The Long Green Table
By Dunn, Pat | |
Proquest LLC |
As aviators, our jobs are filled with choices. Unless you're on an instrument flight, you can choose nearly every aspect of how you will fly, so long as you complete your mission. Would you rather do multiple approaches to build your skills and proficiency or just do the minimum?
Crew resource management (CRM) and operational risk management (ORM) are tools to make those choices and engender mission success. When either degrades, sound decision-making proceeds into a vacuum, and so does your chance of success. As the helicopter aircraft commander (HAC) of a recent Class B mishap, I can tell you that the vacuum can be sneaky, slow and destructive.
This is my account of a mishap that grounded my copilot and I for 148 days, and the lessons I learned during that time. If youve ever read one of these articles and thought, "That's a great lesson, but it's not me; I'd see that coming," then you and I have something in common.
I never expected to find myself at the wrong end of a FNAEB. I will walk you through the events leading up to my mishap, the critical moments before it happened (all of 30 seconds), and some lessons to take from my experience.
The Lead-Up
It was the end of work-ups, COMPTUEX was over, and the squadron would deploy soon. We had just finished our last day being evaluated and were preparing for a night of foc'sle follies. I had been awake from 0140 to 1800.1 was informed that I would have a 0500 brief for a three-hour plane guard and flyoff. I didn't think anything of it; after all, everyone was going to follies at 2045, and I didn't have the earliest flight. I reasoned that being at follies was the same as being in my rack resting - both were low stress - and that I would be fine with a 0445 wake up.
After going to bed around 2300, and waking up at 0445,1 was tired but ready to get off the ship. I had a cup of coffee and a pop tart for breakfast. Not exactly the breakfast of champions, but I figured it would get me through until I could get back to
The brief and preflight were unremarkable. There was a small gripe, but I discussed it with my CDQARs and we moved on. Startup and takeoff went quickly, and we settled in for our 3.0 hour flight. We investigated surface vessels and practiced search and rescues for training.
After our first fuel hit, we realized that some jets were having troubles, and we might be out for a little longer than planned. As the hours ticked on, the crew's mood soured. We were getting impatient. The only things prohibiting our return were four FA-18s that wouldn't start.
The Hornets took off eventually, about an hour late. We landed, picked up our passengers, and then departed for the 60-mile transit home. I had the controls for that entire leg, and I just wanted to get everyone back to their families. We checked weather at
The Critical Moments
At 10 miles from the field, I contacted tower and we were immediately cleared to land. Because it was a Saturday, I gathered that tower just wanted us to land so that they could also go home. I internalized that ATIS had called for winds from the west, but I didn't say anything because it was nothing out of the ordinary. As we closed the field, I told my crew that we'd go to the birdbath to wash the past two months of salt-water from our rotors.
Crossing the field boundary, I set up for an approach to our birdbath landing pad. The approach lined me up with a tail wind of about 10 knots. However, having landed at the pad with a tail wind many times before, I didn't say anything or make changes to my approach. As we neared touchdown, I confirmed the wind with the windsock ahead of me, but still didn't verbalize the tail wind. Trying to be expeditious, I went for a no-hover landing, a maneuver that would save about 10 seconds. On final, my junior aircrewman began to call the deck. He was quickly quieted by my crew chief because the calls were unnecessary. We landed without incident and taxied to the bird bath. We then taxied out, ready to take off and head to our normal landing pad.
I noted the wind sock, but only as an obstruction. I received clearance to take off for an air transition to pad 9 (not more than 2,000 feet away) and got airborne.
The layout of the field allowed me to land at either of two pads. One would have resulted in a 90-degree crosswind (pad 11) while the other a straight tail wind (pad 9). We rarely landed at pad 11, so I continued to pad 9 without giving it a second thought. My copilot called me abeam the spot, and I made a 180-degree turn to line up with the landing zone.
Before executing that turn, I thought I said, "coming right." However, some of my crew remember "buttonhook right." In either case, the disagreement highlights our low CRM. While it was not my intent to fly the buttonhook (a tactical maneuver), I rolled into a sharper than necessary turn. This resulted in a final approach path that was slightly off altitude and high on speed, consistent with an improper buttonhook or messed-up approach.
As I began my descent, I said nothing, nor did my crew. I assumed that they would know what I was doing, as I had just made a no-hover landing. They assumed that I knew what I was doing and didn't need their assistance. I felt slightly fast on final but thought I had the approach under control. No one on the crew said anything. The tail wind had distorted my perception of relative motion, and my corrections were not enough.
Continuing to touchdown, my nose attitude was high and the tailwheel touched earlier than expected. Again, I did not verbalize my perceptions, and I simply made what I thought to be the appropriate control inputs. As I did, unbeknownst to me, my copilot had begun to reach for his pocket checklist to start the postlanding and shutdown checks. Within the blink of an eye, the aircraft pitched violently forward and settled on the mainmounts.
I would later learn the aircraft pitched 20 degrees (10 up to 10 down) in that split-second. The pitch change, caused by my incorrect control inputs, the tailwind landing, and a pitching moment about the tailwheel, caused the
The Lessons
The idiom "Set yourself up for success" has never been truer than in this incident. In the preceding 16 hours, there were numerous choices, decisions, and actions I could have done to have lessened the chance of - if not prevented - this mishap.
The investigation showed me how poorly I had set myself up for success in regards to sleep and nutrition. The sleep debt I had acquired over the course of COMPTUEX was not alleviated by my six-hour sleep. My 200-calorie breakfast put me at dangerously low levels of nutrients and hydration. There are countless studies that link fatigue, nutrition and hydration to flight performance. Even slight amounts of dehydration and fatigue can decrease reaction time by seconds. With good nutrition and rest, my reaction time might have been higher, allowing me to more quickly recognize my off-parameter approach and landing.
The worst person to judge your level of fatigue, nutrition or hydration is yourself. By the time you feel tired, hungry or thirsty, it is too late. Now that I am returned to flying duties, you will never catch me without adequate sleep, food, or water before I fly. I fly with water and a granola bar just in case my flight gets extended. The only way to achieve success is to be prepared.
BEYOND THE FATIGUE AND NUTRITION, the CRM process throughout my flight, and most especially in the last 30 seconds, was woefully inadequate. The MH-60S NATOPS states, "The goal of Crew Resource Management (CRM) is to improve mission effectiveness, minimize crew-preventable errors, maximize crew coordination, and optimize risk management .... Proper CRM requires that all crewmembers actively participate in each phase of flight." My flight was marked by breakdowns in the each of the seven critical CRM skills, crew-preventable errors, and a marginalized crew.
As the delay at the carrier continued, our ability to effectively adapt, flex, and maintain our focus on the mission waned. As the HAC, I should have limited our frustration, refocused my crew on the mission at hand, and kept the crew engaged despite our delay. By getting frustrated, I allowed a sense of get-home-itis to develop that would continue until our final landing. Get-homeitis is insidious and can creep into any crew, especially on flyoffs. It is inevitably linked to degraded CRM. We had mentioned it in the brief, but as an aircraft commander, I never took steps to guard against the threat, I simply gave it lip service. Have a plan to fight it. Use tools such as training opportunities, conversation topics that don't exacerbate your problem, or other means of warding off the CRM challenge.
The CRM breakdowns during the minutes leading up to the final landing were disastrous. By not communicating about factors such as winds, I didn't let my crew help me make the best decision. There was no talk of mitigating the inherent risks of a tail-wind landing because there was no talk about the landing. Whether you are the aircraft commander, a crew member, or a passenger with ICS, you should always have an idea of what your pilot is thinking. If you do not, ask. Never make an assumption when clarification is only a few words away.
Had I analyzed the situation or understood the get-home-itis impact on my mission analysis, I could have easily approached pad 11 (eliminating the tail wind), transitioned to a normal-hover, prior to landing (mitigating the risk), or gone around (reassessing the hazard for better controls). There was no need to push the approach to a no-hover landing when I could have simply transitioned to a normal approach. However, I relied on my understanding and perception, forgetting I was only one part of a full crew. I allowed myself to continue a flawed approach because my situational awareness was poor.
My leadership of the crew failed to address all these issues, including complacency among the crew. Having landed at our home field countless times, and having just completed an approach in the same direction, I allowed complacency to build. That complacency even allowed the copilot to focus on an ancillary task rather than the critical phase of flight in which we were operating. As the aircraft commander and pilot at the controls, I needed to make sure that the crew maintained its focus and integrity with the same dedication we had for the past 4.8 hours. The 30 seconds before landing are just as critical as any other phase in the flight.
Parting Shots
Small changes in the decision-making process, ORM, and most importantly CRM could have changed my crew's fate. At any point, I could have taken 30 seconds to step back, remember the seven skills, reassess my decision-making process, and evaluate my execution.
Had the
Field Naval Aviator Evaluation Boards (FNAEBs)
FNAEBs are administrative boards convened to evaluate the performance, potential, and motivation for continued service of any Naval Aviator ordered by competent authority to appear before such a board. These boards shall review and evaluate the overall performance and the specific element of performance or behavior that is the cause of the evaluee's appearance before the board. These boards are fact-finding, evaluative bodies which shall make recommendations as specified in the "Recommendations"paragraphs of this article, through the chain of command to the type commander (TYCOM). These boards are not bound by formal rules of evidence and may consider and include in the record any type of evidence deemed credible, authentic, and relevant to the case. These boards are neither judicial nor disciplinary bodies and shall make no recommendation for disciplinary action as a result of their evaluations. Any disciplinary action accruing from the same circumstances or events that are the reason for convening an FNAEB shall be kept completely separate from such boards. - MILPERSMAN 1610-020
The idiom "Set yourself up for success" has never been truer than in this incident.
BY LT.
LT. DUNN FLIES WITH HSC-6.
Copyright: | (c) 2013 Superintendent of Documents |
Wordcount: | 2263 |
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