, rivers, helibase, airtanker bases,

VHF Omni-directional Radio (VOR) sites,

Military Training Routes (MTRs), Special

Use Airspace and BLM, USDA-FS and

other agency boundaries. It has zoom

capability and layers can be added or

removed to meet the needs of the user.

IAMS performs an analysis to locate hazards such as MTRs with bearing and distance, route number and Special Use

Airspace. Military updates are available

ever 56 days and FAA airport data updates

are available every 28 days from the

Defense Mapping Agency. There is a warn-
BEAR AIR Spring 1999 - 5

ing flag on these files providing the data

expiration date.

IAMS will identify the closest VOR with

bearing and distance along with complete

FAA airport information. It also provides

information about helibase and airtanker

base locations, bearing and distance from

each facility, contractor, type of contract

aircraft, unit manager, phone numbers, frequency and last data update.

The Temporary Flight Restriction (TFR)

is implemented to provide a margin of

safety while operating over a wildland fire

or incident. The TFR information form

allows an individual to “build” the TFR for

immediate transmission to FAA or other

units within the geographic area. The

majority of the information that was

accessed manually is automatically

entered on the form (FAA ARTCC, including phone and fax numbers, requesting

unit and phone number; distance and

bearing from nearest VOR; MTR and

Special Use Airspace affected by the TFR).

In the stand-alone mode, TFRs must be

taxed to appropriate centers and users.

This program is available to the public

and private users alike, who have a need

for this aviation information. If the IAMS

program is used on the ground it will help

those in the air be more efficient and effective. The program will improve the safety

for aviation personnel and above all

improve mission safety.

From

the

SafeCom Files

Understanding the Delay

I am writing this SafeCom as this is the

second occurrence in as many years that I

have had a local dispatch center tell me

they were getting pressure for ETD’s and

ETA’s, and if the pilots didn’t hurry to get

airborne “they” were going to cancel the

order. The airtanker base or Region is not

relevant as this happened to me in different Regions, different GACC's, and different local dispatch centers. I don’t know

who “THEY” are in the chain of command,

but this kind of thinking needs to be

stopped as safety should always be our

number one priority, not pressuring a crew

to hurry through the “out of area” procedures. The following information may help

dispatchers who are unfamiliar with flight

crew procedures when dispatched out of

the local area. By understanding these

requirements, it should be easier to cope

with delays.

The first thing to be done is to take on

more fuel. This could be 1,000 gallons or

more. Sometimes fuel trucks are servicing

other aircraft. So it can be 10 to 20 minutes before a fuel truck can show up. Then

you have to add the fueling time on top of

that. Air-tankers normally keep only 2.5

hours of fuel on board to allow for a load

of retardant that may be 18,000 to 27,000

lbs. depending on the type of aircraft.

Usually a long distance out of area dispatch means they can take on additional

fuel because they will not have the added
6 - Spring 1999 BEAR AIR

weight of the retardant. This is a benefit to

the government since they won’t have to

stop enroute for fuel. Reciprocating aircraft

may need to top off oil reserves for extended flight, or they may load a 55 gallon

drum of oil to ensure they will have oil at

their final destination, since many airports

do not carry the type of oil required by that

particular aircraft. To load this drum, a

forklift is required to get it on the plane and

not all bases have forklifts on site. This

may add additional delay while locating

one.

Pilots are required by regulation to

research all information pertinent to the

flight, including arrival airport, weather,

NOTAMS, and any other factors which may

affect the flight. They must then file a flight

plan or make provision for flight following.

All this work will be done through FAA

Flight Service Stations in person, by

phone, or through computer. Keep in mind,

everyone from airlines to private pilots use

these services and our tanker crew may

not be the first in line for getting the information they need. If marginal weather is

expected, alternate airports and routes

must be checked as well. Based on all this

information, the pilot will build the flight

plan and itinerary. Now the appropriate

charts must be gathered and reviewed to

plan the exact route of flight. This entire

process could take 1 to 2 hours after

which they still may find it necessary to

further delay if weather conditions prevent

a safe flight.

I have never seen a pilot that would

turn down a dispatch or drag their heels,

most are eager to go and start making the

preflight arrangements as soon as the

resource order comes through. It is important to remember the authority of the PIC,

who is “responsible for preflight planning

and the operation of the flight in compliance with the Federal Aviation Regulations,

Forest Service guidelines, and the contract. The pilot in command has the

authority to delay, divert, discontinue, or

cancel a flight when conditions do not

appear suitable for the safe continuation of

the flight.”

All of this is authorized in the airtanker

contract as well as the clause for relief

from the 15-minute getaway requirement

when the dispatch is out of the local area.

The contract allows the crew to take the

time necessary to meet the regulations and

insure a safe flight. I hope this helps logistical and aviation personnel understand

what takes place for “out of area” dispatches, and that it helps alleviate the

pressure of urgency. Fire fighting shouldn’t

be an emergency, its what we do for a living. If you are dispatching aircraft, I hope

you don’t hear yourself saying those words

“THEY” will cancel you if you don’t get

going, or have an ETA to pass back

through the “SYSTEM”. Think about what

the reason for the flight is and what preparation must go into it to make it a safe

flight.

Finally, do not pass on negative information when you get it from “THEM”. Let it

stop with you.
BEAR AIR Spring 1999 - 7

Following the appearance of a new medication,

the FAA generally waits one

year to determine whether

its use is appropriate and an

adequate profile of side

effects has been established. It is important to recognize that concerns center

not only on the medication

and risk of unacceptable

side effects, but also the

condition for which the medication is being taken and

whether it is disqualifying for

flight status.

The following is a compilation of information from

articles recently published

on this subject. The list is

not inclusive and will

become dated, as new

drugs are introduced and

others are eliminated. It is

crucial for pilots to consider

that they must evaluate each

over-the-counter medicine

they are taking to insure

there are no side effects

which affect flight safety. It

is also important that their

symptoms for the underlying

condition will not affect flight

safety.

Dietary Supplements

Melatonin is sold in

health food stores, and is

not regulated by the Food

and Drug Administration, as

it is considered a food supplement. It reportedly helps

with sleep problems. The

FAA generally permits airmen to use these supplements if there are no side

effects. Rigorous scientific

studies of melatonin’s benefits, and specifically appropriate dosage, are yet to be

completed. General nutrition supplements and most

herbal preparations that are

manufactured and sold within the United States are usually approved for pilots on

flight status, if taken in recommended doses.

Alcohol-Containing

Medications

Many prescription and

over-the-counter liquid medications contain alcohol,

which could result in a positive alcohol breath test. The

FAA prohibits airmen from

ingesting alcohol in any form

within 8 hours of flying.

Antibiotics

The use of antibiotics is

permissible, providing the

airman has been on the

medication for a sufficient

period (usually 48 hours), to

rule out the possibility of

side effects. The illness itself

may be disqualifying, even

before the medication is

started.

Antihistamines for

Allergies and Colds

The FAA permits the use

of Seldane, Hismanal, and

Medications and Flying

By Nestor B. Kowalsky, MD., MS., Area Medical Director and

David K McKenas, MD., MP. H., Corporate Medical Director

Re-printed from THE FLIGHT DECK magazine with permission.

American Airlines Medical receives frequent phone calls inquiries from

pilots regarding the acceptability of various medications while on flight

status. The Federal Aviation Administration (FAA) does not publish a list of

approved medications, because there are thousands of over-the-counter

(OTC) and prescription medications, with continuous additions.
8 - Spring 1999 BEAR AIR

the newer medications

Allegra and Claritin, if the

prescribing physician presents a note giving the indications, dose, and a statement that there are no

adverse side effects. Zyrtec

is not permitted for use by

airmen, as it is reportedly

associated with sedating

effects. The FAA approves

treatment with allergy

desensitization injections.

Documentation and declaration of use to the FAA is

required. Pseudo-ephedrine

is a decongestant found

singly (Sudafed) or as an

ingredient in OTC preparations and is generally

approved for flight duty,

although the FAA warns that

even this medicine should

be individually evaluated for

personal side effects and

safety. As pseud-oephedrine can cause stimulation,

it should be used with care

when planning layover sleep

periods. All other OTC cold

and allergy medications

require that you wait twice

the dosing interval, following

the last dose of the medication, before returning to

flight status. For example,

you must wait at least 12

hours after the last dose of a

medication that is taken

every 6 hours.

Intermittent Use of

Medication

Intermittent use of

sedating antihistamine drugs

for allergies may be permissible, provided that the airman has been cautioned

and will not take the medication within twelve hours

of flying (for short-acting

drugs), and 24 hours (for

long-acting drugs). The

company medical officer or

the aviation medical examiner should have this certification on file.

Pain Medications

Non-steroidal antiinflammatory medications,

such as lbuprofen, Motrin,

Advil, Aleve, Naprosyn,

Voltarin and Ansaid are

acceptable, provided the airman has been free of side

effects for a minimum of 48

hour and the underlying

medical condition is not disqualifying. Airmen are prohibited from flying while taking any medication containing a narcotic, such as

codeine, (for pain or in a

cough preparation), either

singly or in combination with

other drugs (e.g. Tylenol No.

3), Demerol, Darvon,

Darvocet, Percodan, Ultram

and Lortab. A waiting period

following the last dose must

take place before an airman

may return to duty. The

duration of this period

depends upon the specific

drug taken.

Mind and Mood-Altering

Medication

The FAA does not

approve the use of any of

these drugs for active flight

status. Included in this

group are such medications

as Prozac, Xanax, Paxil,

Ativan, Wellbutrin, Effexor,

Zoloft, Lithium, Elavil,

Amitryptyline, Buspar, and

others. For a pilot who has

been on a course of this

medication to be cleared for

flight status, the FAA

requires submission of

reports of thorough evaluation, to confirm full resolution of the problem, clinical

stability, in the absence of

symptoms, off medication

for a minimum of 60-90

days. Zyban, also known as

Wellbutrin, is a medication

recently introduced in smoking cessation programs and

is a disqualifying, moodaltering medication.

Blood Pressure

Medications

The FAA has approved a

variety of medications for

control of elevated blood

pressure. The airman must

have successfully completed

a thorough cardiovascular

examination and demonstrated stable blood pressure, in the absence of any

drug side effects.

Asthma and Allergic

Rhinitis Medications

The FAA does permit the

use of non-absorbed steroid

nasal inhalers (e.g. Nasalcrom, Beconase, Vancenase) for treatment of allergic
BEAR AIR Spring 1999 - 9

rhinitis. Pilots with mild asthma must have submitted

results of an acceptable

evaluation of their condition,

controlled by approved

drugs before the FAA will

consider authorizing use of

lung inhalers for treatment of

this condition. Approval is

not automatic, and each

case is evaluated on its own

merits.

Cholesterol Lowering

Medications

The FAA permits the use

of most medications including Mevacor, Lopid, Questran, Pravachol, and Zocor,

used in lowering cholesterol,

provided there are no unacceptable side effects.

Hypnotic (Sleep-Inducing)

Medications

Over-the-counter medications such as Sominex,

Tylenol PM, Excedrine PM

and Benadryl are permitted

for flight deck use but

require waiting 12-24 hours

from last dose to flight duty.

Prescription drugs such as

Halcion, Ambien and

Restoril are not approved for

airmen.

Intestinal Medications

The use of medications

for the peptic ulcer diseases, such as antacids

(Turns, Rolaids, Mylanta),

Tagamet, Prilosec, Pepcid

and Zantac, are permitted,

depending upon the specific

condition for which the

treatment is prescribed, and

provided there is no evidence of active ulcer disease. OTC preparations

such as Kaopectate and

Pepto-Bismol are of their

diabetes. Extensive evaluation permitted if symptoms

are mild. Prescription medications such as Lomotil,

Bentyl, Levsin and Donnatal

require a waiting period

before an airman may return

to flight duty use.

Headache Medications

The FAA has permitted

use of certain migraine

headache prevention medication, after careful review

of the individual case.

Injectable medications and

oral agents to abort a

migraine headache are generally not permitted for flight

duty use.

Prostate Medications

FAA often approves the

use of such effects, as well

as FAA medication medications as Cardura, Hytrin and

Proscar for treatment of

benign prostatic hypertrophy

(enlarged prostate). Long

term use of this medication

should be declared to the

FAA.

Cancer Medications

Use of chemotherapeutic agents is not assurance

that your medication use is

permitted for pilots on active

flight duty. Following completion of treatment, the FAA

will give consideration, after

results of thorough evaluation of the underlying medical condition have been

submitted.

Diabetes Medications

The use of insulin for

control of diabetes, is disqualifying for a first or second class airman medical

certificate. The FAA has

approved some pilots for

flight status while taking oral

medication for control of

their diabetes. Extensive

evaluation reports, including

proof of clinical stability

must first undergo FAA

review.

General Precautions

Combining medications

(drug interactions) or using

alcohol while taking medications can result in serious,

unpredictable adverse

effects.

Medications and flying is

a complex issue. Be sure to

carefully read the label of

any OTC and prescription

medication you take. The

company medical department tracks developments

in pharmacology and toxicology, technical information

on medication interactions,

elimination half-life and

reported side effects, as well
10 - Spring 1999 BEAR AIR

as FAA medication policy,

and is a handy resource for

any pilot seeking information.

We welcome questions,

anonymous or otherwise, on

the Aeromedical Hotline at

817-967-9862. This simple

call will either ensure a medication clearance notation is

made in your company

medical file, if you desire, or

simply provide you the verbal assurance that your

medication use is safe and

appropriate in flight operations. The company medical

department tracks developments in pharmacology and

toxicology, technical information on medication interactions, elimination half-life

and reported side effects,

and is a handy resource for

any pilot seeking information.

This accident occurred on a National

Forest and is discussed in the article

“General Aviation Accident, on Public

Lands”.

NTSB Accident No. NYC97FA185

On September 23, 1997, about 1600

eastern daylight time, a Piper PA-28R-200,

Canadian registry C-GHUE, was destroyed

when it struck trees in mountainous terrain

on Glastenbury Mountain Glastenbury,

Vermont. The Canadian certificated, noninstrument rated private pilot and passenger were fatally injured. Instrument meteorological conditions prevailed at the accident site. The flight that departed

Massena, New York, about 1455, and was

destined for Willimantic, Connecticut, was

operated on a Visual flight Rules (VFR)

flight plan under 14 CFR Part 91.

The international flight originated in

Ottawa, Ontario, Canada, about 1322, and

entered the United States at Massena. 

While on the ground at Massena, the

pilot contacted the Burlington Automated

Flight Service Station (AFSS), at 1410. The

pilot reported his intended destination, and

the briefer asked about his routing. The

pilot reported that he was going on a direct

route, over the mountains.

The briefer then stated: “Okay I would

say VFR flight not recommended along...

that routing, we have a flight precaution

out for mountain obscuration with lower

cloud cover along... mountains... occasionally obscured in cloud and precipitation

and attributable to the... leading edge of

the cold front, moderate turbulence can be

expected as well below twelve thousand

feet and icing also expected above eight

thousand feet, occasional light to moderate rime or mixed icing in clouds as well as

precipitation again above eight thousand

freezing level forecast to be six to eight

thousand feet, on departure, and looks like

eight to twelve thousand on arrival.”

Further in the briefing, the briefer stated, “...gonna be nice tomorrow once all

this mess runs through but... I think you’d

be very questionable VFR today...” To

which the pilot replied, “Yeah, well, I’ll file

anyway and, ahh, if it looks bad I’ll turn

back.”

From the NTSB Files
BEAR AIR Spring 1999 - 11

After the pilot filed the flight plan, the

briefer added, “and once again VFR flight

would not be recommended.” To which the

pilot replied, “Okay then.”

The airplane departed

Massena, about 1455,

and the pilot activated

the VFR flight plan, at

1459. No further communications were received

from the pilot.

A hiker who was traveling southbound along

the Appalachian Trail

took refuge from deteriorating weather in a shelter near the peak of

Glastenbury Mountain. He reported that he

was in the clouds with visibility of about 10

feet. The rain was intermittent and cool. He

said he suspected there might be freezing

rain due to the temperature. Hail was also

falling intermittently. The wind was from the

west with strong sudden gusts that had a

peak velocity of about 25 to 30 miles per

hour. The hiker reported that at some time

between 1600 and 1615, he heard an airplane engine for about 4 seconds. The

engine was loud, at a high power setting

and screaming. He also

reported that he heard

the engine sputter twice

as if it was hitting trees,

and then he heard a

bang followed by silence.

He stepped out of the

shelter and walked into

the woods in the direction he thought the noise

came from, but was

unable to hear anything

else. He did not observe

the airplane and remained in the shelter

overnight.

The accident site was located about

2,100 feet southeast of Glastenbury Peak

(3,748 feet high), at an elevation of about

3,600 feet, and about 600 feet west of the

shelter.
12 - Spring 1999 BEAR AIR

General Aviation

Accidents on Public

Lands

Brad Bemardy

FAO Green Mountain & Finger Lakes National Forests

Around dusk on September 23, 1997 a

Piper Cherokee en-route to Connecticut

from Ottawa, Canada crashed on a remote

portion of the Green Mountain National

Forest in Vermont (see previous article,

“From the Files of the NTSB”). Two hikers

in a nearby shelter reported hearing the

plane approach with the engine running at

full power. The next sound they heard was

the aircraft crashing into trees and then

total silence. Although September, weather

conditions were poor with wind, hail and

fog present. Due to the conditions, the hikers were unwilling to search for the crash

site unless human voices could be heard.

The ELT was picked up about eight hours

later and the Civil Air Patrol was contacted

to locate the source of the signal.

As the Forest Aviation Officer on the

Green Mountain/Finger Lakes National

Forests, I would like to point out how this

accident was handled from daybreak on

September 24 through final cleanup and

provide some insights to consider should

this occur in your backyard.

In Vermont, the State Police have jurisdiction over search and rescue operations.

We (Forest Service) were contacted late

that night after the ELT signal was discovered and agreed that it was prudent to wait

until first light to access the area. All-terrain-vehicles (ATVs) were used initially for

quick access on an existing trail system.

After locating the site and finding that neither of the two occupants had survived,

ATV access was limited to minimize ground

disturbance. The remains were transported

down the mountain that day. One item to

point out here is the need to protect the

crash site immediately to prevent unnecessary disturbance. Also, individuals entering

the site should be aware of possible biohazard. Sharp, jagged edges of wreckage

and body fluids present significant risk for

hepatitis, HIV, or other blood-borne

pathogens. It is easy to get caught up in

the moment and forget your precautions.

The next day we escorted an accident

investigation team to the site. Team members included investigators from the NTSB

and FAA, in addition to representatives

from Piper and Lycoming (to inspect airframe and engine components). I encourage managers to assist in these investigations as much as possible. We assisted by

looking for evidence around the site, conducting measurements, etc. The investigators may also rely on your knowledge of

the local conditions or weather patterns.

We found the investigation process to be

quite interesting since even small items

may have significance. One interesting find

was a six inch tree branch that had been

sheared off by the propeller (evidence that

the engine had been running at high

rpm’s). One note here: the pilot’s son

wanted to view the crash site for personal

closure. It is essential that working parties

in the area are aware of the presence of

next of kin and are sensitive to the emotions they may be experiencing.

An insurance adjuster from Canada
BEAR AIR Spring 1999 - 13

was at the staging area to discuss removal

of the plane on the second day. In most

cases, the insurance companies want to

have the wreckage removed quickly. It is

important that the land manager maintain

control of this situation. The adjuster had

hired a local auto repair contractor to

remove the wreckage. The contractor then

called me and explained his entire plan for

accomplishing this work adding that he

had done two of these before and would

need little guidance. He also said he

planned to do this in two days. An immediate meeting was scheduled to review

specifics and it became clear that portions

of the plan might have put the salvage

crew at risk. One item of concern was the

size of the staging area in which they had

planned to use a helicopter to “long-line”

the wreckage to a waiting truck. The staging area was not an adequate site for this

operation. We amended the plan and documented it with an internal plan of our

own. Although the Forest Service is not

directly involved with the salvage operation, our concern here dealt with public

safety and resource protection. Our role

was to act as resource advisors to ensure

the site was clean and that no hazardous

materials were left on site. With the assistance of a Bell 206, the airplane was successfully removed from the site in five

loads.

Although the official cause of the accident

has not yet been determined, investigation

has found the Burlington, Vermont tower

advised the Visual Flight Rules (VFR) pilot

three times that VFR flight was not recommended on portions of his route. Given the

account by the hikers, instrument flight

conditions may have been present at the

time of the crash. Icing may also have

been a factor. The report will most likely

show the official cause of the crash as

“Controlled Flight into Terrain”.

Good pre-planning will reduce the chance

of another disaster occurring during the

rescue/salvage phase of an operation and

may save a life in the long run.

Thousands of aircraft fly over

public lands every day.

Are you prepared in the event

of an accident?
A review of the 1997 NTSB statistics

shows approximately 164 U.S. Civil

Helicopter Accidents, resulting in 46 fatalities. A closer look shows that four of these

accidents, categorized as "VFR flight into

IMC", claimed six lives and caused serious

injury to seven. VFR-into-IMC often leads

to spatial disorientation, which can be a

killer. A disproportion of VFR-into-IMC

accidents account for a large percentage

of the fatalities. This has been the case for

a number of years. Most VFR accidents

have no fatalities: whereas VFR into IMC

accidents are often fatal.

NTSB Accident No. LAX97GA325

On September 12 about 1630 pacific

daylight time a Bell 205A was destroyed

during a collision with mountainous terrain

in the takeoff initial climb phase of flight.

The helicopter was operated as a public

use aircraft. The pilot and two passengers

received fatal injuries; five passengers

received serious injuries. The flight originated on the day of the accident as part of

an on-going search for a lost hiker in the

Buckhorn Wilderness Area, of the Olympic

National Forest. Instrument meteorological

conditions prevailed at the departure point

with visibility less than 1/4 mile. The pilot

had flown up for the search effort and had

no prior experience in the Olympic National

Forest. The accident flight was his second

mission in the area and the first landing in

this landing zone. According to ground and

passenger witness interviews, the takeoff

was vertical into fog and a very low ceiling.

A high mortality rate for VFR into IMC

is understandable. Spatial disorientation is

basically a temporary loss of understanding “which way is down”. This often produces a feeling of spinning, dizziness

and/or a confused state of mind i.e. vertigo. Mix vertigo-induced anxiety with (1)

IMC, (2) an aircraft that may not be configured for instrument flight, and (3) a pilot

who may not be instrument rated or competent, and you get one of two things.

• An out of control helicopter that comes

screaming out of the 200 foot ceiling at

high speed in an unusual attitude.

• Or, an in-control helicopter that smashes

into an obstruction or the side of a mountain.

In either case, it is understandable how the

resulting high-energy impacts can and do

have high mortality rates. A number of factors seem to set the stage for Inadvertent

IMC events.

• Helicopter VFR - ceilings and visibility

below basic VFR criteria are commonly

and mistakenly accepted as suitable for

helicopter operations. Pilots operating out

of airports believe they can always get a

special VFR clearance if weather gets bad;

or when operating out of remote areas,

they believe VFR weather does not apply

to their situation, and if the weather gets

14 - Spring 1999 BEAR AIR

Disorientation is a Killer

Condensend from

Heliprops Volume 10, Number 2, 1998
BEAR AIR Spring 1999 - 15

bad they can always set down in a field.

The flexibility provided by helicopters creates a killer norm that permits helicopter

operations in all sorts of weather.

• Unprepared pilots – It’s not uncommon

for a helicopter pilot to

be neither instrument

rated or instrument

competent. Initial ratings and periodic training are costly and time

consuming making it

difficult to justify for a

strictly VFR operation.

This lack of preparedness can create a

tense cockpit during the first moments of

an inadvertent IMC event. A pilot in such a

situation may not be successful in inventing a solution.

• Aircraft Stability – Many helicopters in

today’s operational fleet simply must be

hand-flown all the time. With these aircraft,

basic flight control systems do not allow

extended trimmed, hands-off flight. In an

inadvertent IMC event, these aircraft must

be handled. Unfortunately, they can easily

get out of trim, and consequently add to the vertigo condition.

• Weather

reporting – A

large percentage of helicopter operations are

conducted to/from

remote locations where there is no

weather reporting facility. Without this

information, the helicopter pilot faces a

tough decision and often chooses to

launch and check it out.

Disorientation can occur in VFR conditions as well. Even with unlimited visibility,

the right combination of ambient lighting,

lighted objects, haze/smoke, and surface

conditions can provide

the insidious condition

in which visual cues of

speed, altitude, and

rate of climb may not

be apparent.

Without a visual

representation of the

horizon the human body cannot provide

continuous, reliable indications of spatial

orientation while in flight. This inability to

determine spatial orientation is not a matter of training or experience. No one -

regardless of logged flight hours - can

maintain spatial orientation in flight without

the proper visual cues. As long as humans

fly aircraft, the opportunity for helicopter

disorientation accidents will remain. To

avoid disorientation accidents, two actions

are necessary.

Understand and recognize the limitation of our

visual, vestibular, and

proprioceptive systems.

Learn how these systems

may

provide

false sensations and

illusions, which can be deadly.

Prepare yourself by developing

a plan and the skills to

prevent and cope with these

disorientating situations.
16 - Spring 1999 BEAR AIR

Why We Fail to Communicate

Gary Morgan, Eastern Region

A Lockheed Electra was

just cleared for takeoff on a

routine training mission

with an experienced crew.

The pilot in the left seat

was not the pilot in command, but was making the

takeoff. As the airspeed increased and the

pilot flying switched from nose wheel

steering to rudder, he appeared confused

as though something was not right. The

PIC queried this pilot asking what’s wrong,

after no response, he emphatically said,

“talk to me”.

Meanwhile the aircraft was accelerating

past the point for a safe rejected takeoff.

The pilot at controls maintained heading

control with differential power and got the

aircraft into the air. After the gear was

raised the pilot flying now told the PIC he

had no rudder control during the takeoff

roll. This really got my attention since I was

a jump-seat passenger on this aircraft that

had just taken a minor problem on the runway and turned it into a significant problem

in the air. If the left seat pilot had communicated the problem early enough, the

takeoff would have been aborted and the

problem checked out.

As it turned out, the rod controlling rudder movement had

broken and there was no linkage between the rudder pedals and the control surface.

The aircraft was successfully

landed with no further damage, although the atmosphere

was a little more tense than normal. This

was an incident with an identified cause of

mechanical failure. I believe it was much

more. This was also an incident of communication failure that took a bad situation

and made it worse. Any endeavor that

involves complex operations or multiple

players, depends or strong communication

if they are to be successful. Just ask an Air

Tactical Group Supervisor who is having a

bad radio day.

How well do we communicate within the fire and aviation

community? How are we

doing at communicating with

aviation users outside of fire

fighting (natural resource operations and administrative

flights)? I believe it is safe to say we

aren’t doing as well as we could. We have

a good method in place to report incidents,

we have an extensive IBM and Internet

network, there are an abundance of telephone and fax machines, so why don’t we

communicate as well as we could? The

following obstacles are identified that may

help you better understand why we don't

communicate.

SENDING

Not Important: “The incident was probably not worth the time and effort to report,

and it was probably just an isolated situation.”

Don’t Make Waves: No body wants to get

anyone into trouble over a minor issue. If

no damage was done, why create any

more problems?

Shoot the Messenger: “If the news is

going to really set them off, I certainly

won't be the one to tell them.”
BEAR AIR Spring 1999 - 17

I Can Manage: “I don’t need

any help with this situation

and can handle it by

myself.”

Mechanical Failure: New

network systems, unable to

reach a phone, etc.

They Must Never Know: “The (WO, RO,

SO, RD) office will only complicate things if

they find out.”

RECEIVING

Out-to-Lunch (OTL): Recipient is either

physically or mentally absent.

Denial: “This does not happen at my base,

therefore there is a mistake.”

Reruns: “I don’t want to hear anymore

about this issue.”

Misinterpretation: “If an engine had to be

shutdown, we must be saving fuel, that’s a

good thing, right?”

Communication is a successful transfer of information involving a sender, a

receiver, and a medium

(telephone, Internet, voicemail, homing pigeon etc.) If

any of these breakdown,

vital information may not get to

those who need it. Risk managers require

accurate and complete information, but

they are only as effective as the sum of

information available to them. This applies

on a large scale as well as the two-person

cockpit crew.

The most important communication

tool in accident prevention is the incident

report (SafeCom). For every accident that

occurs, there are many incidents. These

incidents are the warning signs that, if not

corrected, will ultimately yield a failure

(human or mechanical) with catastrophic,

results. The National Business Aviation

Association's top 10 list of attribute common to companies with effective safety

cultures included four items considered

most difficult to implement. Two of those

involved communications:

1. “Inclusive system of communication for

collecting, analyzing and exchanger incident data related to safety.”

2: “A non-punitive environment, one that prevents retribution for submission of incident data.”*

From the first attribute, we

can comfortably say we have a

system in place, the real key to its success

is getting the employee to use it. We must

now focus on the second attribute (no

punitive environment for submission incident data). If we deal with the reports

focusing on the problem and not an individual, we will gain far more information

from the field than we have in the past.

What we must do, is understand and overcome the obstacles to good communications, and continue to use the incident

reporting system in a professional manner

to identify and solve potential problems

before they become a mishap.

*Richard Aarons, “Safety Cultures Vital in

Business Aviation Business and

Commercial Aviation, September, 1998
Reporting Safety Events

In the last year submitting a SafeCom

has been simplified for those who have

access to the Internet. To report an incident or hazard, complete the following

steps:

1. Access the USDA-FS Aviation Safety

Homepage via the Internet at

http://205.173.2.4 or the USDI Office of

Aircraft Services Homepage at

www.oas.gov/oassafety/

2. When the homepage menu appears,

select and left-click on “Submit SafeCom”.

3. Complete the form as much as possible, using pull down menus available (indicated by downward pointing arrows at the

right edge of some information boxes).

Complete the narrative and corrective

action sections if appropriate. If you wish

to keep a hard copy of the report, click on

the print icon on your browser at this point,

you will not be able to print once the form

has been submitted.

4. After you have completed all information, left-click on the pull down menu for

the “Region” and select your USDA-FS

Region. This will send it to the appropriate

safety manager. If you wish to start over, or

clear the form, click on the “Clear Form”

button. If you are ready to submit your

SafeCom, click on the “Submit” button.

Reviewing Safety

E v e n t s

The best way to stay on top of what is

happening by area, type aircraft, or type,

or problem, is to use the SafeCom data

base search program. To review this, complete the following steps:

1. Access the appropriate aviation safety

homepage used for reporting incidents.

2. Select and click the “Search SafeComs”

option.

3. For USDA-FS - select and click on

“Public Access Area” (OAS users select

and click on “Public Query of AMIS data”).

4. Identify the categories and/or data you

are searching.

5. Select and click on the “Submit” button

(“Submit Query” for OAS users).

18 - Spring 1999 BEAR AIR
On May 19, 1998, at 1423, Superior

National Forest Helitack Foreman

Fitzpatrick and Helicopter Pilot Cowan

noticed a medium, gray smoke northeast

of the Grand Marais Airport where they

were on standby. Three minutes later,

Superior National Forestís Beaver 1, who

was on routine fire patrol approximately 45

miles to the west of the fire, reported seeing a smoke in the same general area

which appeared to be growing rapidly.

Beaver 3, who was near Grand Portage,

MN, contacted Beaver 1 relay to Superior

dispatch that he also had a visual on a

rapidly growing smoke 20 miles west of his

position and that he was heading for it and

would update on it shortly. He also reported that the fire was in the Minnesota

Department of Natural Resources

(MNDNR) protection zone. For the next 20

minutes, Beaver 3 watched as the fire grew

from 20 acres to 40 acres with intense

spotting.

Helicopters from Grand Marais, Two

Harbors, and a BIA helicopter that was enroute to Grand Marais from Bemidji began

the attack along with both USFS. Beavers

and a Baron as Air Attack. A PB4Y2 airtanker was dispatched from Hibbing

Tanker Base with instructions to reload at

the Ely Tanker Base on the Superior NF. It

was quickly realized that even with this

amount of air power on this fire, holding it

in the winds and given fuels coupled with

the remote, rough terrain and amount of

grow resources available, would be tough

if not impossible.

The Minnesota Incident Command

System partners decided to call on the

Ontario Ministry of Natural Resources

(OMNR) to see if a CL-215 package was

available (CL-215 package consists of 1

bird dog/Cessna 310 and 2 CL-215s). The

OMNR in Thunder Bay said they would like

to help but no "package" was available as

they were busy with numerous fires in the

area but would see if something could be

freed up elsewhere. It turned out that one

CL-215 based in Dryden, Ontario was just

being released from a fire in close proximity to ours but could only work our fire for

about a hour due to fuel quantity left and

other provincial fire demands. The Ontario

ship contacted Air Attack 10 minutes out

at 1610 hrs. and joined the attack shortly.

Given time constraints and fuel running

low in helicopters, Beavers, and Air Attack

platforms, we opted to call Manitoba for

assistance. The Manitoba Natural

Resources Fire Program Division confirmed

that they could provide a CL-215 package

to us and asked if I would map a route to

the fire and give them lat/long in decimal

minutes. While plotting a course out on a

Canadian WAC chart I was amused that

these folks didn’t bat an eye at initial

attacking a fire almost 300 statute miles

away. As the Ontario ship had to depart,

the Manitoba bird dog (their term for a lead

plane/air attack) contacted the Minnesota

Interagency Fire Center (MIFC) & Superior

dispatch as well as Air Attack over the fire

that they were 20 minutes out. The

Manitoba "package" arrived and went to

work at 1840 and continued until 2022

BEAR AIR Spring 1999 - 19

Initial Attack Air Operations 

on the Esther Lake Fire

Steve Tome, Superior N.F.
20 - Spring 1999 BEAR AIR

when they departed for the tanker base at

Ely for fuel. When they arrived at the base,

the fuel truck was waiting with some suppers and cold drinks.

In this initial attack phase: Three type

III helicopters dropped 14,000 gals of

water, two USFS Beavers dropped 6250

gals of foam, one PB4Y2 airtanker

dropped 6000 gals of retardant, and three

Canadian CL-215s dropped 111,000 gallons of foam.

I was really pleased to see this all

come together so smoothly since considerable time was spent facilitating meetings

and actual exercises with both Manitoba &

Ontario to firm up frequencies, terminology

& tactics between MINCS partners and

them. Everything flowed smoothly, safely

and effectively. The Air Tactical Group

Supervisor, Dennis Danzel, and many others were literally awe-struck by the CL215's effectiveness in the lake country saying that they actually "pounded the fire to

death". The fixed wing and rotary wing aircraft were given their own portions of the

fire; everyone was talking utilizing common

terminology on previously coordinated frequencies. Danzel did an excellent job of

airspace coordination with the 12 aircraft.

The fire was held at what I first heard to be

250 acres, but after mapping turned out to

be 150 acres. Without the Canadian support, I believe this fire had the potential to

become an international incident much like

the Sag Corridor fire in ’95.

The really nice thing is, this proved that

the time, effort, and money spent planning,

training and coordinating before the real

thing happens, was a good investment.

We had a well-organized, safe and fluid

attack on a rapidly moving fire in some of

the toughest, remote terrain in Minnesota

with many different types of aircraft from

two Canadian provinces, the MNDNR and

the U.S. Forest Service.