# Presentation: 095295

## Mishap BriefingN9474L

***Colonel Frank Buethe***
***Commander***
***New Mexico Wing***

- U.S. AIR FORCE

- A U X I L I A R Y

**Notes:**
Good morning
I’d like to update you on the latest safety statistics and accidents since the last NEC

## Overview

**Mishap Pilot (MP) took off from LRU on RWY 26 at 2130L on 9 June 04 to RTB Albuquerque from C/D mission**
**MP radioed he had a “Low Voltage Light” and would return to land at LRU.**
**Two other CAP aircraft were present:**
**One on ground, taxiing for takeoff RWY22**
**One just airborne on RWY 26 behind Mishap Aircraft (MA)**
**MP transmitted “CAP Flt 3074 right base, Rwy 26”   **

## Overview (Con’t)

**Taxiing aircraft took runway and departed Rwy 22, and came back to land and assist**
**Second CAP aircraft recovered at LRU**
**MA was missing**
**Ground perimeter search revealed nothing**
**Local paramedic helicopter with EMT personnel flew perimeter and found the MA and crew**
**Administered first aid**
**Summoned medical assistance    **

## Aircrew Background

**MP: **
**74 year old pilot with private/instrument (non-current)**
**850 hours PIC**
**Ten year CAP volunteer**
**Squadron finance officer**
**Current and in compliance with CAP/FAA regulations**
**April 04 Form 5 with no discrepancies**
**Mission Scanner/Observer**
**Non-pilot, 400 hours as MS/O**
**Five year CAP member **

## Sequence of Events

**“****Sunset Customs Mission” events:**
**1. Depart ABQ 1230L**
**2. Arrive LRU, mission plan for 2020 landing @ LRU (official sunset)**
**3. Refuel, fly FAA 90-day night currency: 3 and 3**
**4. RTB ABQ**
**First two OK**
**No instrument panel lights for take-off to ABQ .**
**Post lights, D. C. powered. All inoperative.**
**Radios and engine instrument lights Ok**

## Sequence of Events (Con’t)

**Flies night re-currency, picks up M S/O**
**Engine start for RTB ABQ:**
**Low Voltage light illuminates.**
**No instrument lights.**
**Decides to takeoff**
**Thinks takeoff RPM will solve low voltage light (has occurred previously)**
**Uses flashlight to illuminate instrument panel**
**Gets airborne on RWY 26**
**Calls two other CAP aircraft and reports Low Voltage Light – still illuminated at higher RPM.   **

## Sequence of Events (Con’t)

**Other CAP aircraft**
**One taxiing for takeoff on RWY 22**
**One airborne behind MA **
**MP elects to return to LRU and land to sort out electrical problem**
**Alternator and Alternator Field CB’s have tripped**
**Pilot doesn’t perform checklist procedure: can’t see**
**No instrument, overhead, or windshield bow lights**
**Mission S/O shining a flashlight on instrument panel**
**MP Calls on UNICOM: “CAP Flight 3074 right base to final, RWY 26”)  **

## Sequence of Events (Con’t)

**MP begins gradual descent **
**Right main hits sand mound**
**Nose gear contacts sand**
**Gradually digs in**
**Shears**
**Prop and spinner dig in**
**Aircraft flips inverted**
**Lands symmetrically on airport perimeter fence**
**Mishap aircrew exits aircraft with minor injuries   **

## Instrument Panel Flashlight Illumination

## Areas Investigated and Determined to be Factors

**Media**
**Man**
**Machine**
**Management**

## Media (Environmental Conditions)

**Night, extreme dark north of airport**
**No visible horizon**
**Winds variable 220-250 at 8 knots**

## Man: Physiological

**Turbulence**
**Five hours of moderate turbulence**
**Five hours of hot and dry desert flying conditions**
**Fatiguing conditions, but not debilitating. Dehydration not a factor**

## Man: Proficiency

**MP Current IAW CAP/FAA Regulations**
**Form 5: April 04**
**Instrument rated, but not current as instrument pilot**
**MP Couldn’t go from night VFR in an airport environment to virtual IMC during missed approach turn to the North**
**Attitude indicator –poor lighting, flashlight only.**
**No visible horizon**
**Total, absolute darkness**

## Man: Proficiency (Con’t)

**Exhibited poor judgment:**
**Took off without instrument lighting.**
**Turned off electrical equipment in pattern.**
**Decision to make a right 360 rather than standard go-around.**
**Retracted flaps prior to establishing a positive rate of climb.**
**Turned right into dark desert, with no horizon, away from airport lighting, instead of left or pattern reentry.**

## Man: Proficiency (Con’t)

**MP lacked aircraft systems knowledge**
**Low Voltage Light**
**Tripped circuit breakers**
**Aircraft history – noted in aircraft forms**
**Misprioritized the situation**
**Decided to land “As soon as possible” rather than “practical” as described in POH **

## Machine

**Maintenance records up-to-date**
**History of electrical systems failures identical to mishap sortie**
**Highly likely that:**
**Loose connection at buss and Alternator CB caused by missing lock washer caused arching and fluctuating voltage as regulator attempted to maintain correct voltage with varying charging resistance.**
**Over-voltage occurred during period of connection, causing CB’s to trip**

## Machine (Con’t)

**MA had tripped Alternator and Alternator Field CB’s**
**MA had missing lock washer**
**MA had loose connection at CB during post-mishap analysis**
**Instrument panel lights were inoperative in the MA**
**Post lights**
**Overhead spots**
**Canopy bow**
**Aircraft maintenance was a factor in this mishap**

## Management: Standards

**Improper diagnosis by contract maintenance personnel**
**Never properly analyzed**
**Never truly fixed**
**Squadron culture**
**“****Carry” discrepancies till 100 hour to save money**
**Quality of maintenance is a factor in this mishap**
**CAP should set the highest standards for maintenance. Aircrew members should expect fully operational aircraft. Otherwise, the mission will suffer and aircraft/aircrews lost!  **

## Management: Procedures

**The mission was appropriate for the crews and aircraft assigned**
**POH procedures dealing with “Low Voltage Light” indications are adequate**
**Airborne, MP was unable to read the POH due to lighting**
**Illumination of the “Low Voltage Light” after engine start, on the ground, could have been dealt with IAW the POH    **

## Management: Control/Supervision

**Quality and adequacy of aircraft maintenance is a factor in this mishap**
**Pilots who note discrepancies that cannot be duplicated by maintenance should confer with squadron/wing maintenance officers to reconcile the discrepancy**
**Aircraft should be grounded if unit safety and command personnel cannot reconcile aircraft discrepancies related to flight safety and/or mission accomplishment **

## Findings

_**CAUSES**_**:**
**Electrical connection to Alternator Circuit Breaker was loose causing sporadic connection and voltage surge tripping Alternator and Alternator Field circuit breakers resulting in Low Voltage Light indication in cockpit.**
**Loose connection due to missing lock washer between the electrical lug, mounting screw, and circuit breaker allowing mounting screw to come loose during normal operations.**
**Contract maintenance repeatedly failed to accurately identify and fix numerous discrepancies relating to Alternator and Alternator Field circuit breakers and Low Voltage light indications noted in the MA maintenance discrepancy log.*****   ***

## Findings (Con’t)

**After engine start on mishap sortie MA electrical systems experienced surges due to loose connection tripping Alternator and Alternator Field circuit breakers producing Low Voltage light indication in cockpit.**
**MP took off with Low Voltage light indication mistakenly thinking it would go out at high RPM.**
**MP mis-prioritized his reactions to the malfunction, electing to land “as soon as possible,” rather than “as soon as practical,” as recommended in POH, Section III, Emergency Procedures.**

##    Findings (Con’t)

**MP lost Situational Awareness (SA), was lined up to land on RWY 22, but called on UNICOM frequency that he was turning “Right base to final, RWY 26.”**
**MP turned of all electrical equipment including landing light, navigation lights and most radios.  The rotating beacon was left on, but was invisible to aircraft on the ground.**

**   ****Findings (Con’t)**

## Findings (Con’t)

** ****A CAP aircraft departing for ABQ, heard MP call RWY 26, visually checked final approach for RWY 22, saw nothing, and took off directly in front of MA which was on short final to RWY 22.**
** ****At approximately 200’ AGL MP saw CAP aircraft taking off on runway directly in front of him and elected to perform a right 360****o**** turn back to final approach and land as soon as possible.**

## Findings (Con’t)

** ****MP initiated 360****o**** right turn, raised flaps, and lost all visual reference to runway environment, had no visual horizon and no effective instrument lighting.  As a result MP lost SA and likely experienced Type I Spatial Disorientation.**
** ****As MP banked the MA he unknowingly entered a very gradual rate of descent, impacting the ground after approximately 120 degrees of turn in an almost flat attitude (approximately 10 degrees right wing down).**

## Recommendations

_**Recommendations focus on**_**:**
**	****1.  Maintenance procedures**
**	****	****a. Ground aircraft**
**	****	****b. Do not “carry forward” maintenance gripes**
**	****	****c. Ensure contractors do thorough maintenance**
**	****	****d. Periodic review of maintenance history**
**	****2.  Aircraft systems knowledge**
**	****	****a. Raise pilot knowledge**
**	****	****b. Safety briefings include aircraft systems**
**	**

## Recommendations (Con’t)

**3.  Pilot proficiency and procedures**
**	****	****a.  Cockpit/instrument panel familiarity**
**	****	****b.  Flight procedures, e.g. “go-arounds”**
**	****	****c.  Situational Awareness, e.g. night operations and loss of depth perception at night**
**	****	****d.  Qualified pilots in IMC/night/etc. conditions**