Zero Accidents Attributable to Forest Service This Year

The following information relates to Vendors with Forest Service contracts

For the purpose of lessons learned.

Changes in Investigations

and Reporting

Public Use Vs Civil – Operational Control

Determined by NTSB

Time lines will be longer, Causal Factors

determined by NTSB

Information Sharing 49 CFR Ch VIII

813.13

(b)

• NTSB states that “Parties to the investigation

may relay to their respective organizations

information necessary for purposes of

prevention or remedial action. However, no

information concerning the accident or

incident may be released to any person not a

party representative to the investigation

before initial release by the Safety Board

without prior consultation and approval.

The NTSB has not finalized or determined

probable cause for all of the accidents at

this time.

This is preliminary information, subject to

change, and may contain errors. Any errors

will be corrected when the final report has

been completed.

The information is for accident prevention

purposes only.

On January 17, 2012, the Forest Service

officially attained the Gold Standard

Status among Federal Aviation Operators

for meeting best aviation safety

practices.

Analysis of this event resulted in the

following lessons learned:

First time in the history of FS aviation

organization, we experienced a zero

accident year in 2011.

Accident s determined charged to unit in

“Operational Control” by NTSB

Dedicated Employees working over the

past five years to develop and implement

Safety Management Systems.

Focus on risk assessment and safety

assurance.

Contract requirements for the operators

to adopt SMS based safety programs.

Oversight that assures high quality

standards.

Bell 205 A Kern County California Tehachapi, California

September 4, 2011 Injuries: None

Forest Service Exclusive use contracted aircraft

Aircraft was supporting Kern County firefighting efforts on the Canyon Fire (Non-FS Operation)

On Sept 4, 2011, at approximately 1445 hours, N205WW (H 522), a Bell 205A, sustained substantial damage when the pilot attempted to execute an emergency landing due to an in-flight malfunction. The downwind landing was hard, spreading the skids and causing significant damage.

9

Air attack was over the fire and providing

aerial supervision

The mission was to provide structure

protection and spot fire suppression

approximately 3 miles South of Mountain

Valley airport (L94)

Another type 2 and a type 1 helitanker

were also operating in the immediate

area under control of Kern County Fire.

H-522 was operating with a Bambi Bucket

hooked directly to the cargo hook.

The aircraft was on approach for a water

drop.

12

With the aircraft at 100 feet AGL and 10

KTS over the drop spot, the pilot heard a

low RPM horn, and then noticed an

illuminated caution light.

He jettisoned the load and executed a left

pedal turn to exit the canyon and move

away from the fire.

The pilot checked his

Rotor/Engine RPM

gauge and noticed

the needles were

split, with rotor rpm

at the 4-5 o’clock

position and engine

rpm at 6 o’clock.

13

The pilot interpreted indications to be the result of a governor failure.

The pilot spotted and

maneuvered toward an area suitable for an emergency landing.

15

The pilot commenced manual governor

procedures.

As he pulled collective, he felt rotor RPM

decrease and noticed the gauge

indicating 90% NR.

At approximately 200-300’ and losing

both altitude and rotor RPM, he lowered

the collective, establishing an

autorotation into the LZ.

Location of Jettisoned Bambi Bucket

Accident Landing Zone

Damage :

• Landing skids

• minor damage to sheet metal around the landing skid cross tube mounts

• Damage to aft tail boom section.

Tail stinger was bent

upward

Greenhouse plexi-

glass section over the

left side pilot cockpit

broken.

RH tail boom near tail skid

Chin bubble

mounted mirror bar

bent and lower wire

cutter assembly was

partially separated

Lower rotating

beacon was

separated.

Bent mirror bar and lower wire cutter

20

Pilot in Command has total PIC time - 8785 hours and 915 hours time in model.

Completed Emergency Procedure Training on 5/10/11.

Pilot who landed in accident LZ after accident occurred, needed 46 lbs torque (max 52 lbs) to land, indicating strong tail wind.

21

Pilot had 400 ft to troubleshoot and select proper course of action.

Once determined, pilot followed procedure for failed governor yet failed to adequately restore rotor RPM.

Tear-down revealed a failure in the Engine N2 Tachometer Generator shaft (Engine RPM indicator system).

Pilot Jettisoned load when situation got bad.

Pilot diagnosed situation, developed a plan and stuck to it.

Altitude limited time for pilot to troubleshoot problem.

A hard landing in an open area is better than uncontrolled crash in trees.

Eurocopter AS 350-BA N230 CH

Juneau, Alaska September 26, 2011

Injuries: None

Aircraft landing on Ridge to pick up 2 Forest Sciences Lab personnel working on a weather station nearby.

Helicopter manager on-board.

NTSB has categorized the accident as a part 135 operation, not public use.

Same aircraft/crew landed in accident LZ approx 3 hours prior to drop off scientists.

About 1230, the aircraft landed on top of

ridge at an elevation of about 3100 ft.

Pilot locked collective and set engine to

flight idle for 2 minute cool-down.

About 30 to 90 seconds into cool-down,

pilot noted vegetation down-slope and to

his right being buffeted by wind.

A strong gust of wind lifted the helicopter about 5 feet and rolled it onto its left side.

When motion stopped, the pilot secured the

engine and both crew exited the right side door.

The manager called dispatch and a helicopter was sent to pick up the crew and passengers.

The crew was taken to hospital for medical evaluation and released.

The mission utilized a Project Aviation Safety Plan.

Pilot landed N/NE into perceived prevailing wind.

There was a forecast for prevailing wind

shift from S to N and associated

turbulence the hour before and during

the accident.

Recorded gusts in the area at 22 mph

from the East.

LZ was along a ridge line with steeply

sloping terrain dropping off toward the

East.

The LZ was south

of considerably

higher rugged

terrain.

Incidents With Potential

PSD operations in support of the

Horseshoe 2 incident, burning out fuels

around a mobile repeater site.

The crew consisted of the pilot, burn

boss, and the PSD operator/helicopter

manager.

After lighting the area around the repeater site, the flight moved to check an area where ground crews were going to burn out around several structures.

The flight was on scene about 35 minutes before heading back towards the repeater site to evaluate the progress of the burnout.

Smoke was becoming worse and the

crew decided to fly under the smoke

column.

The pilot descended to about 125 – 150 ft

AGL and 40 knots.

Due to degraded visibility the pilot

turned back, slowing the aircraft and

making a right 180 degree turn.

The aircraft encountered an un-contolled

right yaw while making the turn in the

drainage along Forest Service Road 42.

The aircraft encountered three 360 degree

spins before the pilot was able to arrest the

yaw rate, 50 ft above the tree-line.

Helicopter

path

winds

The crew concluded that everyone was

ok and that there were no mechanical

problems and everyone agreed to

continue flying.

After about15 or 20 minutes, the crew felt

that winds and turbulence was starting to

exceed their comfort level and the flight

returned to the heli-base.

The pilot was highly qualified in type aircraft and has participated in teaching High Altitude Flying.

Helicopter was operating in the vicinity of the FS 42 road under the influence of right quartering tail wind .

Aircraft was operating in Mountainous

terrain at approximately 5000 ft MSL.

Winds were 20 to 30 knots. Temp: 96 F

Aircraft was heavy but within satisfactory

limits.

Aircraft flying as slow airspeed

After PSD operations, the crew continued

operating as a reconnaissance platform.

FAA advisory circular

90-95

USFS IASA (safety

alert) 11-03

PSD crew exposed

needlessly in recon

mission.

The Bell 407 is not normally recognized for LTE.

The pilot never stopped flying the aircraft and had a backup plan.

Even though left turns are preferred for maneuvering at low airspeed and high weight, conditions will not always be conducive to provide that option.

If a right turn is your best direction, compensate by increasing airspeed and or altitude prior to making the right turn.

June 15, 2011

T-885

Pike/San Isabel National Forest

Region 2, Fremont County Airport

Canon City, Colorado

Structure protection, dropping fire retardant on Duckett fire.

Aircraft had been operating out of Fremont County airport from 0911 – 1145.

The aircraft was under a DOI National On-Call contract.

Aircraft repositioned to Buena Vista airport due to shortage of retardant at Fremont County.

Aircraft had made last drop and was returning to Fremont County to standby.

Winds 150 v 210 (AWOS)

Temperature: 92F (AWOS)

Density Altitude 8800’ (AWOS)

Wind Event- Pilot entered the Fremont

County Airport area around 1316, winds

developed to 21 mph with gusts to 40 at

around the same time.

The pilot) to received the current weather information 12 miles out.

The pilot approached the airport from the

Northwest to enter a downwind to runway 11.

On final approach, the pilot noticed a large “dust devil” or “thermal” crossing the runway and decided to abort the landing attempt and continue heading down runway 11.

The pilot decided to land on Runway 17.

The pilot flew a high observation pass of

the runway to check wind conditions and

continued to land on runway 17.

The pilot entered a

left traffic pattern for

runway 17 and, after

crossing runway

threshold, he

encountered a “wind

shear”, causing the

aircraft to suddenly

drop approximately

80 to 100 feet.

17

11

29

N

The pilot increased power and touched

down about 200’ beyond the approach end of the runway.

On rollout, and, just after crossing taxiway A1, he encountered a left wind shear forcing the aircraft to the right.

He applied rudder, brake and power for additional directional control.

He applied full take

off power. as the

aircraft drifted right,

departing the runway

in a banked left turn.

The left leading edge

of the wing contacted

a runway marker.

The impact broke off

the marker and

damaged the leading

edge, lower wing

skin, left aileron and

contacted the left

lower trailing edge

wing tip.

The pilot

continued into the

air, setting up for

a landing on

runway 29, landing

uneventfully, he

taxied back to the

airtanker base.

June 24, 2011

Heli-Tanker 719

Coronado National Forest

Region 3, Sierra Vista Arizona

The aircraft was a CH54, N719HT on a

National Exclusive Use Contract.

They were assisting crews with water

drops on the Monument fire.

The aircraft was coming in for a second

drop on a specific tree.

Smoke conditions made the drop area

difficult to find.

The aircraft made a 30 knot down canyon

approach for a split drop at 200 feet

(AGL) and around 100 feet above the tree

top.

Immediately after the

drop, the crew heard

a loud “bang” and

noticed the right side

chin bubble broken.

The PIC jettisoned

the remainder of the

load and returned to

the helibase

Snorkel hose length was measured at 18 feet 8 inches.

The snorkel pump housing impacted both left main landing gear outboard tire and right side chin bubble.

A witness in the vicinity of the water drop saw the snorkel hose swinging “violently” and stated the hose seemed much more flexible than others he had seen.

Alignment inputs on final approach to the drop may have created /amplified swinging of the snorkel .

Two variety of hoses, some pilots thought the “white” variety of hose to be “noodley”.

The potential of the

snorkel hose

impacting other parts

of the aircraft,

including the main

rotor system, exists.

Bottom edge of chin bubble

May 14 – June 12, 2011

Multiple Aircraft

Region 3, Large Fires

During a 4 week period from May through June, 2011, large fire activity was occurring along the Arizona and New Mexico border with extensive use of Air-tankers, Heli-tankers, helicopters and coordination aircraft.

Received four reports of airspace conflicts indicating conditions that could lead to a mid-air collision.

One un-reported conflict was discovered during research into one of the reported incidents.

Horseshoe 2 Fire, a Type-1 heli-tanker and

Type-2 helicopter with long-line had a near

miss with approximately 700 ft separation. • Air attack distracted and overloaded while working

an evacuation of spike camps.

• Mission changed since AM brief.

• Helicopters not aware of each others presence.

• No HELCO.

• One aircraft transitioning N-S while other was E-W,

creating intersection.

Horseshoe 2 fire – Two conflicts in one

day, Heli-tankers and type-2 Helo

supporting ground firefighters.

Heli-tanker encountered conflict with a

Lead setting up a tanker drop.

Later that afternoon, Heli-tanker came out

of smoke and saw an un-announced ASM

making dry runs through the area he was

working.

Large numbers of aircraft working the

area with ASM and Lead aircraft.

HELCOs not used.

Emergent missions, with little or no brief

with other aircraft.

Long ATGS transition radio traffic.

Radio traffic extremely heavy, air crew

were turning down certain frequencies

and not hearing warning calls.

Wallow Fire – Helicopters working out of

the Springerville heli-base entering FTA

without establishing radio contact.

Traffic conflicts were occurring between

these helicopters and air-tankers / lead

planes.

Heli-base was just outside and North of

the Fire Traffic Area (FTA).

Helicopters were supporting fire activity

South of the FTA, direct flight most

expedient route.

Insufficient time to contact ATGS.

Area Command was being transported

from one town in the southern part of a

large FTA to a town just inside the

Northern boundary of the same FTA.

The FTA was divided into 3 zones with a

different Air attack for each zone.

Area command aircraft had near miss

with Air Attack in the second zone they

were entering enroute to destination.

Area Command aircraft took off from Reserve and had radio contact with zone 2 air attack.

Zone 1 air attack was

being relieved and its relief was reconning the area before pass-down.

Zone 1 aircraft was un-aware the Area Command aircraft was entering their zone.

Fire Traffic Area Willow

Zone 2

Zone 1

Reserve

Show Low

60 nm

High traffic encountered with both Rotor and Fixed wing.

Incidents occurred during the afternoon. Morning missions briefed in controlled

environments with little distraction. Afternoon, emergent missions develop that

miss the opportunity for crews to get clear and complete information.

Radio traffic was generally heavy. Transition radio conversations were tying

up air to air frequency.

Transition is a particularly vulnerable period until the coordination rhythm is restored.

Critical radio calls not received and position calls were sometimes not made.

Aircraft experiencing incidents involved at least one aircraft that was not in radio communication with the other and was unaware of its location.

Helicopter water operations and fixed wing tanker drops are still set up without “fences” to ensure separation.

Air Attack crews were experiencing high

workloads resulting in reduced attention to the helicopter coordination.

FTA procedural discipline begins to breakdown as radio traffic becomes intense.

When the FTA is close to a base, aircraft are inside the 7 mile area as soon as they are airborne.

Teams interviewed agreed there was a need for a HELCO when air operations got complex.

On March 09, 2012 the NTSB released it’s

Probable Cause and Contributing Factor

for this 3 fatality accident (Pilot and 2 FHP

employees were only soles on board)

The aircraft was heading towards William

T. Piper Memorial Airport, near Lock

Haven, PA when the engine failed within

5 miles of the airport.

Probable Cause: The total loss of engine

power resulting from the fatigue failure of

the engine's number 2 cylinder exhaust

valve. The fatigue failure was due to valve

guide wear that led to excessive

clearance between the valve and valve

guide.

Contributing Factor: Contributing to the

accident was the contract operator’s lack

of compliance with its own maintenance

procedures, which, if followed, would

have prevented the accident.