FS-5700-20a Helicopter Pilot Qualifications and Approval Record

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Overview

FS 5700-20a
Burden Statement
Instructions
Evaluation Check
Justification

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Sheet 1: FS 5700-20a

FS-5700-20a 10/2011

OMB 0596-0015 Omission of Exp. date Approved by OMB

Contract Number:

USFS:

HELICOPTER PILOT QUALIFICATIONS AND APPROVAL RECORD

DOI:

(Reference FSM 5700)

SECTION I - Pilot Information (to be filled out by pilot seeking approval)

1. Name (Last, First, Middle Initial)

2. Date of Birth

3. Primary Telephone Number

4. Home Address (Street, City, State & ZIP Code)

5. E-Mail Address

6. Employed By

7. Address

8. Telephone No.

9. Employed Since (m/yr)

10. Previous Employer

11. Address

12. Telephone No.

13. Period Employed (m/yr)

to

14. Previous Employer

15. Address

16. Telephone No.

17. Period Employed (m/yr)

to

18. Medical Certificate: (attach copy)

Class

Date

19. Most Recent Interagency Pilot Card: (attach copy)

Limitations:

Date Issued:

Expiration:

Insp. Name:

Agency:

20. Airman Certificate: (attach copy)

Commercial

ATP

CFI

21. Most Recent Interagency Flight Evaluation Information

Number:

Other Ratings:

Date Evaluation Conducted:

Insp. Name:

Agency:

22. Aircraft accidents / FAA violations within the last 5 years:

23. Has a Previous Interagency Pilot Card been denied, suspended, or revoked?

Yes

No

(if Yes, explain in box 45)

No

Yes

(If Yes, please explain in box 45)

Helicopter Pilot-in-Command

PIC

(a)

(b)

(c) PIC Hours for Column "a" A/C

Flight Time & Type of Flight

Hours

Make, Model & Series

Are you Type Rated for column "a" aircraft

Aircraft Total

Vertical Reference

Mountain Flying

Preceding 12 Months

Only

seeking approval in

24. Total Helicopter

34.

Yes

No

N/A

25. Total Helicopter

Weight Class

Less than 12,500 lbs

35.

Yes

No

N/A

12,500 lbs or more

36.

Yes

No

N/A

26.

Turbine Engine

37.

Yes

No

N/A

27.

Reciprocating Engine

38.

Signature Page - Operations & Safety Procedures Guide:

Attach Original

28.

Preceding 12 months

39.

FAR 135 Evaluation:

Attach Copy

Not Applicable

29.

Preceding 90 days

40.

Equipment Check Endorsement:

Attach Copy

Not Applicable

30.

Mountain Flying

41.

CFR 14, part 61.56 Flight Review:

Attach Copy

Not Applicable

31.

NVG Operations

42.

FAR 133 Endorsement :

Attach Copy

Not Applicable

32.

Offshore

43.

FAR 137 Endorsement :

Attach Copy

Not Applicable

33.

Vertical Reference, VTR

44.

VTR Training Endorsement: (attach copy)

Snorkel

Long-Line

Not Applicable

45. Applicant Remarks:

I certify that the information listed on this form is true and correct. In addition, I certify that I have read the statements

attached to this form covering information pursuant to Public Law 93-579 (Privacy Act of 1974)

46. Pilot Signature

47. Date

SECTION II - Special Use Mission Approval (to be filled out by Pilot Inspectors only)

1. Approved (Initial)

2. Mission

3. Flight Evaluation

4. Expiration Date (m/yr)

1. Approved (Initial)

2. Mission

3. Flight Evaluation

4. Expiration Date (m/yr)

Administered Date (m/yr)

Not Administered

Administered Date (m/yr)

Not Administered

Low Level Operations

"Trainee Only" Pilot

Helitack/Passenger Transport

2Short Haul

External Load (belly hook)

Float Operations (fixed)

1Water/Retardant Delivery

Platform Landings: Offshore

1Longline VTR (150 ft)

1Vessel Landings

1Snorkel

2Night Vision Goggle Operations

Mountainous Terrain Flight

1ACETA Net Gun (all ACETA)

Aerial Ignition: PSD

1ACETA Eradication (only)

Aerial Ignition: Torch

1ACETA Gathering/Capture (Herding)

2Rappel Operations

1ACETA Darting (only)

1Cargo Letdown

Other

Snow Operations (deep snow)

Other

Designated "Pilot Trainer"

Other

***Recurrence Flight Evaluation: 1 3 years 2 1 year

5. Make/Model/Series Aircraft:

6. Pilot Inspector (Print)

7. Pilot Inspector Signature

8. Agency

9. Issue Date

10. Card Expiration Date

a. ______________

c. ______________

b. ______________

d. ______________

11. T/M/S flight evaluation was administered / Remarks:

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Sheet 2: Burden Statement

				PRIVACY ACT NOTICE
	Collection and use of the information on this form covered under Privacy Act System of Records USDA/FS-44 (Pilot Qualification Records) and consistent with the provisions of 5 USC 552a (Privacy Act of 1974).
	Purpose and Use - - This information, along with data you may have supplied previously, and information developed by investigation will be for use by such as:
		1. To determine your pilot qualifications to comply with contract specifications.
		2. Transfer to the U.S. Department of Justice in the event of litigation.
		3. Transfer, in the event there is indicated violation or potential violation of a statute, regulation, whether civil, criminal, or regulatory in nature, to the appropriate agency or agencies, whether Federal, State, local, or foreign, charged with the responsibility of investigation or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, order, or license violated or potentially violated
			BURDEN AND NONDISCRIMINATION STATEMENTS
	According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0015. The time required to complete this information collection is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
	The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).
	To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

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Sheet 3: Instructions

INSTRUCTIONS
Section I PILOT INFORMATION (To be filled out by the applicant)
1-17	Self explanatory.
18	Attach a copy of the medical certificate.
19	Attach a complete copy of the most recent Interagency Pilot Card.
20	Provide a legible copy of the front and back of each airman certificate.
21	Self explanatory.
22	Provide a detailed explanation of the event and any applicable paperwork. Attach additional page(s), as required.
23	Self explanatory.
24-33	Enter helicopter Pilot-in-Command time, only.
Column "a"	List only aircraft for which the contract is approved and will be operated by the applicant. If more than four aircraft, list in applicant remarks with pertinent item (a), (b), (c) information.
Column “b”	Select yes, no, or N/A (not applicable)
Column "c"	PIC hours only for each aircraft listed column “a” aircraft
38	Attach the original signature page from the Interagency Operations and Safety Procedures Guide for Helicopter Pilots "Pilot Certification"
39	Attach a copy of current FAR 135 Airman Competency / Proficiency Check (FAA form 8410-3) for each standard category make and model helicopter the pilot seeks approval. Required if operating aircraft listed on the operators 135 certificate.
40	Attach a copy of current (within the last 12 calendar months) Equipment Check Endorsement (or comparable document (E.G. CFR 14, part 61.58 Pilot Proficiency Check) for each Limited Use or Restricted Category make and model helicopter pilot seeks approval. (Required if operating aircraft not listed on the operators 135 certificate)
41	Attach a current reproduction of the CFR 14, part 61.56 Flight Review.
42	Attach a copy of FAR 133 endorsement. (If pilot is to be approved for Part 133 operations)
43	Attach a copy of FAR 137 endorsement. (If pilot is to be approved for Part 137 operations)
44	Attach a copy of the Vertical Reference Flight Training endorsement for VTR Snorkel and/or Long-line, as applicable, contained in the Interagency Operations and Safety Procedures Guide for Helicopter Pilots. (Required for long-line operations and snorkel operations conducted in helicopters not equipped with mirrors for external load operations)
45	Explain aircraft accidents / FAA violations within the last 5 years. Explain denial, suspension, and/or revocation of any previous Interagency Pilot Card.
46-47	Self explanatory.
SECTION II - Special Use Mission Approval (to be filled out by Pilot Inspectors only)
1	Pilot Inspector shall initial each approved special use mission. Line through missions not approved.
2	Self explanatory
3	If a flight evaluation was administered, enter the month and year. If it was not administered, check the "Not Administered" box.
4	Record expiration dates of missions that require recurrent flight evaluations.
5	List aircraft approved. If more than four aircraft, list additional aircraft in the remarks section.
6-10	Self explanatory.
11	Enter the T/M/S aircraft the flight evaluation (if any) was administered and any additional remarks. Not any additional aircraft approved for.
SECTION III - Helicopter Pilot Evaluation / Qualification Check
1-4	Self Explanatory
SECTION IV - Statement of Retention of Aircraft Pilot-in-Command Authority
1	To be singed prior to the flight evaluation.
SECTION V - Pilot Evaluation Summary
1-8	Enter “D’ for Demonstrated Ability, “K” for Knowledgeable or “U for Unsatisfactory. Cross out blocks not evaluated.
SECTION VI - Remarks, Limitations & Approvals
1	Record approvals by aircraft make and model, applicable limitations, or remarks detailing reason(s) for disapproval.
2	Initial block indicating final status of this evaluation
3-4	Self Explanatory

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Sheet 4: Evaluation Check

SECTION III - Helicopter Pilot Evaluation / Qualification Check

1. Name: (Last, First, Middle Initial)

2. Employed By:

3. Type of Evaluation:

Initial

Recurrent

Compliance

Post-Accident

4. Aircraft: (make, model, series)

5. Aircraft N Number:

6. Flight Time:

7. Location of Flight Evaluation:

SECTION IV - Statement of Retention of Aircraft Pilot-in-Command Authority

1. Authority Statement: I will remain responsible as the sole Pilot-in-Command of the aircraft during this evaluation flight and that I will refuse to attempt any maneuver which, in my opinion, may be hazardous, unsafe, or result in any contractual, company or FAA violation.

Pilot Signature (sign prior to flight)

9. Date

SECTION V - Pilot Evaluation Summary

D-Demonstrated Ability K-Knowledgeable U-Unsatisfactory

1. Prerequisites

7. Special Use Operations

a.

1MH1 Basic Fire Behavior and Tactics (attach copy)

Expires:

a.

Low Level Operations

b.

1MH2 Organization, Communication, and Airspace (attach copy)

Expires:

b.

Helitack/Passenger Transport

c.

1MH3 Fire Helicopter Operations (attach copy)

Expires:

i.

Crew/Passenger Brief

d.

1A-110 Aviation Transport of Hazardous Materials (attach copy)

Expires:

ii.

Manifest

e.

2Grand Canyon SFAR (attach copy)

Expires:

c.

External Load (belly hook)

***Note Recurrence: 1 3 year 2 1 year

d.

Water/Retardant Delivery

2. General Knowledge

e.

Longline VTR (150 ft)

a.

Interagency Operations and Safety Procedure Guide

f.

Snorkel

b.

Pilot Authority and Responsibility

i.

VTR

c.

Power Assurance Check

ii.

Mirror

d.

Flight Time and Duty Day Limitations

g.

Mountainous Terrain Flight

e.

Personal Protective Equipment

i.

Aircraft Performance

f.

Contractual Knowledge

ii.

Terrain/Orographic Recognition

g.

Emergency / Survival Equipment

iii.

Wind Evaluation

h.

Airspace/Communication Procedures

h.

Aerial Ignition: PSD

i.

Fire Traffic Area/Temporary Flight Restrictions

i.

Aerial Ignition: Torch

ii.

Controlled/Uncontrolled Airspace

j.

Rappel Operations

k.

Aircraft Documents:

i.

Emergency procedures

i.

Rotorcraft Combination Load Manual

ii.

Obstacle Clearance Requirements

ii.

Hazardous Materials Handbook and Exemption Letter

iii.

Standard Configuration

3. Emergency Procedures

iv.

Weight and Balance

a.

Settling with Power

v.

Standard Communication / Crew Resource Management

b.

Dynamic Rollover

vi.

Power Requirements

c.

Emergency Jettison

k.

Cargo Letdown

d.

Autorotation / Forced Landings

i.

Emergency procedures

e.

Loss of Tail Rotor Effectiveness

ii.

Obstacle Clearance Requirements

4. Flight Preparation and Planning

iii.

Weight and Balance

a.

Aircraft Pilot Operating Manual (applicable FMS's/STC's)

iv.

Standard Communication / Crew Resource Management

b.

Weight and Balance

v.

Power Requirements

c.

Load Calculation

l.

Snow Operations (deep snow)

d.

Aircraft Limitations

i.

Aircraft Equipment Requirements

e.

Flight Plan/Flight Following

m.

Designated "Pilot Trainer"

f.

Weather/NOTAMS

n.

"Trainee Only" Pilot

g.

Fuel Requirements

o.

Short Haul

5. Equipment Check

i.

Phase I, II, III, IV

a.

GPS navigation

ii.

Standard Communication / Crew Resource Management

b.

FM Radio Operation

iii.

Weight and Balance

6. Flight Evaluation

iv.

Emergency procedures

a.

Checklist Use

p.

Float Operations (fixed)

b.

Preflight Procedure

q.

Platform Landings: Offshore

c.

Starting/Take-off Procedures

r.

Vessel Landings

d.

Flight Following

s.

Night Vision Goggle Operations

e.

Power Assurance Check

t.

ACETA Net Gun (all ACETA)

f.

Off-Site (Helispot) Operations

u.

ACETA Eradication (only)

i.

Wind Evaluation

v.

ACETA Gathering/Capture (Herding)

ii.

HOGE Power Check

w.

ACETA Darting (only)

iii.

Hi Recon (obstacles, approach/departure, LZ elevation)

x.

Other

iv.

Low recon (suitability, slope, obstacles)

8. Instrument Procedures (if required by contract)

g.

Confined Area Operations

a.

Equipment Check

h.

Pinnacle Operations

b.

ATC Procedures

i.

Ridgeline Operations

c.

Navigation / Orientation

j.

Saddle Operations

d.

Holding

k.

Shutdown/Post Flight Procedures

e.

Approach-NDB,VOR, DME, LOC, ILS

l.

Crew Resource Management

f.

Missed Approach / Circling Approach

m.

Judgment/Decision Making

g.

Speed, Heading Altitudes

SECTION VI - Remarks, Limitations & Approvals

1. Remarks, Limitations & Aircraft Approvals (as appropriate)

2. Evaluation Status (Pilot Inspector Initial)

3. Pilot Inspector (Print)

4. Pilot Inspector (Signature)

Approved

Disapproved (See Remarks)

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Sheet 5: Justification

	5700-20a change summary dated 5 Oct 2011
Executive Summary: The current 5700-20a is outdated, administratively burdensome, and does not contain current requirements for issuance of a Pilot Qualification Card. The form is non-concurrent with applicable references and contractual requirements. The document is not a stand-alone document capturing all documentation required to card an applicant resulting in inefficiency, confusion and redundancy. The Pilot evaluation section was not reflective of evaluation requirements for helicopters for which the applicant is responsible.
The new application is concurrent with Forest Service directives and contractual requirements as well as the Interagency Memorandum of Understanding between the DOI and FS to issue a FS and/or Interagency Pilot Qualification card.
Line Number		FROM	TO	ADDED	DELETED	JUSTIFICATION
Current	Proposed
Title Area	Title Area	Picture AH-1	Picture UH-1			AH-1 not representative of carding process
Title Area	Title Area	(Reference FSH 5709.12)	(Reference FSM 5700)			Reference update
Section I
9	9	Employed Since	Employed Since (m/yr)			Clarification
13	13	Period Employed	Period Employed (m/yr)			Clarification
17	17	Period Employed	Period Employed (m/yr)			Clarification
19	19	Most Recent Interagency Pilot Card	Most Recent Interagency Pilot Card: (attach copy)			Clarification/requirement for certificate issue
18	18	Medical Certificate:	Medical Certificate: (attach copy)			Clarification/requirement for certificate issue
20	20	Airman Certificate	Airman Certificate (attach copy)			Clarification/requirement for certificate issue
25	25	Weight Class	Weight Class			Align with FAA definition
		Under 7,000	Small 12,500 lbs or less
		7,000 to 12,500	Medium more than 12,500
		over 12,500
	33			Vertical Reference, VTR		Contract requirement
24-31	24-32				Deleted "PIC Helicopter"	Redundant
22	23	(if Yes, explain in box 40)	(if Yes, explain in box 43)			Update numbers
23	23	…explain in box 40	…explain in box 45	"box" no applicable		Update numbers / Clarification
(a)	(a)	5 lines for applicant aircraft	3 lines for applicant aircraft			Update (rarely exceed 3 a/c)
(b)	(b)			"box" for type rated		Clarification
(c)	(c)			Vertical Reference		Contract requirement
(c)	(c)	Mountainous Terrain	Mountain Flying			Admin-fit to size
	38			Signature Page - Operations & Safety Procedures Guide:		Contract requirement
38	39			"box" Attach Copy or "box" Not Applicable		clarify and contract requirement
39	40	Bi-Annual Flight Review:(attach copy)	Equipment Check Endorsement	"box" Attach Copy or "box" Not Applicable		Update language
	41			Current Flight Review		Contract Requirement
	42			FAR 133 Endorsement; "box" Attach Copy or "box" Not Applicable		Contract requirement
	43			FAR 137 Endorsement; "box" Attach Copy or "box" Not Applicable		Contract requirement
	44			VTR Training Endorsement: (attach copy) "box for snorkel, long-line and not applicable		Contract Requirement
40	45	Accident / Incident Explanation, Comments;	Applicant Remarks:			Clarification
Section II
Section Title		Approvals	Special Use Mission Approval			Update from Interagency Card Title
1 thru 2	1,2,3,4	Special Use Mission Items and admin procedures updated to reflect DOI and FS Interagency Card				Clarification / Mission Update
3 and 8	5	Combined redundancy of line items 3 and 8 into 5 a,b,c,d				Combined redundancy
	6			Pilot Inspector printed name		Administrative clarification
3 thru 13	5 thru 11					Updated line numbers
Section III
Title Area	Title Area	Change				Administrative
1 thru 8	1 thru 7	Relocation of information				Administrative
2					Type of Evaluation	Not applicable
	New Title	Made SECTION IV as stand-alone pilot signature requirement				Emphasize
Sect IV thru VI	Sect V	Stand-alone Pilot Evaluation Summary				Administrative
Sect IV thru VI	Sect V	Updated specific to helicopter evaluations being completed as the current paperwork was not representative of helicopter evaluations				Clarification
Sect VII	Sect VI				(to be filled out by inspector)	Administrative
Sect VII, 3					Deleted expiration date	Captured elsewhere on form
	3			Pilot Inspector (Print)		Clarification