Announces Administrative Changes
The Forest Service has
released its report into the Sept. 20 crash of a Forest
Service-chartered aircraft in which three people died
and two survived. The agency will implement several administrative
changes recommended by the accident investigation team to prevent a
similar tragedy from occurring.
“The Forest Service’s accident investigation
team’s charter was to review the agency’s
administrative procedures leading up to the crash and during the
search and rescue operation. In addition, our goal was to learn
from what happened and to improve our safety procedures for the
future,” said Team Leader Randy Moore.
“The team was not tasked to identify the cause of the
accident, which is the role of the National Transportation Safety
Board.” The Forest Service is cooperating with NTSB in
its investigation, which is expected to be completed within the
year.
Moore’s team found that the Forest Service’s
contract with Edwards Jet Center did not specify the requirements
for a pilot’s flight experience in wilderness or to properly
define what was meant by “typical terrain” flight
experience. The Forest Service often travels by aircraft to conduct
its day-to-day operations.
For example, the workers
on the Montana plane were traveling to conduct an annual vegetation
inventory and to repair telecommunications facilities. The agency
will now review and modify its current requirements for backcountry
pilot experience as well as issue a standard definition for what
constitutes typical terrain.
Investigators also found that clothing worn by most of the
passengers sustained significant damage from the post-accident
fire. However, a fire-resistant jacket worn by one of the
passengers provided adequate burn protection for areas covered by
the jacket. In light of these findings, the Forest Service will
reevaluate appropriate personal protective equipment requirements
for its fixed-wing backcountry flight operations.
Finally, the team found that while the radio check-in procedures
for flight following were used, they provided limited and
eventually, misleading information in the search and rescue
operation. All personal gear and emergency locators were burned in
the fire. These findings led to the third action item to step up
the already-planned implementation of an automated flight following
program, a real-time tracking system using satellite communication
and internet systems. Until this program is fully implemented,
latitude, longitude and heading reports will be required for radio
check-in on Global Positioning Systems-equipped aircraft.
“My condolences are with the family, friends and coworkers
of Davita Bryant, Ken Good and Jim Long. We will never forget them
for their hard work and their dedication to natural resource
management,” said Forest Service Chief Dale Bosworth.
“My thanks to Randy Moore and his team for doing such a
detailed investigation and for recommending action items that will
improve the way we conduct aviation operations in the
future.”
On Sept. 20, a pilot and four Forest Service employees were en
route in a Cessna 206 from Kalispell, Mont., to the Shafer Meadows
backcountry airstrip when their plane crashed and caught on fire.
Pilot Jim Long, 60, and passenger Davita Bryant, 32, died in the
crash. Ken Good, Jodee Hogg, and Mathew Ramige escaped the fiery
aircraft with burns and injuries, huddling together the first night
to ward off the effects of cold and moisture. Good, 58, died the
following morning, prompting Hogg and Ramige to hike down the
mountain before rescue personnel located the wreckage. Forest
Service ground personnel located the wreckage the next day. Nearly
two days after the crash, Hogg and Ramige, after a courageous and
rigorous hike out of backcountry terrain, emerged on a local
highway and flagged down a passenger car for help. Hogg is
recovering from her injuries; Ramige is still undergoing treatment
for his injuries.
NTSB Preliminary Report
NTSB Identification:
SEA04GA192
14 CFR Public Use
Accident occurred Monday, September 20, 2004 in Essex, MT
Aircraft: Cessna U206G, registration: N206SM
Injuries: 3 Fatal, 2 Serious.
This is preliminary information, subject to change, and may
contain errors. Any errors in this report will be corrected when
the final report has been completed.
On September 20, 2004, approximately 1530 mountain daylight
time, a Cessna U206G, N206SM, impacted mountainous terrain while
maneuvering about 6 nautical miles northwest of Essex, Montana. The
airplane was being operated under contract to the United States
Forest Service (USFS) by Edwards Jet Center of Kalispell, Montana,
as a public use flight. The purpose of the flight was to transport
a forest inventory team from Kalispell to the Schafer USFS Airport,
Schafer, Montana. Four USFS employees and an Edwards pilot were on
board. The pilot and two USFS employees were killed, and the other
two USFS employees sustained serious injuries. Visual
meteorological conditions prevailed for the airplane's departure at
1500 from Glacier Park International Airport in Kalispell. An FAA
flight plan was not filed; however, the airplane was receiving
flight following services from the USFS.
According to USFS personnel, the flight was originally scheduled
to depart at 1300. The scheduled departure was delayed from 1300 to
1500 due to weather conditions. The planned route of flight was to
follow Highway 2 from Glacier Airport to a point about 3 miles
south of the town of Essex, where the highway and the Middle Fork
of the Flathead River separate. At this point, the flight was to
leave the highway and follow the Middle Fork drainage to
Schafer.
According to personnel at the Glacier Airport Tower, their last
contact with the airplane was at 1508, when the pilot reported that
he was through "the canyon" (Badrock Canyon approximately 8 miles
northeast of Glacier Airport) and switching to "backcountry
frequency" (USFS dispatch). Examination of radar data confirmed
that at 1508, the airplane was exiting Badrock Canyon heading
northeast. Radar contact with the airplane was lost at this time
due to mountainous terrain. From Badrock Canyon, the airplane's
planned route proceeded along Highway 2, which follows a large bend
in the Middle Fork of the Flathead, heading first northeast, then
east, and finally southeast towards Essex. At 1515, the airplane
checked in with USFS dispatch, and the pilot reported his position
as "Essex, inbound for Schafer." This was the last radio
communication received from the airplane.
When the airplane did not check in with USFS dispatch as
expected at 1530, a search was initiated. The wreckage of the
airplane was spotted by ground searchers about 1345 on September
21, 2004. Search and rescue personnel reached the accident site via
helicopter about 1510. The Deputy Coroner for Flathead County
inspected the scene and announced that all five occupants were
fatally injured. The ground search was suspended. Approximately
1430 on September 22, 2004, two survivors walked out of the Tunnel
Creek drainage.
The airplane impacted rugged mountainous terrain near the head
of the Tunnel Creek drainage of the Flathead Range at a Global
Positioning System (GPS) location of 48 degrees 19.011 minutes
North, 113 degrees 44.166 minutes West, and an elevation of 6,604
feet. The airplane came to rest in a sparsely wooded, rocky area on
an upslope of 30 to 45 degrees. All major components of the
airplane were accounted for in the main wreckage area. The debris
path measured approximately 80 feet in length along a magnetic
bearing of 165 degrees. The fuselage with both wings attached came
to rest inverted, and the empennage, which remained attached to the
fuselage by control cables came to rest upright. The engine had
separated from the firewall, and the propeller had separated from
the engine crankshaft. All flight controls remained attached to
their respective attach points, and control continuity was verified
from the control surfaces to the cockpit controls. The cockpit,
cabin and the inboard sections of both wings were destroyed by
fire. All three propeller blades were bent and twisted, the blade
tips were broken off, and the blade leading edges were gouged and
scraped.