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### LIST OF EFFECTIVE PAGESKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-TOC-SG i 01 JUL 13 

## TABLE OF CONTENTS

INTRODUCTION . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 1-1

SITUATIONAL AWARENESS . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1

CREW/FLIGHT COORDINATION . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1

COMMUNICATION . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1

RISK MANAGEMENT/DECISION MAKING

. . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1

TASK MANAGEMENT . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1

MISSION ANALYSIS . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1

COURSE REVIEW . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-1

TOOLKIT . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9-1

CASE STUDIES . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-1

NTSB REPORTS . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11-1

APPENDIX . . . . . . . . . . . . . . .

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CRM-IT-01-SG 1-1 01 JUL 13 

## INTRODUCTION

CRM PROGRAM GOALS AN D DEFINIT IONS ............................................................ 1-2

LESSON OBJECT IVES ............................................................................................... 1-2

CRM INTRODUCTION ................................................................................................. 1-3

HUMAN FACTOR CAUSES OF ACCIDE NTS ............................................................. 1-4

CRM CORE CO NCEPTS ............................................................................................. 1-7KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-01-SG 1-2 01 JUL 13 

## CRM PROGRAM GOALS AND DEFINITIONS

The CRM program goals are:

● Maximize operational effe ctiveness and combat capability.

● Preserve Air Force personnel and material resources.

● Ensure the safety of non-combatant civilians

● Facilitate mishap reduction by providing skills, processes, tools and techniques to aircrew members to effect ively identify threats and mitigate errors in aviation operations.

CRM training will be designed and managed to accomplish the following objectives:

● Develop aircrew skills in recognizing and responding to the conditions

and/or threats that l ead to aircrew error.

● Develop aircrew proficiency in CRM skills to anticipate conditions and/or threats and minimize their impact in or der to safely and effectively meet mission requirements.



## DEFINITION

Cockpit/Crew Resource Management (CRM)— The effective use of all available resources--people, weapon system s, facilities, and equipment, and environment -- by individuals or crews to safely and effi ciently accomplish an assigned mission or task.

The term "CRM" will be used to refer to the training program, objec tives, and key skills directed to this end. MAJCOMs may implement their programs as either "cockpit" or "crew" resource management based on their respective missions.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-01-SG 1-3 01 JUL 13 

## CRM INTRODUCTION

LESSON OBJECTIVES

● Identify Human Factor Accident Causes

● Review CRM Core Concepts

● Meet Air Force CRM Training Objectives

CRM INTRODUCTION

In this seminar, you will eval uate flight behavior and aircrew characteristics and assess the role of human factors in aircraft mishaps . Each mission poses unique challenges and problems for its crew. You will be given a "tool kit" of specific concepts and tools to take with you to the aircraft. In addition, th is seminar will provide you with a framework, which will contribute to good ai rcrew coordination, enhance mission effectiveness, and decrease the likelihood of mishaps.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-01-SG 1-4 01 JUL 13 SEMINAR FORMAT

Personal Involvement:

You will become personally involved in Crew Resource Management through three basic academic presentations:

● Seminar Participation

● Scenario Exercises

● Accident Study Analysis

Please take a few moments to write down your thoughts as to why you are attending this seminar.

________________________ _____________________ _________________________

________________________ _____________________ _________________________

________________________ _____________________ _________________________

________________________ _____________________ _________________________



### HUMAN FACTOR CAUSES OF ACCIDENTS

Let's first take a look at where we've come from and where we are now as it pertains to aviation safety, then we'll look at where CRM got its start.

ALPHA MISHAPS/100K HOURS

1922 286 1960 19

1930 163 1970 14

1940 72 1980 6

1950 54

MISHAP RATE % CREW ERROR

USN/USMC 2.20 55

USAF 1.63 55

USA 1.84 60

CORPORATE .45 65

COMMERICAL .19 80

CIVIL 3.35 80

Although stable since 2000, it is unrealistic to think that the mishap rate will continue to

decline unless action is taken to deal with t he human factor issues that are causing the majority of the accidents in aviation.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-01-SG 1-5 01 JUL 13 Most organizations, unfortunately, don't s pend enough time or training trying to solve the issues that are causing over 50% of their mishaps.



### Causes of Aircraft Accidents

50% TO 80%

AIRCREW ERROR

WEATHER
EQUIPMENT

MAINTENANCE

AIRPORT/ATC

OTHER

Typical Aircrew Errors

● Loss of Situational Awareness (22%)

● Violation of Policy and Regulations (19%)

● Poor Judgment or Decision Making (11%)

● Preoccupation with minor mechanical problems

● Inadequate leadership, failing to: — delegate tasks — assign meaningful responsibilities — set priorities

● Inadequate monitoring

● Failure to utilize available data

● Failure to communicate intent and plans

Examples:

Teamwork (lack of support and information sharing)

Lack of judgment skills Copilot failed to ensure pilot complied with checklist procedure. Crew failed to back up pilot during high workload period.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-01-SG 1-6 01 JUL 13 Under abnormal conditions, crew demonstrated difficulty in deviating from a set behavior pattern. Crew had no previous exposure to an emergency situation.

Performance decrement under

stressful conditions

Inappropriate reactions to emotional

stimuli

"Get Home-itis"

Management pressure

Lack of aircraft discipline Poor management of distraction inaircraft. Poor delegation and loadsharing under conditions of

information overload.

Failure to report unusual actions of a

crewmember that is a friend. Domestic problems affected performance aboard the aircraft. "The Wrong Stuff" - failing to convey urgency when an emergency exists.

Cutting corners in order to complete a

task.

Inappropriate deferral to higher authority in order to expedite departure.

Complacency leading to poor monitoring. Non-operational conversation resulting in poor monitoring and support.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-01-SG 1-7 01 JUL 13 CRM CORE CONCEPTS

Situational Awareness - Includes knowledge and skill objecti ves for identifying errors, preventing the loss of situational awarene ss, recognizing the loss of situational awareness, and techniques for recovering fr om the loss of situational awareness

Crew / Flight Coordination - Knowledge and skills required within (internal) and outside the crew/flight members (external) for missi on coordination, flight/mission integrity contracts, team-building, l eadership, command authority, res ponsibility, behavior styles, assertiveness, persistence, conflict resolu tion, hazardous attitudes, legitimate avenues/methods of dissent, and solution driven statements..

Communication – Includes knowledge of commo n errors, cultural influences, and barriers (i.e., rank, age, experience, positi on, etc.). Skills will encompass listening, feedback, precision and effi ciency of communication with all members and agencies (i.e., Crewmembers, Wingmen, Weat her, ATC, Intelligence, etc.).

Risk Management (RM)/Decision Making - Includes risk assessment, the risk management processes (Deliberate, Real Time RM)/tools, breakdowns in judgment and flight discipline, problem-s olving, evaluation of hazar ds, and control measures

Task Management - Includes establishing priori ties, overload, under-load, complacency, management of automation, av ailable resources, check list discipline, and standard operating procedures

Mission Analysis - Includes pre -mission analysis and planning , briefing, ongoing mission evaluation, and post mission debrief. Analysis instruction will include specific Threat and Error Management tools and techniques. D ebrief instruction will include aircrew responses and outcomes to threats and errors.KC-10 Aircrew Training System Crew Resource Management Initial Training

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## SITUATIONAL AWARENESS

OBJECTIVES ............................................................................................................... 2-2

INTRODUCT ION .......................................................................................................... 2-2

SITUATIONAL AWAR ENESS MODE L ........................................................................ 2-3

MAINTAINING GOOD SI TUATIONAL AWARENESS .................................................. 2-3

CAUSES OF LOSS OF SITUAT IONAL AWAREN ESS ................................................ 2-5

CAUSE/SYMPTOMS OF SITUATION AL AWARENESS LOSS ................................... 2-6

REGAINING SITUATIONAL AWARENES S ................................................................ 2-7KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-02-SG 2-2 01 JUL 13 

## SITUATIONAL AWARENESS

OBJECTIVES

● Define Situational Awareness.

● Describe the causes and symptoms of situational awareness loss.

● Identify elements of good sit uational awareness and how to regain it once lost.

INTRODUCTION

We have already learned that human error is the leading cause of aircraft mishaps. But no crew purposely crashes an aircraft! So what allows human error to creep into the picture? The loss of situational awareness (SA) is the most frequent answer. Too often, we read that the pilot became ta sk saturated and that loss of situational awareness led to the mishap. Therefore, it is important to recognize overload and a loss of SA. After this lesson, you should be able to evaluate your own habits and level of awareness, take control of your own performance as a contri buting crewmember, and significantly reduce the probability of a crew-error mishap.

Definition

Situational awareness is defined as:

● The accurate perception of the fact ors and conditions affecting the aircraft and the flight crew during a specific per iod of time. This includes knowing what has gone on in the past in relation to what is going on now; and how it may affect what mi ght happen in the future.

Levels

It's important to realize that:

● Each crewmember has a different level of SA based on the individual’s own perception of reality.

● The group level is limited to the individual level of the pilot in command. It

is not the sum total of the individua l crewmembers. Thus, the level of

situational awareness of t he pilot in command is most important. It is up to the crew to provide feedback during a ll aspects of the f light situation.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-02-SG 2-3 01 JUL 13 Situational Awareness Model

● Each person reacts to a situation in a predictabl e manner, if you measure the ability; pre-conceived beliefs; obj ectives; experience and training.

● These traits, the environment, al ong with workload and feedback, complete the package. These items will determine the individual’s level of

Situational Awareness.

● The first level of SA is Perception . This is the initia l level of SA, and prior to reaching it, no decisions or actions are possible.

● The second level of SA is Comprehension . The individual is aware of the

current situation and under stands the impact on the present situation. At this point, decisions may be made, and actions completed to re-establish normal operations.

● The third level of SA is Projection . The individual is aware of the present situation; understands the impact; and can predict the impact on future operations. This is the desired level of SA.

MAINTAINING GOOD SITUATIONAL AWARENESS

Critical Success Factors:

Attitude

Personal Health The detection of subtle changes in the operating environment

demands that all of our human sens ors be sharp. To detect and process information effectively, you must stay in top physical shape.

Crew Coordination The aircrew must be constantly m onitoring for challenges, sharing information, and working well together. If it is not, reduced SA is

inevitable.

Inquiry This means actively questioning, scrutinizing, investigating and using aggressive skepticism.

Assertiveness There must be a sense of obligati on to speak out if the operation can be improved or when a possible error has been detected.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-02-SG 2-4 01 JUL 13 Analysis

This refers to the continuous evaluat ion of all aspects of the present situation as compared to the fli ght concept. Analysis helps keep the plan up to date.

Skills

Physical and Mental Flying Skills If you have to think about actually flying the aircraft, you are using vast amounts of brain power that ca nnot at the same time scan the
environment for SA clues.

Spatial Orientation You must know where you are at al l times. You must also be able to detect even subtle changes in ai rcraft attitude or flight path.

Knowledge

Experience and Training
This is when our mental data files are built. We use these files to compare with a new situation, to determine its meani ng or required

action.

Remember the acronym ASK (Attitude, Skill, K nowledge). Use it to maintain aggressive skepticism. Demonstrate the willingness and ability to communicate any uneasy feeling. Ensure the Assert iveness of all crewmembers.

Preventing/Minimizing Loss of SA

Periodically using statement s like, "What do we have here?” "What's going on?” and "How are we doing?" have the effect of jogging the mind to peak awareness. Frequent and free flowing information exchange, solicited or voluntary, is the only answer to keeping situationally aware.

Enhancements to situational awareness include:

“I’M SAFE Checklist”

Illness? Do I have any symptoms?

Medication? Have I been taking pre scription or over the counter drugs?

Stress? Am I under excessive psychological pressures? Worried about financial matters, health problems, or family discord?KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-02-SG 2-5 01 JUL 13 Alcohol? Have I been drinking within twelve hours? Am I still experiencing the effects of alcohol or hangover?

Fatigue? Am I tired or not adequately rested?

Eating? Am I adequately nourished?

Exercising good Communication Skills to keep al l crewmembers situationally aware of the status of the flight.

Ensure an attitude of Teamwork pervades t he flight. As PIC/AC keep alert to responsiveness of the other crewmember(s). Know the abilities of others to handle tasking.

Don't allow yourself to get rushed into making decisions. Count to "three", or "wind the clock" before taking a critical step.



### CAUSES OF LOSS OF SITUATIONAL AWARENESS

Strength of an Idea

In the learning process, it is instinctive to relate the perceived environment to personal background (values, beliefs, training, and ex perience). When previous learning is threatened or challenged, one f eels compelled to defend it. This is why an erroneous

idea of a situation will be stubbornly adhered to even if co mpelling evidence is received that it is invalid, ineffective, or dow nright dangerous. To abandon a faulty theory requires time, effort, and coura ge. An individual or group under stre ss, confusion, or task overload will often revert to previously learned (reinforced) behavior (which is usually the easiest solution), no matter how inappropriate it may be at the time.

When a situation occurs out side of previously learned areas, performance is significantly slowed, leading to task overl oad. For example, a crew attempting to accomplish a mission they have not been trained on may lose SA due to task overload resulting in channelized a ttention (tunnel vision).

The Danger Zones

The vast majority of aircraft mishaps occu r during certain critical areas or conditions where, if any degree of SA is lost, the consequence can be fatal. These danger zones include the following crit ical phases of flight:KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-02-SG 2-6 01 JUL 13 ● Takeoff & Final Approach

● Air Refueling Operations

● Fun Flights

● Emergency Situations

Ensure that SA is peaked to maximum prio r to entering and while in a danger zone. Just as in the Accident Zone Model, if you are not fully prepared, consider not entering or getting out until you are.



### CAUSES/SYMPTOMS OF SITU ATIONAL AWARENESS LOSS

● Fixation

● Ambiguity

● Two independent sources disagree and remain unresolved.

● Complacency — The "I've done this a hundred times..." trap.

● Euphoria — feeling like ever ything is just perfect.

● Gut Feeling/Confusion — a subconscious warning.

● Distraction — becoming engrossed in a detail at the expense of others equally or more important.

● Overload/Underload — too busy to stay on top of it all, or just bored

● Poor communications — ideas not comi ng across, difficulty in expression or understanding.

● Failure to meet targets — ETA/ ATA discrepancies, unexpected fuel consumption, unexpected cruise performance, don't know why.

● Improper Procedures — the number one cause of accidents. Exceeding aircraft or personal safe operating limit s, departure from SCOP, violating minimums, etc.

● Unresolved discrepancies — fo rgotten about or ignored.

● No one flying the aircraft — ever yone involved with other tasks.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-02-SG 2-7 01 JUL 13 

### REGAINING SITUAT IONAL AWARENESS

Often one or more crewmembers are vaguely aw are that something is wrong but can't put their finger on what it is. It might ju st be an uneasy feeling, or the crewmember might be sitting there thinking, "TIME OUT." If you find yourself in this situation, immediately verbalize your concerns to other crewmembers. This has the effect of snapping the crew into the reality of a potential threat to their personal safety. Now that you have their attention, it's simply a matter of returning to the conscious monitoring activity as an active, dynamic phase of the AC Cycle.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-1 01 JUL 13 

## CREW / FLIGHT COORDINATION

OBJECTIVES ............................................................................................................... 3-2

INTRODUCT ION .......................................................................................................... 3-2

FLIGHT CREW CHARACT ERISTICS .......................................................................... 3-2

AUTHORITY POWE R BASES ..................................................................................... 3-4

LEADERSHIP ST YLES ................................................................................................ 3-5

CREWMEMBER ASSERTI VENESS ............................................................................ 3-6

CONFLICT RESO LUTION ........................................................................................... 3-7

HAZARDOUS ATTI TUDES .......................................................................................... 3-8

BEHAVIOR STYL ES .................................................................................................... 3-9

RECOGNIZABLE, STANDARD ASSER TIVE STATEM ENT ...................................... 3-13

OUR GOAL ................................................................................................................ 3-15KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-2 01 JUL 13 

## CREW /FLIGHT COORDINATION

OBJECTIVES

● Examine Command Authority

● Identify leadership and responsibility

● Describe assertiveness and conf lict resolution techniques

● Review hazardous attitudes and behavioral styles

● Discuss legitimate avenues of ex pressing concern and team-building

INTRODUCTION

This section covers command authority, leadersh ip/responsibility, asse rtiveness, conflict resolution, hazardous attitudes, behavior styles, legitimate avenues of dissent, and team-building.



### FLIGHT CREW CHARACTERISTICS

Flight crew members are typically self-moti vated, successful over-achievers. We are "controllers" doing a difficult task and doing it very well. A si gnificant majority of flight crewmembers possess certain learned traits, some actually help ensure a successful mission and some are traps wa iting to catch the unwary.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-3 01 JUL 13 Pilot in Command Authority/Traits

● Legal Authority

Definition - Legal power to di rect the actions of others

Source - AF Instructions, UCMJ, FA Rs, Tradition, assumes compliance with minimum requirements

● Pilot in Command Leadership Traits

Setting Priorities

Delegation

Motivation

Problem Solving

Conflict Resolution

● Guide for how to exercise authority

None

Many mishaps show poor pilot in command authoritativeness

CRM can enhance authoritative skillsKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-4 01 JUL 13 

### AUTHORITY POWER BASES

It is critical that an aircraft commander be as strong as possible in the following power bases. The Aircraft Commander must emphasize the positive sources of power, but not be afraid to exercise the negative, such as coercive power, if necessary. We should be careful not to base our trust of people in author ity solely on their referent or connection

power.

Legitimate Power Legitimate power is based on the posit ion held by the lea der. Normally, the higher the position, the higher the legitimate power tends to be. A leader high in legitimate power induces compliance or in fluences others because they feel that this person has the right, by virtue of pos ition in the organization, to expect that his suggestions will be followed.

Expert Power Expert power is based on the leader's po ssession of expertise, skill, and knowledge. These leaders ar e seen as possessing the expe rtise to facilitate the work behavior of others, leading to compliance with the leader's wishes.

Information Power This power is based on a leader's possession of, or access to, in formation that is perceived as valuable to others. Th is power base influences others because they need this information or want to be "in on things."

Referent Power A leader high in referent pow er is generally liked and admired by others because of her personality traits. This liking for, admiration for, and i dentification with the

leader allows her to influence others.

Coercive Power Coercive power is based on fear. A leade r high in coercive power is seen as inducing compliance because failure to comp ly will lead to punishment, such as undesirable work assignments, reprimands, or dismissal.

Reward Power Reward power is based on the leader's ab ility to provide rewards for others. People comply to gain positive incentives such as pay, promotion, or recognition.

Connection Power Connection power is based on the leader's "connection s" with influential people inside or outside an organization. This type of power induces compliance from others because it gains the favor or avoids the disfavor of powerful connections.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-5 01 JUL 13 LEADERSHIP STYLES

A person in a leadership role has to balance the personal needs of his crew against what is required to accomplish the assig ned task. Some leaders are more concerned about their people, while others focus more on tasks. A good leader does everything he can to accomplish the task while taking in to account the needs and desires of his people.

The following chart is used to show different management styles. It is best to be flexible and match the style of leadership to the r equirements of the task. Extremes along

either axis are seldom e ffective in the long run.

A 1/9 places emphasis on ensuring crewme mbers feel happy, content, and accepted,

even at the risk of not completing the task.

A 9/1 is concerned with completing the task and has little concern for the thoughts, feelings, or attitudes of others. He uses authority to control and expects obedience with no if's, and's, or but's. The task may be co mpleted, but his people will be discontented and ultimately efficiency will be reduced.

A 1/1 has a minimum response to both people and performance. He is only on the job to reach some private goal, maybe retirement. He is a coaster, who is visible and looks occupied without doing anything, and contributes as little as possible without getting into

trouble.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-6 01 JUL 13 A 5/5 adjusts to the tempo t hat others have come to adopt. He will not push for more even though the results obtai ned are less than wh at might have been accomplished by a different approach. When confli ct arises, he adjusts by splitting the difference in ways that include compromise, accommodation, and adjustment but falls short of truly meeting the needs of his crew or fully accomplishing the tasks.

A 9/9 strives to accomplish the task while reta ining maximum satisfaction in his people. He is a leader in the purest sense. He believes work is accomplished by committed people in pursuit of a common purpose based on a relationship of trust and respect. He

is involved.

CREWMEMBER ASSERTIVENESS

Crewmember assertiveness is critical for t he safe accomplishment of the mission. Yet

situations exist where a crew member may be hesitant to assert his opinion to the pilot

in command.

Stand up for what you think is right In a relationship to aggressiveness st udy, people rate some behavior assertive for men and aggressive for women.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-7 01 JUL 13 CONFLICT RESOLUTION

Any group, such as a flight crew, starts out by sharing information and coming to a mutual commitment resulting in stability and productivity. Sooner or later; however, someone on the crew will likely feel that the original co mmitment has been broken. Hopefully that person will feel comfortable enough with the pilot in command that he will openly communicate his discomfort in a process known as feedback.

If the pilot in command has not succeeded in establishing a comfortable atmosphere of open participation, the crewmember will hold his feelings in; however, will still communicate feelings nonverbally. When we sense that someone is upset about something, we call that a "pinch." It is im portant to "address the pinch" as soon as you

are aware of it. If this is not done, the pinch may grow into a disruption. At this point productivity will be lost while either attempting to renegotiate a new commitment, or in

termination of the mission. While it is still possible to resolve the problem at this point, it is much easier at the pinch stage.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-8 01 JUL 13 Hazardous Attitudes

There are six hazardous attitudes that can impede our good judgment and decisionmaking abilities and o ften lead to Sudden Loss of Judgm ent. These attitudes may be an inherent part of our persona lity, or may be a short-term factor due to a particular

situation. MEMORIZE THE ANTIDOTE for each hazardous a ttitude, so that it will come to mind when you need it.

Hazardous Attitude Antidote

● Anti-Authority "Follow the rules; they're usually right"

● Impulsivity "Not so fast! Think first"

● Invulnerability "It could happen to me"

● Macho "Taking chances is foolish"

● Resignation "I'm not helpl ess, I can make a difference"

● Get There-itis "It's better to get there late than not at all"KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-9 01 JUL 13 Behavioral Styles

DISC is a model of human beh avior that helps people und erstand “why they do what they do.”

All of us have developed behavior patterns – distinct ways of thinking, feeling, and acting. The central core of our patterns te nds to remain stable because it reflects our identities. However, the demands of the work environment often require different responses that evolve into a work behavioral style

Dominance

1. Key Characteristics:

• “I know what I want and go after it”

• Is motivated to get immediate results

• Tendency to make decisions quickly

• Often adventurous and daring

• Is actively competitive

• May openly question the way things are done

2. Personal Preferences:

• “I enjoy taking charge of situations”

• “I like to take on new challenges in areas of interest that are

a real test to me”

• Prefers opportunities for thei r own personal accomplishment

or advancement

• Likes varied and new activities

3. Personal Development Opportunities:

• Learning to pace yourself be tter and knowing when and how

to relax

• Awareness of the type and imm ediacy of needs that other people also must have satisfied in addition to your own

• Understanding that everyone needs other people at times, including people like yourself

• Accepting the importance of existing limits and ways of doing things, even if they disagree

Influencing

1. Key Characteristics:

• “I make new friends easily, even with strangers”

• Tendency to be warm, trusting of others

• Is open about their own feelings

• Motivated to impress others, be includedKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-10 01 JUL 13 • Enthusiastic, talkative, interacting

2. Personal Preferences:

• “I like to be recognized by others”

• “I really enjoy entertaining people”

• Likes the freedom to express self – including being free of entanglements, complications

• Prefers more favorable, casu al relationships and working

conditions

3. Personal Development Opportunities:

• Prefers more favorable, casu al relationships and working

conditions

• Prefers more favorable, casu al relationships and working

conditions

• Learning to develop more organi zed, systematic approaches to doing things – including following through with consistency in using these methods

• Awareness about others in ways t hat involve more realistic expectations and objective views of others

• Understanding how a nd when to be more firm and direct in dealing with less favorable situations

• Accepting the importance of completing work tasks/agreements with people according to priority

commitments and deadlines for them

Steady

1. Key Characteristics:

• “I’m most comfortable when I know what others expect of me, including how to do these things”

• Tends to be more low-keyed and easy going

• Finds it easy to get along well and work with different types of people

• Motivated to concentrate of tasks, enjoys repeatedly doing similar kinds of things

• Is more comfortable as a lis tener and participator in a group rather than a talker, or director

2. Personal Preferences:

• “I prefer it when things go smoothly and especially when there is not a lot of change”

• “I like the satisfaction I get fr om working together with others on projects, by being part of a collective effort to achieve specific results”KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-11 01 JUL 13 • Prefers known procedures and the stability gained from a defined, proven way of doing things

• Likes sincere appreciation fr om others who are important, including more subtle or quiet recognition

3. Personal Development Opportunities:

• “I enjoy taking charge of situations”

• Learning how to better handle th e reality of unexpected and ongoing change

• Awareness about when to appropria tely delegate to other people to achieve desired results

• Understanding how to be more assertive with people in taking charge of certain situations

• Accepting the opportunity to grow by learning to do new and different things, including a vari ety of ways other than your own standard approach

Conscientious

1. Key Characteristics:

• “I have a need to do things more correctly since I’m uncomfortable making mistakes”

• Is motivated to be thorough, accurate

• Tends to be attentive to c onditions around them, including clues about important expe ctations or standards

• Often demonstrates caution, curiosity

• May become critical of t he quality of work actually performed, their own or others

2. Personal Preferences:

• “I prefer to be more careful, quiet and observant when I am around other people”

• “I like situations where I have the freedom to concentrate on perfecting ideas and work on things that are important to me – without interruption”

• Prefers assurances that identified and agreed-upon standards or objectives will not be changed, sacrificed

• Likes personal responsiveness and support for their efforts, especially those involving desired resources to achieve their

own standardsKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-12 01 JUL 13 3. Personal Development Opportunities:

• Learning to develop a greater tolerance for conflict and human imperfection, includin g realistic approaches to productively preventing and minimizing both

• Awareness of the import ance of more directly communicating and discussing y our views with others about

matters of benefit to either or both

• Understanding of the different types of talents and interest levels of individuals, which can be helpful in achieving desired objectives

• Accepting with a greater s ense of true self-esteem the importance of who you are as a worthwhile person in your own right, rather than only for what you doKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-13 01 JUL 13 Recognizable, Standard Assertive Statement

AMC uses " Time Out" as an assertive statement.

A standard assertive statement provides a non-threatening verbal method for crewmembers to directly communicate conc erns about an uncomfortable situation. It provides a clear warning of a deviation or loss of situational awareness.

Purpose - It notifies all crewmembers that someone sees the aircraft or crew departing from established guidelines, the br iefed mission scenario, or is simply uncomfortable with developing conditions.

Repercussion - There should be no fear of harassment or other repercussions

when "Time Out" is used.

When to Use - Use is not mandatory but is highly encouraged to standardize operations.

Benefit - Provides an opportunity to br eak the error chain before a mishap or

incident can occur.

Command Authority - Each crewmember is responsible to the Aircraft

Commander to be assertive. This is not designed to usurp command authority.

Assertiveness With Respect

Assertiveness with respect can be seen as a three-pronged approach to problem solving.

Inquiry - Respectively asking about ac tions and requesting clarification as required.

Advocacy - Stating what you be lieve to be the proper c ourse of action under the

circumstances.

Assertion - Advocating for the perceived proper course of action or maintaining a

course of action until convinced ot herwise by additional information.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-14 01 JUL 13 "Time Out"

Is not a panacea. It is not intended to be a cure-all for non-assertive behavior or poor leadership.

When properly used, it can allow crew members to gain everyone's attention concerning uncomfortable situations.

It is not a buzzword and it s use must not be abused.

Must be endorsed at all levels of command and rein forced during the course of everyday flight operations.

Provides all crewmembers with a means to speak up when they are concerned about a particular m aneuver or phase of flight.

Guidelines for Use

In order for an assertive statement to work , effective and strict guidelines must be

established and followed. With this in mi nd, as soon as possible after a crewmember voices the term "Time Out", the airc rew will take the following actions:

TIME AND SAFETY PERMITTING, Stabilize the aircraft.

The initiating crewmember will voice his or her concerns to the crew.

The aircraft commander will provide all ot her crewmembers with the opportunity to voice inputs relative to the stated c oncerns, the aircraft's position, potential hazards, and/or the upcoming maneuver or situation.

After considering all inputs, the aircra ft commander will direct the aircrew to

continue the current course of action or direct a new course of action.

THE AIRCRAFT COMMANDE R STILL RETAINS TH E FINAL DECISION

AUTHORITY.

Assertiveness with Respect The crewmembers should respect and s upport the authority of the pilot in command while clearly asserting thei r suggestions or communicating any problems they are aware of.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-03-SG 3-15 01 JUL 13 OUR GOAL

Authoritativeness with Participation The pilot in command should establish clear leadership and command authority, while adjusting the use of that authority to the situation. At the same time he should create an atmosphere where crew par ticipation can flourish, making it clear that she expects to hear about any ideas, suggestions, or problems anyone on the crew might have.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-1 01 OCT 10 

## COMMUNICATION

OBJECTIVES ............................................................................................................... 4-2

INTRODUCT ION .......................................................................................................... 4-2

THE PROBLE M ........................................................................................................... 4-3

TYPES OF COMMUNI CATIONS ................................................................................. 4-4

COMMUNICATION PROCESS .................................................................................... 4-5

COMMUNICATION RESPO NSIBILITI ES .................................................................... 4-8

EFFECTIVE COMMUNI CATION ................................................................................ 4-9KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-2 01 OCT 10 

## AIRCREW COMMUNICATIONS

OBJECTIVES

● Recognize impact of effect ive and ineffective aircrew

communications.

● Develop methods to achieve effective communications

INTRODUCTION

The ability to communicate effectively is a valuable skill that most people take for granted. In fact, poor communica tion skills have caused many aircraft accidents. You will rarely find communications directly cited as a cause factor of an accident, but if you

examine the elements of the mi shap you will usually find some failure of the crew to effectively communicate. Similarly, most of our interpersonal relationships also suffer from poor communications skills.

Individuals who are able to communicate are highly s ought after and can be very powerful and influential. Hist ory has shown that some of our greatest leaders were in fact outstanding communicators. How well we communicate with others will invariably determine the quality of a relationship.

The pilot in command needs to exercise authority and deleg ate tasks without ambiguity while remaining alert to the workloads of ot her crewmembers. How effectively this is done will to a great extent determine crew performance and crew error rate.

THE GREATEST ENEMY OF EFFECTIVE

COMMUNICATION IS THE ILLUSION OF IT!KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-3 01 OCT 10 

### THE PROBLEM

Think back over some recent flights and chances are that you will find that many of your tensions, anxieties, and frustrations arose fr om situations in wh ich you didn't understand what someone said - or they did not understand what you really meant.

Perhaps:

● You were given a new frequency by a controller, switched to that frequency, found out that you had not co pied it correctly and had to go back to the original contro ller to get the proper frequency.

● You got into a disagreement with another member of the crew - an argument that would not have occurred if you had realized that you both were really in agreement.

● You spent time performing an assi gned task only to learn that you

had misunderstood the instructi ons and had not achieved the

desired results.

Most of us take our ability to communicate with each other for granted. We feel that it is a rather simple, natural process, and "once we learn the language" we should be able to understand each other pretty well. In fact, mo st people feel that t hey are pretty good communicators; it's just that everyone el se seems to do a lousy job listening.

When the communication process breaks dow n between people, it may result in interpersonal problems; when it breaks dow n in the aircraft, it may be fatal.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-4 01 OCT 10 TYPES OF COMMUNICATIONS

Communication can generally be broken into th ree different levels of effectiveness:

Poor Communication

This category includes communications where the message is not even received, as indicated by the resulting confusion.

Good Communication

Communication is good if the receiver correctly understands the message, but does not respond with t he desired action.

Effective Communication

Communication is effective only if the s ender achieves the intended purpose; i.e., the receiver not only understands, but res ponds as desired. This may seem to be relatively simple but in actual practi ce communicating effectively can be very

difficult. There are tw o reasons for this.

The ability to convey appropr iately our thoughts and f eelings and in turn to receive and properly interpret the t houghts and feelings of others are learned skills and must be continually practiced and refined.

Effective communications is a shared responsibility. Each person must

have some awareness of and appreciation for others, and why they feel and behave the way they do.

Without either of these factors ef fective communications will not exist.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-5 01 OCT 10 

### COMMUNICATION PROCESS

It is worthwhile to examine the proc ess by which we communicate. A good understanding of this process allows us to co mmunicate more effectively, and to more readily isolate the cause when co mmunication problems occur.

The process of communication is commonly defined as "a person (sender) transmitting information (a message) to another person (receiv er)." To determine if it is accurate, a feedback loop must be added. It is even mo re difficult to determine if the communication has been effective in achieving the desired result.

At each stage the communication proces s can breakdown. Thus each one-way communication has a total of six possibilities for error followed by the same six pitfalls during the return comm unication or feedback. It really is amazing, considering the possibilities for errors that we manage to co mmunicate at all! We will now examine some of these points of vulnerability and see what we can do to ensure the message gets through.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-6 01 OCT 10 Verbal/Non-Verbal Cues

It is surprising to most people how other s get our messages. The spoken word transmits only 7% of the message. 38% is transmitted by the tone of voice that we use. Fully 55% of our message is transmitted through non-verbal cues; i.e. body language. So you can see, that while operating in the confines of the cockpit, over half of our messa ge may be lost due to loss of this last cue. Thus

the tone of voice often transmi ts what we "really" mean.

Encoding/Decoding

Our personality (attitudes) strongly affect the encoding or decoding of the "message." In effect, everything we hear is passed through f ilters based on our past experience to determine the meaning . If the sender and receiver share a similar life experience or background they are likely to encode and decode in a similar manner. If they don't, confusion a nd frustration often result. If either person is prejudiced or biased the chanc e for effective communication is nil.

Barriers

A barrier is anything that distorts, confus es, or interferes with the communication process. Common barriers to comm unication in the aircraft are:

• Physical/Mental — noise, static — multiple simultaneous communications — fatigue/stress

— distractions

• Wording — incomplete message — ambiguous wording — technical terminology or jargon — non-standard phraseology — complexity — not enough information provided

• Interpersonal — boring — lack of credibility — cannot establish rapport — thinking in personal terms — not thinking in observable performance termsKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-7 01 OCT 10 Guidelines for Providing Feedback

Feedback is the only way t he sender can find out if his message was accurately received, and even this does not ensure the listener complete ly or correctly understands it. The following guidelines will he lp ensure effective use of feedback:

● Deal with the statement or behavior itself, not the person.

● Focus on ideas and information ra ther than on giving advice.

● Explore alternatives instead of offering answers or solutions.

● Focus on what was sa id rather than why.

● Include only information the recipient can use as opposed to everything you know on the subject.

Hidden Agenda

One way to ensure poor communications is to intentionally withhold information about intentions or plans. This is called a hidden agenda because the person involved is giving advice and/or maki ng decisions based on information or

reasons that is not communicated to the re st of the crew. It is typically done to prevent objections and conf rontations with other mem bers of the crew, perhaps following a decision to deviate from polic y or regulations. It may also be the result of a desire to get to the destination for personal reasons. In any case, it is a very serious situation that is difficult for anyone except the person involved to

detect.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-8 01 OCT 10 

### COMMUNICATION RESPONSIBILITIES

Up to this point we have looked at the process of communication and have stressed the importance of "effective communi cation." Now let's look at some things the sender and receiver can do to improve their effectiveness.

Sender's Responsibilities

Be Clear and Concise — Clarify what idea it is t hat you want to get across. — Clarify the purpose of the statement. — Try to eliminate emotional overtones.

Consider The Environment — Remove any rank or interpersonal barriers. — Establish your credibility.

Address The Receiver's Needs — Find a good time for the discussion. — Avoid overloading the listener with too much information.

— Remember that the s ender needs to listen also.

Encourage Feedback

Receiver's Responsibilities

Practice Active Listening, whic h entails the following steps:

Hearing — Stop talking and listen.

— Remove distractions. — Put the speaker at ease and show you want to listen.

Interpreting — Listen with understanding. — Listen and respond to feelings.

— Note verbal and nonverbal cues.

Evaluating — Suspend prem ature judgement. — Ask questions.

Responding

— Give feedback/confirma tion of what you heard. — Avoid argument and criticism.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-04-SG 4-9 01 OCT 10 

### EFFECTIVE COMMUNICATION

The following types of communications occur in the flight environment:

Commands - "Put the landing gear down now."

Observations - "All engine and power indications are normal." Suggestions - "We might have better luck on this frequency." Inquiries - "What is our present fuel state?"

Answers with Information - "The visibility is two miles."

Statements of Intent - "We'll land now due to the electrical emergency" Agreements - "Concur." Disagreements - "We can't accept that clearance."

Checklists - "Radios, radar altimeter, and auto pilot - Off." Acknowledgments - "Roger."

Air Traffic Control - "Cleared for NDB 26 approach, report commencing." Repeats - "Say again missed approach procedures." Response Uncertainty - "I don't know."

Tension Release - "Oh shucks!!" (Or words to that effect) Frustration/Anger - "What the heck is going on now."

Embarrassment - "Oops" Contingency - "If that happens let's talk about diverting."

Non-Task - "How was your golf game last weekend?"

Studies have shown that ineffective cr ews communicated less, but had a greater incidence of response uncerta inty, frustration or anger, and embarrassment; along with a lower incidence of agreement s. On the other hand, w hen more information was transferred about various aspects of the fl ight, fewer errors appeared. Crews who planned more and openly discuss ed problems and flight conditions were shown to be more successful in mission accomplishment. In crews where commands, inquiries, and observations were frequently seen, aircraft system erro rs were less apparent.

Commands are associated with a lower in cidence of flying errors and seem to assure the proper delegati on of cockpit duties.

Acknowledgments validate t hat a certain piece of in formation has in fact been

transferred and also serve as reinforcem ent to the input of the other crew

member.

Contingency promotes “next phase of flight” thinking and significantly reduces

channelized attention.

Thus the characteristics of an effectiv e flight crew are fr equent, direct, open, and concise communications. The key to achieving this is to establish an atmosphere open to suggestions and counter proposals, and to be sure to communi cate all ideas and actions, no matter how insignificant they may seem.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-1 01 JUL 13 

## RISK MANAGEMENT (RM)/DECISION MAKING

OBJECTIVES ............................................................................................................... 5-2

INTRODUCTION ......................................................................................................... 5-2

RISK DETECTION AND EV ALUATION ...................................................................... 5-4

DECISION-MAKING STYLES ...................................................................................... 5-5

STRUCTURED DECISION MAKING .......................................................................... 5-7

POOR JUDGMENT CHAIN .......................................................................................... 5-9KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-2 01 JUL 13 

## RISK MANAGEMENT/DECISION MAKING

OBJECTIVES

● Define risk management

● Describe the AESOP Model

● Describe decision making and the structured decision-making process



### INTRODUCTION

In this section we will talk about risk m anagement and the different decision making styles and the situations they are best matc hed with. We will then provide a model for structured decision making which helps the p ilot in command and crew fight some of the common tendencies we all exhibit, es pecially in high stress situations.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-3 01 JUL 13 Risk Management is an assessment of the lik elihood for an acceptable outcome to a given decision or judgment. Judgm ent and decision making must involve risk assessment. Risk management should be ongo ing; it starts in the brief, and continues through the flight. If we aren' t properly assessing risks then we can't and won't make good judgm ents and decisions.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-4 01 JUL 13 

### RISK DETECTION AND EVALUATION

During the decision-making process, a crew will often focus on one problem and not consider its potential effect on all elements of the mission. T hey may also be so focused on one problem that they miss or i gnore other problems. To assure that the total impact of all problems is assessed, use of the AESOP Model is recommended.

AESOP MODEL

Assume in your evaluation of the five ri sk elements that each is now a "go/no go" decision. Assign each risk element to one of your fingers as shown:



### DEAL YOURSELF A GOOD HAND!

Start with a closed fist and raise one finger for each area that is a "go" consideri ng its impact on this particular flight at this particular time. The more fingers not ex tended, the more you should consider not going, or removing one or more risk elements; e.g., wait fo r better weather or decide on a different route of flight.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-5 01 JUL 13 

### DECISION-MAKING

Judgment and decision making are difficult to put into concrete terms. However, start by answering the following questions:

What is your definition of judgment? Do you believe th at it can be taught and if so why?

What is your definition of decision making and what determines the value of a

decision?

Definitions

Judgment is the total mental process used to arrive at a decision. It is normally based on our previous experiences. We can enhance our own judgment by studying the errors committed by others, which led to a mishap. This is why mishap case studies play such an impo rtant role in Airc rew Coordination Training.

Decision Making is the act of rendering a soluti on to a problem by use of one's judgment. Often the value of a decision cannot be determined until the outcome

is known.



### DECISION-MAKING STYLES

There are two sets of decision-making styles — analytical vs. intuitive and choicing vs. expanding. Although we use different decision-making styles depending on the situation, everyone has a pred ominant style they tend to use more than the other. Neither style is better than the ot her, but it is critical that the proper style is matched to

the situation. For this r eason, the pilot in command shoul d be aware of his own and his crewmembers' styles and should ensure in any situation t hat the appropriate style is being used, particularly in relati on to the time available.

Analytical

Analytical thinking is most useful for dealing with structured problems that can be systematically approached. It is thor ough because more information can be taken into account. But the process is time consuming and can be costly due to the resources and people required.

Intuitive

Intuition is most useful for dealing with uns tructured problems. It is quick, making quantum leaps of insight vs. detailed analysis. This allows for unstructured trouble-shooting and creative problem resoluti on. But this intuitive process runs the risk of ignoring previous decisions and may fail to consider all the facts.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-6 01 JUL 13 Choicing

Choicing styles are normally associated with results-orient ed personalities who are practical, tend to choose quickly, su mmarize alternatives and narrow things down with a sense of immediacy. This can be illustrated by a funnel. The choicing style is appropriate and valuable during situations when little time is available to analyze the situation. Howe ver, when time is available these people will tend to decide quickly wit hout considering other alternatives. Once their mind is made up it is very hard to get them to consider other possibilities.

Expanding

Expanding personality styles like to explor e alternatives and look for long term effects. They must be given time, and te nd to slowly shrink available options. This can be illustrated by an upside down f unnel. The expanding style is appropriate and valuable during situations when there is sufficient time to consider alternatives. However, when ti me is short these peo ple will often have a hard time making a decision, and even after the decision has been made they will want to reopen the discussion to cons ider other ideas they have come up

with.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-7 01 JUL 13 

### STRUCTURED DECISION MAKING

The Decision-Making process integrates many of the basic elements of ACT. In arriving at a decision it is important to pull together all the resource s available to the aircrew to achieve "synergy," in which the whole team's effort is greater than the sum of the individual efforts. Synergy is easier to achieve in an en vironment of good communication and good leadership. Normally there is enough time to make a good decision, but there may not be enough time to recover from a bad decision.

Decision-Making Process

The decision-making process can be sym bolized in a model. This model is called the synergy formula, or QPIDR Mode l. If decision-making is based on this model, a synergistic effect will be achi eved because it encourages crewmembers

to make decisions that are a result of a coordinated group effort instead of only one person working from less than complete information.



### (Q)+(PI)+(D)+(R)=SYNERGY

SYNERGY FORMULA

Q - Question

"Q" stands for questioning, seeking and sear ching for information, data, and ideas. While the task is not solely the res ponsibility of the pilo t in command, it is a task that tends to fall primarily on hi s shoulders. However, each crewmember shares the responsibility for making sure that each step of th e formula is used, and for speaking out assertively if he has information he feels would enhance the judgment of the pilot in command.

Questioning is the initial stage of resear ch where information is gathered. All pieces of the puzzle are put on the table in order to diagnose the challenge situation. The principle of questioning r equires that we question, "What is going

on?" and "What are other crew member s doing?" Encourage open discussion, avoid preoccupation with minor details (tunnel vision) and remember to use all available resources. Above all, make su re someone is responsible for flying the aircraft during this process!KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-8 01 JUL 13 PI - Promote Ideas

Some of the ideas or plans presented by various member s of the crew during the questioning process may be in conflict. Op en discussion of such conflict not only leads to a synergistic decis ion, but it gets the whole crew behind the resulting plan.

The pilot in command is responsible for resolving any disagreement between two or more points of view. At the same time, he should test proposed courses of

action to see which offers the best results. Each crewmember is responsible for assertively promoting their own ideas wh ile remaining flexible and open to the

ideas of others. All info rmation and beliefs should be challenged in an attempt to discover any wrong information. Be aware that a lack of conflicting opinions may indicate a fear of speaking up.

D - Decide

Decisions are made by the Pilo t In Command. In virtually all circumstances, it is the duty of the crew to pres erve the authority of command. A flight crew is not a democratic organization, nor shou ld it be. It is a surviv able entity only so long as all decision-making is funneled through the pilot in command.

On the other hand, if the pi lot in command does not comm unicate the plan or if the crew is not committed to it, the im plementation could be in effective. Brief tasks and priorities, keeping task overload/underload in mind.

R - Review

Once the decision has been announced, the pilot in command should seek feedback from everyone involved. If an optimum solution has not been achieved the loop can be closed by reinitiating the Synergy Formula. Repeat this process as many times as necessary.

It is also important to assess the impact of this decision on the overall mission.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-9 01 JUL 13 

### POOR JUDGMENT CHAIN (Error Chain)

Accidents don't just happen; they generally involv e a chain of pilot-aircraft-environment causes, and occur after a series of errors in judgment, called the poor judgment chain.

Decisions are based on information the crewmem ber has about the si tuational variables (aircraft, environment, operat ions, and personnel). Sometimes this information, which may be wrong, is so strongly adhered to that even the correct information can't influence

the outcome. This is what we call the Strength of an Idea. Each poor judgment increases the availability of false in formation, which may then negatively influence judgments that follow. As the poor judgment chain gr ows, the crew's situational awareness becomes impaired an d the alternatives for safe flight decrease.

For example, an inaccurate assessment of deteriorating weather increases the

likelihood that the false information will ne gatively influence other decisions that

follow.

If a pilot elects to fly into hazardous w eather, the alternative to circumnavigate the weather is automatically lost.

Break The Chain

There are four steps we can use to break the poor judgm ent chain.

CHECK FOR STRESS

A high degree of stress and anxiety can reduce our ability to exercise good judgment. If you or other crewmembers are experiencing high levels of stress, this is an indication that you must be especially wary of poor judgments.

RECOGNIZE POOR JUDGEMENT: GET FEEDBACK

Recognize that a poor decision may have been made and admit the error. If recognition does not occur, your ability to prevent further poor judgment is

reduced.

Consistent application of QPIDR is th e best way to get feedback and identify poor judgments. Asking a crewmember for feedback may be difficult because you may be hesitant to admit an error in judgment. Yet relevant feedback is necessary in order to break the poor judgment chain as quickly as possible. If you see an error that no one will ackno wledge, use the A ssertive Statement,

"TIME OUT."KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-05-SG 5-10 01 JUL 13 SEARCH FOR OTHER POOR DECISIONS

Remember poor decisions tend to occur in chains. If one poor decision is recognized, be absolutely certain that it is the only one currently affecting the operation of the aircraft. Use the AC Cycle and follow AESOP to regain situational awareness, ident ify all hazardous situations resulting from the poor judgment, and take corrective actions.

REVIEW ORIGINAL POOR JUDGMENT

After a poor judgment chain has been br oken, review each poor judgment as soon as possible after landi ng. Critically examine wh at they were and how you came to make them. This review prov ides feedback you need to avoid initiating a similar poor judgment chai n in the future. Acknowle dging honestly as a crew

that a certain decision was st upid will also make it eas ier to be assertive about errors or poor judgment on future flights.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-1 01 OCT 10 

## TASK MANAGEMENT

OBJECTIVES ............................................................................................................... 6-2

INTRODUCT ION .......................................................................................................... 6-2

HIGH WORKLO AD ...................................................................................................... 6-3

LOW WORKLO AD ....................................................................................................... 6-6

DISTRACTION S .......................................................................................................... 6-7

STRESS ....................................................................................................................... 6-9

INTERNAL RESO URCES .......................................................................................... 6-13

EXTERNAL RESOUR CES ......................................................................................... 6-14KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-2 01 OCT 10 

## TASK MANAGEMENT

OBJECTIVES

● Discuss performance problems caused by:

— Overload and underload

— Distractions

— Stress

● Develop methods to respond

● Identify internal and external resources.

● Describe how to put these resource to best use.

INTRODUCTION

In this section we will discuss performance and how it's affected by time and pressure. You will learn how perf ormance problems can be caused by t oo little work as well as by

too much work. We will discuss distractions and how to maintain your focus; and stress management. Additionally, many aircraft accidents occur because the crew doesn't use all available resources; you'll review t hese resources and discuss how to incorporate them into the aircrew coordination cycle.

Workload varies according to the phase of a missi on, from the routine of an airways flight to the high workload of a lo w visibility final approach. Ei ther extreme can be dangerous. Our primary concern is t he detection of and response to changes in workload performance. Workload becomes subjective very quickly. The challenge-response operating environment is complex and makes it im possible to define in a simple workload performance formula. Unlike an assembly line worker who has X number of widgets to produce per hour - something definable and meas urable - the crew of an aircraft deals in a three-dimensional dynamic envir onment with ever changing challenges:

● When should a task be accomplished?

● Who should do the task?

● How much attention does the task deserve?KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-3 01 OCT 10 Accident Rate/Phase of Flight

Aircraft that spend most of the time at cruise altitude have most of their mishaps during the takeoff, approach, and landing phase of flight, even though only a small percentage of time is spent in these phases. Aircraft in volved in low level o perations have a much greater percentage of mishaps dur ing the low level portion of the flight, but still typically have a higher percentage of mis haps during the takeoff, approac h, and landing phases of flight than would be expec ted based on the time s pent there. In either case, the mishaps usually occur during times of very high workload.



### HIGH WORKLOAD

The first effect of high workload is that we begin to work fast er. We try to cram more work

into a shorter time frame. Sometimes we split the duties because we can accomplish more separately. High workload leads to a breakdown of the planned flight concept as our overall view begins to narrow and become shorter.

As the pace quickens our attention becomes tunneled, a lot of "inputs" are not picked up and the likelihood of a crew-p reventable error is increased! Planning becomes condensed and decisions are made on possibly incomplete information. We also tend to revert to previous habit patterns (strongly re inforced learned behavior). This may or may not be helpful.

Classifications of Workload

Critical

A critical workload item is one that requires t he immediate attention of the crew. If left unattended, it could have catastrophic results.

Important

An important workload item is one that requires a res ponse of action as soon as possible. If left unattended it coul d become a critical workload item.

Routine

A routine workload item is one that is encountered in the c ourse of the flight and is handled as part of normal crew responsibility. If left unattended it could become an important workload item.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-4 01 OCT 10 Stress Versus Time

Accident Zone ModelKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-5 01 OCT 10 Protecting Against High Workload

Strength in the Critical Success Factors and Elements

● Intimate knowledge of the business

● Professional attitude

● Skills to manipulate airc raft without excessive attention

Recognizing High Workload

● Difficulty adhering to normal performance standards

● Errors - erratic performance

● Getting away from good "fundamentals" of aircraft control

● Uncertainty - indecision - discomfort

● Losing normal scan - tunnel vision - fixation

● Temporal distortion

● Hesitant, confused speech

Managing High Workload

● Delegate

● Prioritize

● Expand Time Available

Effective Monitoring

We will never be able to eliminate human error. On every flight each crewmember will make, or start to make, wrong decisions or actions. It is only through careful monitoring of ourselves and others that we can catch these errors before they cause a serious problem.

● Single Monitoring - During a low workload situation it is usually sufficient to have only one person monitoring the critical flight parameters.

● Double Monitoring - As the workload in creases, so does the likelihood of error. For this reason, two people should be monitoring critical flight parameters during high workl oad situations, if possible.

The monitoring responsibility must be clear ly stated, with specific limits and guidelines. The monitoring crewmember sh ould make call-outs specified by these limits, along with normal call- outs required by the SCOP.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-6 01 OCT 10 LOW WORKLOAD

Under activity due to the lack of stimulation is also a real danger. Nobody is asleep on takeoff, but how about during cruise, when we tend to become complacent? Some of the same symptoms described for overload appear during low workload, along with inattention or drowsiness. It is not practica l to maintain peak alertness by everyone all the time, but it may be necessary to regain a mi nimum level of attention during non-peak phases when these symptoms appear . Possibilities for raising the crew's alertness level include talking about the next phase of the mission, checki ng the weather, or reviewing emergency procedures.

OPTIMUM WORKLOAD

Each individual has different optimum workload levels, which vary depending on the task. An individual desiring optimum performance must be able to match his workload level to the task at hand. In general, simple tasks ar e performed better under higher levels of workload, while complex tasks are performed bette r under lower workload. Thus there is a range of moderate workload which will produce optimum performance in any given situation, but which will vary from individual to individual.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-7 01 OCT 10 

### DISTRACTIONS

The distractions we experience come from tw o sources. Distractions having to do with the mission are referred to as operational while those from out side the mission are referred to as non-operational distractions.

One Step at a Time: At any particular mo ment, humans are able to attend to only a limited range of sensory data. It is po ssible to concentrate on one sensory pattern and then on another, but not both simu ltaneously. If it appears that we are doing two things at once, we are r eally switching rapidly between them.

Length of Attention: Remain ing focused on one stimulus increases its importance and strength. Even casual conversation may capture our attention and create an overload situation, causing us to miss mo re relevant cues that are available.

Large Number of Stimuli: When a lar ge number of stimuli are presented and a large number of responses are requi red, attention can be overloaded.

Fear and Anxiety: Fear and anxiety tend to narrow the range of attention and make us extremely sensitive to distractions. Thus it is during periods of high

workload and stress we are most susceptible to distractions.

Dealing with Distractions

The key to dealing with distractions is our abi lity to maintain a focus of attention. Typically the following options are available:

Ignore : During critical flight periods, consider ignoring distractions, which might interfere with aircraft control and hazard avoidance. Plan to reduce or

avoid distractions at critic al points in the mission.

Delay : Some distractions can wait. Eval uate their importance in conjunction with other priorities and act accordingly.

Delegate : When distractions interfere wit h the completion of your task consider delegating the work to other crewmembers.

Handle : Some distractions require immediat e attention. In this case, first

assure control of the aircraft and then han dle the distraction. It is important

to not become fixated on the distraction at the expense of aircraft control or

hazard avoidance.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-8 01 OCT 10 Sterile Cockpit

Distractions come in many forms and sometimes we become our own worst enemy. There have been mishaps where the cause was directly related to nonoperational conversation in the cockpit. Cockpit Voice Recorders have revealed

that the conversation center ed on everything but the task at hand, even during an approach with the weather at minimums. Some aviation organizations have used the sterile cockpit rule to deal with this i ssue. This rule says that there will be no non-operational conversation during certai n critical phases of flight. The commercial airline industry has generally defined this as any operations below 10,000 feet. If this is not applicable to your flight profile, it is important to establish your own sterile cockpit parameters.

Checklist Discipline

Limitations

The checklist is only valuable when used. And once the sequence is disrupted through distraction, it can't automatically put the user back on track. Furthermore, the checklist cannot take the place of unde rstanding your aircraft. As an aid and reminder of procedure, it's great, but don't ge t lulled into the false expectation that it will make up for any lack of dedication on your part.

Checklist Usage and Skills

Regard the checklist as a collection of meticulously planned steps, compiled through the extensive and sometimes fatal ex periences of others, to reduce the stress of totally recalling all procedures. Have you ever heard the old saying, "There's nothing more worthless than sky above you, airspeed lost, or runway behind you"? Add to that, "Checklists disregarded."

Beware of any break or distraction in t he sequence. Use your finger to keep track of the break and go back several steps to ma ke sure something isn't inadvertently left out. You might even want to verbaliz e, "Break in sequence" just to alert everyone and trigger a mental response to be on guard. In some units there is a requirement to start from the beginning wh enever there is a break/interruption in the sequence. Use the challenge-VERIFY-re sponse technique a nd never give the response until you have confirmed it physically or visually.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-9 01 OCT 10 

### STRESS

Definition

Stress is defined as any activity that requires us to cope. To the extent that stress becomes unmanageable, it becomes distress — resulting in such conditions as anxiety, oppression, or affliction. In this sense, stress equals the demands being made on us minus our coping skills.

Body Signals

Distress produces many symptoms or "body si gnals" in the organs of the body. These may include headaches, hear tburn, cramps, and/or fatigue. When stress becomes a problem, sleep is no longer res tful and our general me ntal and physical

condition is less than it should be. We have come to expect high performance from our fellow aircrew members and particula rly expect it from ourselves. This fact, coupled with the specific stresses that come "with the territory" in aviation, guarantee that we will always have to cope with stress.

Once we admit to ourselves that we are vu lnerable to stress, we can look at some suggestions for coping. Remember this quote from Horace: "Adversity has the effect of eliciting talent s which in prosperous circ umstances would have lain dormant." Thus learning to cope with stre ss and making a conscious effort to use stress in a positive way can help you achi eve a successful and productive aviation

career.

In today's society we have primarily psych ological rather than physical stressors. But we haven't had time to change our reacti on pattern from that of our ancestors. We instinctively respond to stressful sit uations in the same primitive fashion of Fight or Flight. Typical symptoms are:

● Heart increases the output of blood

● Blood vessels constrict

● Kidneys increase their activity

● Pituitary gland secretes ACTH (a stress hormone)

● Adrenaline flow increases

● Liver secretes cholesterol

● Brain is increasingly alertKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-10 01 OCT 10 Stressors:

ENVIRONMENTAL INTERPERSONAL

● COLD ● PERSONALITY CONFLICT

● NOISE ● MISTRUST

● LIGHTING ● LACK OF SUPPORT

● DANGER ● POOR COMMUNICATION

● LIVING CONDITIONS ● AVOIDANCE

PERSONAL PRIVATE LIFE

● TYPE A BEHAVIOR ● FAMILY PROBLEMS

● DRIVER INSTINCTS ● FINANCIAL CONCERNS

● INTRAPERSONAL CONFLICT ● HEALTH CARE

● HEREDITARY TRAITS ● PRESSURE FROM FRIENDS

● TIME FOR PERSONAL INTERESTS

ORGANIZATIONAL

● ROLE CONFLICT

● JOB AMBIGUITY

● UNDERWORK/OVERWORK

● PEOPLE MANAGEMENT

● CHANGES

● TRAVEL

● ORGANIZATIONAL STRUCTURE

The Seven Signs of the At -Risk Aviator/Crewmember

Studies have shown that crew members with the following stre ssors are more likely to be involved in a mishap:

● Recently Engaged ● Marital Problems

● Immaturity/Instability ● Major Career Decision

● Relationship Difficulties ● Trouble With Superiors/Peers

Up to 18% of all mishaps involve an "At-Risk Av iator." Although situations vary, the most typical is a divorce characterized by bitterness. The individual is observed to go through a series of changes in an attempt to cope wi th the massive assault to his/her ego. Intervention is usually successful.

● Smoking — Control

● Drinking — Anesthesia; License

● Trade Auto — Image

● Wreck within 6 months — Usually DUI

● Risk taking — Bravado

● Sexual Misconduct — Proving Self

● Use of Aircraft — DangerouslyKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-11 01 OCT 10 Managing Stress

Your daily stressor juggling act must be in balance before you can balance your mission juggling act. We probably don't like to admit it, but an overload in our daily life goes in the aircraft with us and will most likely degrade our performance. When you become aware that too much stress is leading to frustr ation, implement appropriate stress reduction techniques such as:

● Organize yourself. Take better co ntrol of the ways you're spending your time and energy.

● Change your environment. Contro l what and who is surrounding you to get rid of stressors and gain support for yourself.

● Build up your strength. If you're in good physical condition, you'll be better able to stand up against your stressors.

● Listen to your body. It will let you know when you're pushing too

hard. When the stomach sours or headaches, take time to slow

down.

● Learn to relax. Use relaxation techniques for 20 minutes each day. You'll be prepared for clearer thinking and decision-making.

● Find ways to laugh each day. Laughing is one of the purest and

most total releases of tensions.

● Develop a supportive network of caring people around you. Research indicates that if you do , you'll live longer and be healthier.

For further information on adaptation to stress, see the Appendix.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-12 01 OCT 10 Available Resources

DEFINITION

Available resources are the people, equipmen t, and information accessible by an aircrew, which when properly interrelated and utilized, contribute to a successful mission and a significant reduction of crew-preventable error during aircraft operations.

SYNERGY

Synergy is defined as the combined or c ooperative action of s eparate agencies, which together have greater total effe ct than the sum of their indi vidual effects (Webster's New World Dictionary). It is critical that all resources available be brought directly and dynamically into use. These resources assist in the problem solvin g effort. But, when a challenge of some sort arises, all too oft en we see the "effective team" break down and become "single seat" mind-set individuals trying to do it all themselves. Perhaps this is a carry-over from the old days (not that long ago!) when pilots were in fact forced to solve all problems themselves. Sort of the "Lone Eagle," Lucky Li ndy, night air mail carrier syndrome. Unlike pilots today , they had little or no resources available except the seat of their pants.

The crew working together as a team, combining their knowledge and ex perience with other available sources, will affect a more comp lete solution to any flight challenge. As always it is the pilot in command's responsibilit y to set the tone to insure that this synergy will take place in his or her aircraft.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-13 01 OCT 10 INTERNAL RESOURCES

● Pilot ● Boom Operator

● Copilot ● Crew Chief

● Flight Engineer ● Equipment Knowledge

Crew

If monitoring the flight operati on is one of our primary jobs, it is obvious that to do that job properly, guidelines mu st describe precisely how it is to be accomplished. Clearly identifiable, observable, and veri fiable limits must be in place. Each crewmember must have a complete pictur e of the flight concept in order to contribute effectively to the safety and effi ciency of that flight. That is why a thorough briefing is so important. It's the Pilot in command's job to integrate the creative ability and experience of the crew to affect a valid solution to any flight challenge. Crewmembers desire is to feel that they are part of the team — that they are accomplishing something rather than just being along for the ride.

Equipment Knowledge

● Aircraft Systems Knowledge

● Materials brought on board

Although most crewmembers a ccept the responsibility fo r the knowledge of these areas, many don't keep up with it as well as they could on a day-to-day basis. Our high level of systems k nowledge right after a checkride slips a little if we don't use it on a daily basis.

We must regularly go back to the basics of flight planning and performance of our aircraft. For example, we all have rules of thumb that we go by, but have we use

these crutches so often that we have forgotten their basis?KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-14 01 OCT 10 EXTERNAL RESOURCES

Outside resources are a part of your f light concept - and good communications are essential to put them to use.

Other Aircraft/Crew

Other aircraft and crews can be of valuab le assistance in relaying information, obtaining weather, PIREPs. They can also serve as a problem solver for you.

ATC

ATC can provide many forms of invaluable assistance, or they can assist you right down the tube (e.g., A-7, Indianapolis, IN). Have you visited an ATC center to clarify just what they can do to help you? It just might pay to know what information they can provide and how long it takes when your troubles mount up.

Are you also familiar with the tower, ground control, approach and departure control, or FSS services? Just what emergency services are available? What do they understand about your type aircraft?

Stan/Eval

These resources are available to you 24/7. They are a virtual TO library that can provide you with guidance because they represent the most experienced

crewmembers in the field. Use them!

Technical Representative/Maintenance Personnel

Professional ground maintenan ce personnel are a valuable information source for technical data. They can be useful in help ing to solve problems that are out of the

realm of the ATM or the aircraft handbook.

FSS/Scheduled Broadcasts

It would seem obvious, but some folks don' t bother to keep track of how to quickly find good VFR in case they really need it. Whenever you're IFR, try to visualize what's below you; know what the bottoms are and where the nearest good VFR

conditions are.

Time

Time can be on your side, especially w hen the crew is thinking far enough ahead - creating the resource. Spacing out tasks during a flight prevents dangerous overloading and puts TIME on your team.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-06-SG 6-15 01 OCT 10 In summary, be sure you know ex actly what is available to y ou, how to get it, and when to

use it!

KEEPING THE DECISION MAKER IN THE COCKPIT

A common occurrence that happens to many fliers is that they often defer to decisions made by individuals other than crewmembers. All too often, the "command element" or ATC, or some controlling agency attempts to help the flier by taking decision making out of his/her hands. There may be the belief that the flie r can then concentrate on the business of "just flying the aircraft, and not hav ing to worry about the correct decision to make." As fliers, you must remember th at other agencies may not have all of the information needed to make the safe, correct decision to allow you to recover in one piece. You must ensure that you retain the ul timate decision making authority with you in the cockpit. Other agencies ca n and do provide very valuable and timely information, but you must meld it into your scheme to arrive at your best judgment.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-07-SG 7-1 01 JUL 13 

## MISSION ANALYSIS

OBJECTIVES ............................................................................................................... 7-2

INTRODUCT ION .......................................................................................................... 7-2

PLANNING ................................................................................................................... 7- 3

MONITOR .................................................................................................................... 7- 4

CHALLENGE ............................................................................................................... 7-4

DETERMINE TIME AVAILABLE .................................................................................. 7-4

RESPONSE ................................................................................................................. 7-5

BRIEF ........................................................................................................................... 7-5

IN-FLIGHT PLA NNING ................................................................................................ 7-5

DEBRIEF ...................................................................................................................... 7-6KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-07-SG 7-2 01 JUL 13 

## MISSION ANALYSIS

OBJECTIVES

● Define flight concept.

● Describe procedures for response to unanticipated challenges.

● Define debrief goals.

● Define Threat and Error Management (TEM)



### INTRODUCTION

In this section, we will discuss how to use crew resource management skills to plan and brief our flight, deal with in-flight situations which were not anticip ated while planning the mission, and debrief our mission to get the most out of the experience.

Flight Concept

The goal of preflight planning is to develop a flight co ncept, which is shared by everyone on the crew. The flight concept should include all elements and factors of the flight, including the responsib ilities and duties of each crewmember.

Unless the crew has a shared flight concept, much of the advantage of thorough flight planning is lost.

Unanticipated Situations

We all know that we cannot react as well when we are taken totally by surprise. Yet some people seem to pride themse lves in not thoroughly planning the mission, and then reacting qu ickly and instinctively to the many unanticipated situations that occur during the flight. Wh ile it may seem impressive to be able to

react over and over at a moment's notice to everything that occu rs, in reality that person or crew is using short term planning which requires broad, thorough knowledge of the aircraft, mission and tactics, along with superior skills in operating the aircraft and its systems. Th ey are riding the cutting edge of their skills with no margin to allow for fa tigue, error, or multiple problems.

Long-term Planning

As opposed to the crew mentioned above, a crew, which starts the mission with thorough preflight pla nning, is using superior knowle dge to avoid having to use their superior skill. In atte mpting to anticipate everything that might occur on that flight, they are reducing uncertainty and allowing themselves a margin ofKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-07-SG 7-3 01 JUL 13 capability to compensate for less than optimum performance or multiple problems.

In-Flight Planning

Once airborne, we come into the realm of in-flight planning. Seldom does the original flight concept come out unsca thed due to challenges encountered during the mission. Once the original plan beg ins to break down, we must face new challenges and all the stress t hat goes with them. It is im portant to buy time so we don't give way to a hasty decision that may prove fatal.

If we have a framework for our response, we will be much more successful than if we just instantly react/respond. A goo d crew is trained to act quickly, but disciplined to react slowly.



### PLANNING

The greater the perceived trip urgency and the more challenging the trip's circumstances, the more important it is to fully develop and share the flight concept! This underscores the need to develop a formalized crew brief. If we hurry or eliminate the briefing or just say "standard briefing", we may have two or more totally separate flight concepts in operation at the same time. However, a good SCOP will minimize the time which is spent briefing standard re sponse items and will a llow the necessary emphasis to be placed on the critical point s of the particular mission being briefed.

Developing the Flight Concept

● Identify the operation

— Mission

— Weather — Crew Composition

— Aircraft Status

● Define observable limits

● Anticipate possible problems

● Discuss "What-if" alternatives

Sharing the Flight Concept

● Brief and share the flight concept

● Verify with the aircrew - get feedback!KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-07-SG 7-4 01 JUL 13 

### MONITOR

Monitoring is the responsibility of all crewme mbers. This is a normal phase of flight operations where the crew is monitoring the pre-briefed flight concept and watching for challenges to the flight concept. A challenge is anything that might not allow the flight to proceed according to the flight concept. Be sure to continually use the AESOP model to

avoid tunnel vision.

Monitoring Process

● Everyone is responsible for monitoring

● If no challenge adhere to the flight concept

● Continue to monitor



### CHALLENGE

Identification

Sometimes the challenge is obvious but ot her times we may fe el that something is just not right. We call this feeling a "p inch." Often the first step toward solving the problem is to verbally state that "so mething isn't right" to yourself and other

crewmembers.

Verification

When a crewmember detects a challenge to the flight concept, he informs the pilot in command, who confirms or verifi es it with other crew members. If others don't see the challenge or do n't agree with its identificat ion, the pilot in command

either amends or abandons his initial id entification. If anyone still sees a challenge he should continue to attempt to convince the rest of the crew.



### DETERMINE TIME AVAILABLE

The pilot in command must determine if there is time available or not. Even a few seconds may be enough time for the pilot in command to include pertinent crewmembers in the decision-making proce ss. The more antici pated a challenge has been, the more expanded our time concept becomes.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-07-SG 7-5 01 JUL 13 

### RESPONSE

Time Limited

When no time is available to get crew input, the pilot in command must respond immediately, drawing upon hi s training and experience to select the best course

of action. When the initial or immediat e response is completed, the pilot in
command should use the QPIDR model as appropriate to assess his response and bring the crew into the decision-making process.

Time Available

When time is available to deal with the challenge the pilot in command uses the QPIDR model to organize a response. U nder his direction, the flight crew examines every aspect of the challenge, every option available in response to the challenge, and then select the best opti on. As you recall from the previous discussion, QPIDR consists of inquiry or asking questions, pr omoting ideas and resolving conflict, deciding, and then reviewing the decision.



### BRIEF

Once the response is decided upon, the pilot in command mu st brief the plan. It is especially critical to brief each individual on his revised procedures, assignments and limits. The pilot in command should solici t feedback from the crew to determine if clarification of any of these areas is required.



### IN-FLIGHT PLANNING

Revised Flight Concept

After responding to challenges such as system malfunctions, changes in the existing weather, and/or degraded aircraft performance, it is important to reexamine the original flight concept. Even if it's still possible to reach the planned destination, it will probably be necessary to revise the original flight concept to include different procedures. In more serious situations, the flight concept revision may call for a return to the poi nt of departure, an unscheduled landing, a change of destination, or an immediate diversion to a planned alternate.

If the challenge causing flight concept re vision involves any degradation in airplane system performance, the revisi on must include plann ing against followon complications. If the flight is proceeding with only one radio navigation system, the contingency plan should include the use of NAV audio for the receipt of ATC transmissions if it's necessary to leave the ATC frequency for any reason. Finally, the pilot in command must brief the crew and get feedback to assure full understanding of the revised flight conc ept, including any contingency planning.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-07-SG 7-6 01 JUL 13 After the challenge has been dealt with, al l crewmembers return to monitoring to detect any new challenges to the revised f light concept. Make sure the cycle is completed for each challenge, especially if there is more than one challenge active at a time. Always be an "aggressi ve skeptic" Take nothing for granted and brief EVERYTHING, no matter how obvious it may seem to you.

DEBRIEF

After the mission is complete, ask the fo llowing questions to reaffirm and finalize the flight concept:

1. What results did we achieve?

2. What barriers did we overcome?

3. How did we achieve the results?

4. How can we do better?

When we ask ourselves the kind of questions that cause us to reflect on all the factors that make up CRM: situational awareness, crew coordination, communication, risk management and decis ion making, task management, and finally mission planning, we increase our chances of not only improving our performance, but also our abi lity to analyze future performances for the purpose of improvement.

THREAT AND ERROR MANAGEMENT (TEM)

TEM Definition - Crews and flight members proactively using a combination of CRM

skills and automation to address internal and exte rnal threats to avoid, trap or mitigate their impacts on mission safety and effectiveness.

Types of Threats

1. Internal and External 2. Latent (Hidden)

Some of the common tools and techniq ues used to manage threats include: 1. Reading weather advisories 2. Turning weather radar on early 3. Thorough preflight 4. Correct use of procedures to di agnose unexpected aircraft malfunctions 5. Briefing an alternate runway in case of a late runway change 6. Briefing the crew as to acceptabl e times and reasons for interruptions 7. Considering adding extr a fuel when destination air port is in question due to poor weatherKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-08-SG 8-1 01 OCT 10 

## COURSE REVIEW

OBJECTIVES ............................................................................................................... 8-2

SAFETY GUIDELINES ................................................................................................. 8-3

BIBLIOGRAPHY ......................................................................................................... 8-5KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-08-SG 8-2 01 OCT 10 

## COURSE REVIEW

OBJECTIVES

● Recall the core concepts of CRM

● Utilize these concepts to analyze a case studyKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-08-SG 8-3 01 OCT 10 

### SAFETY GUIDELINES

There once was a farmer in Texas who used to go out to his fields the day before plowing and kill every rattlesnake he could find. When asked if it wasn't a dangerous thing to do, he replied, "I reckon so. But if I don't kill 'em today when I'm looking', they might get me tomorrow when I ain't."

Safety is the preservation of our human a nd material assets. Hazard detection and

elimination must be our top priorities. Unfortunately, all too many hazards come to light as the result of a major mishap. Being personally aware of an unsafe condition or practice and doing nothing to correct it rev eals a lack of professionalism and a lack of pride in one's organization.

Do you —

● know a crewmember whose skills are a little weak and who always needs a nudge to get his act together?

● promote the "I can hack it attitu de" and fly an aircraft or operate a system that is not OK?

● selectively disregard standard oper ating procedures in order to meet operational commitments?

● believe that crew rest is for wimps?

● know someone who routinely takes risks with an aircraft?

● pass over a hydraulic leak on preflight because "it's only a small

one and I'm sure a mechanic has already looked at it"?

● walk by, ignoring maintenance personnel using unsafe procedures

to work on an aircraft?

● allow shortcuts in procedures to get your aircraft "up"?

● forget about proper hearing protec tion in noise hazard areas?

Sadly, the majority of our safety require ments have been written in someone's blood. The farmer correctly recognized that he was exposed to a hazard and took steps to

eliminate it. How about you?

As a final thought to this course we would like to leave you with six safety guidelines

that summarize most of what we discussed in this program. If you come away from this course with these concepts firmly implanted in your mind, you will be a better and more effective pilot or crewmember.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-08-SG 8-4 01 OCT 10 ● The first step during any abnormal si tuation must be the delegation of flying duties.

● The pilot at the controls should not attempt to do secondary tasks during dynamic flight situations.

● Delegate duties to other cr ewmembers if appropriate.

● Positive delegation of monitori ng responsibilities with specified

identifiable limits mu st accomplished.

● Conflicting information or sit uations - use the conservative response rule, then resolve any ambiguities.

● Speak up if in doubt about a clearanc e, procedure, situation, or

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### BIBLIOGRAPHY

Adler, Mortimer J. How to Speak, Ho w to Listen. New York: Macmillan Publishing Company, 1983.

Alkov, Robert A. Pilot Error and St ress Management: U.S. Navy Experience. IALPA/Aer Lingus Flight Oper ations Symposium, 1983.

Alkov, Robert A. Lifeline. Norfol k, VA: Naval Safety Center, 1973.

Berlin, J.I., E.V. Gruber, C.W. Holmes, P. K. Jensen, J.R. Lau, J.W. Mills, and J.M. O'Kane. Pilot Judgement Training and Eval uation (DOT/FAA/CT-82/56). Daytona Beach, FL: Embry-Riddle Aer onautical University (NTIS No. AD-117 508), 1982.

Blake, Robert R., et al. Executive Achi evement: Making It At The Top. New York: McGraw-Hill Book Company, 1986.

Blake, Robert R., and Jane S. Mouton. Cockpit Resour ce Management. Text & Seminar Study Materials Manual. 1982.

Blake, Robert R., and Jane S. Mouton. The New Manageria l Grid. Houston, Texas: Gulf Publishing Company, 1978.

Blake, Robert R., Jane S. Mouton, and Un ited Airlines CRM Steering Committee. Cockpit Resource Management. Denver, Colorado and Austin, Texas: 1982.

Boud, D., R. Keough, and D. Walker (Eds). Reflection: Turning Experience Into Learning. London: Kogan Page, 1985.

Buzan, Tony. Use Both Sides of Your Brain. New York: E. P. Dutton, Inc., 1974.

Charles, J. P., G. Willard, and G. Healy. Instructor P ilot's Role in Simulator Training (Technical Report NAVTRAEQUI PCEN 75-C-0093-1). Orlando, FL: Naval Training Equipment Center, 1976.

Charles, J. P. Instructor Pilot's Role in Simulator Training (Phase II) (Technical Report NAVTRAEQUIPCEN 76-C-0034-1). Orlando, FL: Naval Tr aining Equipment Center,

March 1976.

Chubb, Gerald P. A Comparison of Anxiety and Frustration Impacts on Performance in Manned Systems (AFAMRL-TR-81-129). Ohio : Air Force Aerospace Medical Research Laboratory, Wright Patterson Air Force Base, 1982.

Collins, Richard L. Air Crashes: What Went Wrong, Why and What Can Be Done

About It? New York: Macmill an Publishing Company, 1986.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-08-SG 8-6 01 OCT 10 Cooper, C. L. Stress of Work: An Overvi ew. Aviation Space Environment Magazine.

56:627-32. 1985.

deMare, George, et al. Listening: It C an Change Your Life. New York: McGraw-Hill Book Company, 1983.

Editors of "Flying Magazine." Pilot Error. New York: Van Nostrand Reinhold Company,

1982.

Flight Safety Foundation and Aircraft Owner s and Pilots Association. Summary Proceedings Of An International Industry Gove rnment Pilot Decision Making Workshop. Maryland: 1985.

Foushee, H. Clayton, "The Role of Communications, Soci-Psychological, and Personality Factors in the Ma intenance of Crew Coordinati on." Aviation, Space, and Environmental Medicine, Nov. 1982, p. 1064.

Geier, John The Personal Development Prof ile. Carlson Learning Company Mpls, MN. Copyright 1991

Grayson, David. Terror in the Skies. New Jersey: Citadel Press, 1988.

Hamilton, Cheryl, and C. Pa rker. Communicating For Resu lts: A Guide For Business

And The Professions. Second Edition. Calif ornia: Wadsworth Publishing Company,

1982.

Hawkins, Frank H. Human Factors in Fli ght. Vermont: Gower Publishing Co.,1987.

Heller, William. Airline Safety - A View Fr om The Cockpit. Calif ornia:Rulorca Press,

1986.

Hurst, Ronald and Leslie. Pilot Error: The Hu man Factors. Second Ed ition. New York: Jason Aronson, 1977.

Jensen, Richard S., Aviation Psychology. Vermont: Gower Publishing Co., 1987.

Lederer, Jerome. Subtle Pilot Cognitive Incapacitation. Paper presented at the 20th Annual SAFE Symposium, Las Vegas , Nevada, December 6-8, 1982.

Levitt, Eugene E. The Psychology of Anxiety. New York: The Bobbs Merrill Company,

1967.

Nance, John J. Blind Trust. New York: William Morrow and Company, Inc., 1986.

National Aeronautics and Space Administration (NASA) Conference Publication 2455, Cockpit Resource Management Training . San Francisco, CA: 1986.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-08-SG 8-7 01 OCT 10 Ohio State University, FAA, AOPA, HAI and Transport Canada Systems Control Technology. Aeronautical Decision Making for Helicopter Pilots. 1986.

Ohio State University. The Summaries Of The First, Second, Third, Fourth and Fifth Symposia On Aviation Psychology. Co lumbus, Ohio: 1981, 1983 , 1985, 1987, 1989.

Skjenna, Olaf, W. Cause Factor: Human, A Treatise On Rotary Wing Human Factors.

Canadian Minister of National Health and Welfare, 1981.

Sloan, Stephen, et al. Pilots Under Stre ss. New York: Routledge and Kegan Paul,

1986.

Springer, Sally P., et al. Left Brain, Right Br ain. Revised Edition. New York: W. H. Freeman and Company. 1981.

Swets, Paul W. The Art Of Talking So That People Will Listen. New Jersey: PrenticeHall, Inc., 1983.

Taylor, Franklin and Richard Adams. Inve stigation And Root Causes Of Helicopter Accidents (Report DOT/FAA/PM 86/28). Syst ems Control Technology, Inc., 1986.

Telfer, Ross, and Biggs, John, The Psychology of Flight Training. Iowa: Iowa State Universtiy Press, 1988.

Transport Canada. Proceedings Of The Third International Symposium On Aeronautical Decision Making. Ottawa, Canada: 1986.

Zillman, D. Hostility and Aggression. Hillsdale, NJ: Lawrence Erlbaum Associates,1979.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-1 01 JUL 11 

## TOOLKIT

AIRCREW COORDINATION CYCLE (A CC) ................................................................ 9-2

AESOP Model (RISK MA NAGEMENT ) ........................................................................ 9-3

CRITICAL SUCCESS FACT ORS (CSF’s ) ................................................................... 9-4

MOST CONSERVATIVE RE SPONSE RULE .............................................................. 9-5

CRITICAL SUCCESS ELEM ENTS (CSE’ s) ................................................................. 9-6

I’M SAFE CHECK LIST ................................................................................................. 9-7

STANDARD COCKPIT OPERATING PROCEDUR E (SCOP) ..................................... 9-8

TWO CHALLENGE RULE ............................................................................................ 9-9

TIMEOUT .................................................................................................................. 9-1 0

SYNDROMES ........................................................................................................... 9-12

THREAT AND ERROR MANAGE MENT (TEM) ........................................................ 9-14

CRM SKILLS CRITERIA TRAINING/ EVALUATION FORM ...................................... 9-16KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-2 01 JUL 11 Aircrew Coordination Cycle (ACC)

The Aircrew Coordination Cycl e (ACC) is a useful tool that can be applied throughout the flight. It is a systematically organize d, practical, and very effective operational approach for coping with challenges as an integrated flight crew.

R

E

S

P

O

N

S

E C H A L L E N G E

THE AC CYCLE

PLANNIN GKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-3 01 JUL 11 AESOP Model (Risk Management)

It's critical that aircrews identify all risks prio r to and during the fligh t. Often risks are not fully appreciated for their potential to affect fa ctors, which are less obvious. The five risk elements, which affect flight crew performances, are:

The AESOP Model can be very effective as a mind-jogger to be sure that important (though less obvious) factors are not inadvertently overlooked.

• Aircraft — Power plants, cockpit design/standardization, endurance, performance limits, charts, damage tolerance, and crash-worthiness

• Environment — Obstacles, traffic, terrain, weather, ATC system, airports, elevation changes

• Situation — Aircrews should consider the old axiom: "The actual risk is usually greater than the su m of the risk elements"

• Operation — Purpose, criticality and duration, backup un its, frequency of takeoffs and landings, and duty cycle

• Personnel — Procedures, training, ex perience, complacency, physical stress, health, fatigue, psychol ogical stress and workload

After the risk or challenge is detected, its impact is qualit atively analyzed against the five risk elements. The analysis should consider the crew's relative ability to cope with changes in each basic risk element for the existi ng situation. It is im portant to be aware of the synergy of risk. Two or more risk elements often combine to produce a risk factor far greater than the sum of the individual risks. Wh ile AESOP cannot provide an easy answer as to what to do about various risks, it at least ensures that all risk factors are

identified and dealt with. 

## AESOP

Aircraft

Situation Environment

Operation Personnel

01T-03KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-4 01 JUL 11 

### CRITICAL SUCCESS FACTORS (CSF's)

Intimate Knowledge

Successful flight crews have intimate knowledge of their business, including systems, procedures, limitat ions, and strategies. This course will add the knowledge of aircrew coordination topics.

Proper Attitude

Successful flight crews have developed an attitude that dictates an operating strategy of aggressive skepticism (what if?) and a time-dependent conservative response. They are always looking for opportunities to enhance their knowledge

and skills. This course will instill a desire to implement the knowledge and skills

attained.

Skills

Successful flight crews have developed t he physical and mental skills necessary to accomplish their assigned duties. This course will provide specific concepts and tools for use during all phases of the mission.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-5 01 JUL 11 Most Conservative Response Rule

Occasionally there is a disagr eement in the cockpit, whic h cannot be resolved due to

lack of information. It is bes t to agree in advance to take the most conservative action

in these situations until additio nal information is available.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-6 01 JUL 11 CRITICAL SUCCESS ELEMENTS (CSE's)

Since the Critical Success Fa ctors are too general to work with, we have further divided them into elements, which give a struct ure to the concept of Crew Resource Management and allow us to individually di scuss smaller parts of the whole.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-7 01 JUL 11 “I’M SAFE Checklist”

Our situational awareness resources vary fr om day to day. Unfortunately, we don't have any external readouts telling others or ourselves when they are dimini shed. Therefore, it is important that we preflight ourselves daily. "I'M SAFE" is a simple checklist to

determine if we are re ady and fit to fly.

● Illness

● Medication

● Stress

● Alcohol

● Fatigue

● EatingKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-8 01 JUL 11 Standard Cockpit Operating Procedure (SCOP)

A Standard Cockpit O perating Procedure (SCO P) provides a predictable environment for developing and reinforcing aircrew coordinat ion skills. By SCOP we mean a written set of procedures which go beyond the existing checklists that details:

— Who flies the aircraft — Who briefs the emergency

— Who makes the call outs and when — Who does the miscellaneous procedures

Most of the concepts and tools described here should be included in the squadron

SCOP.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-9 01 JUL 11 Two-Challenge Rule

The key to early response to incapacitation li es in the ability to establish a norm against which the results of incapacit ation can be measured. The tw o-challenge rule provides for automatic assumption of duties from any crewmember that fails to respond to two consecutive challenges. This overcomes our natural tendency to believe the pilot flying must know what he is doing, even as he departs from estab lished parameters.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-10 01 JUL 11 Recognizable, Standard Assertive Statement

AMC uses " Time Out" as an assertive statement.

A standard assertive statement provides a non-threatening verbal method for crewmembers to directly communicate conc erns about an uncomfortable situation. It provides a clear warning of a deviation or loss of situational awareness.

Purpose - It notifies all crewmembers that someone sees the aircraft or crew departing from established guidelines, the br iefed mission scenario, or is simply uncomfortable with developing conditions.

Repercussion - There should be no fear of harassment or other repercussions

when "Time Out" is used.

When to Use - Use is not mandatory but is highly encouraged to standardize operations.

Benefit - Provides an opportunity to br eak the error chain before a mishap or

incident can occur.

Command Authority - Each crewmember is responsible to the Aircraft

Commander to be assertive. This is not designed to usurp command authority.

Assertiveness With Respect

Assertiveness with respect can be seen as a three-pronged approach to problem solving.

Inquiry - Respectively asking about ac tions and requesting clarification as required.

Advocacy - Stating what you be lieve to be the proper c ourse of action under the

circumstances.

Assertion - Advocating for the perceived proper course of action or maintaining a

course of action until convinced ot herwise by additional information.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-11 01 JUL 11 "Time Out"

Is not a panacea. It is not intended to be a cure-all for non-assertive behavior or poor leadership.

When properly used, it can allow crew members to gain everyone's attention concerning uncomfortable situations.

It is not a buzzword and it s use must not be abused.

Must be endorsed at all levels of comm and and reinforced during the course of everyday flight operations.

Provides all crewmembers with a means to speak up when th ey are concerned about a particular maneuver or phase of flight.

Guidelines for Use

In order for an assertive statement to work , effective and strict guidelines must be

established and followed. With this in mi nd, as soon as possible after a crewmember voices the term "Time Out", the airc rew will take the following actions:

TIME AND SAFETY PERMITTING, Stabilize the aircraft.

The initiating crewmember will voice his or her concerns to the crew.

The aircraft commander will provide all ot her crewmembers with the opportunity to voice inputs relative to the stated c oncerns, the aircraft's position, potential hazards, and/or the upcoming maneuver or situation.

After considering all inputs, the aircra ft commander will direct the aircrew to

continue the current course of action or direct a new course of action.

THE AIRCRAFT COMMANDE R STILL RETAINS TH E FINAL DECISION

AUTHORITY.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-12 01 JUL 11 SYNDROMES

Excessive Professional Courtesy

In general, we are hesitant to call attent ion to deficient performance in others, particularly if they are senior to us. Thus, even when one crewmember does point out performance which is outside of established parameters, it is typically done with very little emphasis. For example, a copilot will usually inform the pilot that he is "a little fast," or "a little low," no matter how far off he is.

Halo Effect

One cause of Excessive Professional Courtesy is the Halo Effect. The Halo Effect comes into play when an indi vidual with a significant amount of experience on one type of aircraft is transitioning to another type of aircraft. Typically that pilot or crewmember is given a very accelerated checkout on t he new aircraft, because if he has so much experience on "X", he can certainly handle "Y"! The "Halo" of expertise and the rush to get the person on line blinds everyone to th e major differences between the aircraft and

the need for a more extens ive training program.

The problem continues into the aircraft where the crew also is impressed by the vast experience of this person and will tend not to speak up about problem s they see, even though they may have much more experience on that type of aircra ft. Sometimes the

individual involved is aware of this effe ct and may even attempt to use it to his advantage. Even without this conscious effort the halo effect is strong and must be recognized and overcome by all involved.

Copilot Syndrome

Copilot Syndrome is based on a comfor ting premise that one or more other

crewmembers have the situation under control and are looking out for your best interest. It can be experienced by any cr ew position resulting in that person being "along for the ride". The Halo Effect can lead to Copilot Syndrome.

Sudden Loss of Judgment (SLOJ)

Sudden loss of judgment is a condition in whic h an individual's decision making abilities become impaired. Even the most capable and experienced crews are susceptible to this condition. It's generally precipitated by a real or per ceived pressure to perform or by workload/stress related issues.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-13 01 JUL 11 Hazardous Attitudes

There are six hazardous attitudes that can impede our good judgment and decisionmaking abilities and o ften lead to Sudden Loss of Judgm ent. These attitudes may be an inherent part of our persona lity, or may be a short-term factor due to a particular

situation. MEMORIZE THE ANTIDOTE for each hazardous a ttitude, so that it will come to mind when you need it.

Hazardous Attitude Antidote

● Anti-Authority "Follow the ru les; they're usually right"

● Impulsivity "Not so fast! Think first"

● Invulnerability "It could happen to me"

● Macho "Taking chances is foolish"

● Resignation "I'm not helpless, I can make a difference"

● Get There-itis "It's better to get there late than not at all"

Strength of an Idea

Strength of an idea can be de fined as an unconscious attempt to make available evidence fit a preconceived situation. It has been observed that on ce a person or group of people get a certain idea in their head(s), it can be difficult or impossible for them to

alter that idea no matter how much conflicti ng information is received. Use AESOP as a tool to keep your sensors working in all potential risk areas and to avoid channelized

attention or a closed-minded a ttitude which might allow a se rious threat to the mission to develop without any awareness on the part of the crew. In a highly stressful situation it becomes even more important that we not allow our attenti on to focus or become channelized on only one area.

Hidden Agenda

Sometimes a crewmember may be making sugges tions or decisions on information or

desires the rest of the crew are not aware of, such as a strong desire to make it back to base due to important plans fo r that evening. We need to communicate honestly all

motives involved so that decisions can be made rationally and based on the facts rather than on wishful thinking.

Additionally, there may be instances wher e a crewmember fails to share certain information about his intentions regarding the completion of a particular maneuver, task, or mission in order to prevent objections and confrontation from ot her crewmembers.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-14 01 JUL 11 THREAT AND ERROR MANAGEMENT (TEM)

TEM is not a new program and is not in any way replacing CRM – it is simply an aviation industry advancement with a sharper focus in pr eventing, managing, and/or correcting aircrew induced errors before they lead to a mishap. This is accomplished in part by using data-based, proac tive training objectives.

Following every major conflict since WW II, the Air Force has endured a dramatic increase in mishaps as crews return from their deployments and rejoin their home station training environments. The reasons for this increase have never been fully understood, but post-conflict escalations in mishap rates are well-documented throughout military aviation history. In an e ffort to combat the mishap spike following Desert Storm, the ANG introduced their fi rst ever CRM training curriculum, and AMC completely revised their existing 1985 era pr ogram. AMC is now ta king the lead by preemptively introducing Threat and Error Management to our ai rcrews prior to suffering the inevitable increase in mishaps as personnel return fr om their extended deployments.

Aviation Safety Action Program (ASAP) – A program designed to enhance aviation
safety through the prevention of accidents and incidents. Its’ focus is to encourage
voluntary reporting of safety issues and related events encountered by the
crewmembers as they perfo rm their daily missions.

Military Flight Operat ions Quality Assuranc e (MFOQA) – A flight data gathering system
designed to capture and analyze the da ta generated and stored by the aircraft
throughout the progress of the mission. A pplying the information learned from this
analysis is a proven method of identifying latent trends and t hereby ascertaining ways to
improve flight safety and increase overall operational efficiency.

Threat and Error Management – A critical component of Human Fa ctors/CRM Training
designed to assist in identifying threat s to mission accomplishment and effectively
manage human error. It prov ides a framework to analyze data and assess errors, along
with what factors contribute to making mist akes and how aircrews manage unpredicted
situations. TEM helps organizations by integr ating data from different sources such as
ASAP, MFOQA and other safety reporting sources. TEM is currently the aviation
industry standard for reducing human errors, which consequently reduces conditions
that induce human error mishaps.

Threat – Threats are defined as events or conditions that normally occur outside the
influence of the flight crew, but require crew att ention and management if safety
margins are to be maintained. Threats c an include weather, ma intenance or ground
crew error, unfamiliar airports, automat ion events, unexpected missed approaches,
systems malfunction, high terrain, ATC, high traffic density, et c. Threats can also come
from within the crew, such as fatigue, co mplacent attitudes, hi dden agendas, personalKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-15 01 JUL 11 distractions, etc. A mismanaged thr eat is a threat that is link ed to or induces flight crew

error.

Error — Errors are defined as flight crew acti ons or inactions that; (1) lead to a deviation
from crew or organizational intentions or expectations; (2) reduce safety margins, and
(3) increase the probability of adverse operati onal events on the ground or during flight.
The three main error categories incl ude aircraft handling, procedural and

communications errors.

Undesired Aircraft State – An undesired aircraft state (UAS) is defined as a deviation in
aircraft position, speed or attitude, or inco rrect configuration of an aircraft that; (1)
results from flight crew error, actions, or inaction, and (2) clearly reduces safety
margins. Examples typically include headi ng and altitude errors, speed unnecessarily
high or low, unstable approach, near miss, fuel level belo w minimums, long landing,
hard landing, wrong runway or ta xiway, wrong airport, etc.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-09-SG 9-16 01 JUL 11KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-1 01 OCT 10 

## CASE STUDIES

TABLE OF CONTENTS

SUBJECT PAGE

C-5 MISHAPS

AIRCRAFT CRASHED DURING AN EMER GENCY RETURN TO THE FIELD

FAULTY JUDGMENT/DECISION MAKING ..................................................... 10-5

C-130 MISHAPS

AIRCRAFT IMPACTED EZ DURING LAPES MISSION P & R, LOSS OF S/A, HA ZARDOUS ATTITUDES,

SUPERVISORY ER ROR ................................................................................. 10-6

IMPACTED TERRAIN DURING LOW LEVEL TRAINING

FAULTY JUDGMENT/DECISION MAKING ................................................... 10-10

STALLED AND CRASHED DU RING LOW-LEVEL AIRDROPS P & R, LOSS OF S/A ..................................................................................... 10-14

IN-FLIGHT STRUCTURAL FAILURE, EXPLOSIVE DECOMPRESSION

GOOD CREW COORDINA TION ................................................................... 10-17

AIRCRAFT IMPACTED WATER LOSS OF S/A, HAZA RDOUS ATTITUDES, ASSERTIVENESS ................... 10-19

LANDED GEAR-UP DURING SIMULATED ENGINE OUT LOSS OF S/A, WO RKLOAD ......................................................................... 10-23

COLLISION WITH ANTENNA ON NIGHT LANDING APPROACH

VISUAL ILLUS ION ........................................................................................ 10-27

DRAGGED WINGTIP ON LANDING KNOWLEDGE, CREW COORDINATION , HALO EFFECT .......................... 10-29

HARD LANDING POOR BRIEFING, INEXPERIENCE, VISUAL ILLUS IONS .......................... 10-31

STALLED ON FINAL POOR CREW COORDINATION, JUDGMENT, AWARENESS ..................... 10-33KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-2 01 OCT 10 KC-135 MISHAPS

AIRCRAFT DESTROYED FOLLOWING SIMULATED ENGINE FAILURE JUDGMENT, WORKLOAD, POOR COMMUNICATION S ............................ 10-35

TAKEOFF ABORT, SHEARE D/COLLAPSED GEAR

POOR COMMUNICATIONS .......................................................................... 10-39

CRASHED DURING PRACTICE INSTRUMENT APPROACH POOR JUDGMENT, OPERATING STRATEGY, LOSS OF S/A .................... 10-41

LOST WATER INJECTION, CRASHED AFTER TAKEOFF WORKLOAD PERFORMANCE, DISTRA CTIONS, LOSS S/A ...................... 10-45

HARD LANDING/GO-AROUND, IMPACT WITH TERRAIN VISUAL ILLUSION, WORKLOAD .................................................................. 10-49

IMPACTED APPROACH LIGHTS KNOWLEDGE, VISUAL ILLUSION S, COMMUNICATIONS ......................... 10-53

DEPARTED RUNWAY, BROKE UP, BURNED

P & R ............................................................................................................. 10-57

A-7 MISHAPS

COLLISION WITH GROUND

TASK MANAGEMENT BR EAKDOWN ......................................................... 10-61

A-10 MISHAPS

COLLISION WITH GROUND CHANNELIZED ATTENTION, PRIORIT IES, COMPLACE NCY .................... 10-63

COLLISION WITH GROUND

CHANNELIZED ATTE NTION ........................................................................ 10-65

F-4 MISHAPS

COLLISION WITH GROUND COORDINATION, CHANNELIZED A TTENTION, ILLUSION ........................ 10-67

CONTROL LOSS, EJECTION LACK OF COMMUNICATION, COORDINATION ......................................... 10-69

LOSS OF CONTROL

AIRSHOW AND COPILO T SYNDROME ...................................................... 10-71KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-3 01 OCT 10 F-15 MISHAPS

MIDAIR COLLISION

FLYING UNBRIEFED MA NEUVERS, FATIGUE, DISCIPLINE ..................... 10-73

COLLISION WITH GROUND SUPERVISION, DISCIPLINE, COMPLACENCY, OVER-CONFIDENCE, A ND TASK SATURATION ........................................ 10-75

UNAUTHORIZED FLY-BY, AIRCRAFT BREAKUP SUPERVISION, DISCIPLINE, COMPLACENCY ........................................... 10-77

F-16 MISHAPS

COLLISION WITH GROUND IN NIGHT GCA PATTERN

LOSS OF S/ A ................................................................................................ 10-79

UNINTENTIONAL ENGINE SHUTDOWN, EJECTION

HABIT PATTERN INTE RFERENCE ............................................................. 10-81

COLLISION WITH GROUND DURING EGRESS

PERCEIVED PRE SSURE ............................................................................. 10-83

F-111 MISHAPS

COLLISION WITH GROUND DISCIPLINE, JUDGMENT, LOSS OF S/ A .................................................... 10-85

RAPID FUEL DEPLETION, EJ ECTION DURING LANDING

POOR CREW COORDI NATION ................................................................... 10-87

LOST CONTROL/IMPACTED TERRAIN CHANNELIZED ATTENTION, PRIORITIES .................................................. 10-89

T-37 MISHAPS

IMPACTED TERRAIN AFTER SI NGLE ENGINE GO-AROUND CSF'S, STRE SS ............................................................................................ 10-91

T-38 MISHAPS

FLIGHT CONTROL MALFUNCTION, EJECTION IMPROPER ANALYSIS, LACK OF COMMUNICATION ................................ 10-93

CIRCLING APPROACH, COLLI SION WITH GROUND

IMPAIRED JUDGME NT ................................................................................ 10-95KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-4 01 OCT 10 USN/USMC MISHAPS

UH-1 MISHAPS

RAPPELLER KILLED DURING DEMO

POOR AIRCREW COMMUNI CATION .......................................................... 10-97

FLEW INTO THE GROUND

FAILING AVIAT OR ........................................................................................ 10-99

WIRE STRIKE AT NIGHT DURING NVG TRAINING

COMMAND AUTHORIT Y ............................................................................ 10-101

COLLISION DURING MOUNTAIN FLIGHT

OPERATING STRATE GY ........................................................................... 10-103

CH-46 MISHAPS

FLEW INTO SEA AT NIGHT

DISTRACTION ............................................................................................ 10-105

FLEW INTO SEA ON NIGHT SHIP TAKEOFF

DISTRACTION ............................................................................................ 10-107

COLLISION WITH TREES IN LZ

COPILOT SYNDROME ............................................................................... 10-109

FLEW INTO SEA AT NIGHT

SITUATIONAL AWAR ENESS ..................................................................... 10-111

FLEW INTO GROUND AT NIGHT

FAILING AVIATOR ...................................................................................... 10-113

CRASHED ON SHIP/NIGHT SINGLE ENGINE LANDING

STRENGTH OF AN IDEA ........................................................................... 10-115

FLEW INTO SEA AT THE 90

P & R ........................................................................................................... 10-117

SH-60 MISHAPS

FLEW INTO SEA AT NIGHT

DISTRACTION ............................................................................................ 10-119

FLEW INTO SEA/UNAUTHORIZED AIR SHOW

HAZARDOUS ATTIT UDES. ........................................................................ 10-121KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-5 01 OCT 10 AIRCRAFT CRASHED DURING AN EMERGE NCY RETURN TO THE FIELD

FAULTY JUDGEMENT

DECISION MAKING

SUMMARY Aircraft 84-0059 (C-5B) crashed after an in-flight emergency involving an indication that a thrust reverser was not locked. On 3 Ap ril 2006, the aircraft, assigned to the 436th Airlift Wing and flown by a reserve crew fr om the 709th Airlift Squadron, 512th Airlift Wing crashed about 2,000 ft (610 m) short of runway 32, while attempting a heavyweight emergency landing at Dover Ai r Force Base, Delawa re. The airplane, carrying 17 people, had taken off from Dove r about 21 minutes earlier and reported an in-flight emergency (number 2 e ngine thrust reverser not locked indication) 10 minutes into the flight. All 17 aboard survived, 15 with no injuries, 2 with serious.

HUMAN FACTORS ANALYSIS

The Air Force's accident investigation conc luded the crash was a re sult of human error, most notably the determination th at the crew kept one of the functioning engines in flight idle while manipulating the throttle of t he (dead) number 2 engine as if it was still running, while having the number 3 engine at idle, an error t hat was further amplified by the crew's decision to use a high flap se tting that increased drag beyond normal 2 engine performance capabilities.

The accident investigation board determined the pilots and flight engineers did not properly configure, maneuver and power the aircraft during approach and landing. The pilots and flight engineers continued to use the shut-down No. 2 engine’s throttle while leaving the fully-operational No . 3 engine in idle. Both inst ructor and primary flight engineers failed to brief, and pilo ts failed to consider and us e, a proper flap setting. The pilots’ attempt at a visual approach to runw ay 32 resulted in the aircraft descending well below a normal glidepath for an instrument-a ided approach or the normal visual flight rules pattern altitude. The aircraft comm ander failed to give a complete approach briefing that would have include d non-standard factors, confi guration, landing distance and missed approach intentions.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-6 01 OCT 10 AIRCRAFT IMPACTED EZ DURING LAPES MISSION P & R, LOSS OF S/A, HAZARDOUS ATTITUDES

SUPERVISORY ERROR

SUMMARY

During a practice LAPES mission, the mishap pilot executed a steep approach, two-step flare, and a very aggressive climb out that was outside established standards in MACR 55-130. The LAPES sequence wa s observed by Wing and s quadron supervisors. The aggressiveness of the practice maneuver on the day prior to the mishap frightened the copilot and the flight engineer . After the mission the copi lot expressed concern about the practice LAPES delivery to the mishap pilot and he agreed to "shallow out" the maneuver the next day.

During the practice mission debrief, the squadron commander praised the aircrews for an outstanding performance, th ereby inappropriately rein forcing the mishap pilot's

behavior. Prior to the actual LAPES demon stration flight, a copilot change was made, thereby negating the previous agreement to "shallow it out" and significantly reducing the pilot crew experience level.

Intent on making a steep approach to enhance the entertainm ent value of the event, the mishap pilot established an excessive nose low attitude and a vertical velocity of 2900 feet per minute within 100 feet of the ground, a flight condition from which recovery was not possible. The aircraft impacted the gr ound with sufficient force to fracture the

aircraft structure at station 737. The airc raft departed the extraction zone, struck three army vehicles and fatally injured one army solider. The aircraft continued into a wooded area, the wing and portions of the fuselage flipped over and came to rest 2,400 feet from initial impact, followed by fire. The copilot and engineer escaped with serious injuries while four other crewmembers were fa tally injured. The ai rcraft was destroyed.

NARRATIVE

The mishap aircraft was the lead of a four-s hip (two/two-ship element s) formation. The mission was planned and briefed as an adv erse weather aerial delivery system (AWADS) visual route to a LAP ES extraction. At the initial point (IP) the first element

continued their run-in to the EZ while the second entered an orbit. Shortly after passing the IP the lead was cleared by ATC to desc end to 3000 feet and then cleared at "pilots discretion" to 1,175 feet. Passing thr ough 1,400 feet the mis hap aircraft obtained VMC approximately 10 miles out from the EZ. Th e mishap crew acquired the EZ environment at approximately 7 miles. The copilot iden tified the LAPES panels at approximately 2

miles. At about 1 1/2 mile s out the pilot began a right tu rn for final EZ alignment.

Eighteen seconds prior to impact the pi lot had identified the LAPES lanes and all LAPES checklist items had been accomplished as the mishap aircraft was prepared for drogue chute deployment. The pilot del ayed drogue chute deployment until nine seconds prior to impact. The drogue was depl oyed and the mishap pilot aggressively pushed the nose of the aircraft down obtaini ng a vertical velocity of 2900 feet perKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-7 01 OCT 10 minute. During the descent to extraction alti tude (5-10 feet wheel height), a flare was

initiated to arrest the rate of descent. However, the aircraft impacted the ground with a vertical velocity of 2200 f eet per minute. After the ai rcraft impacted the ground, the aircraft ramp and portions of the ramp convey ors passed through or remained in two of

the extractor chutes. One ex tractor parachute later inflat ed. The load was extracted and decelerated to a stop. The aircraft im pacted the ground with the left and right aft main landing gear and the cargo ramp. T he right aft gear strut failed and the right forward tire blew. The upper fusel age skin and empennage su pporting structure fractured at station 737 causing a total loss of aileron, elevator and rudder control.

Roll out across the impact/slide-out zone was relatively smooth, however, at 1,200 feet, the terrain became rougher, increasing shock and vibration loads. The aircraft passed over a crest, the propellers contacted t he ground and at approximat ely 1,680 feet the engines and propellers departed the aircraft. At approximately 1, 800 feet, the right wingtip contacted a parked vehicle, whic h was propelled down track about 35 feet and exploded. At approximately 1, 850 feet, a jeep was struck by the left external fuel tank and an Army soldier in the passenger s eat of the jeep was killed instantly.

At approximately 1,900 feet, the aircraft fl ipped over and fell to the ground 2,040 feet from the initial impact. During the rota tion the empennage separated at station 737 and came to rest vertically 160 feet beyond the center wing section. There were many sources of ignition: hot engines and co mponents, hot electrical components and possible sparking. All four main fuel tanks, oil, and fuel vapors ig nited resulting in a fireball and flash fire that diminished rapidly.

Both loadmasters sustained fatal injuries during the mishap sequence. The pilot and navigator survived the crash, but received fata l burn injuries in the post-crash fire. The copilot and flight engineer were found outside t he flight deck area but within a broken perimeter of fire and received se rious burn injuries. The aircraft was destroyed by fire.

The flight engineer, copilo t and navigator were all ov erdue on ground training events some of which were grounding events. T he formation as planned and flown for this mission did not have a lead crew in the deputy se rial lead position as required by MACR 55-130. Additionally, MACR 55- 130, paragraph 29-5 states, "I t is permissible to use an approach altitude higher than 200 feet if operational requirem ents dictate; however, in all cases, base the descent point on gross weight, ground speed, and pilot judgment. ...."the descent rate should normally be 1000 to 1500 feet per minute.

NTSB analysis showed the aircra ft at time T -20 to be between 250 to 290 feet AGL. At

T -5 the rate of descent was 2520 FPM with a nine degree nose low attitude. At T -0 the aircraft was 6 degrees nose up, airspeed 136 knots, and a vertical velocity of 2200 FPM. Aircraft gross weight was 137,922, car go weight 34,850, fuel weight 19,000, CG of 25.4, airspeed 130 CAS and 70% flaps. T he time and altitude required to recover from this nonstandard maneuver were beyond the ability of the pilot to interpret and he could not avoid contact with the ground.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-8 01 OCT 10 As a result of a currency discrepancy, a cr ewmember change was requ ired at the last minute. Since both copilots had practiced fo r the event and the pilot was an instructor pilot, the squadron commander simply exchanged the two copilots. As a result the squadron commander chose to n egate the advantage of having established dedicated, "hard" crews. The original copilot believed that he would have taken action to abort the extraction when the normal sequence of ev ents was delayed by the mishap pilot.

The mishap chain of events began with the mi ssion briefing for the Monday practice. Significant emphasis to provid e a "big show" was directed at all aircrews from the airborne division commanding general. Although the wing commander stressed it was just another training exercise and to pe rform the mission safely, the mishap pilot intended to put on a good show.

HUMAN FACTORS ANALYSIS

After Monday's LAPES practice mission, the mishap pilot made certain conscious decisions regarding the manner in which he would perform the next extraction (Hidden Agenda). At the onset of the mishap t he pilot intentionally delayed drogue chute deployment and descent in order to steepen the approach to the EZ. His confidence level played an important role in his decis ion making process. The mishap pilot's confidence level can best be exemplified by the comments he made to the originally scheduled copilot. He expressed his feelings and concerns of being startled by an aggressive nose high climb that exceeded 20 degrees, accompanied by a significant loss of airspeed. The mishap pilot explai ned that he had a lot of experience flying LAPES that way, was very comfortable with the maneuver and that it made for a good show. However, he finally stated that if th e maneuver really bothered the copilot that he

would "shallow all that stuff out." Later Monday a fternoon, the mishap pilot was overheard to say that he would make the next r un-in a little steeper. The mishap pilot assumed that the LAPES approa ch would be accomplished as he intended even though he had not successfully performed such an extr emely aggressive maneuver in the past.

Other squadron members' confirmed the mis hap pilot to be compulsive, devoted, and a perfectionist. These traits were important in determining how the pilot became internally motivated. The underlying factor was self-mo tivation, a desire to magnify self-image, reputation or career. The ro le of outside motivating factor s can be illustrated by the premission briefing. The commanding general clearly emphasized the need to "fill the sky with parachutes" and to put on a "big show." The mishap pilot's aberrant behavior on the previous days demonstration caused concern for the Wing DO and the squadron commander, however, at the debrief the airc rews were praised for an outstanding performance. This inappropriate positive re inforcement was an additional factor, which

resulted in anomalous motivation.

A no drop/go-around was not suggested by the mishap copilot or any other crewmembers. The mishap pilot was perceived by the other crewmembers as being highly experienced and skilled. (Excessive Professional Cour tesy) The copilot had only 200.1 hours of C-130 flying time; he was dedica ted, highly motivated individual, but lacked knowledge and experienc e in not only LAPES, but in the C-130 in general.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-9 01 OCT 10 During the mishap sequence, the copilot relie d entirely on the mishap pilot's ability to conduct the approach. The CVR indicated a nine second period of silence from the time the pilot says, "got the lane," until he states, "deploy the drogue." The pilot consciously delayed the descent, but there were no inputs or suggestion from any crewmember to begin the descent. Even mo re alarming was the lack of crew input when the pilot initiated the steep nose down attitude and the ensuing excessive descent rate. What developed was a copilot syndr ome whereby the copilot and possibly other crewmembers were satisfied to have the pilot in complete control of the final approach.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-10 01 OCT 10 IMPACTED TERRAIN DURING LOW LEVEL TRAINING

FAULTY JUDGMENT/DECISION MAKING

SUMMARY

A C-130 aircraft impacted the terrain in a remote mountainous area on U.S. Forest

Service land. The aircraft was destr oyed and ten crewmembers and a survival specialist were fatally injured. This mish ap occurred when the effect s of three different

factors combined at a critical time: t he man, the machine and the environment.

The events leading up to this mishap began several months prior when a flight engineer from the mishap crew's wing submitted a wr itten report concerning the mishap IP pushing the aircraft too far, not taking inpu ts from the crew and handling the aircraft aggressively in critical phases of flight. On a subsequent occa sion, two students (both aircraft commanders) complained about the mis hap IP's seeming disregard for Air Force and MAC directives, other crew member's inputs and weather hazards. In response to these grievances, the squadron DO ver bally counseled the mishap pilot, and the squadron CC was notified of these sessions . After the second incident, Stan/Eval

administered a no-notice f light evaluation.

In another incident, the mishap IP and navigator were flying on a low level route, which intersects the SR route in the vicinity of th e crash site. During this flight, the aircraft (same aircraft as mishap aircraft) experienc ed an in flight emergency (IFE) due to turbulence and excessive speed for turbulence penetration. The significance of this incident shows the mishap IP and the mishap navigator were both aware of the

turbulence hazards associated with this area when the winds were out of the southwest

at 20-40 knots.

On the morning of the mishap, the mishap nav igator expressed concern to the mishap IP and others about flying the western low-leve l routes due to forecasted weather. The mishap IP ignored a later SIGMET broadcast ed over center frequency reporting severe

turbulence for the entire area. Interviews with other members in the Wing (all crew positions) almost always contained such wo rds as: "aggressive, pushed the aircraft, pushed the crew, not receptive to inputs, ex tremely confident, mission hacker" and one report, "dangerous."

The mishap aircraft flew missions resulting in relatively low airframe stress over the period of initial delivery in 1967 through 1979. At that ti me, the mission was altered to

include low level terrain follow ing missions from 300 to 500 feet AGL. This type of flying

increased the stresses on the aircraft structure. At some point in the 1970's, extensive centroid riser repairs were accomplished. A titanium heat shield was removed leaving a row of plugged rivet holes along outer wing stations (OWS) 158. Forward of these holes, also along OWS 158, a 25/32-inch fati gue crack developed at the outboard-most portion of the centroid riser repair.

In repairing the centroid riser, a new stress concentration was created. The repair lowered the structural integr ity of a chord-wise fatigue crack at the stress point. TheKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-11 01 OCT 10 repair increased the propagation of this fatigue cr ack by a factor of two and at the time of G over load, the fatigue crack went unsta ble and propagated at t he speed of sound in the metal along the row of plugged rivet holes.

At the time of the mishap the prevailing winds were fr om 240 degrees at 30 knots gusting to 40 knots. There were some gusts as high as 55 knots. SIGMET Hotel

advised of severe turbulence wi th strong up and down drafts. Vertical gust velocities of 1000 to 3000 feet per minute were calculated to be present at the ti me of the mishap.

NARRATIVE

The mission was scheduled for a 1630Z depar ture with 30 minutes planned for personnel delivery at a drop zone (DZ) and then low leve l training on two separate routes. Following low level tr aining, the flight was sche duled for one hour and thirty

minutes of aerial deliv ery training and then return to base.

After take off at 1655Z the mishap aircraft r eported its intentions to FSS enter VR at 1705Z, with an estimated exit at 1740Z. At 1656Z the mishap aircraft contacted center and reported their intentions to cancel IFR to proceed to their low level route due to a change in flight plan. This change was due to out-of-limit winds at the DZ that prevented personnel deployments. AT 1701Z the mishap aircraft reported its intentions to return to center in approximately one h our and fifteen minutes. At 1703Z, center broadcast in the clear to all aircraft, SIGM ET Hotel Alpha, valid until 2036Z. The

SIGMET advised of occasional severe turbul ence below 15,00 feet with very strong up and down drafts reported by numerous aircraft.

At 1822Z, a local resident observed the aircra ft near the base of a mountain in a steep bank approximated to be 90 degrees plus, with the lower wing appearing to be shorter than the upper wing. Immediat ely thereafter, he observed a large ball of black smoke and a fireball. The aircraft impacted near centerline of the intended flight path approximately 30 miles pr ior to the exit of the low level route.

The mishap IP was the C-130 flight comma nder and had considerable experience in the

aircraft and the rescue mission. The s quadron DO and CC were interviewed concerning complaints by two students and a permanent-party fli ght engineer against the mishap IP, The first complaint occurre d when the flight engineer presented the squadron DO with a two-page lette r and his personal testimony. He stated that on one mission the mishap pilot placed the aircra ft in an unplanned staff buffet twice while demonstrating air-refueling techniques and onc e while aggressively maneuvering the aircraft on a practice airdrop. The next two complaints surfaced two months later by two students on the same flight. Both students were concerned with the mishap pilot's apparent disregard of air traf fic control clearances and t hunderstorm avoidance criteria.

In response to each complaint the squadron DO counseled the mishap pilot. The DO had been close friends of the mishap pilot for the past fourteen years, he however, told the mishap pilot not to push so hard duri ng training missions. He also advised the squadron commander of actions taken. Afte r the second inciden t, squadron Stan/EvalKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-12 01 OCT 10 administered a no-notice evaluati on of the pilot, which he successfully completed. Most

crewmembers felt that the IP did not alter his conduct in any way as a result of the counseling. Since the feedback from these grievances was limited, crewmembers may have felt that further complaining was futile.

Students and contemporaries in terviewed admitted that th e pilot was a meticulous,

intense instructor who tended to push students hard and talked a great deal while flying. He commanded a "tight ship" and left no doubt as to who was in char ge of the aircraft. He would not be swayed from a decision after making up his mind. The term "mission

hacker" was most often used to describe his style.

When comparing his supervisory style with the mishap missi on setup, the pilot would attempt to maximize training for all crew positions. This meant flying both low-level routes at 500 feet while hopi ng for the winds to diminish enough for the paradrops. In doing this, he ignored the fore cast weather, the SIGMET reporting sever turbulence in the area, and his navigator’s request to fly low-level rout es in another less hazardous

area.

HUMAN FACTORS ANALYSIS

On the morning of the mishap, the navigator expressed concern to the IP about flying

the western routes under the forecast weather conditions. The IP, however, chose to remain with the preplanned/preb riefed routes. This attitude of ignoring crew inputs and pressing on as planned was the rule rather t han the exception in the case of the IP. When those interviewed were asked to describe the IP in terms of piloting skills, he was

described as excellent in cont rolling the aircraft. He wa s confident and there was no

doubt he controlled the aircraft and not the ot her way around. Howeve r, the description "aggressive," "mission hacker," and "danger ous" were recurring themes among some interviewers. During a navigational mission, the IP deliberately entered an active MOA even though cautioned by ATC. On return to base the IP selected a route of flight that would have taken them dangerously close to thunderstorms. A high time student pilot took physical control of the aircraft to pr event this after his inputs regarding crew endangerment and regulation vi olations were ignored.

Flight engineers found the IP di fficult to work with because he pushed both the aircraft and the personnel. One said he had to stay on top of the mishap IP to keep the aircraft within acceptable operating limits. As an instructor he was felt by most to be excellent,

but often was too far ahead of the student and tr ied to impart too mu ch information at a given time. The IP's closest friend described him as someone you ei ther liked or stayed away from. Persons who contacted him even briefly in social situations described him as aggressive and obnoxious. His demeanor was not that of anger or ill temper but was usually serious.

The IP had above-average in telligence and exhibited no evidence of cognitive impairment. However, he had poor insight into his character traits as exhibited by his lack of response to verbal counseling. P oor judgment was evident by his continually flying into dangerous conditions and endangeri ng crew and aircraft. There was noKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-13 01 OCT 10 evidence that an air of "missi on hacking" pressure existed at the supervisory level, though no formal reprimands were documented as a result of the written complaints against the mishap pilot.

The IP was apparently satisfied with where he was in his career and flying status. Pressure to perform at the level to which he did were internally generated and were not a function of the flying unit's "personality." He was not receptive to crewmember inputs

and was over confident in his abilities. He had flown the aircraft to its maximum earlier with no adverse consequences a nd therefore received no negat ive reinforcement for his behavior. On the day of the mishap, crew inputs were ignored an d the IP proceeded as planned and flew into forecast turbulent weather conditions.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-14 01 OCT 10 STALLED AND CRASHED DURI NG LOW-LEVEL AIRDROPS P & R, LOSS OF S/A

SUMMARY

The mishap aircraft was number two in a flig ht of eight C-130s sch eduled to depart for a five-hour sortie. The formation planned to fly three low-level routes dropping training bundles simulating personnel (TBP) on a DZ. Afte r the airdrops at the DZ, the formation planned to fly a low-level route to a si mulated heavy equipment (TBH) airdrop at

another DZ.

The formation flew the departure and entered the low-level training route. After formation join-up, the instructor pilot vacated the copilot fli ght station and put the student copilot in the right seat. At the second turn point the formation broke up into three elements (3-3-2) with five-minute spacing bet ween elements. The flight proceeded normally until slowdown when t he student pilot closed to withi n 500-700 feet of the lead aircraft, then drifted back to about 1700 feet. The proper position is 2000 feet. After the one-minute warning the student pilot again cl osed on the lead and stabilized at 120 KIAS approximately 1200 feet behi nd lead. While maneuvering to regain proper airdrop position, the mishap aircraft dropped into lead' s wake turbulence. Witnesses’ saw the aircraft yaw to the left, lose altitude, drop it s right wing, and begin its final descent. The mishap aircraft impacted on the DZ.

NARRATIVE

After formation takeoff and join-up, the instruct or pilot (IP) got out of the right seat and placed the copilot in the seat. (This is a standard practice and is permitted by MACR 41-130.) The IP stood behind the pilot and communicated through the instructor's interphone panel for the remainder of the flight. During the r oute, the pilot had difficulty maintaining formation position and was periodically flying close to the lead aircraft. The flight proceeded normally up to slowdown.

At 8.8 nautical miles from the DZ, the forma tion ascended to drop al titude, 1750 feet msl (800 feet AGL), set flaps 50 percent, and r educed to airdrop airspeed of 125 KIAS. During the slowdown maneuver, the mishap aircraft closed to within 500-700 feet from the lead aircraft. The pilot m aneuvered the aircraft to the ri ght to keep from overrunning

lead. He stabilized at 120 KI AS and started to drift back to the correct formation airdrop position. The pilot established a posit ion 1700 feet behind lead. He then moved forward to about 1200 feet in-trail, but still offs et to the right. This was the first run-in with right drift as high as 7-10 degrees the pilot experienced during his training. With the possible exception of the visual picture for th is right drift situation, the IP felt the pilot knew the correct formation position. The following is an expansion of the last sixty seconds of flight and analyzes each movemen t. Many of the movements and actions occur simultaneously. The symbol "I-:XX" represents seconds prior to impact.

As the pilot maneuvered left to the correct position, he encounter ed wake turbulence form the lead aircraft (I-:53). The turbulence moved the aircraft back out to the right.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-15 01 OCT 10 He tried to maneuver to the correct position a second time by adding more left aileron and left rudder. During this m aneuver, at approximat ely 1200 feet behi nd lead, the IP said, "Don't drop down 'cause you'll drop right into his prop wash," meaning stay above the wake turbulence (I-:30). The pilot pul led back on the yoke, increasing the pitch angle, without addi ng power. At approximately I-: 25 the mishap aircraft entered the wake turbulence. Simultaneously, the airc raft began to yaw to the left and the rolling motion from lead's left wing tip vortex caused t he left wing to rise. To counter the rolling motion, the pilot added almost full left aile ron and some left rudder. The airspeed decayed slightly. Also, while in the wake tur bulence, the aircraft started to sink. This sequence occurred over a peri od of about five seconds.

The IP noticed the low airspe ed and called, "Airspeed" (I-: 19), followed immediately by the flight engineer (FE) calling, "Stall" (I-: 18). The pilot added power while still in a slight right wing low, slightly nose- high attitude. The combinat ion of P-factor (propeller), torque, left rudder, and wake turbulence caused the nose to yaw further to the left. Early indications of an approach to stall may have been masked by the wake turbulence, but sufficient warning was availabl e to initiate normal stall recovery. Right after calling "Stall," the engineer called, "Airs peed! You're getting into the rudders!" (I- :17). Over the next two sec onds, the nose continued to tra ck left to approximately 20 degrees yaw and the pitch increased to 5 to 10 degrees now up. At this point, the aircraft stalled and began a descent. Nex t, two critical events happened. The FE

assessed the attitude of the aircraft to be in a fin stall and said, "Fin stall." Simultaneously, the IP, sensing an aircraft st all, instructed the pilot, "Power, add power, add power!" (I-:11). The pilot said, "Reducing, " (I-:08) and brought the throttles to flight idle. This was confirmed by the sound of t he landing gear warning horn from I-:08 to I-

:06.

During the rapid sequence of event s, the IP did not instruct the pilot to push the nose down to complete the stall recovery procedur es. Additionally, the inexperienced copilot neither said to push the nose down, nor di d he take action to push the nose down. When the aircraft yawed to the left, none of the crewmembers exper ienced any strong

lateral forces. Had this been a true rudder force reversal (fin stall), the standing crewmembers would have had difficulty performi ng their duties. Ae ronautical engineers knowledgeable in the rudder force reversal phenomenon characterized it as a violent maneuver that exposes the crew to substantial lateral forces.

When the power was reduced to flight idle (I -:08) the aircraft ente red a power-off stall from which recovery was not possible. The pilot recognized t he impending crash and reapplied nearly full power (I-: 06). In an attempt to stay airborne, he continued to hold back pressure on the yoke. The aircra ft impacted the ground in a power-on stall condition, 5 to 10 degrees nose high, appr oximately 60 degrees ri ght bank, at a low forward groundspeed of 85-95 knots.

The first people to arrive at the crash si te were two combat control team (CCT) members who were the ground party on the dr op zone. The next two people to arrive were civilians who were working nearby. O ne CCT individual and one of the civilians moved the evaluator flight engi neer away from the burni ng wreckage. The other twoKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-16 01 OCT 10 people assisted the instructor pilot survivor . The CCT searched for other survivors

without success.

CONCLUSION

The pilot had difficulty mainta ining formation position and afte r slowdown was constantly flying close to the lead aircraft. The pilot st alled the aircraft. Th e aircrew misidentified

the condition of the aircraft to be a fin stall. The IP fail ed to direct the proper stall recovery. The board recognizes long-standing efforts of MAC and AFLC to develop and acquire a new stall warning system for t he C-130. While these efforts should be continued, the aerodynamic or natural stall warning charac teristics of the C-130 are sufficient to alert trained aircrews of an appr oaching stall in suffici ent time to react.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-17 01 OCT 10 IN-FLIGHT STRUCTURAL FAILURE , EXPLOSIVE DECOMPRESSION

GOOD CREW COORDINATION

NARRATIVE

The mishap aircraft was on a transoceanic missi on, cruising at flight level FL 220, and the autopilot was engaged. A 5000-foot cabin altitude was being maintained with a pressure differential of 13.5 in ches of mercury. Flight c onditions were VMC, negative turbulence, and cloud tops at 6,000 feet. At the time of the mishap, the aircrew noted an explosive sound and a white mist. The pilo ts also stated that the aircraft pitched down and began a slight right turn. Both pi lots felt pressed up into their shoulder harnesses while several unrestrained passengers reported being lifted up in their seats. At this point the autopilot was still engaged. Yoke movement was erratic, causing moderate to severe buffeting.

Once the autopilot was disc onnected, the aircraft buffe ting stopped, but a moderate

level of airframe vibration continued. Aircraft control wa s sluggish. Primary aircrew

members and both crew chiefs donned oxygen equipment. The pilot initiated a 500 to 1000 foot-per-minute rate of descent at 200 KI AS. The loadmaster informed the pilot of a large hole forward of the wing on top of the aircraft fuselage. The flight engineer (FE) scanned the aircraft engine instruments and fuel gauges. He reported number 3 and 4 main tank gauges indicated zero fuel. All ot her instrument indications were observed as normal. The pilot stated that the aircraft did not feel le ft-wing heavy. The loadmaster scanned the right wing and reported no visible l eaks. The engineer then realized the number 3 and 4 gauges were off scale lo w and pulled the num ber 3 and 4 circuit

breakers. The ACM FE came forward and re lieved the primary FE while the primary FE went into the cargo compar tment to assess damages.

Prior to the decompression, the navigator provided the aircraft commander (AC) with information on the closest emergency airfield rela tive to their flight track position. The

AC now confirmed this information with the navigator, and initiated a five-degree bank turn towards the airfield, which was 250 m iles away. The copilot (CP) attempted to declare an emergency using the HF radios.

Unable to directly contac t the ATC agency, the CP passed emergency information and diversion intentions using a nearby U.S. military aircraft to relay information. The primary FE informed the AC of associated da mage to components in close proximity to the hole. This included mission right outboar d and center fairings, damage to electrical wiring bundles and cannon plugs, bent and to rn air-conditioning ducting, and possible damage to the flight control cables. The air conditioning du cting had been blown upwards into the flight control cables, a pplying tension to these cables. The FE attempted to remove litter st raps which were entangled in the throttle/condition lever

control cables. He could not remove one of the C-clamps. He then returned to his duty

station. The crew used the aircraft sextant to further assess dam age to the top of the aircraft. They noted that the number 1 HF antenna was missing and number 2 was

disconnected from the aft mount.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-18 01 OCT 10 The crew initiated a contro llability check passing through 9000 feet MSL while in a

continuous descent. The aircraft commander elected to fly the approach at 150 KIAS using 50 percent flaps, with a planned t ouchdown at 140 KIAS. During the controllability check, the AC slowed the ai rcraft to 140 KIAS in five-knot increments and lowered flaps to 50 percent in five-percent increments. For every five-knot airspeed change or five-percent flap change, the pilot made an S-turn using five degrees of bank and make a slight pitch up and down to determine controllability. No control difficulties

were noted other than control response.

A rescue aircraft and helicopter were launched from the emergency airf ield to escort the mishap aircraft. Thirty miles from the airf ield the landing gear wa s lowered, and the AC intercepted a precision approach final with ground radar monitoring. Landing was

uneventful. Reverse thrust was not used d ue to the loose HF antenna. After landing and clearing the runway, a crewmember depl aned to determine if further taxiing was safe. From this assessment, the AC elected to taxi the aircraft to parking. Engine shutdown was uneventful. Flight time from decompression until landing was one hour

and twelve minutes.

CONCLUSION

After the explosive decompression, the airc raft commander maintained aircraft control, while the rest of the crew, including the ACMs and the crew chiefs, worked in union to assist passengers and analyze the situation. The systems within the damage area included air conditioning, hydraulics, flig ht control cables, bleed air, oxygen, and

throttle/condition level cables. A thor ough aircraft systems kno wledge and analysis was required to take the appropria te coordination corrective ac tion. The board determined aircrew actions/coordination were both adequate. During individual interviews, both pilots and both engineers st ated that mission or iented simulator training (MOST) enhanced crew coordination during this mis hap. Although an explosive decompression and subsequent structural/systems damage o ccurred in this mishap, the rapid decompression and controllability procedures were sufficient when combined with the synergistic knowledge of the crew.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-19 01 OCT 10 AIRCRAFT IMPACTED WATER LOSS OF S/A, HAZARDOUS ATTITUDES, ASSERTIVENESS

SUMMARY

The mishap flight was the first leg of a th ree-sorties, routine resupply mission carrying equipment, rations, mail and passengers. The mishap ai rcraft departed on schedule and proceeded along the flight -planned route. Once air borne the aircrew requested a phone patch with a command post for a routine operations report. This report was relayed by an airliner because the mishap ai rcraft was unable to establish direct radio

contact.

The mishap crew requested and was given clear ance to descend from flight level 220 to

200 with further clearance to descend in VMC fo r landing at their first stop. Shortly thereafter the crew attempted to make a nother routine operations report, but received no reply due to another mission working at t he time. The command post later attempted contact with the mishap aircraft but no reply was received.

The distance from the last reported intersection to the mi shap site was approximately 185 miles and the elapsed time to fly this di stance was estimated to be 61 minutes. During this leg the flight path, type of descent, airspeed used and weather encountered could not actually be determi ned. However, the mishap crew should have penetrated an overcast cloud deck at 8,000-12,000 feet and another broken deck at 1,500-4,500 feet. The visibility could hav e been as low as 1/2 mile.

The mishap aircraft was last seen visually passing over a peninsu la at 300-500 feet, then it initiated a right turn towards the open sea. Shortl y thereafter, observers and

local residents heard a loud crash from the direction the aircraft had traveled. Two

individuals rushed to the s hore and observed what they assumed was the tail section floating off the coast. The wreckage floated for approximately 15 minutes before sinking out of sight.

The aircraft was destroyed and the crew and pa ssengers, a total of 21 personnel, were fatally injured.

NARRATIVE

The mishap crew's last contact with a ground agency was through an Eastern Airlines aircraft, when they departed flight level 220 and were cleared to descend under VMC to landing. The crew had to penetrate several layers and scattered clouds could be found

as low as 300-500 feet. The di stance from the last report ed intersection to the crash

site was 185 and was covered in 61 minutes . This suggests that the aircrew maneuvered significantly to descend to a point where they could maintain visual contact

with the surface.

The aircraft was visually last seen over a peninsul a near the field of intended landing.

Weather for that area was ch anging constantly with rain, fog, and low clouds obscuringKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-20 01 OCT 10 visibility to as low as 1/2 a mile at times. The aircraft flew along a peninsula and then made a right turn out to sea. The turn could have been made for a number of reasons. As the aircraft proceeded along the peninsula, the aircrew should have been able to

observe the area of the terrain on the left. In all likelihood weather at the intended point of landing was worse than over the water. The right turn could have also been made

because of a decision to terminate efforts to reach the airport and turn away from the

mountainous terrain of the ma inland. The turn also could have been made to place the aircraft in an area of percei ved better weather. The crew could have been maneuvering for another attempt to approach the airport or to remain in visual conditions to obtain an

IFR climb clearance from a cont rolling agency. Either of the latter three would also explain the aircraft rema ining at low altitude.

When the aircraft turned to the north, the aircrew probably did not have a definite horizon for visual reference because of poor weather conditions. The aircraft could

have been flown into the water because of vi sual illusion such as a false horizon or spatial disorientation. Aircrew attent ion could have been channelized outside the aircraft in an attempt to mainta in visual contact with the surf ace. Conversely, attention

could have been focused in side the aircraft because of some aircraft system malfunction. Any of these factors could ha ve resulted in an undetected descent and bank. Although unlikely, the crew could have been faced with a mechanical problem,

which could not be resolved in the existing weather conditions and available altitude. The aircraft's initial impact with the water wa s in a left wing low attitude. The above

factors could have resulted in this attitude. Initial impact caused the aircraft to violently pitch down and rotate to the left.

HUMAN FACTORS ANALYSIS

The crew was very experienced except for the copilot w ho had only about 182 hours in the C-130. He did have, however, an aviati on degree and a civilian pilot's license. The copilot may have been hesitant to take acti on and express his opinions based on his relative inexperience. The pilot was a high ly motivated, mission-oriented flyer who may not have recognized his own limitat ions in this situation.

The weather conditions were probably a fact or in obscuring the horizon and causing a loss of perspective cues. There are three human factors, which may have contributed to this mishap.

The decision to operate the aircraft at low altitude in marginal weather conditions.

The loss of situational awareness which ca n be reconstructed by the use of two

scenarios: The loss of a tr ue horizon by cloud decks crea ting visual illusions or

the loss of outside visual cues result ing in spatial disorientation while maneuvering.

The distraction of the crew through chan nelized attention on inside or outside

factors.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-21 01 OCT 10 There is no evidence of problems within t he aircraft that would have caused channelized attention, theref ore, poor weather conditions caused an obvious focus of attention leading to a neglect of flight instruments.

CONCLUSIONS

The pilot probably violated AFI 11-202, Volume 2, General Flight Ru les in the descent through the overcast cloud laye r. The pilot operated the aircraft at low altitude in marginal weather conditions for an undetermined reason. Other violations include, overdue aircraft isochronal inspection, over due flight physical on the copilot, aircraft commander was carrying a concealed weapon lo aded with a full clip, and the alternate

destination was invalid due to insufficient rese rve fuel to reach the designated field.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-22 01 OCT 10 THIS PAGE INTENTIONALLY LEFT BLANKKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-23 01 OCT 10 LANDED GEAR-UP DURING SIMULATED ENGINE OUT LOSS OF S/A, WORKLOAD

SUMMARY

The crew of a C-130 aircraft was schedule to depart on a five-hour local sortie. The mission was to provide copilo t upgrade training, consisti ng of instrument approaches and visual pattern work for two students. D ue to local pattern saturation, the mission was scheduled and planned to be completed at a regularly used satellite base. The crew departed on schedule and accomplis hed seven instrument approaches, nine visual patterns, and twelve landings. The inst ructor pilot occupied the left seat during the first 21⁄2 hours of training with a Coast Guard copilot upgrade student in the right seat. The aircraft landed, a Marine copilo t upgrade student got in t he left seat and the instructor pilot got in the right seat.

The mission proceeded normally unt il the last visual pattern pr ior to departin g for return to base. The mishap aircrew completed a si mulated engine out landing pattern and goaround. During the three-engine go-around, the instructor pilot raised the landing gear.

Since the number 1 throttle was within five degrees of flight idle , raising the gear activated the landing gear warn ing horn. The instructor p ilot then pressed the landing gear warning horn silence switch. The instru ctor pilot raised the flaps and completed the after takeoff touch-and-go checklist. The left seat copilot maneuvered the aircraft to a closed downwind for another simulated engi ne out pattern to a touch-and-go. The number 1 throttle remained within five degrees of flight idle with the landing gear warning horn silenced. The left seat c opilot briefed the landing and directed the instructor pilot to lower the flaps to 50 percent.

As the aircraft approached midfield downwind fo r landing, tower directed the aircraft to make a left 360-degree turn. After comple ting the left 360-degree turn, the aircraft

reentered on downwind. The tower controller directed the mishap aircraft to turn to base leg earlier than the crew planned in order to establis h spacing between them and other landing aircraft. The mishap aircraft configuration was flaps 50 percent and gearup with the landing gear warning horn silenced. After completing t he turn to final and final approach, the aircra ft touched down 1,030 feet fr om the approach end of the runway, five feet left of c enterline, and slid for 3,140 feet before coming to rest 18 feet

left of centerline. The aircraft sustained subs tantial damage to t he lower portion of the fuselage and ramp. Six crewmembers egressed the aircraft with no injuries.

NARRATIVE

After demonstrating a flaps-up to uch-and-go landing, the instru ctor pilot planned for the left seat copilot to accomplish two simulate d engine out visual patterns to the runway

and then return to base. The instructor pilot transferred cont rol of the aircraft to the left seat copilot. During the downwind leg of the fi rst pattern, the instruct or pilot simulated a

nacelle overheat on the number 1 engine. The left seat c opilot reacted properly and directed the engine shutdown procedure. The instructor pilot pulled the number 1 throttle back to just above a zero torque se tting and silenced the landing gear warningKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-24 01 OCT 10 horn. The left seat copilot briefed the appr oach and landing, called for flaps to 50 percent, directed the landing gear down, and ca lled for the before l anding touch-and-go checklist. The crew completed the checklist pr ior to final. On short final, the instructor pilot directed a three-engine go-around due to a simulated vehicle on the runway. The left seat copilot increased power on engines 2, 3, and 4 to maximum power, checked flaps at 50 percent, and called for gear-up. W hen the instructor pilot raised the landing gear, the landing gear warning horn sounded because the number 1 throttle was still within five degrees of the flight idle position. The instruct or pilot silenced the horn. Once the gear was up, flaps were brought up and the cr ew accomplished the after takeoff touch-and-go checklist; they requested a closed pattern. The warning light in the landing gear handle probably remained on until the engines were shut down in preparation for emergency egress.

After turning onto the downwin d leg, the left seat copilot briefed the approach and landing, and called for flaps to 50 percent. Tower clear ed another aircraft for an opposite direction takeoff from runway 36 and instructed the mishap aircraft to accomplish a left 360-degree turn to provide spacing for the departure. Entering the turn interrupted the left seat c opilot's habit patterns, resultin g in his failure to call for landing gear extension and ch ecklist initiation. The landing gear warning horn was sounding during the beginning of this maneuv er. Approximately 15 seconds after reentering the downwind leg and when approximately abeam the threshold of the runway, tower instructed the mishap crew to tu rn base leg. Tower's intent was to allow the mishap crew to complete their touch- and-go landing before other landing traffic. Due to the proximity of the mi shap aircraft to the runway, the instructor pilot directed the left seat copilot to extend downwind a fe w seconds and to reduce the power to

minimum. As the left seat c opilot started his turn to base, the instructor pilot made the radio call, "...base gear down simulated engine out, option. " The left seat copilot reduced the power to about 2,000 inch-pounds torque, not fli ght idle, to avoid engaging the negative torque signal system. The throttl es were never pulled back far enough to activate the landing gear warning horn switches.

After completing the turn to final, the left seat copilot, using all his concentration, established the aircraft on centerline, on glid epath, and on airspeed. The instructor pilot was concentrating on the approach, coachi ng the student, and mentally preparing for the departure back to base. The flight engi neer was monitoring the runway, descent rate, and the engine instrument s. As the aircraft crossed the threshold, the left seat copilot was on centerline, on glidepath, and on airspeed. The tower controller checked the mishap aircraft to confirm its position in the traffic pattern but did not notice that the landing gear was up. The left seat copilo t flared the aircraft and touched down in an appropriate landing attitude. The unusual noise initially confused the entire crew. Both the instructor pilot and the f light engineer thought the aircraft had a blown tire. The left seat copilot brought the throttles into flight idle, then ground idle, an d used a very slight

amount of reverse thrust. The landi ng gear warning horn began sounding upon retarding the throttles to flight idle; howev er, the crewmembers on t he flight deck do not remember hearing it. The instructor pilot sa w the landing gear handl e in the UP position and the warning light in the handle illuminated and realized they had made a gear-up landing. Approximately half- way through the slide, the inst ructor pilot transmitted toKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-25 01 OCT 10 tower that they made a gear-up landing. Just prior to the aircraft coming to a stop, the instructor pilot transmitted to tower that t he crew would be evacuating the aircraft on the runway. Once the aircraft came to rest, the instructor pilot shut down the engines using the emergency egress procedures. The aircrew then egressed the aircraft in a safe and orderly manner.

HUMAN FACTORS ANALYSIS

Several factors contributed to the fact th at the mishap aircrew failed to maintain

situational awareness. The crew did not receive an aural gear-up warning. The horn would be expected to sound during the approach and landing as the throttles were retarded to near the flight idle position. However, the left s eat copilot never retarded the throttles to this range because of the highe r power setting required during a simulated engine out landing and his in tention of keeping the engines out of a negative torque condition. If the warning horn had sounded during the final approach, it may have averted the mishap.

It is highly probable that the l anding gear warning light was i lluminated for the previous three-engine approach as well as for the mis hap approach. This condition resulted in the warning light's effectiveness as a warn ing being lowered due to habituation, the adaptation and subsequent inattention to an environmental cue after prolonged exposure to it. With the aural portion of the landing gear warning system not activating and the visual portion being reduced in effectiveness fo r the mishap landing, the following human factors developed.

The left seat copilot, an initia l phase I student, was in the seat approximately one hour and thirty-seven minutes prior to the mishap. He accomplished seve ral instrument and visual approaches. Following a three-engine go-around the crew pl anned to fly a threeengine approach to a touch-and-go. The left seat copilot became task saturated during the critical phases of his la st pattern and approach. Duri ng the downwind leg, following the briefing and setting of flaps, the left s eat copilot was directed by the tower to execute a 360-degree turn into the simula ted dead engine. This interrupted his prelanding habit pattern and his a ttention was directed to re turning the aircraft to the proper downwind position. So on after reestablishment on the downwind leg, the tower requested the aircraft turn base. This resulted in a 1⁄2 mile final, which, for a pilot of the left seat copilot's experience, required a subs tantial amount of concen tration. This is especially true when it is taken into consider ation that the left seat copilot had been having difficulty landing on ce nterline on this and previous missions. Due to his preoccupation with flying the airc raft and aligning it with the runway, the left seat copilot

never directed that the landi ng gear be lowered.

The instructor pilot was occupied by clea ring and monitoring the left seat copilot's progression through the 360-degree turn and inst ructing this relatively difficult short approach. The left seat copilot's inexperienc e was evident when he attempted to make an early turn which would have resulted in a steep angling fina l. The instructor pilot corrected him. When the aircraft was positi oned on final, the left seat copilot found himself closer to the runway than he wa s accustomed to. Therefore, this approachKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-26 01 OCT 10 necessitated more attention and instructi on by the instructor pilot than had been required on previous approaches. In additi on, the instructor p ilot was occupied with opposite direction takeoff traffic, which was a potential conflict in the traffic pattern. Review of the tower tapes indicates frequent radio transmissions from the tower and

two other aircraft from the time the ai rcraft turned base until touchdown. This

combination of events contribut ed to the instructor pilot not being aware t hat the gear had not been lowered or the checklist completed.

The flight engineer was subj ect to the same anomalies of attention. Throughout the 360-degree turn and base leg, th e flight engineer was occupi ed with clearing for other traffic in the pattern. When the left seat copilot failed to init iate the checklist, the flight engineer was deprived of a cue that would have initiated his own routine associated with checking the landing gear co nfiguration. During final approach, the flight engineer was observing the runway in order to prepar e for a hard landing, if necessary. Any scanning of the instrumentati on would not necessarily reveal an illuminated landing gear warning light, due to habituation.

The C-130 flight manual indicate s that the aircraft is confi gured for a typical three- or four-engine approach on downwind. The pilot may direct lowering of flaps and gear before initiating the applicable checklist. T he pilot flying the aircraft initiates the checklist and the pilot not flying the aircraft completes the checklist. The before landing touch-and-go checklist may be completed without direct reference; however, the checklist must be referenced as a clean-up.

CONCLUSION

The instructor pilot accomplished instruction during the mission, up to the last approach, in a highly professional manner through cr itique, coaching and demonstration. The instructor pilot had his norma l sequence of events in terrupted: first by the tower call for a left 360-degree turn for spacing, then by the tower directed turn to base. He did not realize the gear had not been lowe red or that the before landi ng touch-and-go checklist had not been completed. The instructor pilot failed to provide adequate supervision/instruction by not monitoring the ai rcraft configuration during a critical phase of flight, thus allowing the left seat copilot to land the aircraft gear-up.

The mishap crew did not operate the aircraft in accordance with the flight manual. They did not properly configure t he aircraft or refer to the checklist prior to landing.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-27 01 OCT 10 COLLISION WITH ANTENNA ON NIGHT LANDING APPROACH

VISUAL ILLUSION

NARRATIVE

During a night three-engine approach into an unfamiliar airfield, a KC-130 struck a localizer antenna with its right main landi ng gear. The aircraft sustained minor damage and landed safely.

HUMAN FACTORS ANALYSIS

The PIC was a 37-year-old O-4 with 3081 hours of total flight time, 1317 in type, 3 hours in the 30 days prior to the mishap. His la st night landing was 4 months prior to the mishap. He had only made 2 night landings in the year prior, and had a total of only 4 night landings since returning to a flying st atus 18 months prior. He was a NATOPS instructor pilot, a WTI, and holds a special instrument card. He had the reputation as an outstanding pilot in the squadron. The copilo t was a 25-year-old O-2 with a total of 357 flight hours, 160 in type. He graduated from the RAG without having completed the night FAM flight syllabus.

A low prop oil light came on the #4 engine while the aircraft was en route on a transoceanic routine navigatio n-training mission. (It late r proved to be a faulty indicator). The engine was secured IAW NA TOPS and the aircraft diverted to a nearby unfamiliar field for inspection and service of the engine. Winds were 28-30 kts gusting

to 45 kts at the divert fiel d. Ceiling was 900 scattered, 1500 broken and 3000 overcast with 12 miles visibility. At 3 miles from runway threshold, the PIC abandoned his ILS approach and went visual. It was his regular practice to land 500 feet down the runway,

instead of at the 1000-foot ILS glideslope intercept, to si mulate a short field landing. The copilot, while continuing to monito r airspeed, abandoned his scan pattern and did not give the briefed altitude calls after the PIC announced he had gone visual.

The PIC was concentrating on li ne-up while looking past the bright approach lights to the dark hole where the runway was located. Approximatel y 2 seconds before impact the flight engineer, after che cking altitude visually, shouted "that's not the runway." The

aircraft struck the ILS antenna 85 feet below the normal 3-foot glideslope and 650 feet from the runway threshold. The PI C responded instantaneo usly and aborted the landing. This prevented a more serious mishap.

CAUSE FACTORS OF THE MISHAP

The AMB and subsequent endorsers concluded that t he cause of the mishap was aircrew error and supervisory error. Specific ally, the pilot, while executing a landing to an unfamiliar airfield at night, abandoned t he published ILS approach procedures in favor of a totally visual approach. He a llowed his scan to breakdown due to lack of proficiency in night landings.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-28 01 OCT 10 The aircrew also suffered a breakdown of cr ew coordination on final approach. The copilot duplicated the pilot's scan, and did not make briefed altitude calls. The aircrew did not recognize the hazard created by the night visual illusi ons they encountered Supervisory error was assigned because of a lack of minimum requirements in SOP for currency in night landings for KC-130 pilots. Annual/s emi-annual currency requirements for night hours do not ensure night landing proficiency fo r individual pilots. The squadron was cited because the copilot had not received night familiarization training in the KC-130 prior to the mishap. NA TOPS was faulted for not addressing crew coordination during the landi ng phase and for not providing adequate tasking for the navigator in the crew responsibility section.

CONCLUSIONS

The mishap aircrew were unaware of a visual illusion created by a number of factors. On the approach, the PIC had an impression of his altitude based on a visual

observation several miles out. This created an illusion that he was higher than he actually was. They crossed the coast at about 3 miles from the runway threshold. The runway altitude was 438 feet above mean sea level (msl). The runway rose 20 feet over its 8000-foot length. There was a sm all valley on the approach, approximately 50 feet deep, which terminated with a rapid rise of terrain 650 feet from the runway threshold. The ILS antenna array sat at the t op of this rise. The illusion of a higher altitude than they actually we re was created by the loss of updated visual cues. In an April 1974 APPROACH article entitled, "The Last Run of F light Nine One Five," Dr. Robert Alkov of the Naval Safety Center descr ibed the illusion that results in the aircraft arcing far below the intended gl ideslope when there is up sl oping terrain with bright lights beyond the runway and no other visual cues from the surrounding terrain. The pilot tends to maintain a constant vertical visual angle to the li ghts beyond the runway

which would cause him to land short.

The copilot failed at crew coor dination when he stoppe d calling altitude to the PIC as he was briefed to do. He felt complacent wit h his highly experienced aircraft commander at

the controls. When the PIC said he was vis ual, the copilot relaxed and became just a passenger. He should have remembered "It ain't over til it's over."KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-29 01 OCT 10 DRAGGED WINGTIP ON LANDING KNOWLEDGE, CREW COORDINATION, HALO EFFECT

NARRATIVE

During landing rollout on an i cy runway, the port wing of a KC-130F began to rise and the aircraft began to drift/slide toward the ri ght side of the runway. The number four propeller and gearbox separated upon striking packed snow.

HUMAN FACTORS ANALYSIS

The mishap pilot (MP) was a seasoned airc raft commander in P-3s and had recently

become aircraft commander in the C-130. In his training, howev er, he had never been exposed to icy runways or severe crosswinds. He was at the controls at the time of the mishap. He was a 34-year-old LCDR with 3433 total flying hours, 368 in type. He had flown 83 hours in the past 30 days prior to the mishap. He was under some personal stress due to a divorce and the death of his 5-y ear-old daughter in the year prior to the mishap. His peers described him as a well-composed, thorough, diligent pilot, who showed no outward signs of difficulty with adjustment.

His copilot (MCP) was a seas oned C-130 copilot, qualified as 2nd pilot. He was a 29- year-old LT with 1982 total flying hours, 532 in type. He had flown 68 hours in the 30 days prior. The flight engineer (MFE) wa s a 36-year-old ADJC with 9000 total flying hours experience, 7500 hours in type, 13 hours in the past 30 days. He was considered a veteran flight engineer by the squadron. His knowledge of the aircraft was never in doubt by squadron pilots.

The flight progressed without incident until destination wa s reached and they were cleared to land on runway 04. Runway conditions were repor ted as icy, but with fair braking action. On approach the winds were reported as 340 at 11 kts. They were actually 330 at 11 gusting to 19 kts. Although there was a brief discussion, prior to touchdown, of holding off the brakes for as l ong as possible, due to runway conditions, there was no thorough discussion of landing on icy runways. The crosswind factor was

not discussed at all. The aircraft touched down at 85 kts on centerline with full flaps, 2000 feet down the runway, 700 feet beyond the displaced threshold. The touchdown was smooth, but immediately a fterward the right win g dipped. The MP used the yoke to attempt to correct the attitude.

After 1800 feet of roll, the aircra ft veered slightly to the right of centerline. The pilot put reverse thrust on the port engines and posit ive power on the starboard engines. The wing lifted, then fell again. At 2700 feet of roll, the #4 outboard right prop struck the runway, 46 feet from centerline. Thirty feet later t he right wing tip struck the ground leaving a 4 1/2-foot wide gouge in the snow bank for 67 feet of travel. Flying shrapnel entered the compartment from t he right side in the area of t he prop arc. As the right wing lifted, the number 4 pr op and gearbox fell off. A fire in number 4 engine was extinguished using the fire handle. The aircraft now veered to the left of the runway and

started to slide. The MP compensated with positive pow er on the port engines andKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-30 01 OCT 10 reverse thrust on the remaining starboard engi ne. Nose wheel steering was ineffective and full braking action was app lied without evidence that the tires were grabbing. The plane came to a stop on the runway approx imately 4000 feet from touchdown with 2000 feet of runway remaining. Engines were shut down and an orderly evacuation of the aircraft took place through the left front entrance door. The aircrew and passengers egressed unharmed.

CAUSE FACTORS OF THE MISHAP

This mishap was closed out by the Naval Safe ty Center as caused by aircrew error. The pilot was faulted for failure to condu ct a thorough approach briefing: inaccurate approach airspeeds and inadequate preparation fo r landing in crosswinds on a known icy runway. He was also listed for poor tech nique in executing a landing rollout with 100 percent flaps selected; disorientation with respect to the runway centerline position during rollout; and for being unfamiliar with the cro sswind characteristics for this aircraft. The aircrew were recorded as a probable c ause factor in failing to recognize a

hazardous situation and for poor crew coordination.

CONCLUSIONS

Although the MFE had extensive experience with the C-130, most of it was with the EC130Q. The model in the mishap had only re cently been obtained from the Marines.

There are numerous small differences in thes e two models. Because of the difference in gross weights, there is a difference in the approach and landing speeds. The aircraft had a placard mounted in it which gave 3 speeds; thres hold, touchdown, and stall speeds. The MFE was accustomed to give 3 speeds in the landi ng brief; approach, threshold, and touchdown. As a result, he used the speeds given on the placard, which resulted in a touchdown speed that was actua lly the stall speed (83 kts for 100% flaps).

The crosswind component was marginal for i cy runways and out of limits with the added gust factor. Although the tower had been advised of these gusts, it did not report them. The MP, due to his years of P-3 experienc e, was put through an accelerated aircraft commander syllabus that did not allow him sufficient exposure to various landing

conditions in the C-130.

NATOPS stated that 50% flap with corre sponding higher landing speeds should be used in crosswinds and the flaps should be raised as soon as possible after touchdown. Reverse engine thrust causes increased lift on that wing wh en 100% flap is used. The MP's reaction time may have been impaired by stress from family problems that he encountered recently.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-31 01 OCT 10 HARD LANDING POOR BRIEFING, INEXPERIENC E, VISUAL ILLUSIONS

NARRATIVE

During Expeditionary Air Field (EAF) training, a KC-130 struck a berm prior to the runway sustaining damage to the right main and nose landing gear.

HUMAN FACTORS ANALYSIS

A 27-year-old O-2 copilot was t he pilot at the controls (PAC) at the time of impact. He was relatively inexperienced wi th 391 total flight hours, 196 in type. He had flown 25 hours in the past 30 days. He had never l anded on an unimproved surface. The only

time he had ever been to the airfield befor e was as a copilot observing a landing from the left seat, 5 months prio r. He had received no formal ready-room briefing from the aircraft commander on EAF landing techniques or the airfield on which they were to be made. The upsloping runway, use of a disp laced threshold, and the presence of a berm prior to the runway were not discussed. In fact, due to a last-minute schedule change,

he was not aware he would be fl ying the mission until 20 minutes prior to takeoff. This short notice did not give him adequate time to prepare for the mission. Due to a lack of dedicated flight hours for tr aining, the squadron operati ons department must often conduct training flights on very short notice.

The aircraft commander (AC) was a 27-year-o ld O-3 with 1096 total hours flight time, 911 in type, 34 in the past 30 da ys. He had only instructed on five EAF landings prior to the day of the mishap. He did not have access to a site survey, which had been made

of the field. There was no training department in the squadron to assure such information was disseminated to pilots who were new to the squadron.

The aircrew flew a low and flat glideslope, causing them to touch down on the berm. The runway had a 9-foot upslope. Neither pilot was aware of this fact. The low and flat approach was flown because of t he visual illusion caused by upsloping terrain. The AC did not understand how an upslo ping runway could affect an approach profile due to the

visual illusion. The PAC t ook the controls on downwind i mmediately after strapping in after he changed seats with another copilot who had just completed 4 touch-and-go landings. He made a long a nd wide crosswind turn from the 180 and pulled back power to 3000 inch-lbs. He ended up deep in th e approach with a str ong headwind, and was forced to add power to re-intercept the gli deslope. The glideslope was intercepted at 400-500 feet above MSL, one mile out.

The PAC then reduced power and dropped fl aps to 100%. He se t up a 500-600 fpm

descent rate and slowed to 180 kts. He left power at 300 0 inch-lbs and slowed to threshold speed of 108 kts as briefed. N ear the ground he noted an exaggerated rate of

descent. The AC felt a sensation of negative Gs, called for power and felt a tremendous jolt. The AC applied power as the aircraft bounced off the ground and began to fly again. The flight engineer (FE) called for power , advised against raising the landing gear, and asked for a damage report. The loadmaster reported that the rightKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-32 01 OCT 10 rear landing gear stru t had broken through into the cargo bay. Th e FE went aft to inspect, then came forward and asked the AC, w ho was flying the aircraft, to come aft to inspect the damage. He turned over the ri ght seat controls to the copilot, who was

seated in the rear and went aft. The new copilot declar ed an emergency and climbed to orbit at 5000 feet. The AC returned and repl aced the PAC in the left seat. The AC

discussed the situation with th e FE and called the squadron to talk to the CO and

maintenance officer about the damage. He elected to try to land at a nearby base

rather than return home. Meanwhile the FE secured the landing gear strut to the cargo

deck with chains. The crew briefed l anding gear emergencies and emergency egress procedures in accordance wit h NATOPS. The rear and forward emergency egress hatches were opened. Fuel was dumped down to 8000 lbs. Due to winds from the north, the AC elected to land on a crosswind runway rather than the duty. This would enable him to use the wind to keep the damaged right landing gear off the runway as long as possible. A low-leve l fly-over was made to allow the crash crew to assess the damage. The AC then executed a smooth l anding, stopping the ai rcraft with reverse thrust. He set the left parking brak e and the crew egressed the aircraft.

CAUSE FACTORS OF THE MISHAP

The aircraft mishap board and subsequent endorsers conclu ded that the mishap was caused by failure of the pilot in command to recognize an unsafe situation and take positive corrective action. Aircrew error wa s assigned the pilots because they persisted in accepting a low approach. The PAC was not proficient in EAF l andings. The AC was not a WTI or NATOPS instructor, but was flyi ng an EAF training evolution in violation of squadron SOP. Supervisory error was a ssigned to the AC because the PAC was inadequately briefed; and to the squadron for improperly sc heduling a flight and for not establishing the requirement to use disp laced threshold during training flights.

CONCLUSIONS

This squadron detachment has a high tu rnover of personnel , with inadequate pass down of information on the problems unique to the area and the characteristics of local

airfields.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-33 01 OCT 10 STALLED ON FINAL POOR CREW COORDINATION, JUDGMENT, AWARENESS

NARRATIVE

An LC-130R, on an authorized cargo/passenger logistics f light, crashed at a remote Antarctic field camp during l anding approach to a skiway. On final, the mishap pilot (MP), who was a flight instructor sitting in the right seat, took t he controls from the copilot who was unable to visually acquire the landing area due to lowered visibility in blowing snow. One half-mile from the skiway, at low altitude and slow airspeed, he banked the aircraft into a sharp right 30°-4 5° turn. The aircraft descended rapidly and impacted the ground ri ght wing down and nose low. On impact it rolled inverted and broke in two. The cargo se ction was engulfed in flames. Two passengers were killed, while one passenger suffered an open dislocati on of the ankle and fractured lower left leg. The pilot, copilot, five crewmember s, and two passengers received "D" class injuries. All occupants suffered momentary loss of consciousness from concussion.

HUMAN FACTORS ANALYSIS

The 36-year-old MP was a highly experienc ed LCDR with 4480 total flight hours, 2942 in type, 2217 in model. He was consi dered to be a mechanical pilot. Although he possessed an exceptional knowledge of airc raft systems, NATOPS, and the nuances of antarctic flying, he had a cava lier reputation of fl ying the aircraft close to the edge of the envelope. Ten days prior to the mishap he was seen to fly a very similar profile on approach to the same skiway. He was very aut horitarian and inflexible as an instructor pilot. Because of his domineer ing and condescending attit ude in the cockpit, several flight crew personnel request ed not to be scheduled to fly with him. The squadron NATOPS and Operations Officers had discussed with him his poor instructor technique and its negative impact on training.

The mishap copilot (MCP) was a 38-year-old LCDR with 4059 total p ilot hours, 1843 in type, 118 in model. He was convinced that he had been assigned to the MP's crew because his own seniority and ex perience would allow him to act as an effective buffer

between the MP's behavior and the crew. However, he found the MP unyielding, insisting on flying the aircra ft his own way. The MP woul d not compromise or accept suggestions on his flying style. The MCP re marked that he "felt a little burned out

because of the no-win situat ion with (the MP)." Other crewmembers commented that

there was obvious friction between the MP and MCP. The MP had been instructing the MCP to fly the final approac h profile at speeds below those of squadron and NATOPS

standards. Other crewmembers considered t he MP to be an intimidating personality.

CAUSE FACTORS OF THE MISHAP

The Aircraft Mishap Board and subsequent endorsers concluded that the causes of the mishap were pilot error, aircrew error, fa cilities and supervisory error. The MP was faulted for improper approach selection, failu re to wave off, loss of situational awareness, failing to maintain a safe ma rgin above stall speed, and NATOPS violationKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-34 01 OCT 10 for performing an in-close, low altitude, low airspeed, high ang le-of-bank maneuver. Both pilots were named for lack of effect ive communications, violation of NATOPS for failing to maintain a safe margin above stall speed on final approach to landing, and failing to maintain VMC on a visual approach. Aircrew error was mentioned for a lack of cockpit coordination because flight stati on members failed to maintain critical

information flow. Facilities were cited fo r a lack of skiway markers and electronic NAVAIDS. Supervisory error wa s mentioned for failure to st andardize instructor pilots prior to polar skiway training.

CONCLUSIONS

This mishap was caused by a violation of air discipline and gross error in judgment on the part of the MP, exacerbated by a loss of situational awareness, and a breakdown of cockpit crew coordination.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-35 01 OCT 10 AIRCRAFT DESTROYED FOLLOWING SIMULATED ENGINE FAILURE JUDGMENT, WORKLOAD, POOR COMMUNICATIONS

SUMMARY

A KC-135 aircraft was making a VFR touch and go landing with a simulated engine failure, takeoff continued, emergency to be prac ticed during the takeoff phase. During this maneuver, the aircraft departed the left side of the runway with approximately 5300 feet of runway remaining. The aircraft brok e up, caught fire and was destroyed. Five of the seven crewmembers were fatalities; two crewmembers were uninjured. The aircraft was airworthy for the entire durat ion of the flight up to the point of the mishap itself.

Direct command and control was not a contributing factor during this mishap; however, it is apparent that higher authority did not insure t hat an adequate and complete analysis was accomplished before allowing th is maneuver to be performed for training student pilots. Test flights c onducted prior to approval of this maneuver were flown and all recommendations regarding precauti onary measures to be taken before accomplishing this maneuver were included in the appropriate regulation except one: "Rotation should be delayed as necessary until rudder and direct ional control is

stabilized."

NARRATIVE

A KC-135 aircraft launched on a normal training mission and after an uneventful refueling and celestial navigat ion leg returned to base for transition training. They began their descent from the TACAN initial approach fix for a HI-TACAN penetration and approach to a missed approach. The crew subsequently performed five additional approaches. One was followed by a missed approach, the last four by touch-and-go landings. Following the fourth touch-and-go landing, the cr ew requested and received a clearance from tower for a VFR closed pattern. When the aircraft was on downwind the instructor pilot briefed t he crew that this would be a VFR four-engine approach and touch-and-go landing. He also briefed that they would be doing a si mulated engine failure, takeoff continued during the ta keoff portion of the touch-and-go.

Training records indicate that this was t he student pilot's first si mulated engine failure, takeoff continued maneuver in 20 days and his fi rst ever from the left seat. There is no

indication that the instructor had demonstrat ed the maneuver in flig ht prior to this attempt. However, he had performed this maneuver several times in the Cockpit Procedural Trainer (CPT). The training receiv ed in the CPT teaches the student to look into the cockpit to determine which engine is fa iled. This response is contradictory to what is taught in the aircraft, which is to lo ok outside. Visual cu es should be the only method used to determine control inputs wh ile on the ground. The student pilot had a tendency to "under-control" the rudder duri ng the previous engine failure takeoff continued maneuvers, which he had previously accomplished fr om the right seat. In addition, previous instructors stated that he tended to rotate before the aircraft was under control while performing this maneuver.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-36 01 OCT 10 The aircraft touched down in th e center of the runway and bo unced two or three times. Following the touchdown, t he aircraft proceeded down the runway in a three-point attitude. The flaps were reset to 30 degrees and the trim to 3.0 nose-up. Power was advanced and the engines accelerated. Afte r the power was advanced and stabilized at touch and go EPR, and prior to the 6000 feet remaining ma rker the instructor pilot

simulated failure of number 1 (left outboard) engine by retardi ng the throttle to idle. At that moment the student pilot rotated the airc raft sufficiently to lift the nose wheel off the runway and simultaneously applied full left rudder. T he absence of nose wheel skid

marks indicated the nose whee l never returned to the runway surface. One second after incorrect control input we re completed the aircraft was two feet right of centerline, slightly nose up, right wing low and beginning an rapidly increas ing side slip to the left. At this point, the instructor pilot has approximately 2.25 seconds to react and accomplish full rudder reversal before the vert ical fin stalls. If the instructor pilot does not initiate positive counteracti on by the time the rudder reaches full left, recovery is virtually impossible because the yawing mom ent cannot be reversed. This critical

reaction time factor was not discovered during the test flights conducted before authorizing this training maneuver.

At this point the aircraft continued left and the right main gear crossed the centerline and lifted off the runway 2.75 sec onds from incorrect control inputs. At 3.25 seconds of elapsed time the left main gear began to leave the runway and the aircraft heading increased from 16 to 25 degrees left of center line. The sideslip angle increased from 8 to 16 degrees and the vertical fi n stalled. The violent left yaw and roll rate continued to

increase until the outboard nu mber 1 engine nacelle contacted the runway. The number 1 engine departed the airc raft prior to the aircraft l eaving the runway. Elapsed time for incorrect control inputs is now six seconds. The nose section impacted the ground approximately 70 feet fr om the edge of the runway. The initial impact was on the left side of the fuselage just forward of the crew entry hat ch. The aircraft pivoted on its nose after initial impact, as the tail continued in a count er-clockwise rotation. This impact caused the cockpit compar tment to separate from the main fuselage in the area of the cargo door. The tail of the aircraft continued to rotate counter-clockwise and impacted the ground in the area of the boom pod after approximately 220 degrees of

rotation. The aircraft slid backwards on its tail nearly 3500 feet to its final resting place after turning 285 degrees from runway centerline. The two-crew members in the rear of the aircraft exited uninjured by jumping out of the aft escape hatch. The cockpit, fuselage and other components of the wreckage continued to burn after coming to rest.

HUMAN FACTORS CONSIDERATIONS

The following are some of human factors that were considered but were not validated:

1. Student pilot using incorrect control inpu t, thereby distracting the instructor pilot.

2. Lack of cautiousness on the part of the instructor pilo t since the student is older, previously experienced, and knowledgeable.

3. Pressure to get all the trai ning required by the mission profile.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-37 01 OCT 10 4. The instructor's self-image that he can salvage the maneuver.

5. The student pilot suddenly induces a surpri se factor into the cockpit environment not anticipated, such as st eering with ailerons, prematur e rotation, and improper

rudder.

6. A verbal communication misinterpreted by the student.

7. The hesitation by the instructor pilot to warn of possible incorrect control inputs, and take over immediately w hen performance was incorrect.

8. The instructor pilot not being conscious or aware of the full implication of the maneuver should control be used incorrectly.

CONCLUSIONS - FINDINGS

1. The mishap occurred as a result of t he loss of thrust from the number 1 engine coupled with the simultaneous rotation an d application of full left rudder. If the instructor pilot does not in itiate positive counteraction by the time the rudder reaches full left, recovery is virtually impossible because the yawing moment cannot be reversed in time to prevent a mishap.

2. KC-135 simulated engine failure, takeo ff continued on the runway was authorized without an adequate analysis of this critical maneu ver during touch-and-go landings.

3. In response to the simulated number 1 engine failure, the student pilot applied incorrect inputs by rotating premat urely and applying full left rudder.

4. The instructor pilot did not counteract t he student pilot's incorrect inputs in time to stop an increasing yaw rate.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-39 01 OCT 10 TAKEOFF ABORT, SHEARED/COLLAPSED GEAR

POOR COMMUNICATIONS

SUMMARY

The crew was attempting a wet thrust takeo ff on a wet runway at a gross weight of 252,221 pounds. Approximately 1800 feet down the runway, t he pilot initiated an abort due to a noise in the nose gear area and lo w EPR on number 3 engine. Upon initiating abort procedures, the aircraft deviated to the right and departed t he right side of the runway at approximatel y 3120 feet from the takeoff thre shold. The aircraft continued rolling for approximately 1100 feet. The nose gear separated from the aircraft and the right main gear collapsed as the aircraft came to a stop. The crew successfully egressed the aircraft. Post mishap invest igation concluded that neither material

malfunction nor maintenance error contribut ed to this mishap. Also, there was no evidence of a lack of qualification by any crewmember prior to the scheduled flight.

NARRATIVE

The pilot and instructor pilot had met curre ncy requirements but they had not flown the KC-135 for 35 and 40 days respectively. The pilot elected to make a rolling takeoff and was aware of the possibility of nose whee l scrubbing on the wet runw ay during the turn to centerline alignment. The instructor pilot stated that the pilot used approximately 79 percent RPM throughout the turn to centerline. Throughout t he takeoff roll the pilot was distracted by a noise in the nose gear area; however, the inst ructor pilot felt the noise was nothing abnormal and dismissed it as the r ough runway. The source of the noise in all probability was over cont rolling of nose wheel steer ing since a post mishap inspection determined that there was no preexisting malf unction in the nose wheel assembly.

The pilot and copilot stated t hat a sustained left rudder def lection was not used during the takeoff roll. The pilot al so stated that his technique for transfer of directional control to complete rudder input is approximately 85 knots. More positive rudder inputs should have been used to reduce the possibility of over controlling the nose wheel steering. During the takeoff roll the copilot wa s making final throttle adjustments and concentrating on number 1 engine pressure ratio (EPR) gauge. He stated that number 1 EPR would not advance beyond the 2.70 reading. He did no t notify the pilot that the engine would not produce an EP R of 2.76. As the copilot was attempting to adjust number 1 throttle, number 3 throttle decreased to 2.50 EPR setting. It is a possibility that the copilot misinterpret ed the number 1 EPR gauge as r eading 2.70 when in fact it was reading 2.80. The EPR gauge was in spected and found to be accurate. The instructor pilot also confirmed that all e ngines had reached full thrust during the initial portion of the takeoff roll. The instructor pilot stated that he saw the number 3 throttle decrease noticeably behind the ot her throttles early in the ta keoff roll. The instructor pilot did not notify the pilots of the throttle position.

The pilot continued to be distracted by t he reported noise in the nose gear area and when he saw the number 3 engine at 2.50 EPR, he elected to abort the takeoff. TheKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-40 01 OCT 10 aircraft at this point had traveled to approx imately 1800 feet on t he takeoff roll and had accelerated to approximately 85 knots. During the abort actions, engines 2, 3, and 4 were retarded to idle but number 1 engine remai ned at or near the full thrust position. The aircraft yawed approximately 10 degrees to the right and the pilot used full left nose wheel steering, left rudder and some left main gear brake to counteract the yaw. The pilot and copilot stated that no aileron inputs were used. Ailerons are effective and

could have been used to assist directional control.

In a stress and high workload situation such as this, it is highly unlikely that the pilot

could transfer his hand from the throttle id le position to the sp eed brake handle with number 1 throttle near the full forward position and not feel or hit the throttle. Post mishap analysis indicated that number 1 throttle remained ne ar full forward position approximately 15 seconds after the abort and befor e the instructor pilot discovered it and notified the crew. The p ilot eventually retarded the number 1 throttle but the aircraft had already departed the runw ay approximately 500 feet before the throttle was

retarded. The aircraft continued to roll in the mud and grass. The nose gear assembly failed due to heavy side loads approximately 300 feet prior to t he final stopping point and the right main landing gear collapsed as t he aircraft crossed an old access road. The aircraft came to a stop appr oximately 50 feet after the ri ght main gear collapsed. An attempt to cut off all th rottles after departing the runway was not accomplished until the aircraft came to a stop.

HUMAN FACTORS CONSIDERATIONS

The instructor pilot was on continuous duty for nine and one-half hours prior to the scheduled takeoff time. This may have had an effect on his reaction time and awareness during the mishap. Approximat ely 5 seconds elapsed before number 1

throttle was discovered to be near the fu ll forward position after the abort. The instructor pilot did not realize that the speed brakes had not been extended.

The pilot had not flown for 35 days and he was concerned about the IFR weather conditions. Also, the flight crew was un der some pressure to perform well since a senior staff member was observing t he flight crew for the first time.

CONCLUSION - FINDINGS

1. During the takeoff roll on a wet runway, th e pilot was distracted by a noise from the nose gear area. While making the final power adjus tments, the copilot failed to observe the no. 3 throttle slip back to a position less than takeoff rated thrust.

2. The pilot failed to correctly accomplis h bold print abort procedures; he did not retard no. 1 throttle, raise t he speed brakes and apply both brakes.

3. The pilot, instructor pilot and copilot fa iled to detect the incorrect abort procedure in time to take proper corrective action.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-41 01 OCT 10 CRASHED DURING PRACTICE INSTRUMENT APPROACH POOR JUDGMENT, OPERATING STRATEGY, LOSS OF S/A

SUMMARY

A KC-135 aircraft disappeared from radar during a practice a pproach in IMC conditions. The pilot, who was also squadron operations officer, failed to adequately plan the mission and follow prescribed inst rument procedures. The mission consisted, in part, of a series of practice instrument approache s at a field, which was below published minimums. Following the second missed appr oach and while proceeding inbound for a third practice approach the aircraft desc ended below radar coverage. The aircraft subsequently crashed in a remote area 31⁄2 m iles north of the fi nal approach course and

83⁄4 miles northwest of the field. All occupants of the aircraft were killed.

NARRATIVE

The crew departed at 0900 and fl ew at 13,000 feet to an air port for practice instrument approaches. Upon arrival at the VORTAC the crew did not request ceiling and visibility information prior to the approac h. After holding at the VO RTAC the crew was cleared for an approach to the airport. They were in structed to maintain 9000 feet until on a published segment of the approach and were given the local altimeter setting. The crew departed the initial approach fix (IAF) and flew wit hout specific clearanc e to another IAF. They flew a DME arc until intercepting the final approach course. The crew told ARTCC that they planned to fly a to tal of four approaches. The TACAN portion of the VORTAC was off the air while the crew was flying the approach. The 0955 weather observation, taken shortly after the initial approach cl earance, was a 1500-foot ceiling and one mile visibility. This placed the field below approach minimums. The field remained below minimums for the duration of the flight. At 1010 the crew was given missed approach instruction for their first low approach. They were told to execute the published missed approach procedure, climb to and maintain 9000 feet, and contact ARTCC. ARTCC

then informed the crew that radar services were terminated and directed the crew to

contact FSS. The crew tracked inbou nd on the 054-degree course on the approach

centerline but did not call when departing 9000 feet. They descended below radar coverage passing 7000 feet. The aircraft pa ssed over the airport and made a right climbing turn until disappearing into the weather. The crew contacted ARTCC and requested a second approach. As the ai rcraft ascended above 7000 feet on the centerline of the final approach course heading outbound. Radar plots indicate the crew

flew the course outbound dur ing the missed approach, ra ther than the course as depicted on the approach plate. ARTCC then cleared the crew to 9000 feet for the second approach.

The crew called ARTCC inbound for the approach. ARTCC rep lied: "Radar services terminated, and you can contact radio now, and again on your missed approach, climb out to niner thousand, and vacating five, give me a call on one thr ee three six." The crew contacted FSS, calli ng inbound for the approach. T hey were given and replied with the altimeter setting. At 1029 the aircra ft was tracking inbound on the centerline at

14 DME. The aircraft remained on c enterline and descended below 7000 feet and outKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-42 01 OCT 10 of radar coverage. The crew asked FSS to turn on the high intensity runway lights and VASI's. The reply was, "Negative, I have no c ontrol on it. You have to do it with your own radio there." Witnesses at the airpor t confirm the runway lights were not on and the aircraft passed directly over the runway at 500 to 1000 feet. Once past the departure end of the runway, the aircraft m ade another right climbing turn into the

weather. AT 1037 the crew contacted ARTCC passing 7000 for 9000 feet on the second missed approach. The crew was given clearance for the approach and

instructed to maintain 9000 feet until est ablish on a segment of the final approach course. At this point the aircraft was at 101⁄2 DME on the localizer course tracking.

254 degrees and climbing through 7000 feet. One minute later, the aircraft had crossed the course, and was approximately 1⁄2 mile no rth of the course at 14 DME and at 9100 feet. The aircraft made a right turn and roll ed out at 900 feet tra cking 052 degrees, a heading which paralleled the final approach course. At this point they were out of the radar coverage fan for the approach and had no DME informa tion. This has been verified by subsequent FAA flight checks. Furthermore, the glide slope, navigation runway, and DME flags would have been in vi ew. AT 1040 the crew was given missed approach instructions. Radar contact was terminated, and they were told again to

contact FSS. AT 1041 the crew contacted FSS, "With you, we, ah, descending seven thousand for approach." At 1041:41 the aircra ft descended below radar coverage. The last know position of the aircraft was at 7100 feet tracking 053 de grees, approximately

31⁄2 miles north of the c ourse and about 8 3/4 miles northwest of the field.

HUMAN FACTORS CONSIDERATIONS

The pilot was nearing the end of this PCS t our. This mission presented him with the opportunity to fly a memorable e nd of tour flight. The singl e significant medical finding relates to this end of tour or "finis-flight" attitude. His mission planning completely ignored weather, and he consist ently exercised poor judgm ent during mission planning and throughout the flight. As the operations offi cer, most senior individual and aircraft commander, he was the prime mover in this flig ht. He was responsible for maintaining crew discipline and ensuring es tablished procedures were follo wed. This disregard for discipline and procedures is typi cal of one who decides to fly his "finis-flight" in a grand or daring manner. All exper ts contacted believe "fin is-flights" are common, and subsequent mishaps not at all rare.

All crewmembers were current and qualified at the time of the mishap; however, the pilot had flown only once in the 30-day period prior to the mi shap flight, completing one approach and landing. The copilot had not flown at a ll in the same period. The navigator had flown only one sortie in 60 days. The lack of recent flying impaired crew proficiency and was a significant factor in the mishap.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-43 01 OCT 10 CONCLUSIONS - FINDINGS

1. Wing procedures did not provide for review and approval of all missions

2. The mission was not coordinated or approved.

3. The crew did not adequately plan the mission

4. The crew lost position orientation while maneuveri ng for a third instrument approach.

5. The crew positioned the aircraft outsi de the reception envelope of the approach navigational aids.

6. The crew violated basic instrument procedures by descending without course guidance while in instrument meteorological conditions.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-45 01 OCT 10 LOST WATER INJECTION, CRASHED AFTER TAKEOFF WORKLOAD PERFORMANCE, DI STRACTIONS, LOSS OF S/A

SUMMARY

A KC-135 aircraft crashed shortly after takeoff due to a loss of water injection to number 1 engine and apparent crosswind gust which caus ed the aircraft to roll left. The pilot overcompensated and the aircraft rolled right, resulting in the right wing tip and number 4 engine contacting the ground. At approxim ately the 1000 foot re maining marker, the aircraft became airborne momentarily, entered a stall buffet, and settled to the ground shortly after passing the departure end. The aircraft commander kept the throttles advanced attempting to gain speed for takeoff. At no time was crash landing after takeoff procedure implemented. The aircraft continued on the ground until impacting a creek embankment, broke up approximately 3800 feet beyond the end of the runway, exploded and was engulfed in flames. All crewmembers and passengers were

fatalities.

NARRATIVE

Prior to brake release for takeoff, the aircraft commander advanced the throttles and

retarded them to idle and then advanced them again. This is c onsistent with steps common with a minor water augmentation probl em. During takeoff roll a malfunction which degraded thrust occurred. This most likely was a loss of water augmentation on the inboard engines. The aircraft commander became distracted with the malfunction and did not maintain adequate crosswind contro ls and after rotation the aircraft banked sharply left. To avoid contact with the r unway, the aircraft commander pulled up on the yoke and applied right aileron control inputs. The aircraft rolled right and the number 4 engine scraped the runway leading to a loss of thrust on number 4 and loss of water augmentation on the outboard engines. At this ti me the aircraft had insufficient thrust for sustained flight and a mishap became unavoidable.

In all likelihood during the takeoff roll the pi lot channelized his attention on dealing with

water loss. Witness statements indicate d white smoke from the number 3 engine occurred at a point on the runway afte r decision speed was obtained. Analysis

concluded that failure of inboard water at th is point was consistent with actual takeoff

distance. The aircraft commander in all probability became distracted by the malfunction, channelized his attention and did not maintain proper crosswind control inputs during rotation and liftoff. Immediately a fter liftoff the aircraft yawed to the right

and banked left.

The forecasted winds and wind advisories given to the crew should have alerted them to the possibility of strong crosswinds. With the takeoff clearance, the tower accurately reported the winds of 210 degree s at 16 knots; however, su rface winds of 230 degrees (magnetic) at 16 gusting to 24 knots were recorded during the takeoff roll. Although crosswinds may have contributed to the unst able takeoff, the limits for the aircraft were

not exceeded.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-46 01 OCT 10 The aircraft was observed to abruptly pitch up and start a roll to the right. The board

concluded that the aircraft co mmander pulled back on the yoke and started the right roll to prevent the left wing tip and/or the number 1 engine from contacting the runway. This over-rotation caused a decrease in airspeed appr oaching initial buffet and loss of lateral control authority. The drop of the left wing followed by an over co rrection that lowered the right wing was consis tent with post mishap weapons systems trainer analysis profiles. These profiles indica ted that once the roll to the right was initiated in this flight regime, the roll could not be stopped until t he aircraft reached approximately 15 degrees

of bank. The board felt that the aircraft co mmander attempted to lower the pitch to gain airspeed leading to the right wing and the num ber 4 engine contacting the runway.

Based on the actual takeoff ground distance of 9985 feet, the aircraft experienced a subnormal takeoff acceleration that equates to an increased ground run of 1435 feet

and an increased takeoff time of nine sec onds. A water injection malfunction was

determined as the most likel y source of degraded performanc e. While all maintenance actions to resolve discrepancies were appropriate and no repeat discrepancies occurred, the number of times to the wate r system required maintenance increased the susceptibility to fu ture discrepancies.

HUMAN FACTORS CONSIDERATIONS

The takeoff profile was such that there was little margin for degraded aircraft or pilot performance. Additionally, in the final sta ges of the mishap, optimum pilot technique and awareness was essential for any possibility of a successful recovery.

"Awareness demands attent ion and implies a gras p of the overall situation... attention involves concentration on the appropriate things at the right time." During the takeoff sequence the aircraft experienced a malfunction leading to reduced thrust. The aircraft commander became distracted by the malfuncti on that occurred duri ng the takeoff roll

and he focused his attention toward resolution of that malfunction. The winds at the time of the takeoff resulted in significant crosswinds that required proper control inputs

to maintain the desired aircraft attitude. If the aircraft commander's attention was on

resolution of the thrust problem, there may have been a tendency to relax crosswind controls. This would be especially true if the problem occurred after decision speed but prior to liftoff.

Task management includes the ability to handl e multiple simultaneous inputs and to determine what is important. Task saturation implies the ability to devote the attention required to all tasks or situations encountered. In this mishap, the aircraft commander

was faced with a malfunction after decision s peed occurring in a very demanding takeoff environment, i.e., weight, 30-degree flaps, signifi cant crosswinds. The fact that the malfunction occurred in the most critical phase of the takeoff is significant in that it

reduced the time that the ai rcraft commander had to make an accurate decision.

Physiological factors had minimum influence on this mishap; however, significant psychological factors were present. These in cluded distractions, ch annelized attention,

the influence of stress on fine motor sk ills, and the tendency to continue on a preplanned course of action wit hout consideration of other possible viable alternatives.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-47 01 OCT 10 CONCLUSIONS - FINDINGS

1. During the takeoff roll the aircraft experienced a degradati on in thrust that led to a takeoff roll approximately 1400 feet longer than calculated for the conditions at the time. This degradation in thrust was most likely caused by loss of water augmentation on the i nboard engines after decision spe ed but prior to liftoff. The malfunction which degraded th e thrust occurred after decision speed, and this

distracted the aircraft commander to such an extent that he did not maintain proper crosswind controls during rotation and liftoff. Additionally, he rotated at charted speed in lieu of delaying rota tion to gain additio nal airspeed.

2. Due to distraction created by degraded takeoff thrust, the aircraft commander did not maintain adequate crosswin d flight control inputs during rotation and liftoff, allowing the aircraft to yaw right and bank sharply left.

3. The aircraft commander overcompensated by rotating to an excessively nosehigh attitude while applying right ailer on inputs and entered the initial buffet regime.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-49 01 OCT 10 HARD LANDING/GO-AROUND, IMPACT WITH TERRAIN VISUAL ILLUSION, WORKLOAD

SUMMARY

After completing an air refue ling mission the crew returned for a PAR approach and full stop landing. The aircraft was observed by numerous witnesses to touch down and develop a fire on the right wing. The mish ap aircraft then continued down the runway

and climbed out. At the r unway departure end the aircraft began a right turn and

continued a shallow climb. The aircraft flew about thr ee NM north northeast and disappeared behind a hill. Soon after a fireball appeared. Rescue personnel attempted to get to the scene but were unable to gain access due to darkness, flames and thick vegetation. All on board the aircraft perished.

NARRATIVE

The mishap crew was on the 27th day of a 30-day TDY. The TTF maintains two airplanes at any given time, manned by two TDY crews. The usual flying schedule includes a primary and manned spare for each mission. After the primary launches and gives an "in the green" call the spare crew is released to t he TTF office for one hour. At one hour after primary takeoff the crew is full y released. On the day of the mishap the secondary crew was recalled after being released due a low engine oil pressure condition in the primary aircraft. The reca lled crew subsequently returned to their aircraft, completed preflight and launched. After air refueling the mishap aircraft returned to base, flying an en route desce nt and PAR approach. The crew called the command post and reported the aircraft status as "code one," meaning no discrepancies.

The aircraft was handed off from the approach controller to the PAR controller. The

aircraft commander talked on the radio for the remainder of the flight and the copilot flew the approach. At six miles the PAR controller gave the "begin descent" call and they began an on-speed, 50-degree flap approach. At the pilot replied with "visual for landing, thank you," the aircraft was at 2700 foot range (from 850 foot RPI). The radar history dots showed the airplane at about 155 feet HAT at 2000 feet from the RPI and about 90 feet HAT crossing the th reshold. Continuing the progression of this convex glide path would in dicate a glide path immediately preceding touchdown of over 6.6 degrees. This glide path would have required a rate of descent of 1425 FPM. This constantly increasing g lide slope is indicative of a "push-over" and an attempt to land earlier than would be possible if following the normal three-degree glide path. The landing attempt continued a nd got steep enough to allow a touchdown not at the RPI but 42 feet prior to it.

The runway of attempted landing is 8500 by 150 feet. This is sma ller than most KC-135 crew are used to. There are problems indu ced by both dimensions being smaller. A decrease on this magnitude caused a perceived perception problem of critical landing distance. When landing on 11, 12, and 13,000-foot long runw ays there is a tendency to

be non-critical about touchdown point and complacent about st opping distance. In thisKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-50 01 OCT 10 mishap this illusion resulted in a perceived need to land early on the runway, hence the pushover maneuver. The narrowe r width also has a well-known tendency to cause a perception of being higher than actual. These smaller di mensions work in concert to reinforce the perception of being higher and farther.

As a result of this apparent perception, t he crew made the decision to go around rather

than to land. This would have been an ac ceptable decision if they had re-established themselves on a normal gli de path, adjusted the aim poi nt accordingly and landed normally. With the descent rate establish ed, recovery became impossible. A steep approach such as the one they flew requires low thrust and a high decent rate. These two factors work together against a safe re covery. The aircraft touchdown point was determined by the very wide and dark tire marks found on the runway. The tire marks indicated the heading at touchdown to be within 1.5 degrees of runway centerline, but at the time of impact, the number 3 engine stru t Overwing fitting shear bolt failed (this would require a 7G vertical force whic h would be generated by about a 900 FPM touchdown), this in turn released the number 3 engine and strut. There were aluminum scrape marks 27 feet right of aircraft cent erline and engine scrape marks indicated that the engine rotated then bounc ed and tumbled randomly 1700 feet past the aircraft touchdown point. Upon engine separation fr om the aircraft damage to 1.25-inch hydraulic lines would have resulted in virtua lly immediate loss of the right hydraulic system, which included powered rudder and outboard spoilers. The fuel system was also open through the 1.5-inch f uel line to the engine. Wit nesses stated that the right engine became engulfed in flames upon t ouchdown. With a catastrophic engine removal there would be numerous ignition sources.

After touchdown the aircraft again became airborne. Climbout was described as

shallow but not abnormal and the aircraft flew straight ahead. Witnesses described a large fire on the right wing. Cross cont rols, non-optimum pilot techniques and speed deviations from optimum were all determined to be contributing factors to the nonoptimum climb. Average clim b speed was calculated as 118 KCAS. In-flight minimum control speed in their configuration woul d have been 114 knots, power rudder off.

After passing 16,400 feet from touchdown the airplane began a slight descent from 480 feet MSL (275 FPM). At this point the airplane began a depar ture from its previously controlled condition, started rocking then ro lled left wing low, followed by a sudden descent (170 feet in 3.5 se conds at 2900 FPM). The airc raft impacted the trees, left wing down, at the top of a 28 0-foot ridge. The general wreckage sca tter was similar in

both size and distribution to another KC- 135 stall mishap. Both wreckage scatter patterns were highly suggestive of a stall, both by part distribution and size.

HUMAN FACTORS CONSIDERATIONS

During the mission, demands on the crew we re significantly increased due to the presence of darkness, visual illusions, an obscure horizon, a short runway, and a perceived pressure to avoid a go-around. The crew had the mistak en impression that they had more time, distance and altitude with which to correct back to the desired glideKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-51 01 OCT 10 path than they actually had. Thus, when t he attempted "duck-under" was begun, the

aircraft was much closer to the runway than the crew perceived.

Immediately after touchdown, the pilots were faced with an inoperative engine, a fire on the wing, inoperative instruments and cockpit lighting, and inoperative flaps. This situation of overwhelming task saturation al most certainly contributed to the apparent non-performance of emergency procedures and to the stall and resulting impact.

During the copilot's landings at CCTS, he typi cally had problems with glide path control, sink rate, aimpoints, and recognizing the need to go around. The copilot received two

sorties before his check ride. From the time he arrived at his unit, the copilot received at least the required minimum training to ma intain currency. The average number of landings for all SAC copilots was 42 for this period compared to the mishap copilot's 27.

CONCLUSIONS - FINDINGS

In addition to low flight time, the copilo t had a CCTS (TAPR) identified problem with landings.

The decision to not land and go around was probably a resu lt of the perceived landing distance problem with the 8500-foot runway. T he pilot or copilot initiated a go-around,

either too late to avert the hard touchdown or as part of the bounce recovery. Given the

information available and the limited time to process it, this was a reasonable course of action even though another alternative wa s available (abort on the runway).

Upon becoming airborne, the crew had a ta sk saturation problem due to degraded performance and multiple serious emergencie s that would have been an extremely demanding situation for any crew. With an in experienced crew that had only flown three sorties together, it was overwhelming.

Although evidence indicated that the crew could have safely recovered the aircraft, the

tasks were excessive and the loss of cont rol given the circumstances was not an unexpected result once the engine sheared off.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-53 01 OCT 10 IMPACTED APPROACH LIGHTS KNOWLEDGE, VISUAL ILLUSIONS, COMMUNICATIONS

SUMMARY

A KC-135 flight was planned as a seven-hour training sortie consisting of an air refueling and simulated data collection runs. Upon comple tion of mission airwork, a radar-vectored descent was flown to a night precision radar final. The visibility was restricted by snow and there were gusty winds . During the final portion of the approach, after decision height and visu al acquisition, the aircraft im pacted three approach lighting

structures and the crest of a ground upslope 200 feet short of the runway threshold. The aircraft continued onto the runway slidi ng in a right turning arc and departed the runway surface approximately 960 feet beyond the threshold. The wreckage came to

rest at the bottom on an embankment on the s outh side of the runway and the aircraft was subsequently destroyed by fire.

NARRATIVE

The mission progressed normally from takeoff th rough air refueling. Prior to descent the pilot briefed the TACAN pen etration and precision radar final approach. A weather update was received indicating t hat the weather was below approach minimums. As a result the aircraft requested and received a cl earance to hold at FL200. A later weather observation brought the field above approach minimums with an RVR of 2600 feet.

CCA later advised that the RV R had risen to 2600 feet and cleared the aircraft to 6000

feet then to 1700. The radar final controlle r established contact with the aircraft at 8 miles from touchdown. The aircraft was pr operly configured for a precision approach with gear down and 50 degrees of flaps. T he nominal airspeed computed and flown on final approach, 159 KIAS, was correct for the aircraft gross weight of 210,000 lbs. The pilots failed to add the 5 knots required by the wind last reported to them of 25 knots gusting to 30.

The pilot established an initial rate of de scent of 700-800 FPM at glide path intercept. This closely correlates to rates of descent which would be correct for flying the 2.7 and 2.75 degree precision appr oaches at the pilo t's home base.

In a post-mishap interview, the pilot displa yed less than working knowledge of the effect of headwind on glide path vertical velocity. The aircraft flew a "lazy-S" glide path profile

which was consistent with the pilot's misconception of the required rate of descent. The pattern continued into the visual phase of the approach. The radar final controller advised the aircraft "at decision height" and received the response, "Sir, we've got the lights." Neither pilot could recall two subseq uent glide path advisories: "Slightly below," approximately 3/4 mile from runway thres hold and "Well below," approximately 1⁄2 mile from runway threshold. The pilot also did not respond to a warning of "It looks a little low" from one of the navigators. After decision height both pilots' attention became channelized on the approach ligh ting and the pilot became preoccupied with crosswind control. In response to several questions re lating to the visual environment the pilot could only recall looki ng "real hard" at the lights. Ne ither pilot saw the green runwayKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-54 01 OCT 10 threshold lighting; however, the embedded portion of the thre shold lights was obscured by a low snow bank. The remaining approac h/runway lights, in cluding free-standing threshold lights, were operat ing and viewable from all appr oach angles. Once the pilot had allowed the excessive descent in poor vi sibility, he became visually disoriented viewing the lights through darkness and falling and blowing snow. Both pilots

maintained that the VASI lights had not been on; however, the VASI lights located 700 and 1300 feet beyond the runway threshold we re on. The pilot's disorientation was further complicated by his perception that the runway began at the la st row of red lights in the approach centerline li ght sequence. As the aircraft approached the red approach lights, which the pilot correlat ed with runway threshold, he ra ised the nose of the aircraft 2-3 degrees in preparation for the landing flare. The p ilot never saw the projected runway contact point, but he knew they were going to be in the very first part, "probably the first 500 feet." The copilo t never saw the actual runway.

The aircraft was 46.5 feet below glide path when first impact occurred. The number 3 and 4 tires clipped two approach lig hts on a lighting structure 368 feet prior to and 3.8 feet below runway threshold height. The aircraft then struck anoth er set of lights 284 feet from the threshold. The major impac t followed as the aircraft hit the approach lighting structure and ground upslope 200 feet short and 8.2 feet below runway threshold height. The aircraft bounced ai rborne and settled to runway approximately 275 feet beyond runway threshold and 7 feet le ft of centerline. The aircraft began to yaw and skid to right. The pilot attempte d to go around, but was unable to move

number 3 throttle and believed it to be in interlo ck. As the aircraft exited the runway the copilot retarded the throttles to idle. T he aircraft then experienced a rapid nose right yawing motion like a jack-knife and the ri ght outboard wing cont acted an embankment and failed just outboard of the right wing juncti on. Shortly thereafter the number 1 and 2 engines contacted the embankment and separated from the aircraft.

HUMAN FACTORS CONSIDERATIONS

The excessive rate of descent was allowe d to continue unabated. Four of the five classic component of channeliz ed attention were present: fatigue, contingency situation, lack of knowledge, and excessive motivation.

Fatigue was not a major factor but existed in some measure. Crew rest requirements had been met, but the time of the mishap was 2236 following a 7-hour mission.

The contingency situation criteri on was a significant factor. By the pilot's testimony, it

was the worst weather in which he had ever flown an approac h. It was his first landing at the field in three months and the runway was covered with snow and he was unsure of the stopping capability.

Lack of knowledge was a signific ant factor in that the pilo t clearly did not follow prescribed procedures and techniques for transit ioning slowly, as visual cues improved, from instrument to visual flight.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-55 01 OCT 10 Excessive motivation was a significant factor in that this was the pilot's first operational deployment as an aircraft commander without an instructor pilot on board. The weather was reported above minimums, which would in fer that he should be able to land. The pilot's anxiety and desire to land caused hi m to fixate on the appr oach lights. In his testimony the pilot related that his visu al cues at some poi nt suddenly stopped improving. By then, fear of not acquiring an accept able runway environment only increased his fixation on the lights to the exclusion of controller advisories and aircraft

instruments.

CONCLUSIONS - FINDINGS

1. The pilot did not understand the effect of headwind in g lide path vertical velocity and failed to stabilize the aircraft on the pr ecision radar glide path. Just prior to decision height, he allowed the rate of decent to become excessive.

2. At decision height the pilot's a ttention became channel ized on the approach lights and crosswind control, allowing the excessive rate of descent to continue

unchecked.

3. The copilot failed to effectively monitor aircraft performance and position.

4. The aircraft descended to a position fr om which the pilots were unable to correctly interpret approach and runway lighting through darkness and snow.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-57 01 OCT 10 DEPARTED RUNWAY, BROKE UP, BURNED

P & R

SUMMARY

A KC-135 aircraft returning from an air re fueling mission at home base made a hard landing and bounced back into the air moment arily. The aircraft rolled and yawed while the aircraft commander attempted to regain cont rol; he applied power to the aircraft but an asymmetric condition developed due to pow er on the number 4 engine not being fully advanced. The right wing contacted t he runway and shortly thereafter the aircraft departed the runway. All four engines and their mounts were to rn from the aircraft. The

aircraft came to rest with the nose on the ground and the tail in t he air. Passengers safely exited the aircraft moments before the aft body exploded and became engulfed in flames. Six crewmembers were fatally in jured by fire and smoke and ten passengers successfully egressed.

NARRATIVE

The mishap crew's flight duty began with a minimum interval tak eoff briefing. The aircraft departed in a two-ship KC-135A MITO/cell and conducted air refueling operations with two B-52G's. The mishap airc raft then flew a routine navigation leg and landed off station to pick up a ten-member assistance team. A practice navigational orbit exercise was the only flight activi ty accomplished enroute to home station.

The mishap aircraft was planning a full stop landing from a localizer approach. At about eight miles out approach control handed the ai rcraft over to tower. Landing clearance was received and tower gave the winds at three zero zero/three one zero at six knots. The mishap aircraft's approach to the runway was characterized by a steep glide path of approximately 4.5 degrees versus the normal 2.6 degrees for the precision approach and bank angle deviations of 10-15 degrees. T he mishap aircraft arrived over the landing threshold at an alti tude of approximately 240 f eet AGL instead of the normal threshold crossing height of 48 feet. The initial touchdown o ccurred 3,720 feet down the runway (8,080 feet remaining) with a rate of descent of 385 ft/min versus the average of 150-175 ft/min. The aircraft then bounced hard, banked slightly left, obtaining a height of approximat ely 25 feet. The aircraft re-contacted the runway 4,424 feet down the runway (7,376 feet remaini ng) with a descent rate calculated at 440

ft/min.

Aircraft power was advanced in an attempt to recover from the bounce. The aircraft briefly lifted off the runway while rolling a nd yawing back to the right. The aircraft

commander was able to maintain essentially a wings-level bank attitude. However, after power was applied, an asymme trical condition developed due to power on the number 4 engine not being fully advanced. As the right gear contacted the runway, the aircraft was in a right wing low, 8 degrees nos e up attitude and had a yaw angle of 14.5 degrees right. The right asymmetrical yaw continued to approximately 23 degrees and a bank angle of 12 degrees right. The righ t wing tip and outboard ai leron contacted the runway at this time, which wa s approximately six seconds a fter initial touchdown. FullKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-58 01 OCT 10 left aileron was applied as the aircraft continued to the right with the ri ght wing tip still in contact with the runway.

During the time the aircraft departed the pa ved surface, power was advanced on the number 4 engine. The aircraft rolled back to a near wings-level attitude with an extreme pitch attitude of at least 11 degrees. At this point, both main gear, the air-refueling boom and boom pod impacted the ground. To arrest the ri ght roll, control wheel inputs were applied to the left. As the number 4 engine spooled up, the aircraft began to roll left at a rate estimated to be 10 degrees/sec . The left wing tip then briefly touched the ground. As the aircraft passed over a slight rise in the terrain, it cont inued its left roll to where the left wing tip again contacted the ground and the botto m of the number 1 engine scraped across a paved access road with e nough force to fail the gear box angle drive on the bottom of the engine.

The number 1 engine became i noperative, which resulted in a nose left asymmetric condition. The aircraft skipped of the ground while continuing to bank to the left keeping the left wing tip in firm contact with the ground. The aircraft began a movement to 18 degrees nose down pitch as well as a bank attitude to the left, which also increased to approximately 18 degrees. Insufficient lift and ra te of climb capability existed at this time. With the left wing tip in firm cont act with the ground, the aircraft nose began a rapid turn to the left. As the aircraft turned back to the runway the nose dropped at an estimated 835 ft/min. Number 1 and 2 engines impacted the ground, followed shortly by the nose gear and forward fuselage. The nose gear was torn out of th e aircraft to the left, which severely crumpled the left side of t he forward fuselage. Additionally, all four engines with their forward and aft mounts we re torn loose from the engine strut structure by side loads and departed the aircraft.

The aircraft came to rest at a point 6,824 feet down the runway and 663 feet right of runway centerline. The airc raft initially came to rest with the nose on the ground and the tail high in the air. Passenger egress started imm ediately via the aft emergency escape hatch. The ten passengers were obs erved egressing from the aircraft and were transported to the base hospital. Seconds after passenger egress, the aft body tank exploded and the tail sect ion fell to the ground.

HUMAN FACTORS CONSIDERATIONS

The aircraft commander was under a number of psychological stressors, which had accumulated in the months prior to the accident. The aircra ft commander had landing problems during UPT, CCTS and with squadron instructors. He was not authorized to supervise his own touch-and-go landings. This was a blow to his professional stature as an aircraft commander. Two additional psyc hological factors were stressors for the

aircraft commander. He was re cently married and had just purchased a house. These factors reflect increased stress due to adj usting to a new marriage and increased financial responsibility.

The aircraft commander was flying with a waiver for defective distant vision in his right eye. He was also known to be using weaker glasses t han required under the terms ofKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-59 01 OCT 10 his waiver. With substandard correction t he aircraft commander could meet Air Force standards when well rested, and squinting, but he had diminished visual acuity and depth perception when tired. He had experienced two consecutive nights without his normal sleep quantity. The aircraft commander 's depth perception problem may also help explain the recurring landi ng problems throughout his career.

There is evidence to support the claim that the mishap aircraft co mmander would allow deviations from standard operating pr ocedures and flying regulations.

CONCLUSIONS - FINDINGS

The basic cause of this mishap was pilot e rror. However, supervisory failure and a

breakdown of crew coordination were also causal factors. The aircraft commander had a history of landing difficulties. There was no evidence presented which indicated that the aircraft commander's flying skill problems were brought to the attention of the senior wing staff. No evidence was fo und to indicate that any me mber of the crew attempted

to influence the aircraft commander to make a go-around. The p ilot probably would not attempt to interfere with the airc raft commander's approach and landing.

Following two firm touchdowns and high bounc es the crew attempted a bounce recovery. The rapid departure from the runw ay was caused by asymmetric thrust. This condition developed as a result of the pilots failing to advance the number 4 throttle during the attempted bounce recovery. After t he aircraft came to a stop the crew was incapacitated.

1. The mishap unit's internal review proc ess was not effective in identifying the mishap aircraft commander's landing pr oblem as severe or recurring.

2. Although squadron supervisi on identified landing prob lems and despite several marginal flights with instru ctors, they considered t he mishap aircraft commander qualified and safe and allo wed unsupervised flight.

3. Due to a defect in pilot skills, the aircraft commander flew an unsafe approach and landing.

4. In violation of T. O. warnings, the p ilots delayed the bounc e recovery until after

the second bounce.

5. During the bounce recovery, the pilots fa iled to advance the number 4 throttle, which led to an asymmetric thrust situat ion. They also failed to apply correct flight control inputs.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-61 01 OCT 10 COLLISION WITH GROUND

TASK MANAGEMENT BREAKDOWN

NARRATIVE

The mishap flight was an A-7 Replacement Training Unit (RTU) surface attack tactics mission (SAT-3). The mishap pilot (MP) wa s to provide adversary and forward air control (FAC) support for a four-ship flight of A-7 aircraft. The MP took off before the four-ship flight and was waitin g in the Military Operations Area (MOA) to intercept the flight as briefed. The MP probably saw the flight, and turned to intercept them while he was flying over sloping terrain. His turn to intercept the f our-ship resulted in his flying toward rising terrain. Bank angle at impact in dicated the pilot was pu lling sufficient G to impair his peripheral vision, wh ich may have contributed to his failure to see the rising terrain as he attempted to reta in sight of the flight. The right wing hit a ridge 10 feet below the crest, and the rest of the aircraft impacted 750 feet bey ond. There was no attempt to eject, the pilot was fatally injured, and the aircraft was destroyed.

HUMAN FACTORS ANALYSIS

The MP was 34 years old with 15 39 hours total flying time, 232 on aircraft type. He was

an athletic individual who followed a regular exercise schedule. There was no particular stress on the mission; it was a routine training flight. The MP was uniquely suited for the mission, having an extensive aggresso r background. He had demonstrated a history of sound judgment and decision-making and all super visors noted that he was a pilot they would send on a mission with little or no supervision. During the mishap flight the MP apparently showed sound, conservative decision-making. The MP's judgment broke down, however, when he rolled into the final right turn and did not look out the

front of the aircraft to clear his flight path.

CAUSE FACTORS OF THE MISHAP

The Safety Investigation Board's findings were that low altitude task management breakdown and visual misperceptions caused th is mishap. On the mishap sortie, the MP allowed the mission task of completing the intercept to take priority over terrain clearance tasks, i.e., the MP 's cross-check between terrain clearance tasks and

HUD/radar altimeter tasks broke dow n and he failed to clear his flight path. It was also

determined that the MP failed to see the ri sing terrain early enough to avoid a collision due to spotty lighting conditions, a lack of vegetation (providing no contrast), and "G" effect on peripheral vision which mask ed speed rush cues of an impending ground impact.

CONCLUSIONS

This very responsible, very capable pilot ch annelized his attention so lely on the task of completing a low-level intercept and, due to a breakdown in task management, failed to perceive the rising terrain in front of his aircraft and was fata lly injured on ground impact.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-63 01 OCT 10 COLLISION WITH GROUND CHANNELIZED ATTENTION, PR IORITIES, COMPLACENCY

NARRATIVE

The mishap pilot (MP) was the instructor for a two-ship A-10 Replacement Training Unit (RTU) surface attack sortie. Prior to th e mishap, the flight had accomplished low altitude navigation and tactical range work. After exiting the range, the MP gave the navigational lead to the upgrading pilot and dropped back to chase from a wedge formation position. The student initiated a 90- degree turn. As the mishap pilot rolled out of the turn, his aircraft impacted a ridge line, clipping the right wing and the tail. Realizing the aircraft was out of control, the mishap pilot ej ected, suffering a broken arm and concussion. The mishap aircraft impacted the ground and was destroyed.

HUMAN FACTORS ANALYSIS

The MP was a 31-year-old pilot with a total of 2494 hours, 1138 on aircraft type. The

MP was characterized as an excellent/above average pilot. He was very motivated to provide maximum student training. His technique was to expose his student to maneuvering and formation positions expect ed from a wingman. He allowed his technique to distract him from his responsibility of instructor/chase in his attempt to fly a precise formation; situati onal awareness deteriorated and he failed to meet his responsibility to clear his own flight path.

CAUSE FACTORS OF THE MISHAP

The Safety Investigation Board's findings were that the MP failed to perceive a threat from high terrain in his intended flight path because of a combi nation of channelized attention, geographic mis-or ientation, complacency and task prioritization. Reconstruction and testimony from the MP suggest channelized attention was the most significant factor in the MP's failure to acqui re the ridgeline in th e three miles prior to impact. The MP stated that he monitor ed the student throughout his reposition maneuver to wedge formation. In his atte mpt to fly precise formation, the MP

channelized his attention on the student.

An explanation for the MP's lack of concer n with his flight path is geographic misorientation. This would account for the MP's perception that the fli ght was in the middle of the valley and well clear of high terrain. The MP was also satisfied with his formation position and his perception of th e student's flight path in relati on to the high terrain. The MP was not aware of the ridge line in his flig ht path, and his mis-orie ntation led to a lack of concern with the high terrain. The possibili ty of insidious complacency is increased due to the student's strong performance on the range. The MP's loss of situational awareness resulted in inappropriate task priori tization. The MP failed to allot adequate

time to terrain clearance ta sks in his attempt to fly prec ise formation and monitor the

student.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-64 01 OCT 10 CONCLUSIONS

This conscientious, well motivated instru ctor pilot became too engrossed with his precise formation flying and, for a number of reasons, failed to de-conflict his flight path and struck the ground.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-65 01 OCT 10 COLLISION WITH GROUND

CHANNELIZED ATTENTION

NARRATIVE

The flight was briefed as a four-ship surf ace attack mission with a planned low altitude tactical navigation route to a range for st andard bombing/strafing events, then RTB. The Mishap Pilot (MP), number 1 of 4, was acting as instructor for number 2, who was in the mission qualification- training program. Number 2 had fouled in low angle strafe the previous day for firing past the cease- fire line. Lead and 2 had pre-briefed for approximately one hour the afternoon prior to the mis hap and the mission was briefed on the day of the mishap. Fo llowing the MP's last strafe pass, the MP made a normal pull off and began a left turn out. The ai rcraft impacted the ground approximately 16 degrees nose down in a 45-degr ee left bank, 19 seconds after firing his burst, and the pilot was fatally injured.

HUMAN FACTORS ANALYSIS

The MP was 27 years old with a total of 1129 hours, 908 hours on aircraft type. He was fully qualified, properly trai ned, and in good health. Airbor ne Tape Recordings (AVTR) revealed that the amount and length of co mmentary offered by the MP showed an inordinate concern for number 2, who had been performing well. Life support analysis

showed the MP was turned to the left with his head forward and left of the headrest, looking left at impact.

CAUSE FACTORS OF THE MISHAP

The Safety Investigation Board's findings we re that the MP wanted to see number 2's firing burst and was looking back as he apex ed in his pulloff, channelizing his attention and did not recognize a high si nk rate developing as he ma intained a high bank angle in a low G loading. The MP continued a slow but constant reduction of bank as he watched number 2 and finally collided with the ground.

CONCLUSIONS

This fully qualified, well- trained pilot became so engross ed with watching his number 2's performance that he forgot to fly his own aircraft and flew into the ground.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-67 01 OCT 10 COLLISION WITH GROUND COORDINATION, CHANNELIZED ATTENTION, ILLUSION

NARRATIVE

The mishap aircraft was number two of a two- ship night air-to-surface weapons delivery mission. The mishap flight took off and entered a night low level to the range with the mishap aircraft in 2 NM trail. At a preplanned point the Mis hap Crew (MC) was to increase their spacing to 4 NM in preparati on for a level-bombing pass. The mishap aircraft crashed 5.0 NM short of the target and prior to simulating any weapons delivery. There was no attempt at ejection.

HUMAN FACTORS ANALYSIS

The Mishap Pilot (MP) was a 28-year-old wi th 1,680 hours total flying time, 130 hours in type. The MP was fully qualified for the mission. The flight lead had briefed that the MC should take spacing by "reduc ing power and making small S-turns." The MP may have

taken this as a subtle hint to continue to reference lead for azimuth and elevation during the spacing maneuver. During t he low level, using visual references, the MP apparently became comfortable in a positio n that placed the mishap aircraft 400 feet below lead for the entire low level. The MP pilot most likely became very concerned about losing a

visual on lead while ta king spacing. The MP would have been forced to fixate on lead to maintain a visual when getting further back in trail. Keep ing lead at the same reference point on the windscreen during t he deceleration and spac ing maneuver would require the MP to continue to descend further below lead's altitude. The S-turns and subsequent acceleration to 500 KIAS would have exacerbated this illusion. This visual illusion led to the aircraft descending into th e ground. The MC instrument cross check

and crew coordination broke down.

The Mishap Weapon Systems Operator (MW SO) was a 34-year-old with 1,120 hours total flying time, 1,000 hours in type. The MWSO was fully qualified for this mission. On final for a radar delivery, the MWSO mo st likely channelized his attention on refining the radar for the delivery.

The mishap occurred on the last day of an O perational Readiness Ex ercise (ORE). The flight lead briefed not to let their guar d down. The MC could have been fatigued.

CAUSE FACTORS OF THE MISHAP

The aircraft mishap board's findings as mo dified by subsequent endorsers were that the crew caused the mishap. The MC's a ttention may have been channelized toward keeping a visual on lead and refining the radar for a good bomb and not toward the task of maintaining a safe altitude. The MC may have been complacent because the ORE was winding down, the mission was in good weather, the ride was a "milk run," and the

low-level altitude could be maintained using visual references under the moon

illumination. Neither the MP nor the MWSO applied the proper cockpit cross check to maintain the required altit ude control at low altitude.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-68 01 OCT 10 The flight leader briefed the MC to increase spacing from 2 NM to 4 NM by decreasing power and making small S-turns, in preparation for the level bomb delivery. En route, the MP established a position based on visu al references, which he incorrectly perceived to be nearly level with the lead ai rcraft. During the spacing maneuver and

descent to final run-in altitu de, the MP most likely continue d to use visual references

from the lead aircraft for azimuth and elevati on information. Using visual reference exclusively, the MP would have experienced a visual ill usion perceiving that he was nearly level with the lead aircraft while in fa ct he was lower than lead and descending. The MP most likely channelized his attenti on on the lead aircraft while the MWSO

channelized his attention on the radar. Neit her crewmember properly monitored flight

instruments. A breakdown in crew coordination occurred, wh ich allowed the aircraft to descend below the planned run-in altit ude and the MAJCOM-directed minimum night weapon delivery altitude. Neither crewmem ber attempted to recover the aircraft or initiate ejection.

CONCLUSIONS

The MC did not properly coordi nate their responsibilities durin g a very critical phase of flight. Both crewmembers channelized their attention and this prec luded either from recognizing their shallow descent into the ground.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-69 01 OCT 10 CONTROL LOSS, EJECTION LACK OF COMMUNICATION, COORDINATION

NARRATIVE

Mishap aircraft and crew were deployed to pr ovide mission support (adversary air) for

C-130 Low Altitude Air Threat Awareness Training (LOWAT). The mishap aircraft was configured with a centerline f uel tank. The aircraft took off and entered the military operating area (MOA), established an orbit at 8,500 feet MSL (5,000 feet AGL), and

waited for the arrival of the C-130's. Prior to intercepting the first C-130, the mishap aircraft was placed in a stalled/ loss of control condition from which it was not recovered. The WSO initiated a dual sequenced ejection out of the envelope, which proved fatal to both aircrew. The mishap aircraft impact ed the ground seven minutes after takeoff.

HUMAN FACTOR ANALYSIS

The mishap pilot (MP) as a 27-year-old wi th 550 hours total flying time, 330 hours in type. The MP was an inexperienced part-time ANG pilot. He was recently hired by an airline, which accounted for a move halfway across the continent. This new job and move accounted for a decline in the partici pation in unit activiti es. His wife had a complicated pregnancy that concluded 3 months prior to the mishap. The MP averaged seven sorties per month for the first half of the year while his peers had been averaging about 20 sorties per month. The MP h ad been counseled for losing his LOWAT currency 3 times and landing currency 4 times in the previous 12 mont hs. He had also missed 7 of the last 12 Unit Training Activity (UTA) weekends. Most likely to keep out of trouble, the MP had falsely logged four LOWA T sorties in the previ ous 4 months for an

indicated total of 5 LOWAT sorties. The MP was not current/qual ified for the mission; however, this was not evident to the training officer. Based on th e currency information

available and that the MP had flown this mission scenario previously, the MP was scheduled for these LOWAT support sorties.

The Mishap Weapon System O perator (MWSO) was a 39-yea r-old with 2170 hours total flying time, 1080 hours in type. He was fully qualified for the mission.

CAUSE FACTORS OF THE MISHAP

The aircraft mishap boards's findings as modified by subsequent endorsers were that the aircrew caused the mishap. The pilot fals ely recorded training events, most likely in an effort to prevent more confrontation with his supervisors ov er a low level of participation in his flig ht activities. This false documentation presented his supervisors and schedulers with an inaccurate picture of his currencies and qualifications. The MP had flown this type of LOWAT mission wit h C-130s previously and was scheduled on this deployment in an attempt to get his sortie count up. The MC a llowed the aircraft to

slow below minimum Dash One reco mmended minimum maneuvering airspeed and started a decent. Improper crew coordinati on and channelized att ention accounted for the ignored indications of a slow airspeed and excessive decent rate. The MP, having recognized and reacted to the altitude loss, im properly applied flight controls and powerKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-70 01 OCT 10 resulting in a stalled aircraft. The stall deve loped into a departure at low altitude. The WSO initiated a dual sequenced ejection out of the safe ejection envelope and both crew members were fatally injured on ground impact.

CONCLUSIONS

The MP's falsification of fli ght training records led to his being scheduled to fly a mission for which he was not qualified. During a basic flight maneuv er, holding, crew coordination broke down to a point that both crewmembers channelized their attention on maintaining visual contact with their first target aircraft to the exclusion of flight parameters. An abrupt reacti on to stop the descent rate resulted in the aircraft being stalled and subsequently depar ting controlled flight.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-71 01 OCT 10 LOSS OF CONTROL

AIRSHOW AND COPILOT SYNDROME

NARRATIVE

While on a scheduled airshow sortie, the Mishap Crew (MC) was scheduled to perform a high-speed pass, a low-spee d pass, and then return to home base. The aircraft was configured with three external fuel tanks, a travel pod, and a full load of fuel. The MC

held for 25 minutes at low altitude befor e making their first high-speed pass (estimated 650 KIAS, 150 feet AGL). Duri ng the transition turn for a slow-speed pass, the tower informed the MC that a part had fallen off thei r aircraft. The MC co nfigured the aircraft and flew the slow-speed pass as low as 50 feet AGL and as sl ow as 160 KIAS with a computed Angle Of Attack (AOA) of 22.6 units . During the transition turn (45 to 75 degrees of bank, high AOA) for a second hi gh-speed pass, the aircraft was maneuvered (overshooting centerline) into a position from which recove ry was not possible. The dual sequenced ejection attempt, out of the envelope, was unsuccessful. The aircraft was destroyed upon water impact.

HUMAN FACTORS ANALYSIS

The Mishap Pilot (MP) was a 31-year-old win g-training officer wit h 1,270 hours total flying time, 1,000 hours in type. Norma lly, the MP displayed good judgment and conservative decision making processes. While watching a Jaguar fly by in slow flight, the MP commented that he wished he could do that. The MP knew something had fallen off the aircraft yet elected to do ano ther high-speed pass. While overshooting final, the MP appeared to tighten up the turn, causing the aircraft to lose airspeed and exceed critical AOA. It appeared the MP was interested in pu tting on a "show," not just flying a mission; this was not consistent with his normal behavior.

The Mishap Weapon Systems Officer (MWSO) was a 24-year-old with 223 hours total flying time, 133 hours in type. He was an inexperienced and quiet person who had a tendency to not make inputs to correct erro rs. Most likely he was experiencing the copilot syndrome and would not question airspeed or altitude.

The Deputy Commander for Operations had not passed the USAFE guidance OR requirements for airshow maneuvering to the squadrons. Local guidance on airshow maneuvering was not readily av ailable. Squadron superviso rs had come to consider this airshow mission as commonpl ace and had not briefed the MC.

The guidance from USAFE required the follo wing: weather requir ed was a 2,000 foot ceiling (Wx was 600 feet); speed restrictions were 550 KIAS max and not above normal approach (19.2 units min) speed (650 KIAS flown and 22.6 unit s); altitude minimum was 500 feet (150 feet and 50 feet flown).

Although the MC violated the USAFE airshow re strictions, there is no indication they were aware of them. They were, however, aw are of the standard rest rictions that theyKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-72 01 OCT 10 violated, including the restrict ion on the use of afterburner below 1,000 feet and the 500 KIAS limitation on the travel pod.

CAUSE FACTORS OF THE MISHAP

The aircraft mishap board's findings as mo dified by subsequent endorsers were that the pilot's lack of discipline and the lack of pr oper guidance by the supervisors caused the mishap. The MP was also named causal fo r demanding more from the aircraft than it was aerodynamically capable of a ttaining. In addition, t he inexperienced MWSO most likely did not provide any input as the mis hap aircraft lost a part on its first high-speed pass, flew slower than "On Speed" during its slow speed pass, and was not allowed to accelerate prior to starting the maximum AOA turn which resulted in the aircraft departing controlled flight.

CONCLUSION

Wing and squadron supervisors did not provide t he aircrew with sufficient information or guidance to perform their mission. The MP displayed uncharacteristic behavior and lack of discipline by electing to fly an airc raft with a suspected malfunction and by violating known directives. The MP aggres sively maneuvered below a reasonably safe speed at low altitude. That ma neuvering caused the loss of control of the aircraft. The MWSO apparently did not attempt to prevent the MP from continui ng the airshow or from exceeding the capabilitie s of the aircraft. There we re communications breakdowns

at all levels.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-73 01 OCT 10 MIDAIR COLLISION FLYING UNBRIEFED MANEUVERS, FATIGUE, DISCIPLINE

NARRATIVE

The mishap sortie was a scheduled two- ship neutral BFM upgrade mission for the Mishap Pilot (MP) number 2 as par t of his TX syllabus RTU pr ogram. MP number 1, an instructor pilot, had briefed the mission IAW directives and the syllabus requirements, which specified tactical intercept training, followed by neutral Basic Fighter Maneuvers (BFM). The IP briefed aircraft handling ex tensively and included a thorough discussion about aircraft handling during a scissors. The IP then mentioned to MP number 2 that

he would see a scissors on the mission. Star t, taxi, takeoff, en route, and intercept training, including neutral BFM, were uneventful. MP number 2 then called joker fuel.

The IP then directed MP number 2 to hol d 350 KIAS and start a climb and that they would do a scissors exercise from this point wit hout a turn away. At "fights on" call, the IP abruptly pulled high to MP number 2's 6 o'clock position. The scissors exercise progressed rapidly to a nose-high slow -speed fight with both aircraft falling uncontrollably towards each other. The result ing impact killed the IP instantly; rendered

MP number 2's aircraft uncontrollable from wh ich he ejected. MP number 2 received minor ejection injuries.

HUMAN FACTOR ANALYSIS

The IP was a 32-year-old F-15 pilot with 2,769 total flying hours, 987 F-15 hours with 389 as an IP. MP number 2 was a 38-year-o ld former F-15 pilot undergoing recurrency training with over 1,000 F- 15 flying hours, 479 as a former IP. MP number 2 was

described as one of the "bes t track II students seen to date." The IP was heavily tasked in his daily duties. He was a flight commander, SEFE, squadron phase briefing monitor and project officer for an upcoming HHQ Stan Ev al visit. During his off time he was pursuing a masters degree, wa s an instructor for a bible study group, and participated in a church basketball league. In addition, his wife and two children all had the flu the week of the mishap. The IP had flu sympt oms the day before and had taken himself off the flying schedule. The investigation boar d determined the IP had less than 13 hours sleep during the prev ious 48 hours.

Both pilots violated known directives. Th e IP exceeded guidance in the syllabus by using more power than called for in the m aneuvers and flying a scissors maneuver in violation of the syllabus and without first briefing the maneuver. This caused great

confusion on the MP number 2 w ho did not know what to expec t from the IP or what he, MP number 2, was expected to do. Finally, both pilots failed to comply with numerous rules of engagement by not stopping th e scissors when the maneuver became dangerous, and when the 1000-foot bubble was broken. The IP abandoned his role as an IP, lost self-control, and fought MP number 2 as an equal pilot. This was most likely compounded by fatigue and an underlyi ng competitive personality.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-74 01 OCT 10 CAUSE FACTORS

Supervision was faulted for loading down t he IP with duties that detracted from his duties as a flight commander and SEFE. The IP 's judgment was felt to be impaired due to excessive personal commitm ent, fatigue, and illness. The IP was faulted for breech of discipline due to the numerou s violations of the syllabus. The MP number 2 was also faulted for judgment in that he also ha d a responsibility for stopping the final engagement, but allowed the scissor to pr ogress below controllable airspeed.

CONCLUSION

All members of a formation, regardless of po sition, are responsible for the safe conduct of every mission flown. Pilots are not supe r humans, but just people too, and need to recognize the limits of their capabilities. Once again, the rules are in the books for a reason. There are usually a lot more reas ons to follow the rules than to break them.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-75 01 OCT 10 COLLISION WITH GROUND SUPERVISION, DISCIPLINE, COMPLACENCY, OVER-CONFIDENCE, AND TASK SATURATION

NARRATIVE

The mishap sortie was a single-ship aircraft change out at a distant alert base. The filed

route was direct to the aler t base with an intermediate stop at a MOA for air work. During the initial contact with center, the pilot requested a change to his clearance indicating stops at two intermediate bases fo r practice approaches. He was informed by

the center controller that onl y the VOR was available at one of his requested bases due to other equipment being NOTA MED out of service. The pilot changed his request to stop at only the other bas e prior to continuing to his dest ination. Following completion of his MOA work, he proceeded to the inte rmediate field for his approaches despite being advised of deteriorating weather at his final destination. The pilot coordinated for an ILS low approach to be followed by some VFR sightseeing. As the pilot let down towards the intermediate location, the weather there was also rapidly deteriorating. During the approach, the pilot seemed rus hed, made a number of procedural errors, missed the approach, and was asked for his int entions by the controlling agency. The pilot, now clearly in the clouds, asked for a tu rn to remain VFR. The aircraft then impacted a hill approximately 2220 feet MSL while still on cent erline for the runway after failing to execute the published missed approach procedure.

HUMAN FACTORS ANALYSIS

The mishap pilot (MP) was 36, an experienced F- 15 pilot with over 2880 total flying

hours and 867 F-15 hours. He was current and qualifi ed for the mishap mission, a relatively undemanding one. During the inve stigation, the MP was discovered to have been receiving contact lens therapy from priv ate ophthalmologists for the previous 10 years to improve his visual acuity. Had the MP been lax about wearing his lenses during the previous 72 hours, he would ha ve had difficulty reading his approach plate, especially in darkened weather conditions. The pilot changed hi s original flight plan to induce a series of practice approaches at an intermediate base, but failed to check NOTAMS or weather as required. Flight pl anning was a factor. The pilot was violating longstanding directives regardi ng wear of contact lenses, was in the "red" for overdue annual survival training and was not wearing mandatory cold w eather flying clothing. He changed his planned route of flight without coordi nating with operations and indicated intent to fly VFR in violati on of command and Air Force directives. He exhibited an air of complac ency by not reviewing a relati vely complex approach he was obviously not familiar with and electing no t to continue immediately to his planned destination despite being advised of poor w eather there. In an attempt to fly the approach anyway, he became task saturated, wa s unaware of his close proximity to high terrain, and impacted rapidly rising terrain.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-76 01 OCT 10 CAUSE FACTORS

Complacency, inadequate pla nning, discipline, lack of situational awareness, overconfidence, and a f eeling of invulnerability all co mbined on this day in an error chain that led to this pilot's death and the destruction of his ai rcraft. Also faulted was an inadequate program to make pilots aware of hazards at local divert fields and an inaccurate depiction of the locati on of the mountain the MP hit.

CONCLUSION

This pilot had a long chain of discipline prob lems, complacency, and overconfidence on this flight. Similar tendencies had been previ ously exhibited by the pilot. During the mishap, he received numerous indicators that he should have recognized were trying to tell him it just wasn't his day. But, because of his personality type, an d the fact that no one had attempted to correct him previously, he blindly pressed on, confident his experience and skill would take him safely to his destination.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-77 01 OCT 10 UNAUTHORIZED FLY-BY, AIRCRAFT BREAKUP

SUPERVISION, DISCIPLINE, COMPLACENCY

NARRATIVE

The mishap pilot and his airc raft were sitting alert when he was scrambled on a routine practice intercept mission. During the mi ssion, the pilot declared an emergency for a bleed air light diverting to another airfield. While the aircraft was being repaired, the pilot talked with the personnel there and planned his return fli ght. Prior to starting his engines, he spoke with the local supervisor of flying, advising hi m of a planned "highspeed pass" on departure. After starting, the pilot received permission from the tower for an opposite direction low pass prior to departure from the airfield. After takeoff, the pilot performed a series of turns to ali gn himself with the runway 180 degrees opposite to his departure. He overflew the runway at a very high rate of speed, 100-200 feet from the runway, and when approximately 1000 feet from the departure end, he performed an abrupt pull-up with afterbur ner engaged. The aircraft suddenly and violently broke up, burst into fl ames, and crashed, killing the pilot.

HUMAN FACTORS ANALYSIS

The pilot was 24 years old, on his first oper ational tour in the F-15, and was considered inexperienced with a total of 315 hours in type, 513 hours total flying time. The investigation revealed no psychological pr oblems. He was flying regularly and was qualified for the mission. Crew rest and duty day were not fact ors. Weather was clear. The pilot had planned and pre- coordinated a fly-by with the local on-scene supervisor (SOF). This was a fairly routine o ccurrence and was condoned as being a morale booster for the local maintenance personnel . Furthermore, wing level personnel were aware of the practice of performing these fly- bys and did not correct this practice. The fly-bys were in violation of a number of Air Force regulations and local MAJCOM regulations, including the AFR 60- 16 350 KCAS airport restriction.

On the day of the mishap, the pilot failed to arm his ejection seat, fasten his parachute chest strap, or to insert the external fuel tanks configuration into the armament control panel (AP). Without the prope r configuration into the ACP, a conflict would have developed within the overload wa rning system (OWS) as it received signals from the aircraft fuel gauge of more fuel on board the ai rcraft than the ACP showed it could carry. This conflict most likely would have caused the OWS to shut down. As the mishap pilot made his fly-by at an estimated 550-605 KIAS, he pulled back on the stick listening for the OWS warning tone of an approaching ov erload. The wings then failed at approximately 8.5Gs due to the hi gh speed and high fuel weight.

CAUSE FACTORS OF THE MISHAP

The mishap was a result of improper wing le vel operations superv ision, the pilot's preoccupation, complacency, or carelessne ss shown in regards to the impending high task fly-by, improper local supervision, la ck of knowledge on th e OWS, and lack of understanding by the mishap pilot of the relationship of low altitude, high speed, andKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-78 01 OCT 10 high weight to severely reduced G requi red to exceed design load limit at these

conditions.

CONCLUSION

The rules are written usually for very good reasons. We may not always understand why, but oftentimes someone's bl ood was spilled prior to the writing. Supervisors must supervise at all times. The reason superviso rs exist is to aid y oung inexperienced pilots when they get into trouble. Bu t, most of all, supervisors keep inexperienced pilots out of trouble until they can gain the experience necessa ry to keep themselves out of trouble. The regs are written fo r a reason -follow them.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-79 01 OCT 10 COLLISION WITH GROUND IN NIGHT GCA PATTERN

LOSS OF S/A

NARRATIVE

An F-16 pilot's instrument crosscheck brok e down while descending to an assigned altitude during a night GCA due to low flying proficiency and an unknown distraction. Unrecognized spatial disorient ation prevented the pilot fr om resuming his crosscheck and initiating a recovery until immediately prior to impacti ng the ground. A ground radar low altitude alert system was set to prov ide warning 200 feet below the normal IFR setting in order to avoid false alarms from da y VFR traffic in the same area. Due to the descent gradient and incomplete radar co verage in the mishap sector, the mishap aircraft disappeared from the GC A radar screen prior to acti vating an audio low altitude

alert. The radar altimeter in the F-16, which could have provided a low altitude warning, was being redesigned and not operational at the time of the mishap.

HUMAN FACTORS ANALYSIS

The mishap pilot was a senior officer who had not flown in 26 days. Although current and qualified for the mission flown, his relative ly low UE time (181.6) and poor flying continuity (6/10 sorties in the last 60/90 days) indica ted a likelihood of low flying proficiency. Supervisors were aware of t he mishap pilot's recent flying time and continuity, and had scheduled the mishap pilot on a day flight the week prior to the mishap. However, the mishap pilot took himself off the schedule due to fatigue from a recent trans-oceanic trip. Wing supervisors def erred to the mishap pilot's judgment and allowed him to fly his first sortie in over th ree weeks on a night ai r refueling mission with hazy weather.

CAUSE FACTORS OF THE MISHAP

The mishap pilot's unrecognized spatial diso rientation, which allo wed him to continue

his descent after his crosscheck broke down , was a cause of this mishap. Possible reasons listed for the unrecogniz ed spatial disorientation were temporal distortion, loss of situational awareness, lack of visual cues or low flying/ev ent proficiency. Supervision was not considered causal since the mishap pi lot was basically his own supervisor. The mishap pilot's crosscheck breakdown was not c onsidered causal sinc e it was a fairly common occurrence that would normally be det ected and overcome well prior to ground impact. The ground radar low altitude aler t system setting discrepancy and lack of a

radar altimeter were not considered caus al; while either might have prevented the mishap, they did not cause t he deviation from desired fli ght parameters which resulted

in the crash.

CONCLUSIONS

The mishap pilot flew a night mission, which was likely to overtask his limited proficiency. His instrument crosscheck br oke down during a descent in the GCA pattern and the mishap pilot did not detect and correct the breakdown in a timely manner.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-80 01 OCT 10 Warning systems (GCA radar low altitude al ert and radar altimeter) which might have alerted the mishap pilot in time to avoid collision with the ground were not optimized for IFR traffic or were not operat ional at the time of the mishap, and did not provide a warning.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-81 01 OCT 10 UNINTENTIONAL ENGINE SHUTDOWN, EJECTION

HABIT PATTERN INTERFERENCE

NARRATIVE

The mishap was a 26-year-old Captain with 930 total flying hours and 677 hours in the F-16. While completing checklist procedures for a possible gear-up landing, the mishap pilot inadvertently moved the f uel master switch to the closed position, closing the main fuel shutoff valve. The engine flamed out, t he mishap pilot was unabl e to restart it, and he ejected successfully.

HUMAN FACTORS ANALYSIS

The mishap pilot was aware of the mishap aircraft's recent history of gear indication problems. He combined this information with three distinct "klunks" he heard during gear extension and wingman observance of what appeared to be all three gear extended normally to conclude that the red light in the gear handle and lack of a green nose gear light were false indications of unsafe gear. While reviewing applicable emergency checklists, the mishap pilot dela yed completing the landing gear up landing procedure because he considered the problem to be only an indicator problem. The mishap pilot began VFR straight-in approach, and was then direct ed to open the air refueling door (depressurizing ex ternal fuel tanks) and acti vate tank inerting (reducing internal fuel tank pressures) IAW the l anding gear up landing pr ocedure as a precaution in case the nose gear collapsed on landing. T he mishap pilot attempted to activate both switches without visually c onfirming that he had the correct ones. At this point, the mishap pilot properly opened the air-refueling door, but reverted to a habit pattern from daily main fuel shutoff valve ground checks and inadvertently closed the fuel master switch instead of activating the t ank inerting switch next to it.

CAUSE FACTORS OF THE MISHAP

The cause of the mishap was the mishap pilot' s inadvertent moving of the fuel master switch to OFF due to habit pattern interfer ence while attempting to move the tank inerting switch to tank inerting. The mi shap pilot's delay in completing applicable portions of the landing gear up landing checklist since he c onsidered the problem to be with the indication syst em was not causal, but did place the pilot in a pos ition where he had to accomplish the checklist while simultaneously flying the straight-in approach. The pilot's decision to activate the require d switches without visual confirmation was probably a technique to avoid task satu ration while continuing the approach.

CONCLUSIONS

The mishap pilot attempted to complete requir ed checklist items while flying a straight-in approach, and elected to do so without visually confirming he was activating the proper switches. The mishap pilot reverted to a fu el master switch operational ground check habit pattern and inadvertently closed the main fuel shut-off valve instead of activating the adjacent tank inerting switch.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-82 01 OCT 10 THIS PAGE INTENTIONALLY LEFT BLANKKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-83 01 OCT 10 COLLISION WITH GR OUND DURING EGRESS

PERCEIVED PRESSURE

NARRATIVE

The mishap pilot was a 30-year-old 1st Lieutenant with 553 hours total flying time and

258 hours in the F-16. He was the last man in a 14-ship of attackers, and was flying his first major exercise mission as part of a 51-ship strike package opposed by 12 fighters and an array of simulated ground threats. A fter coming off dry from his first run attack 20 degree high altitude delivery, the mishap pilot attempted to regain visual on his element lead while proceeding to the planned egress point. Low, layered clouds at the egress point forced the first 13 aircraft to devia te from planned course to maintain VMC. Using min comm procedures, preceding flight members, including the mishap pilot's element lead, chose not to call for a revi sed egress route/plan. The mishap pilot

allowed his aircraft to enter IMC in the vi cinity of high terrain, then elected to press ahead in hopes of regaining VMC instead of route aborting to a pr e-briefed altitude

which would maintain terrain clearance. T he mishap aircraft impacted sharply rising terrain in controlled flight without an ejection attempt and the pilot was fatally injured.

HUMAN FACTORS ANALYSIS

The mishap pilot became task saturated while attempting to regain visual contact and follow preplanned routing during the egress. He mis-prioritized these tasks ahead of maintaining VMC. Once IMC, he failed to apply well-established, pre-briefed weather route abort procedures to ensure terrain clear ance. Peer pressure and a desire to hack his first major mission without having to resort to a non- tactical peacetime training procedure (weather route abort) were probable fa ctors. In-flight supervisors (flight leaders) elected to maintain min communications in the target area rather than making a

radio call to direct or advise of a modified egress route.

CAUSE FACTORS OF THE MISHAP

One factor in this mishap was the mishap pilo t's failure to modify course to maintain VMC during the egress while attempting to regai n visual contact with his element lead. However, while not a desired ou tcome, going IMC did not caus e the mishap. Failure to

follow established weather rout e abort procedures by initiating a climb to the pre-briefed route abort altitude caused the mishap. P eer pressure and the desire to hack the mission probably induced the mishap pilot to accept what was clearly an unacceptable risk given the high terrain in the vicinity of the egress route. In-f light supervisors might have helped the mishap pilot avoid his fatal e rror, but they chose to follow briefed min comm procedures to avoid saturating avail able frequencies, reas onably assuming that all attacking pilots would recognize and ac t on the need to deviate from course to maintain VMC during the egress.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-84 01 OCT 10 CONCLUSIONS

The mishap pilot mis-prioritized tasks dur ing the egress, placing maintaining the preplanned route and regaining visual contact with the element lead ahead of maintaining VMC. Once IMC, he failed to apply established and briefed weather route abort procedures. In-flight supervisors (fli ght leads) might have built their flight

member's situational awarenes s and been a more tactically effective force had they elected to make a directive modified egres s radio call, but it was not reasonable for them to anticipate the mishap pilot' s dangerous mistakes during the egress.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-85 01 OCT 10 COLLISION WITH GROUND DISCIPLINE, JUDGMENT, LOSS OF S/A

NARRATIVE

The scheduled mission was a night, three-ship, flight lead upgrade so rtie for a young F111 pilot and his WSO. One aircraft aborted pr ior to takeoff, but otherwise the mission

went as briefed until the ni ght range work. The plan was to use TFR for 400 feet AGL level passes. The mishap crew had TFR sy stem problems (aircraft had history of TFR problems) and called off "dry" on the sec ond pass. On the third pass, the RCO observed the aircraft descending below 400 f eet and transmitted, "Pul l up, pull up, pull up" but the crew did not respond and flew in to the ground. Both were fatalities.

HUMAN FACTORS ANALYSIS

The mishap pilot was a 28-year-old Captai n with 1333 total hours and 385 in the F-111. The mishap WSO was a 27-year-old Captai n with 919 hours total wit h 800 hours in the F-111. The pilot's history wa s characterized by frequent lapses in judgment on the ground and in the air. He was universally characterized as argumentative, stubborn and

hardheaded. He felt that every mission should be flown as a "combat mission." The mishap WSO was described as t he opposite in personality. He was consid ered quiet and passive, but still a competent WSO. Inve stigation revealed the crew elected to hand fly the last pass at 400 feet AGL, in dire ct violation of directives and exhibiting extremely poor discipline. The fact that the WSO had only computed ballistics for 400 feet may have influenced their decision. R egulations require passe s at MEA without the use of TFR. In spite of the lack of TFR, t he crew did not use available aids such as the altimeter, radar altimeter and VVI to maintain their situati onal awareness. It is most likely that the MP was looking outside for vis ual cues on the range and did not perceive the shallow descent to ground impact. Th e WSO was probably looking at the radar

scope.

CAUSE FACTORS OF THE MISHAP

The Safety Investigation Board's findings, as modified by subsequent endorsers, were that discipline, judgment and situational awareness were t he cause factors of this mishap. Hand flying below MEA was a con scious decision to viol ate directives and indicated a breakdown in discipline by both crewmembers. It also showed extremely poor judgment. The mishap pilot's lack of situational awareness caused him to miss several clues and allowed him to fly into the ground.

CONCLUSIONS

This mishap has many different facets: the diverse aircrew personalities, the malfunctioning TFR, the breakdown in disc ipline and judgment and finally the lack of awareness that led to flying a good aircraft into the ground.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-87 01 OCT 10 RAPID FUEL DEPLETION, EJ ECTION DURING LANDING

POOR CREW COORDINATION

NARRATIVE

Mishap aircraft was scheduled as number four on a low level/range mission. During the rejoin after range work, the RCO reported to the mishap crew their aircraft was trailing vapor. The crew determined they had rapid fuel depletion and turned immediately for home base, 25 miles northeast. A pproximately four minutes la ter, the AC shut off the affected engine and on short final the IWSO fi nally pushed the fire pushbutton. The AC configured the aircraft late and crossed the r unway threshold excessively fast in idle power. Due to excessive demands on the hydraulic system, the aircraft pitched down striking the nosegear first and porpoising in to a nose high attitude. The WSO, recognizing the aircraft was out of control, initiated ejection.

HUMAN FACTORS ANALYSIS

The mishap pilot was a 25-year-old 1Lt wit h 353 hours total time and 137 hours in the F111. The mishap IWSO was a 44-year-old Major with 2830 hours total time and 680 hours in the F-111. The mishap crew perceiv ed they were losing fuel at a rate that required an immediate landing. This was an important fact to the rest of the crew's decisions. The pilot was so intent on getting back and landing befor e running out of fuel that he failed to accomplish important emergency and landi ng checklists. The IWSO concentrated exclusively on t he fuel depletion checklist to the exclusion of monitoring the pilot's navigation and aircraft control. The result was ending up on short final excessively fast and without gear and flaps. The pilot, still believing they had only one chance to land, pulled the power to idle and planned to land mid-field. The aircraft hydraulic system could not keep up and pitched the aircraft down. The IWSO finally looked up from his checklist and pulled the ejection handle. They ejected with sufficient fuel for at least one more approach. Had the crew accomplished the fuel depletion checklist in a more timely manner, this recovery would have been a routine emergency recovery with an aircraft malfunction.

CAUSE FACTORS OF THE MISHAP

The Safety Investigation Board's findings as modified by subse quent endorsers were that logistics, channelized attention, situati onal awareness, task management, task saturation, habit continuation and crew coor dination were factors in this mishap. Logistics, channelized attenti on and failure to accomplish re quired checklists were the primary cause factors.

CONCLUSIONS

This mishap is a good example of why a c hecklist can be so im portant during an emergency. It allows the crew to methodi cally solve an aircraft malfunction during a high stress situation. Unfortunately, the cr ew took too long to do one checklist (fuel depletion) to the detriment of other important checklists (land/single engine). RushingKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-88 01 OCT 10 the approach, not monitoring aircraft perform ance and forcing the landing even though it should have been taken around put this flyable aircraft in an out-of-control situation.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-89 01 OCT 10 LOST CONTROL/IMPACTED TERRAIN CHANNELIZED ATTENTION, PRIORITIES

NARRATIVE

During the low level, tar get egress phase of a mission, an F-111 began maneuvering to defeat ground threats. Aft wing sweep, continuous max perfo rmance turns at or near stall warning and an insufficient power setting c aused the aircraft to bleed off more than

250 knots. The crew initiated a left rolli ng ridge crossing at a low airspeed and departed controlled flight while attempting to roll out and pull up for the nex t ridge. The crew ejected out of the envelope an d were fatally injured.

HUMAN FACTORS ANALYSIS

The mishap pilot was a 25-year-old 1Lt with 736 total flying hours and 439 hours in the F-111. The mishap IWSO was a 32-year-old Captain with 1053 total hours and 957 in the F-111. They were a formed crew, and had fl own together many times. A review of AVTR tapes revealed t hat the crew was concentrating so lely on the threats and their

reaction to them. Their concentration was so channelized that they failed to recognize the decaying aircraft energy state. Habit pa tterns developed in the European flying environment may also have contributed to the mishap. Restrictions on afterburner use in Europe and the crew's techni que of routinely pulling to the stall warning at sea level density altitudes could have led the crew to ov erestimate their energy state. The right seater, an IWSO, failed in his primary task as an in-flight supervi sor when he didn't monitor aircraft performance. He was so intent on directing t he threat reactions that he didn't notice the aft wing sweep and decaying airspeed.

CAUSE FACTORS OF THE MISHAP

The Safety Investigation Board's findings as modified by subse quent endorsers were that channelized attention, mi sperception of low le vel visual cues and task prioritization caused this mishap. The MP failed to rec ognize a 175-knot loss of airspeed in a 28- second period prior to departing controlled fligh t. He was so intent on performing threat

reactions that he didn't notice the aft win g sweep, decaying airspeed and other visual cues. The mishap IWSO didn 't properly prioritize tasks. He was directing threat

reactions when he should have been monitori ng aircraft control. Finally, the MP attempted a nose-low ridge crossing with insuffi cient airspeed and lost control of the

aircraft.

CONCLUSIONS

This mishap was a classic breakdown of crew coordination. The crew was concentrating on one part of the mission to the exclusion of their pr imary flight duty:

MAINTAIN AIRCRAFT CONTROL.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-91 01 OCT 10 IMPACTED TERRAIN AFTER SINGLE ENGINE GO-AROUND CSF'S, STRESS

NARRATIVE

The mission was a cross-country navigation-tr aining sortie. On takeoff leg, the number 1 engine overheat warning light came on. The instructor (IP) declared an emergency

and asked to return to the field. She shut down the engine and m aneuvered the aircraft to accomplish a single-engine overhead pattern and landing. On the downwind leg, she angled toward the runway resulting in an ov ershooting turn to final. She reported going around and flew a descending turn back toward the runway. Nearing midfield, the

aircraft was observed to turn to align with the runway in what appeared to be a second attempt to land. Shortly thereafter a second go-around was initiated. The aircraft turned away from the field and hit a tree 1 NM from the r unway. The IP and student ejected and were fatally injured. The airc raft impacted the ground and was destroyed.

HUMAN FACTORS ANALYSIS

The IP was relatively inexperienced with 530 to tal flight hours. S he was considered to be below average in flying skills, but was full y qualified. She had recently experienced several medical problems and was scheduled to undergo su rgery several weeks after the mishap date. Outwardl y, she appeared to be happy and well adjusted, but was most likely under significant internal stre ss. The student pilot had approximately 66 hours of flying time and was described as belo w average. He was dissatisfied with the instructor, had doubts about her flying skills and believed she was inconsistent in her grading practices.

During the mishap sequence, the IP misjudged the downwind spaci ng. She made a timely decision to initiate what appeared to be a successful go- around then apparently decided to attempt a landing nea r midfield. This decision wa s reversed at low airspeed and altitude. She reestablished level flight t hen flew the aircraft, in a thrust deficient situation, into an area of rising terrain. When it became apparent she could not avoid the terrain she commanded ejection.

CAUSE FACTORS OF THE MISHAP

The mishap board's findings, as modified by subsequent endorsers, were that an equipment malfunction and the IP caused this mishap. Just after takeoff, the number 1 engine overheat light illumi nated for an undetermined reas on. The IP accomplished appropriate emergency procedures and attempt ed to land via a single-engine pattern. She flew an angling downwind that resulted in an overshoot ing final turn. She then inappropriately discontinued her go-around and made a second attempt at landing. For an unknown reason, she disconti nued that attempt at low airspeed and altitude and was unable to accomplish a successful go-around.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-92 01 OCT 10 CONCLUSION

The IP was faced with a serious emergency immediately after ta keoff. Her initial reaction was correct but, the improperly fl own single-engine pattern compounded the stress she was under. Her indecision, after the first go-around, resulted in the situation deteriorating to the point where it was not salvageable.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-93 01 OCT 10 FLIGHT CONTROL MALFUNCTION, EJECTION IMPROPER ANALYSIS, LACK OF COMMUNICATION

NARRATIVE

The mishap occurred during an undergraduate p ilot training formation sortie. A solo student was flying the mishap aircraft. On ta keoff the aircraft pitched up, then, as flaps were retracted, pitched down. The formation continued to the working area where after coordinating with the S upervisor Of Flying (SOF), the st udent attempted to accomplish a controllability check. He lost control of the aircraft after extending the flaps and successfully ejected.

HUMAN FACTORS ANALYSIS

Immediately after takeoff, the student inform ed the IP that during takeoff the aircraft pitched up then down. The IP responded by a sking, "Is that what happened, did it pitch up when you retracted the flaps?" The st udent responded, "Affirmative." When the student relayed the information to the supervisor of flying (SOF), he told him that the aircraft had pitched up when he retracted the flaps and that he had regained control after the flaps were retracted. He did not mention that the aircraft had pitched down. Actually the aircraft had pitched up as it became airborne then back down when the flaps were retracted. The SOF advised the flight to burn down fuel and do a controllability check to determine if t here would be any contro l problems when the aircraft was configured. He further advised him to leave the gear retracted during the check and place the flaps to 60%.

CAUSE FACTORS OF THE MISHAP

The mishap board's findings as modified by subsequent endorsers were that local maintenance personnel, the student pilot, and s upervisory error caused this mishap. The T-38 flight control system incorporat es an interconnect device between the flaps and horizontal tail which compensates for th e change in tail position required when flaps

are extended or retracted. Maintenance technicians faile d to connect the interconnect cable during maintenance accomplished imm ediately prior the mishap sortie. The student did not verify proper operation of the interconnect assembly during preflight checks and he failed to properly analyze the situation and provide an accurate and complete description of the takeoff sequence to the IP and to the SOF. The wingman and the SOF did not adequately ana lyze the malfunction, which led to the SOFs improper direction to lower the flaps during the controllability check.

CONCLUSION

The student did not recognize the pitch- up on takeoff as a flap-to-horizontal-tail interconnect failure. The suggestive question by the IP led to inaccurate/ incomplete information being passed to the SOF. This resulted in the misana lysis of the problem and inaccurate direction provided by the SOF.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-95 01 OCT 10 CIRCLING APPROACH, CO LLISION WITH GROUND

IMPAIRED JUDGMENT

NARRATIVE

The mishap occurred on the final leg of a 3- day, 6-sortie cross-country flight. The mission progressed normally through two prec ision approaches at the home field. During the final pattern, a circling approach, the aircraft overshot the final approach course, began correcting toward the extended runway centerline, and then impacted the ground. The aircraft was destroyed. Ther e was not attempt at ejection and both crewmembers were fatally injured.

HUMAN FACTORS ANALYSIS

The mishap pilot was a 24-year-old instructor pilot (IP) with 540 total flight hours. The rear cockpit crewmember was an undergraduat e pilot training (U PT) student with 152 hours of flying time. There were no defici encies found in the st udent's training and since the IP was flying at the time of t he mishap, the student's performance in UPT was

not considered a factor. The IP was relative ly inexperienced but fully qualified. His flying skills were average to slightly below average. He was descr ibed as "very sharp" with outstanding book knowl edge. His approach to flying wa s an attempt to capitalize on his superior mind by mentally construc ting a series of preplanned responses to

situations. This made him more mechanica l and slowed his development in aircraft

"feel" and "air-sense."

A circling approach is flow infr equently and allows little time to establish a course and glide path. The pilot is much more likel y to misjudge the approach due to the different aspect from a lower altitude in comparison to the more familiar overhead pattern. The IP had never flown a circling approach to this runway. Additional factors that possibly affected the IP's judgment at t he time of the mishap were li mited rest the night prior to the mishap, no recent food intake, and low fuel.

CAUSE FACTORS OF THE MISHAP

The mishap investigation board's findings identif ied the IP as causing this mishap. He misjudged the base turn of the circli ng approach and overshot to a degree that interception of the final appr oach course could only take pl ace well inside the desired roll out point. He then failed to initiate a go-around. Possible fa ctors include impaired judgment due to fatigue and lack of recent f ood intake, overconfidence in his ability to complete the approach due to previous succe ss in overshoot situations, and/or over

concern with a low fuel state. The IP failed to recognize the high sink rate, the low airspeed, increasing airframe buffet and high ang le of attack until there was insufficient

altitude to recover.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-96 01 OCT 10 CONCLUSION

This IP was confronted with a poorly flown circling approach. Several factors probably induced him to attempt to salvage the patte rn and complete the l anding: the low fuel, personal pride, etc. Becaus e his judgment was impaired a nd/or due to his limited air sense and feel for the aircraft, he was late to recognize the hazardous situation develop.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-97 01 OCT 10 RAPPELLER KILLED DURING DEMO

POOR AIRCREW COORDINATION

NARRATIVE

During a rappelling demonstration one rappel ler was fatally injured and another sustained spinal strain and contusions.

HUMAN FACTORS ANALYSIS

The 28-year-old Pilot In Command (PIC) was a Marine Captain with 1343 total flight hours, 1069 in the UH-1N. He was substituting for the instructor pilot who normally flew such mission. He had completed 30 rappel ling missions prior to the mishap. The copilot, a 28-year-old 1st LT had only 319 total hours, 91 in type with no prior rappelling experience. He had nothing to eat in the 20 hours prior to the mishap and had only 5-6 hours sleep each night during the 48 hours prio r to the mishap. The Crew Chief (CC)

had a total of 475 hours in t he UH-1N, with 7 prior rappel ling missions. The HAC gave the CC final authority for all cabi n activity during the mission.

After the UH-1N entered a hover in front of the reviewing stand, four rappellers went out of the cabin and reached the gr ound safely. Once they we re on the ground, the Rappel Master (RM), Safety Insert Officer (SIO), and CC began to disconnect ropes. The SIO had the starboard forward rope, the RM the port aft rope, and the CC the starboard aft rope. Tension was felt on all ropes. No o ne in the aircraft was visually monitoring the rappellers. The PIC stated he heard a "ropes clear" call, gave a cursory glance to the rear and verbally attempted to verify over t he ICS. The copilot at the controls (PAC) transitioned to forward flight at the directio n of the PIC. The SIO, RM, and CC still had tension on all ropes. All four rappellers we re still attached to the ropes. The two aft rappellers were taken airborne as they applied their rappel br akes upon perceiving excessive drift. The two forward rappellers did not have time to apply brakes and their 120-foot ropes played out to the ends. Th e lines did not feed completely through the assault descenders due to deployment bags, which were tied to the ends of the ropes. The two dragged rappellers impacted a trash dumpster 127 yards from the initial rappel site. Subsequent to the mishap, the aircra ft landed and assumed the role of medical evacuation aircraft, transporting t he two injured to the naval hos pital. The fatally injured

man died of blood loss duri ng surgery 4 hours later.

The focus of such missions is on speed si nce these demonstrations are for recruiting purposes. The idea is to impress viewers wit h apparent tactical prowess. They are not conducted for training and are not tactical. There is no SOP for them and the potential

for shortcuts to enhance the ta ctical image without literally vi olating safety procedures is high.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-98 01 OCT 10 CAUSE FACTORS OF THE MISHAP

The Naval Safety Center found the causes of the mishap to be all aircrew, personnel, and supervisory error. The pilot in command and the SIO lost situational awareness. The PIC and CC failed to obtain equipment for the mission (gunner's belt). The crew chief was named for failure to keep the pilo t informed of mission progress. The PIC, CC, and SIO were also faulted for maintain ing a perceived sense of urgency during the mission. The squadron and battalion were both bl amed for supervisory error in failing to comply with the ASH manual a nd SOP. The battalion was fu rther cited for failure to revise the SOP containing an unsafe pr actice. The squadron was mentioned for assigning a PIC who was unqualified as an inst ructor to conduct an in structional flight. Supervisory error was also assigned to the di vision and the wing for failure to provide a joint SOP for rope operations.

CONCLUSIONS

There was a complete breakdown of crew coordination/communications during the mishap. Specific roles of t he RM, SIO, and CC were not clearly delineated in the brief. The lack of standardized terminology exacerbat ed the situation. With more than one person relaying information, the HAC might have heard a second "ropes out" call and misinterpreted it for the "ropes clear" he sa id he heard. The perce ived sense of urgency due to wanting to impress the crowd during a demo led to shortcuts being taken. The mission proceeded despite the last minute repl acement of the instructor pilot with the less experienced HAC. The mission continued without the full complement of gunner's belts for everyone. The riggi ng used in the rappel was nonst andard. All fo ur rappellers left the aircraft at once to give the illusion of speed. The two injured men laid down after dropping to the ground so that they would not be seen by the crowd due to a slight depression in the ground. Th is also enhanced t he appearance of speed in the rappel. However, this left them in a position from whic h it was more difficult to apply brakes. All

three members of the cabin crew turned thei r attention inside to release snap links before ensuring the rappellers we re free of the ropes. Finally , the pilot's cursory glance

to the rear and order to go evidenced urgency.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-99 01 OCT 10 FLEW INTO THE GROUND

FAILING AVIATOR

NARRATIVE

A UH-1N on a SAR training mission impacted the ground during low altitude maneuvers. The pilot, copilot and an aircrew member were killed. Three aircrew members were seriously injured.

HUMAN FACTORS ANALYSIS

The Mishap Pilot (MP) was a 44-year-old, twice passed-over LCDR with 4355 total flight hours, 230 in type. He was to be retired in one year, and was bitter towards the Navy about it. Married, with four children, he had become romantically involved with a

married woman. He was havi ng problems with in terpersonal relationships, not getting along well with his su periors and peers. A loner, he exhibited a ll the symptoms of a failing aviator. Two weeks prior to the mish ap, he flew under a bridge at night with no warning to his startled crew. On at least one occasion, earlier in the year, he failed to pass the UH-1 NATOPS closed book exam. He requested to see a psychiatrist about his personal problems and was referred to a non-aviation oriented clinical psychologist who diagnosed him as undergoing a mid-life cr isis. He was offered stress management training, but turned it down. His command was completely unaware of his consultations. He saw the psychologist on four occasions. Shortly thereafter, he broke off his relationship with the "other" woman.

The 27-year-old Mishap Copilot (MCP) was a LT with 1090 total hours, 256 in type. On his second helo tour, he was considered to be a weak aviator. A conservative, "safe" aviator, he enjoyed flying helos. Happily married with a 6-month-old baby, he was a good natured individual, not very aggressive, and easily intimidated. He was known not to have liked flying with the MP.

After completing scheduled SAR training, the MP, contacted t he pilot of an other helo in order to join in and conduct a tail chase. No formal brief was conducted. Each helo alternated being in the chase position. The MP and MCP al ternated at the controls. High angle of bank maneuvers, descending below 100 feet at high airspeeds, were employed. Gusty winds at be tter than 30 knots were reported in the area. An excessive rate of descent was set up from less than 100 feet of altitude in a steep turn, and the aircraft impacted the ground before the pilots c ould recover. An aircrewman survivor said that the MP was pulling collective and had gotten the nose up using cyclic at the time of impact. The MCP probably never knew what happened, according to this

witness.

CAUSE FACTORS OF THE MISHAP

The AMB concluded that the causes of t he mishap were aircrew error and supervisory error. The aircrew was assigned blame for fa ilure to maintain safe indicated airspeed, using incorrect control inputs, and engaging in unauthorized, unbriefed maneuvers. TheKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-100 01 OCT 10 base CO was assigned supervisory error for fa ilure to set an example of air discipline and professionalism, and failure to establish a proper safety program. The base AIR

OPS officer failed to ensure and monitor the sa fe flying conduct of his flight crews. The mishap pilot's referring flight surgeon was also assigned supe rvisory error for failing to take appropriate action with a failing naval avia tor. The CO of the local Naval Hospital was also named for failing to provide the fli ght surgeon with the oppor tunity to routinely interact with the pilots assigned to the base.

CONCLUSIONS

There is a serious deficiency in the way av iators with psychiatric problems are handled in the Navy. This mishap is not the first exam ple of this mishandling. Aviators are very reluctant to go to a flight surgeon with problems of a psych iatric nature. When they do, no one knows how to handle them. Navy m edicine is only prepared to deal with psychologically healthy aviators. The rare av iator with problems of this nature is not always referred to a flight surgeon psychiat rist, but frequently is sent to clinical psychologists or others who have no av iation medicine background. Typically, these specialists do not inform the individual's comm and for fear of breaching the trust implicit in the doctor-patient relationshi p, and because they do not fe el the problem is a serious one for aviators. Normally they refer thes e patients to stress management training or therapy without any follow-up. T he situation is a very delic ate one. On the one hand, the individual aviator with problems should not be discouraged from seeking help; while on the other hand, the command needs to be kept informed about the mental and physical health of personnel assig ned to fly their aircraft.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-101 01 OCT 10 WIRE STRIKE AT NIGHT DURING NVG TRAINING

COMMAND AUTHORITY

NARRATIVE

A UH-1N struck power lines while conducting a Night Vision Gogg le (NVG) navigationtraining mission in a foreign country. The aircraft, with five souls aboard, impacted the ground and exploded. There were no survivors.

HUMAN FACTORS ANALYSIS

The pilot of the mishap aircraft (MP) was an experienced 37-year-old Marine Major with 3,336 total hours of flight time. He had demonstrated tactical pr oficiency, particularly at night on NVGs. He had been under pressure due to his collateral duties in the squadron. He was known for his harsh treatm ent of subordinates. Three weeks prior to the mishap he had a run-in with his mishap crew chief in wh ich he implied that the crew chief was trying to sabotage his controls w hen they were binding. This angered the

crew chief who went to the CO, who then counseled the MP.

The Mishap Copilot (MCP) was a 25-year-o ld 1st LT with 567 total hours flight experience, 334 in model. His wife in the States was pregnant, the baby was due within 12 days following the mishap.

Due to intense ops tempo over the prio r 4 months, fatigue was becoming evident among squadron members. Th e detachment was bivouacked in the "boonies" while their squadron mates were enjoying s hore leave in a foreign country.

The mishap crew briefed a two-helo section NVG mission in support of a night training exercise. The mishap airc raft did not have an OMEGA navigation system installed. The wingman's responsibility to assist in navi gation to ensure the flig ht stayed within the designated training area was not discussed. The MP had previously stated that his philosophy on calling "Magellan" (code for "check your navigation") was to allow the

lead to correct his own error and to not interf ere until the lead asked for assistance. The CO, learning of his attitude following a flight in which the MP was wingman, counseled him that squadron SOP called for a wingman to immediately assist when the lead is off course and not correcting.

After the section took off, the MP got lo st and the wing had to ca ll Magellan. Twice more, the wing had to call lead during the flight to inform him of clearances he had not received. Upon landing back at the base after t he first flight, the MP strode over to the wing aircraft and verbally reprimanded the two j unior wing pilots and their crew chief for violating radio discipline. The wing pilots not ed that this was completely out of character and were surprised by his behavior.

The MP briefed the NVG portion from memory . Two checklist items not discussed were barriers/limiting terrain features and crew c oordination. Specific aircrew duties and responsibilities were not discussed IAW SOP. The section took off a second time. TheKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-102 01 OCT 10 section proceeded to get lost. The wing copilot told the wing pilot (W P) that they were flying "off the top of the map." After watching the lead make two c ourse reversals, then proceed off the map again, the wing crew discussed making a Magellan call. The WP said ..."he just chewed our ass for radio di scipline...Let him continue for a few more

moments and then we'll call..." Approximately 30-60 seconds later the wing crew chief called wire towers. The WP immediately st arted a climb and simu ltaneously saw sparks from the impact of the lead with wires.

CAUSE FACTORS OF THE MISHAP

The aircraft mishap board and subsequent endor sers concluded that the cause factors were: (1) aircrew error - mishap crew -loss of situational aw areness; (2) aircrew error - mishap pilot - PIC failed to exhibit proper judgment and aer onautical leadership; (3) aircrew error - mishap wingman -lack of crew coordination; (4) ai rcrew error - mishap wingman - loss of situational awareness; (5) supervisory error - type commander - lack of adequate self-contained navi gational equipment; (6) supervisory error - Model manager - failure to include RMI alignment in pre-takeoff che cklist.

CONCLUSIONS

Communications is a two-way process invo lving a sender-communicator and a willing listener. Aircrew who are not open to critic ism of their flying and navigating are not professionals. Aviation has no place for non-professional behav ior. Lack of crew rest

and stress could have led the MP to reac t the way he did through frustration and fatigue. The MP and his crew paid for this mistake with their lives. The wingman now must live with the consequences.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-103 01 OCT 10 COLLISION DURING MOUNTAIN FLIGHT

OPERATING STRATEGY

NARRATIVE

A UH-1 was on a search-train ing mission in mountainous te rrain. Rotor RPM was lost, and the anti-torque system becam e ineffective during an approac h to a pinnacle. The helicopter crashed into trees and was destroyed.

HUMAN FACTORS ANALYSIS

The 33-year-old HAC had more than 700 rotary wing flight hours, wit h more than 500 in type. He had no mountain experience before his current unit assignment and had not

flown in mountainous terrain in five months . The 38-year-old copilot had more than 1500 rotary wing hours, with more than 700 in ty pe. He was not trained in mountain flying operations.

The crew was assigned a mission to take a se ven-person search team to a site in the mountains and drop them off. T he search team was going to look for an aircraft that

had crashed several months ear lier. The HAC, copilot, cr ew chief and one passenger

took off from an airfield and flew to a town to pick up the search team.

Three members of the search team boarded the helicopter and were flown to a landing site on the mountain. Arriving at the site, the HAC did a high flight recon and the copilot computed the landing dat a. The HAC was unable to land at the first proposed landing site because of the degree of slope and his uncertainty about the snow-covered terrain.

The UH-1 was then flown to anot her landing site at an altit ude of 11,800 feet MSL,

where the three members of t he search team were unloaded.

The aircraft left the landing site, refueled at a local airport, and flew back to the town to pick up the remaining four members of the sear ch team. Returning to the landing site, the copilot told the crew chief to drop a sm oke grenade to determine the wind direction. The smoke indicated the wind was generally fr om the west and the velocity was light. The copilot began an approach to the we st using an approach angle somewhere between steep to normal. About 20 to 30 feet above the ground, the HAC told the pilot that RPM was decreasing. The aircraft began a shallow right turn , and the copilot made a go-around.

Once control of the aircraft was regained, t he HAC took the contro ls and immediately tried a second approach into the same landing site. During this approach, the HAC maintained 34 to 35 pounds of torque almost until touchdown. He said he applied a little more torque as he came over the edge of his intended landing site, and the RPM began to bleed off rapidly. A go-around was init iated, but the airc raft began a slow spin to the right. The HAC pulled additional collective pitch to clear a rock formation, then applied forward cyclic and reduced the colle ctive to gain RPM as the aircraft spun

toward lower terrain.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-104 01 OCT 10 When the HAC realized the aircraft was going to hit the trees regard less of his flight control inputs, he decelerated to dissipat e forward airspeed and pulled all remaining collective pitch to cushion the impact. The ai rcraft hit several trees during the descent, severing the tail boom. Continuing to turn, t he aircraft hit two trees about 2 1/2 to 3 feet

in diameter and 60 to 70 feet ta ll. The force of the impact caused the trees to uproot and fall in the downhill direction on the 70° slope. The aircraft came to rest inverted on top of the two trees.

One of the passengers was killed as a result of a tree penetrating the passenger area. Five of the occupants sustained major injuri es, and the other two sustained bruises and

abrasions.

CAUSE FACTORS OF THE MISHAP

The HAC did not re-compute landing data afte r significant changes had occurred that he knew would affect aircraft performance capabili ties. On the second insertion, there was one more passenger with his survival equipment, as well as 50 addition al pounds of fuel on board. The air temperature at the high al titude-landing site had increased during the 1 1/2 hours between insertions. Regulati ons require re-computation of performance

data when load and/or environmental conditions change significantly.

The HAC attempted a second ap proach to a pinnacle after the copilot had aborted the first approach because of inadequate en gine power. The second approach was attempted without re-computing aircraft perf ormance data despite indications that adequate power was not available.

The HACs medical conditions, combined with probable self-medication, use of cigarettes, and a high operational flight al titude, caused him to become hypoxic and

make what was for him uncharacteristic erro rs in judgment. Pulmonary function tests

conducted after the accident revealed that the HAC entered a hypoxic state at 6,000

feet MSL.

CONCLUSIONS

Even though there is an establis hed training program for mount ain qualification, there is inadequate regulatory guidanc e governing evaluation and currency requirements for aviators operation in mountainous terrain. There is no guidance, which specifies a certain period, or elapsed time in which an aviator must have flown in mountainous terrain to maintain currency and/or qualificati on. Neither is there a requirement for an aviator to demonstrate proficiency in planni ng or performing a flight into mountainous terrain to an instructor pilo t/standardization instructor p ilot during the Annual Aviator Proficiency and Readiness Te st evaluation period.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-105 01 OCT 10 FLEW INTO SEA AT NIGHT

DISTRACTION

NARRATIVE

A CH-46 impacted the ocean afte r a pre-dawn takeoff from spot 2 on an LPH, following a passenger pickup. The airc raft never gained more than 90 f eet of altitude. It made a wings-level descent into the water. The en tire flight lasted 12 seconds. After water entry, it rolled left and sank immediately. The pilot, crew chief, and 13 passengers were

killed. Twelve of thes e passengers drowned without su staining any incapacitating injuries which would have prevented them from egressing the aircraft. However, the escape hatches were partially blocked by gun mounts. One passenger actually did egress, but drowned afterwards. The copilot and three passengers escaped. The copilot suffered broken bones, one passenger sustained a broken eardrum under water and the other two weren't injured.

HUMAN FACTORS ANALYSIS

The pilot was a 28-year-old Marine 1st LT with 925 hours of total flight time, 529 in type.

He had almost 40 hours of fli ght time in the 30 days prior to the mishap. He had a total of 82 helo ship landings, 11 at night. He had only been designated a HAC for 6 months. Due to an oversight or an outright misrepres entation on the part of unknown parties, he

had never finished his initial Ca rrier Qualifications (CQ). Prior to the mishap, he had been in bed only 6 hours, but he didn't sleep we ll, according to his companions. He was

a bachelor.

The 30-year-old copilot, a Marine Captain, had 506 total flight hours with 155 in type. He had flown 34 hours in the past 30 days, had a total of 39 helo ship landings, with 12 of those at night. He had minimum rest with only 6 hours sleep before the mishap. Married, he has no children.

The mishap occurred on a dark, moonless night with no horizon. Spot 2 aboard the LPH lacks any visual references for night takeoffs without a visible horizon. This necessitates a precision Instrument Takeoff (ITO). The copilot noted that a false

horizon could be created on the windscreen by the reflecti on of the overhead console lights. It was later determined that neit her pilot had adequate in strument training, specifically ITO training. The tower cleared t he helo to lift off and switch radio channels to the center frequency. Immediately after liftoff the pilot, to t he copilot's surprise, looked down and changed frequencies. The c opilot was still look ing up the frequency on his kneeboard, intending to switch it hims elf, when he realized im pact was imminent. He attempted to grab the controls, but was too late.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-106 01 OCT 10 CAUSE FACTORS OF THE MISHAP

The mishap was closed out as due to aircrew error because of a lack of crew coordination (aircrew performi ng inappropriate duties) a nd a loss of situational awareness. Also, the pilot did not employ proper flight techniques for existing meteorological conditions. Undetermined per sonnel were assigned error in that a misrepresentation of qualifications had taken place. The squadron was assigned supervisory error due to thei r failure to determine the qua lifications requirements of assigned aircrew. The squadron was also blamed for failure to channelize commonly used shipboard frequencies and failing to ens ure radar altitude warning system was operational and in use for night/overwater flight as per wing policy. The ship was faulted for failure to use case III departure procedures . Supervisory error was also assigned the MAU/Phibron for failure to provide adequate shipboard preparation prior to passenger carrying operations.

CONCLUSIONS

These two aviators were allowed by superviso rs to get into a situation they could not handle. The lack of a procedure for determini ng aviator qualifications and the sloppy bookkeeping on the logbooks allowed the pilot to be designated when he wasn't qualified. However, he knew he wasn't qualified, yet took upon himself the responsibilities of HAC. This lack of integrity on his part cost him his life and the lives of many others. This mishap is a perfect example of why a Ga rrett (Malcolm) Horizon should be installed in all helos, which fly off ships at night! Carrying passengers who have received no underwater egress training, with the escape routes partially blocked by gun mounts is gross negligence! A cras hworthy cabin and seats would have saved the pilot, crew chief and the passenger acting as first mechanic.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-107 01 OCT 10 FLEW INTO SEA ON NIGHT SHIP TAKEOFF

DISTRACTION

NARRATIVE

During a night takeoff from a ship, a CH- 46E impacted the water and sank. Four aircrew members and fourteen passengers we re lost at sea. Eight passengers

survived. Two obtained brok en bones; the rest suffered va rious contusions, abrasions

and lacerations.

HUMAN FACTORS ANALYSIS

The mishap helicopter aircraft commander (MHAC) was a 27-year-o ld Marine Captain with 1137 total flight hours, approximately 900 in type. He was assertive, had an abrasive sense of humor (though not to the point of damaging ridicule), and was one of the squadron's strongest personalities. Le ss experienced pilots treated him with cautious respect. He was the squadron's schedules officer, and was highly regarded for his hard work and attention to detail, even to the point of being obsessive-compulsive. He had flown 37 hours in the past 30 days and had last flown a week before the mishap. His last night flight was 9 days prior.

The mishap copilot (MCP) was a 27-year-old Marine 1st LT with 520 total flight hours, 278 in type. He been a De signated Naval Aviator for one year, and had joined the squadron 10 months before as t he squadron's legal officer. He was very religious, soft spoken and an excellent athlete. He had flown 21 hours in the 30 days prior to the mishap. His last night flight was the night before. He had expr essed concern the day before and the day of the mishap to roommates and t he ship's chaplain about recent minor mental errors he had made while flying. He also expressed concern over his upcoming flight that night and in dealing one-on-one with the MHAC.

The mission was a three-helo troop lift. The low altitude warning system's aural tone generator was disconnected in the mishap aircraft (MA). Since it was VFR, no instrument takeoff checklist was read, althou gh it was a dark night wit h no horizon. At the time of takeoff, the Air Boss noted that the MA's red dome li ght was still on. He decided to wait until the MA was safely ai rborne before informing t he aircrew. Takeoff

and initial climbout were observed to be shal lower than the other two helos. About 5

seconds after takeoff the Air Boss cleared t he MA saying, "You're cleared to cross, check your dome lights." At this time MA was observed to level off and begin a slight descent. Blade tip lights were not on. Maximum altitude attained was approximately

100 feet. The descent cont inued, and about 28 seconds afte r takeoff, the MA impacted the water about 350 yards abeam the ship.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-108 01 OCT 10 CAUSE FACTORS OF THE MISHAP

The conclusion of the Aircraft Mishap B oard and subsequent endorsers was that the mishap was caused by pilot and copilot error, spatial mis-orientati on and a lack of crew

coordination.

CONCLUSIONS

The probable mishap scenario occurred as fo llows. Takeoff was behind schedule, two other helos were circling, awaiting thei r departure. The MHAC probably wanted to get on with the mission, since they had been preparin g for it for 9 hours. During preflight and engine start the MCP felt the MHACs urgency to get airborne, and was intent on pleasing him. Thus, he may have overlooked some light switches. As they lifted into a hover, all systems checked good. Transitioning to forward flight crossing the deck edge, the MHAC became aware that he coul d not see outside the cockpit since the canopy was reflecting red light. He then glanced qui ckly up to the dom e light switch at the same time that the ship's tower call ed him. The MCP prob ably also looked up at

that moment to turn the switch off. T he MHAC then checked hi s airspeed, saw it increase as it should have been, and looked out to see where his wingmen were. The MCP was too busy catching up with the aircra ft's lighting configuration to back up the MHAC on the flight instruments. The MHAC let himself get di stracted at a critical phase of flight, at night, at low altitude. Poor inst rument procedures in wh at was, in fact, an instrument takeoff, complicated by poor crew c oordination, led to spatial mis-orientation and controlled flight into the water.

If proper crew coordination had been utilized, communicati on between the MHAC an the

MCP would have been established to ensure co mpletion of the takeoff checklist. The MCP would not have let the MHAC hurry him. But the personalitie s of these pilots

blocked this kind of communication. The MC P was reticent, building confidence, aiming to please the MHAC, so he wouldn't have comp lained that he was being rushed. He should have been backing up the MHAC on inst ruments and waited to get the light switches after they had est ablished a positive rate of climb. The crew chief and observer could have interrupted the chain of ev ents by warning the pilots of their low

altitude.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-109 01 OCT 10 COLLISION WITH TREES IN LZ

COPILOT SYNDROME

NARRATIVE

While conducting a section approach to a confined mountain area landing zone, a CH46E impacted trees sustaining a hard landing. The three-man crew egressed unharmed except for minor bruises.

HUMAN FACTORS ANALYSIS

The 31-year-old Marine Captain seated in the copilot's seat was at the controls at the time of the mishap. He h ad accumulated 902 total flight hours, 655 in type. He had started flight training at age 27, the maximum allowable. He was a marginal performer as a Student Naval Aviator, receiving a to tal of 5 downs. Immediately upon completion of flight training, he was gi ven a 6-month non-flying assignm ent, prior to reporting to his Replacement Training Squadron. He had been designated a HAC for 10 months prior to the mishap. He was married and had a 4-year-old daughter. His wife was five months pregnant. A reservist, he was awaiting word on his request for augmentation at the time of the mishap. He was unable to complete the high altitude and mountain flying lectures, but had received a 30-minut e brief and a 4.6-hour training flight on mountain procedures.

The H2P was a 25-year-old Marine 1st LT wh o had 506 hours of tota l flight time, 380 hours in type. He was a bachelor and had ju st returned from a disappointing liberty weekend, filled with va rious annoying hassles. He had not eaten in the 12 hours prior to the mishap.

In following immediately behi nd the lead aircraft, the pilot put himself in the most likely position to encounter wake and rotor turbulenc e. In a steep descent to land, he was unable to initiate recovery before contacting the trees. There was a perceived pressure to look sharp, get in fast, and land. Prac ticing combat conditions, the aircraft would have to minimize time close to the groun d, while picking up or discharging troops. There was little, if any, crew coordination during the final moments prior to impact. The copilot had not turned on his radar altimeter. He gave the pilot no warning of high sink rate, nor did he attempt to aid in controlling t he aircraft's descent rate. He appeared to be just "along for the ride." He stated that he didn't think anything was unusual about

their situation until he saw tr ees go by the cockpit. Visual illusions and loss of normal perceptions are always present in mountai n flying. The clea r mountain air makes

distances seem closer than at sea level. Rugged terrain and an upward sloping LZ can change the estimate of glide slope and closi ng speed compared to on flat, level ground.

CAUSE FACTORS OF THE MISHAP

The mishap is being closed out as due to airc rew error. The pilot used poor judgment in attempting to approach and land without due r egard to the lead aircraft's wake/rotor turbulence. The copilot showed a lack of crew coordination in faili ng to alert the pilotKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-110 01 OCT 10 that the aircraft was enteri ng a high-sink rate situation and failed to recommend any

corrective action.

CONCLUSIONS

The copilot was more of a passenger than a crewmember on the mishap flight. The pilot's age and Training Command history pr obably had little to do with the outcome of the mishap. Perceived pressure to perform , a lack of crew coordination, and visual

illusions were the bi g factors here.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-111 01 OCT 10 FLEW INTO SEA AT NIGHT

SITUATIONAL AWARENESS

NARRATIVE

A CH-46E on a night fli ght flew into the sea and cras hed. The pilot had just enough time to take one last breath of air prior to th e cockpit filling with wate r. Disoriented as to up and down in the dark, he inflated his LPU un der water and swam to the surface. He sustained class C injuries with broken bones, cuts, and bruises. The copilot and crew

chief were lost at sea.

HUMAN FACTORS ANALYSIS

The survivor was the pilot in command. He wa s also the pilot at the controls on impact. He was a 28-year-old Marine captain with 1042 total flight hours, 829 in type. His 28- year-old copilot was a Marine 1st LT with 681 total hours, 456 in type. Returning to base due to low fuel, the aircrew inadvertent ly penetrated a hot restricted area due to their lack of understanding of the restrictions to flight there. They believed that they were safe if they stayed be low 500 feet and wit hin 5 miles of the beach. Spotting a fixed wing aircraft flying direct ly over their position, the pilot descended to 300 feet to increase separation. Trying to maintain an "IFR/VFR scan" pattern the pilot instructed the crew to keep an eye out for other aircra ft. Suddenly, the helo impacted the water at 90 kias, flipped end over end, and rapidly filled with water.

CAUSE FACTORS OF THE MISHAP

The Naval Safety Center endorsement listed the cause factors as all aircrew error

because of a lack of crew c oordination, loss of situat ional awareness, and improper preflight planning. The pilot at the controls was named for employing improper flight techniques for the existing meteorological conditions.

CONCLUSIONS

The pilot was trying to do the impossible, i.e ., maintain an IFR scan at the same time he was scanning outside for other aircraft. The c opilot and crew chief were also looking out

the window and no one noticed the hel o slowly losing altitude until water impact. This is

a classic case of lack of cr ew coordination, where no on e is "minding the store." Coupled with a loss of situat ional awareness at night, this is a dangerous combination.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-113 01 OCT 10 FLEW INTO GROUND AT NIGHT

FAILING AVIATOR

NARRATIVE

A CH-46E en route to a night vision goggle training area im pacted mountainous terrain at night. Three aircrew members were killed instantly on impact.

HUMAN FACTORS ANALYSIS

The pilot in command was a 37-year-old Ma rine reserve Major with almost 3100 total flight hours, 2519 in type. Although the wi ng policy was to plac e a newly assigned reserve aviator on probation for 6 months, his CO waived this due to his experience. He was flying under a medical waiver to service group 2 for defective visual acuity, which was 20/70. He was not wearing glasses at the time of impact, but may have been wearing contact lenses although they were not found on the body or in the wreckage. The pattern of his facial in juries indicates he was wearin g night vision goggles, however. He was known to be under a significant amount of stress. During the week before the mishap he demonstrated sympt oms of depression, anger , fatigue, indecision and difficulty concentrating and remembering details.

Two years prior to the mishap he was remov ed as maintenance officer by his squadron CO and received a damaging fitness repor t. He was refused augmentation and was separated from active duty 5 months prior to the mishap. He entered civilian life as an

insurance sales trainee. Th ree months prior to the mis hap he rolled and totalled his BMW. His wife of 3 years, unhappy with what she perceived as a loss of status (civilian life), considered this to be t he last straw and kicked him out of the house. He moved in with his parents. (He had lived with them 7 of the 11 years he was on active duty.) He was said to be more dependent on his mother than most men his age. She did his laundry and managed his bank acc ount and financial investment s. Much of his marital discord stemmed from his relationship with hi s mother. During his marriage his ties to his mother were partially severed through his wife's intervention.

Communications within the marriage were extremely poor. He was known to never argue with his wife. During t he days immediately prior to the mishap he gave a great deal of thought and emotion towards the decisi on of a divorce. Two days prior to the mishap he picked up his wife to drive to their ta x accountant in order to go over and sign their tax return. They got into the firs t argument of their marriage when she announced that she wanted their condominium. They had never discussed a divorce up until that point. She jumped out of the car and left on foot to avoid further argument. When he tried calling his mother-in-law, who was sympathetic to him, he couldn't remember the number, a number he had called frequently. He had been working long hours and was observed to be fatigued and emotional in the evenings during the days before the mishap. He was sad and occasionally dem onstrated outbursts of anger. During the brief for his last mission he neglected crew coordination, IFR procedures, navigation responsibilities and incorrect ly briefed emergency procedures . It was apparent that he was preoccupied, significantly impairing his mental performance. He had a 13.5-hourKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-114 01 OCT 10 duty day at the time of the mishap and h ad worked 15 hours the day before. The copilot, a 33-year-old Marine Ca ptain, was probably at the cont rols at the time of the mishap. He had 1827 total fli ght hours, 300 in type. He wa s also separated from his wife. He had been living with his girlfriend for two years at the time of the mishap. There were no children from his 8-year marr iage. His only previous night vision goggle experience was flown the month before for 1.5 hours. He wa s not wearing them at the time of impact. There is some evidence to indicate that he may have been distracted by a loss of power on his number 2 engine, but had not had time to say anything about it before impact.

CAUSE FACTORS OF THE MISHAP

The AMB found that the causes of the mishap were all human. The aircrew was faulted for failure to navigate, complacency, failure to conform to course rules, diminished crew coordination, and failure to utilize recommended NVG departure procedures. The mishap pilot's skills was found to be diminished due to his life stress fa ctors. The copilot was cited for his inability to recognize a visual illusion. The air station operations department was assigned supervisory error for accepting a non-procedural departure. The squadron CO was named for failure to in sist on course rules compliance and for waiver of the six-month probation per iod for new aviators in the unit.

CONCLUSIONS

The mishap pilot was stressed and was not coping with his stresses well. He was fatigued and preoccupied at the ti me of the mishap. His br iefing was inadequate and he failed at crew coordination. The copilot (at the controls) was complacent in not asking more questions and was misled by a visual illusion at night. He also may have been distracted by a loss of power.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-115 01 OCT 10 CRASHED ON SHIP/NIGHT SINGLE ENGINE LANDING

STRENGTH OF AN IDEA

NARRATIVE

A CH-46E carrying four cr ew and sixteen passengers experienced a single-engine failure due to oil starvation shortly after tak eoff from an LHA at ni ght. While executing a precautionary approach to the ship, the ai rcraft slowed below single-engine airspeed, settled, and landed hard aft of spot eight. It rolled over and came to rest on the aft port catwalk and phalanx gun system. One passenger fell into the sea and was lost. The helo was destroyed.

HUMAN FACTORS ANALYSIS

The HAC was a 28-year-old Marine Captain wit h 1450 total flight hours, 1228 in type. He was using Night Vision Gogg les (NVGs) at the time of the mishap. The copilot was a 26-year-old 1st LT with 844 h ours total, 627 in type. They were carrying an observer as part of an evaluation the squadron was undergoing. They were highly motivated to complete the mission due to their unsatis factory performance on a similar mission two days prior. The 23-year-old crew chief ha s a reputation for being one of the top crew chiefs in the squadron. However, he was tired, having slept onl y 3 hours during the 36 before the mishap. The enlis ted berthing area was not conduc ive to daytime sleep for crewmembers who have to fly night missions. Announcement s over the ship's intercom system, bell ringing, and daytime air operations, pl us the fact that all hands were turned out at 0600 for field day, regar dless if they were aircrew who had flown the night before, kept them from ge tting adequate rest.

Crew chiefs had been working 12-18 hours per day, since a third of the maintenance department was assigned to various ship det ails. The workload imposed on the maintenance department was tremendous. They had to work their people 15-18 hour days prior to and during embarkation. The marked variability in working hours resulted in an adverse affect on psychomotor function due to disruption of circadian rhythms. To make matters worse, the tempo of ops and pressure to perform well increased during the deployment since the evaluation occurr ed in the latter part of the deployment. Multiple errors were made due to the sh ortage of personnel and the tempo of ops. Following the investigation of a malfunction with the #2 engine emergency throttle actuator there was a failure to inspect wo rk performed on the mishap aircraft. In order to gain quick access, the center beam, heat shields, and oil line quick disconnect were

removed.

During reassembly, the quick disconnect was improperly connected c ausing an inability to provide oil to the #1 engine. Since bo th ends of the quick disconnect have self contained valves blocking the flow of oil when disconnected, there was no visible oil leakage. The crew chief should have detect ed a faulty connection during preflight, but did not. After turn up, the pilot discovered an indication of zero oil pressure on the #1 engine. The crew, including the observe r, all concurred that the gauge had malfunctioned and opted to conti nue with the mission. Once airborne, the crew wasKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-116 01 OCT 10 immediately notified of the engine problem by the air bo ss, who saw sparks coming from the #1 engine. At that point there was a breakdown in crew coordination. There

was no communication between the crew regarding the ability to maintain flight. It was

decided that there wasn't time to execut e NATOPS procedures for single-engine failure in spite of a good climb rate. On short final the copilot relinquished the controls to the HAC, who might have been reluctant to land while wearing NVGs, which was prohibited by the CO. Furthermore, the lack of depth perception and visual acuity using NVGs may have adversely affected the landing.

CAUSE FACTORS OF THE MISHAP

The cause factors of the mishap were lis ted as all human by the AMB and subsequent endorsers, including aircrew, maintenance, and supervisory error. The aircrew were cited for failure to comply with NATOPS in that the pilot, abett ed by all other crew members, continued to operate an engine with a zero oil pressu re indication. The pilot

was faulted for failure to maintain single-engine airspeed and for performing a prohibited maneuver. The pilot and copilot were nam ed for failure to execute single engine emergency procedures and for a breakdown of cr ew coordination. The crew chief was blamed for inadequate crew rest, failure to conduct a daily preflight, and inadequate troubleshooting procedures. The CDI was assigned maint enance personnel error for failure to properly inspect zonal area of maintenance action. The squadron maintenance department was in cluded for failure to follo w prescribed maintenance procedures as specified by OPNAVINST 4790. 2D. The squadron CO was criticized for having no established system for monito ring and reacting to lack of adequate rest experienced by aircrew members schedul ed for flight; for deficient personnel assignment and distribution; and for failure to manage squadron personnel and assets effectively during period of increased op tempo.

CONCLUSIONS

The major factor in this mishap was supe rvisory error for lack of adequate rest for aircrew and maintenance personnel. This led to short cuts in maintenance, poor judgment and crew coordination on the part of the aircrew, and slowed reaction time for the pilot.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-117 01 OCT 10 FLEW INTO SEA AT THE 90

P & R

NARRATIVE

A CH-46E impacted the water during night de ck landing qualifications. The HAC, copilot and observer egressed under water and were rescued with minor injuries. The

crew chief was lost at sea.

HUMAN FACTORS ANALYSIS

The Mishap Helicopter Aircraft Commander (MHAC) is a 32-year-old Captain in the Marine Corps. He had a total of 2843 total f light hours, 1376 in CH- 46's. A month prior to the mishap he flew night FCLPs with a new cop ilot who erroneously listed the code for carrier landings, rather than FCLPs. The error was not corrected by the MHAC, ODO or Ops department. The result was that the MHAC was consi dered qualified to act as HAC for day and night CQ when his jacket was reviewed. In fact, his last day shipboard landing was a year before the mishap. His la st night landing on a ship occurred 4 1/2 years prior. He was neither cu rrent nor proficient. Considered to be an above average pilot, but not the best, he had difficulty getting along with other squadron pilots. He used the instructor role in the cockpit to facilitat e working interactions with his copilots. Because of this, some pilots aske d not to fly with him. Divorced, he has two young children living several thousand miles aw ay. His mother and other relatives had visited him immediately prior to the mishap.

The 25-year-old Mishap Copilot (MCP) is a Mari ne 1st LT with 487 total flight hours, 215 in CH-46 helicopters. He was on his first fleet tour following t he TRACOM, where he had a number of problems copi ng in the aircraft. An av erage copilot, he is happily married. He is highly motiva ted towards the Marine Corps. He was scheduled to give a class to a group of enlisted pe rsonnel immediately prior to t he brief on ship operations. His lecture ran over time, so he missed the br iefing. He also missed the briefing by the MHAC on night shipboard qualification landings.

The MHAC flew out to the ship with eight squadron pilots, one as his copilot, the others as passengers. Five of them were copilo ts who were scheduled for night deck quals. The MHAC would not be required to fly requal s since he was erroneously thought to be qualified. After landing and di sembarking passengers, he tur ned the controls over to the first copilot, who comple ted his required 5 l andings. The MCP then replaced the first copilot. The MHAC, sitting in the left seat took a couple of mi nutes to instruct the MCP in the boat pattern. He briefed the MCP that he would demonstrate the first pattern to him. They never used a NA TOPS checklist, never did a complete NATOPS brief, didn't discuss aircrew coordination, th e hazard of night flying with no horizon, nor instrument flight procedures.

In deteriorating weather, with rain shower s and shifting winds, they took off on instruments. The ship was on a 005- degree true course heading with a port to starboard landing pattern established. The MH AC, a little high abeam (350 feet insteadKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-118 01 OCT 10 of 300 feet) close and a little slow (60 knot s instead of 80 knots), decreased power and made a shallower than normal turn (15 de grees rather than 20-25 degrees angle of bank). Approaching the 90-degr ee position, descending from 200 feet to 175 feet, between 60 and 80 knots, the vertical speed indicator was passing through 400-500 foot per minute descent. His "snapshot" view of the VSI gave him no clue to add power to arrest his vertical sink rate. The ship's deck lighting created an up sloping illusion, based on its 4-degree port roll and 2 degree pitch, reinforcing the pilot's perception of being high. Because of his shallower than norma l turn and the wind coming from 110 degrees true, the MHAC felt as if t hey were going to overshoot. He attempted to correct by increasing his AOB to 20-30 degrees with no c hange in power. At this time the crew

chief call "sink rate". The aircraft hit the wa ter a moment later. LAWS were not installed

in the aircraft.

CAUSE FACTORS OF THE MISHAP

The AMB concluded that th is mishap was caused by the aircrew and supervisory factors. The MHAC misjudged his altitude above the water, exceeded his experience level and did not adequately brief prior to fli ght. The aircrew was faulted for failure of aircrew coordination. The squadron CO and operations officer were both assigned supervisory error for providing an improper schedule that did not allow the MHAC and MCP to brief together. They were also lis ted for scheduling a non- proficient pilot for night carrier landing qualifications. The oper ations officer was singled out for failing to

correct the NAVFLIR and ATRIMs.

CONCLUSIONS

The MHAC was dishonest in not correcting the squadron's perception that he was day and nigh landing qualified. His lack of an adequate briefing and t he failure of the copilot

to communicate led to a breakdown in aircrew coordination, which left the copilot as just a passenger in the aircraft. Instead of callin g out altitude, airspeed and sink rate, he sat on his hands while they flew into the sea. The HAC lack of night deck landing proficiency and the breakdown in his in strument scan led him into a trap.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-119 01 OCT 10 FLEW INTO SEA AT NIGHT

DISTRACTION

NARRATIVE

Returning from an night FAM/NAV hop to allo w the H2P experience in the right seat, an SH-60B was entering the GCA pattern at 1600 feet when a report of a sinking boat in the area led them to join the SAR effort. With the H2P at the controls and the HAC busy plotting the position of the sinking boat into the multi-purpose display (MPD), the aircraft began a 1400-fpm descent until water impact. T he H2P had intended to level off at 200 feet, but became preoccupied with locating the position of the distressed boat on the MPD. The crew escaped with minor injuries . The HAC sustained a compound fracture of the left leg. The aircraft broke up and sank. The report of a sinking boat was found to

be false.

HUMAN FACTORS ANALYSIS

The HAC was a 28-year-old LT with 1020 total f light hours, 528 in type. The H2P was a 27-year-old LT with 722 total hours, 149 in ty pe. These pilots ha d crewed together for about a month at the time of the mishap. Bo th were second tour aviators whose first tours found them flying the UH-1N . This was their first tour in the LAMPS environment.

The HAC had been on continuous duty for 14 hours prior to the mishap. The H2P had been on continuous duty for 11 hours. They had flown for 3.5 hours at the time of the mishap, thus were approaching an end of f light letdown when an opportunity to participate in a SAR presented itself and t hey both became preoccupied and task over saturated. The HAC was proba bly overconfident in the H2 P's capability since they had flown together a good bit, and had complet ed a similar SAR mission just two days

before.

CAUSE FACTORS OF THE MISHAP

The mishap was closed out at the Naval Safety Center as aircrew error. The pilot failed to monitor his instruments during night inst rument flight, while the copilot failed to monitor instruments and assist the pilot at t he controls. A lack of crew coordination was present during the descent.

CONCLUSIONS

Crew coordination problems played a prominent role in this mishap. Aircraft assignments became confused, with the H2P/ PAC getting involved with the MPD and internal cockpit decisions to the detriment of awareness outside the cockpit. The HAC stopped being a safety backup and concentra ted on the MPD. The entire three-man crew developed cockpit fixation trying to loca te the SAR position and get ready for the

SAR effort.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-120 01 OCT 10 THIS PAGE INTENTIONALLY LEFT BLANKKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-121 01 OCT 10 FLEW INTO SEA/UNAUTHORIZED AIR SHOW

HAZARDOUS ATTITUDES

NARRATIVE

After performing a series of low altitude aerobatic maneuv ers, an SH-60B impacted the sea alongside a ship which wa s conducting a "tiger cruise." The pilot and copilot both drowned, secondary to incapacitation from severe head and chest injuries. A third crewman escaped with a fractu red back and bruised heart.

HUMAN FACTORS ANALYSIS

The pilot was a 28-year-old LT with 2228 total f light hours, 222 in type. He had flown 88 hours and was on travel for 32 of the preceding 90 days. He was in the process of PCS and had sold his home and purchased land near hi s new duty station in order to build a house on it. The 29-year-old LT copilot had 1896 total flight hours, 34 3 in type. He had

flown 111 hours and was on travel during 48 of the preceding 90 days. Thus both were isolated from the routine AOMs, safety re views, and stand down s of the squadron and were observed infrequently by their supervisors.

They had both undergone jet transit ion in preparation for Test Pilot School (TPS). Though they may have had some limited experienc e with dive-bombing ov er water, it is highly unlikely that they were fully pr epared for the problems associated with smooth water depth perception and illusions, target fi xation, and the minimu m altitude for dive recovery. Their radar altimeters were se t for 30 and 37 feet, far too low to provide adequate warning for the type of maneuvers t hey were performing. Experienced witnesses stated that they had never seen a helicopter exec ute this type of maneuver, typical of jet aircraft in di ve bombing patterns. The pilo t had been warned to "knock it off" doing similar maneuvers a week prior to the mishap. This info was not transmitted up the chain of command.

During the week of the mishap, episodes of high speed, low altitude over water flights

was observed. These ended in low-level aerobatics near observers who noted rotorovers, high speed sideways and reverse flight.

CAUSE FACTORS OF THE MISHAP

This mishap was due to aircrew and supervisory error. Both pilots were faulted for disregarding existing rules and regulati ons, being complacent, and exercising poor judgment in conducting low al titude maneuvers. They misj udged their proximity to the

water and failed to arrest their rate of descent. Their command was assigned supervisory error for a lack of checks and bal ances to correct warning "flags" known to on-scene supervisors.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-10-SG 10-122 01 OCT 10 CONCLUSIONS

These pilots demonstrated a la ck of the self-discipline and professionalism that is considered to be a required characteristic for all military aviators. Their proven lack of maturity and judgment, evidenced on other occasions, should have brought them to the attention of supervisors and called into questi on their being assigned to TPS. Although they had tacit approval of the CO of the ship to put on a demonstration for the "tigers," they did not have the author ization of their squadron CO to perform an air show.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-1 01 OCT 10 

## NATIONAL TRANSPORTATION

SAFETY BOARD REPORTS

TABLE OF CONTENTS

SUBJECT PAGE

UNITED AIRLINES FL IGHT 173 ............................................................................... 11-2

SOUTHERN AIRWAYS FLIGHT 242 ......................................................................... 11-9

UNITED AIRLINES FL IGHT 2860 ............................................................................ 11-15

AIR FLORIDA FL IGHT 90 ........................................................................................ 11-20

EASTERN AIR LINES FLIGHT 401 ......................................................................... 11-27

NORTHWEST AIRLINES FLIGHT 255 .................................................................... 11-31

PACIFIC SOUTHWEST AIRLIN ES FLIGHT 182 ..................................................... 11-35

GALAXY AIRLINES FL IGHT 203 ............................................................................. 11-39

CONTINENTAL CONNECT ION FLIGHT 3407 ........................................................ 11-46KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-2 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ UNITED AIRLINES FLIGHT 173 DC-8-61, N8082U PORTLAND, OREGON

DECEMBER 28, 1978

History of the Flight

On December 28, 1978, United Airlines, Inc. Flight 173, a McDonnell-Douglas DC-8-61 (N8082U), was a scheduled flight from John F. Kennedy International Airport, New York, to Portland International Airport, Po rtland, Oregon, with an en route stop at Denver, Colorado.

Flight 173 departed from D enver about 1447 with 189 pers ons on board, including 6 infants, and 8 crewmembers. The flight was cleared to Port land on an Instru ment Flight Rules (IFR) flight plan. The planned time en route was 2 hours 26 minutes. The planned arrival time at Portland was 1713.

According to the automatic flight plan and monitoring system the to tal amount of fuel required for the flight to Port land was 31,900 lbs. There was 46,700 lbs of fuel on board the aircraft when it departed the gate at Denver. This fuel included the Federal Aviation Regulation requirement for fuel to des tination plus 45 minutes and the company contingency fuel of about 20 mi nutes. During a post accident interview, the captain stated that he was very close to his predicted fuel for the entire flight to Portland ". . . or

there would have been some discussion to it." The captain also explained that his flight

from Denver to Po rtland was normal.

At 1705:47, Flight 173 calle d Portland Approach and advis ed that its altitude was 10,000 feet and its airspeed was bei ng reduced. Portland res ponded and told the flight to maintain its heading for a visual approach to runway 28. Flight 173 acknowledged the approach instructions and stated, " . . . we have the field in sight."

At 1707:55, Portland Approach inst ructed the flight to descend and maintain 8,000 feet. Flight 173 acknowledged the in structions and advised that it was "leaving ten." At 1709:40, Flight 173 received and acknowledged a clearance to continue its descent to 6,000 feet.

During a post-accident interview, the c aptain stated that, when Flight 173 was descending through about 8,000 feet, the first officer, w ho was flying the aircraft, requested the wing flaps to be extended to 15 degrees, then asked that the landing gear be lowered. The captain stated that he co mplied with both requests. However, he further stated that, as the landing gear exten ded, ". . . it was noticeably unusual and (I) feel it seemed to go down more rapidly. As (i t is) my recollection, it was a thump, thump

in sound and feel. I don't re call getting the red and transient gear door light. The thumpKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-3 01 OCT 10 was much out of the ordinary for this airplane . It was noticeably different and we got the nose gear green light but no other lights." The captain also said the first officer remarked that the aircraft "yawed to the righ t . . . . " Flight attendant and passenger

statements also indicate that there was a loud noise and a severe jo lt when the landing gear was lowered.

At 1712:20, Portland Approach requested, "United one seven three heavy, contact the tower (Portland), one one eight point seven." The flight responded, "Negative, we'll stay with you. We'll stay at five. We'll mainta in about a hundred and seve nty knots. We got a gear problem. We'll let you know." This was the first indication to anyone on the ground that Flight 173 had a problem.

At 1712:28, Portland Approach r eplied, "United one seventy- three heavy roger, maintain five thousand. Turn left heading two zero zero." The flight acknowledged the

instructions.

At 1714:43, Portland Approach advised, "United one sevent y three heavy, turn left heading, one zero zero and I'll just orbit you out there 'til you get your problem." Flight 173 acknowledged the instructions.

For the next 23 minutes, while Portland Approach was vectoring the aircraft in a holding pattern south and east of the airport, the f light crew discussed and accomplished all of the emergency and precautionary ac tions available to them to assure themselves that all landing gear was locked in the full down positi on. The flight engineer checked the visual indicators on top of both wings, wh ich extend above the wi ng surface when the landing gear is down-and-locked.

The captain stated that during this same ti me period, the first flight attendant came

forward and he discussed the situat ion with her. He told her that after they ran a few more checks, he would let her kn ow what he intended to do.

About 1738, Flight 173 contac ted the United Airli nes Systems Line Ma intenance Control Center in San Francisco, Calif ornia, through Aeronautical Ra dio, Inc. According to recordings, at 1740:47 the captain explain ed to company dispatch and maintenance personnel the landing gear problem and what the flight crew had done to assure that the landing gear was fully exte nded. He reported about 7,000 lbs of fuel on board and

stated his intention to hold for another 15 or 20 minutes. He stated that he was going to have the flight attendants prepare the pa ssengers for emergency evacuation. At 1744:03, United San Francisco asked, "Okay, United one seventy three...You estimate that you'll make a landing about five minutes past the hour. Is that okay?" The captain responded, "Ya, that's good ball park. I'm not gonna hurry the girls. We got about a hundred sixty five people on board and we ... want to ... take our time and get everybody ready and then we'll go. It's clear as a bell and no problem.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-4 01 OCT 10 The aircraft continued to circle under the di rection of Portland Appr oach in a triangular pattern southeast of the airport at 5,000 feet. The pattern kept that aircraft within about 20 NM of the airport.

From about 1744:30 until about 1745:23, the cockpit voice recorder (CVR) contained conversation between the capt ain and the first flight a ttendant concerning passenger preparation, crash landing procedures, and evacuation procedures. During his initial interview, the captain indica ted that he neither designated a time limit to the flight attendant, nor asked her how long it would take to prepare the cabin. He stated that he

assumed 10 or 15 minutes would be reaso nable and that some pr eparations could be made on the final approach to the airport.

At 1746:52, the first officer asked the flight engineer, "How much fuel we got?" The flight engineer responded, "F ive thousand." The first officer acknowledged the

response.

At 1748:38, Portland Approach adv ised Flight 173 that ther e was another aircraft in its vicinity. The first o fficer advised Portland Approach that he had the aircraft in sight.

At 1748:50, the first officer asked the captain,” . . . what's the fuel show now . . .?" The captain replied, "Five." The first officer repeated, "Five." At 1749, after a partially unintelligible comment by the flight engineer concerning fu el pump lights, the captain stated, "That's about right, the feed pumps ar e starting to blink." According to data received from the manufacturer, the total usable fuel remaining when the inboard feed pump lights illuminate is 5,000 lbs. At this time, according to Flight Data Recorder (FDR) and air traffic control data, the aircra ft was about 13 NM south of the airport on a west southwesterly heading.

From just after 1749 until 1749:45, the flight crew engaged in further conversation about the status of the landing gear. This c onversation was interrupted by a heading change from Portland Approach and was followed by a traffic advisor y from Portland Approach.

About 1750:20, the captain ask ed the flight engineer to "Give us a current card on weight. Figure about another fifteen minutes." The first officer responded, "fifteen minutes?" To which the captai n replied, "yeah, give us th ree or four thousand pounds on top of zero fuel weight." The flight engi neer then said, "Not en ough. Fifteen minutes is gonna - really run us low on fuel here. " At 1750:47, the flight engineer gave the following information for the la nding data card: ". . . Okay. Take three thousands pounds, two hundred and four." At this time the aircraft was about 18 NM south of the airport in a turn to the northeast.

At 1751:35, the captain instructed the f light engineer to contact the company representative at Portland and a pprise him of the situation a nd tell him that Flight 173 would land with about 4, 000 lbs of fuel. From 1752:17 until about 1753:30, the flight engineer talked to Portland and discussed the aircraft's fuel state, the number of persons on board the aircraft, and the emergency landing preparations at the airport. AtKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-5 01 OCT 10 1753:30, because of an inquiry fr om the company representativ e at Portland, the flight engineer told the captain, "He wants to know if we'll be la nding about five after." The captain replied, "Yes." The flight engineer relayed the captain's reply to the company representative. At this time the aircraft was about 17 NM south of the airport heading

northeast.

At 1755:04, the flight engi neer reported the “ . . . approach descent check is complete." At 1756:53, the first officer a sked, "How much fuel you got now?" The flight engineer responded that 4,000 lbs remained, 1,000 lbs in each tank.

At 1757:21, the captain sent t he flight engineer to the cabin to “ . . . kinda see how things are going . . .." From 1757:30 until 1800:50, the captain and the first officer engaged in conversation which included discu ssions of giving the flight attendants ample time to prepare for the emergency, cockpit procedures in the event of an evacuation after landing, whether the brak es would have antiskid protection after landing, and the procedures the captain would be using during the approach and landing.

At 1801:12, Portland Approach r equested that the flight turn left to a heading of 195 degrees. The first officer acknow ledged and complied with the request.

1801:34, the flight engineer returned to the cockpit and reported that the cabin would be ready in "another two or three minutes." The aircraft was about 5 NM southeast of the airport turning to a southwesterly heading. Until about 1802:10, the captain and the flight engineer discussed the passengers and their attitudes toward the emergency.

At 1802:22, the flight engineer advised, "We got about thr ee on the fuel and that's it."

The aircraft was then about 5 NM south of the airport on a southwest heading. The captain responded, "Okay. On touchdown, if the gear folds or something really jumps the track, get those boost pumps off so t hat...you might even get the valves open."

At 1802:44, Portland Approach a sked Flight 173 for a status report. The first officer replied, "Yeah, we have indica tion our gear is abnormal. It' ll be our intention, in about five minutes, to land on two eight left. We would like the equipment standing by. Our indications are the gear is down and locked. We've got our people prepared for an

evacuation in the event that should become necessary."

At 1803:14 Portland Approach asked that Flight 173 advise them when the approach would begin. The captain responded, " . . . They've about finished in the cabin. I'd guess about another three, four, fi ve minutes." At this time the aircraft was about 8 NM south of the airport on a southwesterly heading.

At 1803:23, Portland Approach asked Flight 173 for the num ber of persons on board and the amount of fuel remaining. The captain replied, ". . . about four thousand, well, make it three thousand, pounds of fuel," and "you can add to that one-seventy-two plus six laps - infants."KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-6 01 OCT 10 From 1803:38, until 1806:10, the flight crew engaged in a conversation which concerned (1) checking the landing gear warn ing horn as further evidence that the landing gear was fully down and locked and (2) whether automat ic spoilers and antiskid would operate normally with the landi ng gear circuit breakers out.

At 1806:19, the first flight a ttendant entered the cockpit. T he captain asked, "How you doing?" She responded, "Well, I think we're r eady." At this time the aircraft was about 17 NM south of the airport on a southwesterly heading. The conversation between the first flight attendant and the captain cont inued until about 1806: 40 when the captain said, "Okay. We're going to go in now. We should be landing in about five minutes."

Almost simultaneous with this co mment, the first officer said, "I think you just lost

number four . . ." followed imm ediately by advice to the flight engineer, ". . . better get some crossfeeds open there or something.

At 1806:46, the first officer told the captain, "We're going to lose an engine . . ." The captain replied, "Why?" At 1806:49, the first, officer a gain stated, "We're losing an engine." Again the captain asked, "Why?" The first officer responded, "Fuel."

Between 1806:52 and 1807:06, the CVR revealed conflicting and confusing conversation between flight crew members as to the aircraft's fuel state. At 1807:06, the first officer said, "It's flamed out."

At 1807:12, the captain called Portland A pproach and requested, “ . . .would like clearance for an approach into two eight le ft, now." The aircraft was about 19 NM south-southwest of the airport and turning left. This was the first request for an approach clearance from Flight 173 since the landing gear problem began. Portland Approach immediately gave the f light vectors for a visual approach to runway 28L. The flight turned toward the ve ctor heading of 010 degrees.

From 1807:27 until 1809:16, the following intra-cockpit c onversation took place:

1807:27 Flight Engineer: "We're going to lose number three in a minute, too." 1807:31 Flight Engineer. “It’s showing zero.” Captain: “

1807:31 Flight Engineer: "It's showing zero ." Captain: "You got a thousand pounds. You got to." Flight Engineer: "Five thousand in there . . . but we lost it." Captain: "Alright." 1807:38 Flight Engineer: "A re you getting it back?"

1807:40 First Officer: "No number f our. You got that crossfeed open?" 1807:41 Flight Engineer: "No, I hav en't got it open. Which one?" 1807:42 Captain: "Open'em bo th - get some fuel in there. Got some fuel pressure?” Flight En gineer: "Yes, sir." 1807:48 Captain: "Rotati on. Now she's coming." 1807:52 Captain: "Okay, wa tch one and two. We're sh owing down to zero or a thousand." Flight Engineer: "Yeah" Captain: "On number one?" Flight Engineer: "Right."

1808:08 First Officer: "Still not getting it."KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-7 01 OCT 10 1808:11 Captain: "Well, open a ll four crossfeeds." Flight E ngineer: "All four?" Captain: "Yeah."

1808:14 First Officer: "Alr ight now it's coming." 1808:19 First Officer: "It's going to be-on approach though." Unknown Voice:

"Yeah." 1808:42 Captain: "You gotta keep 'e m running. . ." Flight Engineer: "Yes, sir."

1808:45 First Officer: "Get this . . .on the ground." Flight Engi neer: "Yeah. It's showing not very much more fuel." 1809:16 Flight Engineer: "We're down to one on the totalize. Number two is empty."

At 1809:21, the captain advised Portland Approach, "United, one seven three is going to turn toward the airport and come on in." After confirming Flight 173's intentions, Portland Approach cleared the flight for the visual approach to runway 28L.

At 1810:17, the captain request ed that flight engineer "res et that circuit breaker momentarily. See if we get gear lights." T he flight engineer comp lied with the request.

At 1810:47, the captain request ed the flight's distance fr om the airport. Portland approach responded, "I'd call it eighteen flying miles." At 1812:42, the captain made another request for distance. Po rtland Approach responded, "Twelve flying miles." The flight was then cleared to contact Portland tower.

At 1813:21, the flight engi neer stated, "We've lost two engines, guys."

At 1813:25, he stated, "We just lost two engines - one and two."

At 1813:38, the captain said, "They're all goi ng. We can't make Troutdale." The first officer said, "We can't make anything."

At 1813:46, the captain told the first officer, "Okay. Declare a may day." At 1813:50, the

first officer called Portland International Airport tower and declared, "Portland tower, United one seventy three heavy, Mayday. We're - the engines are flaming out. We're going down. We're not going to be able to make the airport." This was the last radio transmission from Flight 173.

About 1815, the aircraft crashed into a wo oded section of a popul ated area of suburban

Portland about 6 NM east southeast of the ai rport. There was no fire. The wreckage path was about 1,554 feet l ong and about 130 feet wide.

The accident occurred during the hours of darkness at latitude 45°31'21"N and longitude 122°29'59"W. The elevation of the accident site was 285 feet.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-8 01 OCT 10 Injuries to Persons

Injuries Crew Passengers Others

Fatal 2 8 0

Serious 2 21 0

Minor/None 4 152 0

Damage to Aircraft

The aircraft was destroyed.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-9 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D. C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ SOUTHERN AIRWAYS FLIGHT 242 DC-9-31, N13354 NEW HOPE, GEORGIA APRIL 4, 1977

History of the Flight

On April 4, 1977, Southern Airways, Inc., Flight 242, a DC-9-31 (N 1335U) operated as a scheduled passenger flight from Muscle Shoals, Alabama, to At lanta, Georgia, with an intermediate stop at Huntsvill e, Alabama. F light 242 departed Muscle Shoals at 1521

and landed at Huntsville about 1544.

About 1554, Flight 242 departe d Huntsville on an Instrument Flight Rules (IFR) flight plan for the Hartsfield-Atlanta Internati onal Airport; there were 81 passengers and 4

crew members aboard. The f light's route was direct to the Rome VOR and then a Rome runway 26 profile descent to Atlanta. Its estimated time en route was 25 minutes and its requested en route al titude was 17,000 feet.

At 1554:35, Flight 242 estab lished communications with Hu ntsville departure control and at 1554:39, the controller cl eared the flight to climb to 17,000 feet. At 1555:14, the controller cleared the flight to proceed direct ly to the Rome VOR. According to the cockpit voice recorder (CVR), at 1555:58 the c aptain remarked, "Well the radar is full of it, take your pick."

At 1556:00, the controller told Flight 24 2 that his radarscope was showing heavy precipitation and that the ec hoes were about 5 NM ahead of the flight. Flight 242 responded, "Okay . . . we're in the rain right now . . . it doesn't look much heavier than what we're in, does it?" At 1556:12, the c ontroller said, ". . . I got weather cutting devices on which is cutting out t he precip that you're in now . . . however, it's not a solid mass, it . . . appears to be a little bit heavier t han what you're in right now." Flight 242 replied, "Okay, thank you."

At 1556:37, the first officer, w ho was flying the airplane, said, "I can't read that, it just looks like rain, Bill. What do you think? There's a hole." The captain responded, "there's a hole right here. That's all I s ee." He added, "Then coming over, we had pretty good radar. I believe right straight ahead . . . there the next few m iles is about the best way we can go."

At 1557:36, the controller said, ". . . you're in what appears to be about the heaviest part of it now, what are now, what ar e your flight conditions?" F light 242 replied, ". . . we're getting a little light turbulence and . . . I'd say moderate rain." At 1557:47, the controller acknowledged Flight 242's report and told t he flight to contac t Memphis Center.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-10 01 OCT 10 At 1558:10, Flight 242 est ablished communications with Memphis Air Route Traffic Control Center (Memphis Cente r). At 1558:32, the captain said, "As long as it doesn't get any heavier we'll be all right." The firs t officer replied, "Yeah, this is good.

At 1558:26, the Memphis Center controller advised the flight that a SIGMET was current for the vicinity of Tennessee, southeastern Louisiana, Mississippi, northern and western Alabama, and adjacent coastal waters, and advised them to monitor VOR broadcasts

within a 150-nm radius of the SIGMET area. At 1558:45, the controller told Flight 242 to

contact Atlanta Air Route Tra ffic Control Center (Atlanta Center). At 1559:00, the captain said, "Here we go . . . hold 'em cowboy."

At 1559:06, Flight 242 established communicati ons with Atlanta Cent er (Sector 39) and

stated that it was "out of el even for seventeen." The contro ller replied, ". . . roger; expect Rome runway 26 profile descent." Flight 242 acknowledged the controller's

transmission. Between 1559:18 and 1602:03, the Atlanta C enter controller conversed with TWA Flight 584 about its deviations eastward around thunderstorms between Chattanooga, Tennessee, and Rome, Georgia. At 1600:30, the sound of rain was recorded on Flight 242's CVR. At 1602:57, the capt ain of Flight 242 sa id, "I think we'd better slow it up right here in this . . ." The first officer replied, "Got ya covered."

At 1603:01, an Atlanta Center controller (sector 40) contacted an Easter n Airlines flight, which had just crossed the storm area northwe st of Rome, and asked, "How would you classify your ride through that line up there? You recommend anyone else come through it?" The flight answered that "it was not too comfortable but we didn't get into anything we would consider the least bit haz ardous." At 1603, Flight 242 was told to contact Atlanta Center (sector 40). About 11 seconds later, the sound of li ght rain was

recorded on the CVR. At 160 3:20, Flight 242 es tablished communications with Atlanta

Center on the new fr equency and said, ". . . level at seventeen." At 1603:48, the captain said, "Looks heavy, nothing's going thr ough that." Six seconds later, he said,

"See that." The first officer sa id, "That's a hole, isn't it?" The captain replied, "It's not showing a hole, see it?" At 1604:05, the sound of rain was recorded on the CVR, and 3 seconds later the first officer asked, "Do y ou want to go around t hat right now?" At 1604:19, the captain said, "Hand fly it about 285 knots," and the first officer responded,

"285."

At 1604:30, the sounds of rain and hail were recorded, and 20 seconds later Flight 242 reported to Atlanta Center t hat the flight was reducing speed. At 1605:53, the first officer said, "Which way do we go cross here or go to - I don't know how we get through there, Bill." The captain repli ed, "I know you're just gonna have to go out . . .” The first officer said, "Yeah, right across that band." At 1606:01, the captain said, "All clear left approximately right now; I think we can cut across there now." At 1606:12, the first officer said, "All right, here we go."

Between 1604:42 and 1606:02, Atl anta Center was coordinati ng with TWA-584 about its route and altitude to intercept the Atlanta VOR 313 radial inbound. At 1606:30, the controller said, "I show weather up northeast of that position, north of Rome, just on theKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-11 01 OCT 10 edge of it . . . maintain 15,000." TWA-584 replied, "Maint ain 15,000, we paint pretty good weather at 1 or 2 o'clock."

At 1606:41, the first officer on Flight 242 said , "He's got to be right through that hole about now." About the same time, Atlanta C enter cleared Flight 242 to descend to and maintain 14,000 feet. At 1606: 46, the captain said, "Who's t hat?", and the first officer replied, "TWA." At 1606:53, the captain reported to Atlant a Center, "242 down to 14." About the same time, the sound of heavy hail or rain was recorded on the CVR. The sounds continued to 1607:57, at wh ich time the CVR ceased to record for 36 seconds; it began operation again at 1608:33, and the sound of rain continued for another 40

seconds.

Between 1607:00 and about 1608:01, Atlanta C enter made four transmissions to Flight 242; none was acknowledged. About 1608:34, Atlanta Cent er said, "Southern 242, Atlanta." At 1608:37, the first officer said, "G ot it, got it back, Bill, got it back." At 1608:42, Flight 242 told Atlanta Center to "standby." At 1608:49, At lanta Center transmitted, "Roger, maintain 15,000 if you understand me, maintain 15,000, Southern 242." At 1608:55, Flight 242 replied, "We're trying to get it up there."

At 1609:15, Flight 242 reported to Atlanta Center, "Okay . . . we just got our windshield busted and. . . we'll try to get it back up to 15, we're 14." At 1609:36, the first officer said, "Left engine won't spool," and Flight 242 reported to Atlant a Center, "Our left engine just cut out." Atlanta Center rep lied, ". . . roger, and lost your transponder, squawk 5623." At 1609:43, the first officer sa id, "I'm squawking 5623, tell him I'm level

14."

At 1609:59, the captain said, "Autopilot off," and the first officer replied, "I got it, I'll hand fly it." At 1610:00, Atlanta Center cleared Flight 242 to descend to 13,000 feet. At 1610:04, the first officer said, "My . . . the other engine's going too . . .," and at 1610:05, Flight 242 reported to Atlanta Center, ". . . the ot her engine's going too. " Atlanta Center replied, " . . . say again." Flight 242 said, "Standby, we lost both engines."

At 1610:14, the first officer said , "All right Bill, get us a vector to a clear area." At 1610:16, Flight 242 told Atlanta Center, "Get us a vector to a clear area Atlanta." Atlanta Center replied, ". . . continue present southe ast bound heading, TWAs off to your left about 14 miles at 14,000 and says he's in the clear." Flight 242 replied, "Okay."

At 1610:27, Flight 242 asked Atla nta Center, "Want us to turn left?" The Center replied, ". . . contact approach control 1 26.9 and they'll try to get you straight into Dobbins. At 1610:36, the first officer said, "Give me - I'm fa miliar with Dobbins, tell them to give me a vector to Dobbins if they're clear." At 1610:38, Flight 242 asked Atlanta Center, "Give me a vector to Dobbins if they 're clear." The Center replied, ". . . 126.9, they'll give you a vector to Dobbins." At 1610:45, F light 242 replied, "269, Okay."KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-12 01 OCT 10 At 1610:50, the first officer said , "Ignition override, it's gotta work . . ." At 1610:52, an Atlanta Approach Control trans mission to Lear Jet 999M was recorded on Flight 242's CVR; at 1610:56, the CVR ceased operation for 2 minutes 4 seconds. Between about 1611:17 and 1612:50, Atlanta Cent er made three transmissions to Flight 242. About 1612:00, Atlanta Approac h Control made one transmission to Flight 242: 10 seconds later, TWA 584 called Flight 242. No responses were recorded.

At 1613:00, the CVR resumed operation, and at 1613:03 the captain said, "There we go." The first officer responded, "Get us a vector to Dobbins." At 1613:04, Flight 242 transmitted to Atlanta Approach Control, ". . . Atlanta, y ou read Southern 242?" Approach Control replied, "S outhern 242, Atlanta, go ahead." Flight 242 said, "...we've lost both engines, how about givi ng us a vector to the neares t place, we're at 7,000 feet." At 1613:17, Approach Control rep lied, "Roger, turn right heading 100°, will be

vectors to Dobbins for a stra ight-in approach runway 11...your position is 15, correction

20 miles west of Dobbins at this time." Conc urrent with this transmission, the first officer said, "What's Dobbins' weather, Bill? How fa r is it? How far is it?" Flight 242 transmitted, "Okay 140° heading and 20 miles."

At 1613:35, Atlanta Appr oach Control directed, ". . . ma ke a heading of 120, Southern 242, right turn to 120°." Flight 242 replied, "O kay, right turn to 120 and . . . you got us our squawk, haven't you, on em ergency." Concurrent with this transmission, the first officer said, "Declare an emergency, Bill." At 1613:45, Approach Control replied, ". . . I'm not receiving it but radar contact, your posit ion is 20 miles west of Dobbins." Flight 242 replied, "Okay."

At 1614:03, the first officer said, "Get thos e engines . . ." At 1614:24, Flight 242 transmitted to Approach Control, "All right, lis ten, we've lost both engines, and . . . I can't . . . tell you the implications of this . . . we . . . only got two engines, and how far is Dobbins now?" Approach Contro l replied, "...19 miles." Fl ight 242 transmitted, "Okay, we're out of ...5,800, 200 k nots." At 1614:45, Approach C ontrol asked, "Southern 242, do you have one engine running now?" Flight 242 replied, "Negative, no engines."

At 1615:04, the captain said, "Just don't stall this thing out." The first officer replied, "No I won't." The captain said, "Get your wi ng flaps," and the sound of lever movement was recorded. At 1615:11, the first officer said, "Got it, got hydraulics, so we got." The captain replied, "We got hydr aulics." At 1615:17, the firs t officer said "What's the

Dobbins weather?" At 1615: 18, Flight 242 asked Approac h Control, "What's your Dobbins weather?" Approach Control said, "Standby." At 1615:46, Approach Control said, "Southern 242, Dobbins weather is 2, 000 scattered, estimated 7,000 overcast, visibility 7 miles." Flight 242 replied, "Okay, we're dow n to 4,600 now." Approach Control responded, "Roger, and you're approximat ely . . . 17 miles west of Dobbins at this time." At 1616:05, Flight 242 said, "I don't know whether we can make that or not."

At 1616:11, the first officer said, " . . . a sk him if there is any thing between here and Dobbins?" The captain said, "What?" and t he first officer repeated his request. At 1616:25, Flight 242 asked Appr oach Control, "... is t here any airport between ourKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-13 01 OCT 10 position and Dobbins?" Approach Control replied, "...no sir, closest airport is Dobbins." At 1616:34, Flight 242 said, "I doubt we're going to make i t, but we're trying everything to get something started." Approach Contro l replied, "Roger, well there is Cartersville, you're approximately 10 miles south of Cart ersville, 15 miles west of Dobbins."

At 1616:45, Flight 242 asked Approach Cont rol, "Can you give us a vector to Cartersville?" Approach Cont rol replied, "All right, tu rn left, heading of 360, be directly...direct vector to Cartersville." Fli ght 242 said, "360, roger." At 1616:53, Flight 242 asked Approach Control, "W hat's the runway heading?" Approach Control replied, "Standby." Flight 242 than asked, "And how long is it?" Approac h Control replied, "Standby."

At 1617:08, the captain said, "...I'm picking out a clear field." The first officer replied, "Bill, you've got to find me a highway." Th e captain said, "Let's get the next clear open

field." The first officer said , "No..." At 1617:35, the captain said, "See a highway over -- no cars." The first officer said, "Right there, is that straight?" The captain replied, "No." The first officer said, "We'll have to take it."

At 1617:44, Approach Control transmitted, "Sout hern 242, the runway configuration...at Cartersville is...360 and running north and south and the elevat ion is 756 feet, and . . . trying to get the length now--it's 3,200 feet long." At 1618:02, Flight 242's last transmission to Approach Control was recor ded: "...we're putting it on the highway, we're down to nothing." From 1618:36 to 1618:43, crash sounds were recorded on the

CVR.

According to one of the passengers, a comme rcially licensed pilot who was seated on the left side of the airplane just forward of the left engine intake, the flight was routine

until the aircraft encountered severe turbulence followed by very heavy precipitation, a lightning strike on the left wingtip, and hail. The hail increased in intensity and size; then the right engine quit and the left engine qu it shortly thereafter. He thought the cabin lights went out shortl y after the lightning strike, but before the hail began. Additionally, almost simult aneous with the turbulence, he not iced that the power was reduced on the engines. He es timated that the turbulence la sted from 1 to 2 minutes, the heavy precipitation from 45 to 60 seconds, and the hail lasted from 45 to 60 seconds. The engines quit shortly after t he hail ceased; just before the right engine quit, he heard loud popping sounds from an ar ea ahead of the engine. Similarly, just before the left engine quit, he heard sounds of engine surging and loud popping. He

also noticed that the inlet fa iring in the center of the left engine was dented. After the engines quit, he heard sounds that he associated with attempts to start the Auxiliary Power Unit (APU) followed by sounds of the unit in operation. The two flight attendants

recalled details similar to thos e expressed by the passenger.

About 1615, several witnesses in Rockmar t, Georgia, saw Flight 242 flying over Rockmart in a westerly direction. The airc raft made a left turn and flew back toward the east. They heard no engine sounds and saw nothing peculiar about the aircraft.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-14 01 OCT 10 The aircraft crashed during daylight hours, at an elevation of 1,020 feet, and latitude 33°57'45" and longitude 84°47'13".

Injuries to Persons

Injuries Crew Passengers Others

Fatal 2 60 8

Serious 1 21 1

Minor/None 1 0 0KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-15 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ UNITED AIRLINES FLIGHT 2860 DC-8F-54, N8047U NEAR KAYSVILLE, UTAH DECEMBER 18, 1977

SYNOPSIS

About 0138:28 MST on December 18, 1977, a United Airlines, Inc., DC-8F-54 cargo aircraft, operating as Flight 2860, crashed into a mountain in the Wasatch Range near Kaysville, Utah. The three flight crew me mbers, the only persons aboard the aircraft, were killed, and the aircraft was destroyed.

Flight 2860 encountered electric al system problems during it s descent and approach to the Salt Lake City Airport. T he flight requested a holding cl earance, which was given by the approach controller and acc epted by the flight crew. The flight t hen requested and received clearance to leave the approach control frequency for a "little minute" to communicate with company maintenance.

Flight 2860 was absent from the approach control frequency for about 71⁄2 minutes. During that time, the fli ght entered an area near hazardous terrain. The approach controller recognized Flight 2860's predicam ent but was unable to contact the flight. When Flight 2860 returned to a pproach control frequency, the controller told the flight that it was too close to terrain on its right and to make a left turn. After the controller repeated the instructions, the flight began a left turn and about 15 seconds later the controller told the flight to climb immediat ely to 8,000 feet. Eleven seconds later, the flight reported that it was clim bing from 6,000 feet to 8,000 feet. The flight crashed into a 7,665-foot mountain near the 7,200-foot level.

History of the Flight

On December 17, 1977, Unit ed Airlines Flight 2860, a DC-8F-54 (N8047U), was a scheduled cargo flight from San Francisco, California, to Chicago, Illinois. About 21⁄2 hours before Flight 2860's sch eduled departure fr om San Francisco, an intermediate stop at Salt Lake City, Utah, was scheduled.

According to the flight dispat cher, the flight crew reported for duty at 2300. The captain and dispatcher discussed the w eather situation at Salt Lak e City, and the dispatcher informed the captain that t he flight would be dispatched with the aircraft's No. 1 AC electrical generator inoperat ive. This conformed to co mpany minimum-equipment-list procedures, and the dispatcher later stated that the lack of the generator seemed to present no problems to the capt ain. However, before the f light crew left the dispatch office, the dispatcher received informati on that the generator had been repaired, and heKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-16 01 OCT 10 passed this information to the captain. On December 18, 1977, at 0017, Flight 2860 departed San Francisco on an Inst rument Flight Rules (IFR) flight plan for Salt Lake City. The flight's estimated time en rout e was 1 hour 12 minutes, and its planned cruise altitude was flight level (FL) 370.

Flight 2860's departure and en route portions of the flight were flown without reported difficulty, except the Salt Lak e air route traffic control cent er (Salt Lake Center) sector

43 controller was unable to establish radio communications with the flight between 0105 and 0109 on frequency 133.45 mHz. At 0111: 41, Flight 2860 established radio

communication with the Salt Lake Center se ctor 41 controller on frequency 132.55 mHz and requested descent clearance for the approach to Salt Lake City Airport.

At 0111:52, the Salt Lake Cent er controller cleared the flight to descend to 15,000 feet and gave the altimeter setting as 29.58 in. At 0115:42, Flight 28 60 requested landing and weather information for Salt Lake City Airpor t. The controller replied that the flight

would soon be transferred to Salt Lake City approach control and the latter would provide the information requested. Flight 2860 said, "Okay, cause we're working with radio problems too it looks like."

At 0116:43 the controller cleared Flight 2860 to contact Salt Lake City approach control on frequency 126.8 mHz, and at 0116: 58, Flight 2860 established radio communications with that facility. The Salt Lake City approach controller gave Flight 2860 radar vectors for a VOR approach to runway 16R at Salt Lake City Airport 3/ and cleared the flight to descend to 8,000 feet. The controller also gave the weather information as: "...measured 1,700 overcast, visibility 15, li ght rain, temperature 41, altimeter 29.58."

The approach controller continued to vect or Flight 2860 for alignment with the VOR approach to runway 16R, and at 0120:38, he cleared the flight to descend to 6,000 feet. The flight acknowledged the descent clearance and asked t he controller, "What's the ceiling...?" the controller responded, "Measured 1,700 broken, the wind is 160 at 10."

At 0122:32, Flight 2860 advised, "Okay, we got...a few little pr oblems here, we're trying to check our gear and stuff right now." The c ontroller replied, "Okay, if ...you need any help, I'll give you a vector back around to final, but you're 6 miles from the VOR." Flight 2860 said, "Okay...."

At 0124:18, the controller cleared Flight 2860 to land and gav e the surface wind as 160° at 13 knots. Flight 2860 rep lied, "Roger, we got to check our gear first." At 0124:36, Flight 2860 indicated it w ould not land and the approach controller replied, "...fly runway heading, maintain 6,000, will vector you ba ck around for an approach." Flight 2860 said, "Okay...."

The approach controller gave Flig ht 2860 instructions to turn right to a 330° heading and to maintain 6,000 feet. The f light acknowledged, and said, "O kay, we'd just as soon not get back in it if we can help it." The controller re plied, "Okay, minimum vectoringKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-17 01 OCT 10 altitude is 6,000, that's the best I can do fo r you to vector you back for the approach." Flight 2860 said, "Okay, we'll try that."

At 0127:31, Flight 2860 asked, "Take us out about 20 miles, can you do that?" The controller replied, "Affirmative," and Fli ght 2860 responded, "Okay 'cause we're gonna have to get the gear down and try to find ou t what the heck is going on." At 0128:08, the controller said, "United...2860 turn right heading 345," and Flight 2860 replied, "345, twenty eight sixty."

At 0129:01 Flight 2860 transmitted, "Ah to wer, we're gonna have to, ah nuts, just a second." Fourteen seconds later, Flight 2860 asked, "You put us in a holding pattern at 6,000 here on the VOR for awhile?" The contro ller replied, "...roger, turn right, proceed direct to the Salt Lake VOR, hold on the, at the VOR, mainta in 6,000." Fl ight 2860 said, "Okay, we'll hold north of t he VOR, 6,000...right turns, ok ay?" The controller said, "That's correct, northwest of the VOR at 6,000, right turns." Flight 2860 replied, "Okay."

At 0129:51 Flight 2860 asked, "Okay, now can we... leave you for a little minute, we

wanna call San Francisco a minute?" The controller replied, "United 2860, frequency change approved," and at 0129:59 F light 2860 said, "Thank you sir, we'll be back." After this transmission, Flight 2860 contac ted United Airlines' syst em line maintenance

control center in San Francisco. This c ontact was made through Aeronautical Radio, Inc. (ARINC) on frequency 130.6 mHz. Fli ght 2860 began this communication link at

0130:21 and terminated the link at 0137:11.

According to ARINC communications recordings, Flight 2860 established

communications with the DC-8 maintenance c ontroller at 0132:37. Flight 2860 informed

the maintenance controller that the No. 1 electrical bus was inoperative, and the No. 3 generator would not para llel; also, the landing gear indi cator lights did not present a "down" indication when the landing gear wa s extended. The maintenance controller inquired whether the f light crew had attempted to reset the No. 1 bus, and the crew replied that they had. The controller inquir ed whether the No. 1 ge nerator was providing normal volts and frequency, and t he crew replied that it wa s providing "nothing, it's

dead."

At 0133:37, the maintenance contro ller told the flight crew to standby while he checked the electrical power source for the landi ng gear indicating syst em, and at 0135:08, the controller informed the flight crew "...the landing gear position indi cating system comes off the No. 1 bus..." He then inquired whether the flight crew could get another generator to power the No. 1 bus, and the crew responded, "The No. 1 bus is dead and that's it." At 0135:30, the maintenance controller said, "O kay, you can't get any other generator to pick up the dead bus, and that's why your landing gear warning system does not work -- because you got to have power to the 28-volt DC bus, No.1." Flight 2860 replied, "Okay, I've gonna kind of figured it was the 28- volt d.c. No. 1 -- I can't find that landing gear warning circuit breaker on the darn thing. Ah, also, I assume the hydraulic quantity pressure gage is on the same circuit breaker, sa me generator." The controller said that he would "check on it if you lik e," but Flight 2860 said, "oh, before you go... one thing, ifKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-18 01 OCT 10 that's the only way they can get gear i ndicators, we're gonna go ahead and land then."

The controller confirmed that the No. 1 28-volt DC bus powe red the landing gear warning system.

At 0136:28 Flight 2860 terminat ed communications with the maintenance controller. In response to a query from ARIN C on whether to keep the line to maintenance control open, Flight 2860 replied, "We ll no, I guess we're...only got one radio, so we're back to the tower, we're going to l and, we're going to call out the equipment." Flight 2860

terminated radio communication s with ARINC at 0137:11.

While Flight 2860 was on the ARINC frequen cy, the Salt Lake City tower ground controller, at 0136:28, called the Salt Lake City Flight Servic e Station (FSS) and told the specialist on duty there to transmit a message to United Flight 2860 on the Salt Lake City VOR frequency. The message to Flight 2860 was for the f light to contact Salt Lake City approach control on fr equency 124.3 mHz. Between 0137:07 and 0137:22, the Salt Lake City approach controller attemp ted three times to establish radio communications with Flight 2860. At 013 7:22, the ground controller asked the FSS specialist whether he had made t he transmissions; the specialist replied that he had.

At 0137:26 Flight 2860 said, " ...hello Salt Lake, United 2860 we're back. " At 0137:31, the approach controller said, "United 2860, you're too close to terrain on the right side for a turn back to the VOR, ma ke a left turn back to the VOR. " Flight 2860 replied, "Say again," and at 0137:39, the controller said, "You're too close to terrain on the right side for the turn, make a left tu rn back to the VOR." At 0137: 44, Flight 2860 said, "Okay."

At 0137:54 the approach controll er asked, "United 2860, do you have light contact with the ground?" Flight 2860 replie d, "Negative." At 0138:00 t he controller said, "Okay, climb immediately to maintain 8,000." At 0138:07, the controller again transmitted, "United 2860 climb immediately, maintain 8,000," and four seconds later, Flight 2860 replied, "United 2860 is out of six for eight. " At 0138:36, the controller asked, "United 2860, how do you hear?" Fl ight 2860 did not respond to that transmission or to succeeding transmissions from the approach controller.

Shortly after 0135, at least seven witne sses in Kaysville, Ut ah, and the nearby community of Fruit Heights he ard what they described as a jet aircraft flying low

overhead. One of the witnesses saw a red light on the airplane as it flew in an easterly

direction over her location in Kaysville. She c ould see nothing more of the airplane because it was obscured by clouds, rain, and darkness. The airplane continued

eastward and a short time late r, she saw a bright orange glow appear to the east. The glow lasted 3 to 4 secs and disappeared. Four other witnesses saw the orange glow shortly after hearing the airplane pass overhead. All of the witnesse s said that it was raining at the time; several described the rain as heavy.

The accident occurred at night (0138:28) at an elevation of about 7,200 feet, and at latitude 41°02'41"N and longitude 111°52'30"W.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-19 01 OCT 10 Wreckage Information

N80470U crashed on the southwest slope of Ed's Peak in the Wasatch Mountains about

2.85 miles northeast of Ka ysville, Utah. The crest of Ed's Peak is at 7,665 feet. Ground impact marks at an elevation of 7,200 feet indicate that t he aircraft was in a near wingslevel climb and on a magnetic heading of 040° at the time of impact. Most of the wreckage was scattered up the southwest sl ope but the cockpit section, parts of engines, some cargo containers, and other heavy parts were scattered down the northeast slope.

Pilot's Instrument/Controls

Course select--153° Attitude situation indicator--15° climb, 10° right bank Radio magnetic indicator heading--035° Altimeter barometric setting--29.57 in.

Altimeter altitude i ndication--6,820 ft Standby altimeter--6,880 ft

Communications radio receivers--on

Transmitter selector--No. 2 Frequency selector switches --Both switches on VHF

No.1 transceiver--132.55 mHz No.1 navigation receiver--116.8 mHz

Copilot's Instruments/Controls

Course select-000°

To/From indicator--From HSI heading--040°

Attitude situation indicator-- 15° climb, wings level Instantaneous vertical speed indicator--5,500 ft/min climb

No.2 transceiver--126.8 mHz No.2 navigation receiver--116.8 mHzKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-20 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ AIR FLORIDA FLIGHT 90 BOEING 737-222, N62AF

COLLISION WITH 14TH STREET BRIDGE

NEAR WASHINGTON NATIONAL AIRPORT WASHINGTON, D.C. JANUARY 18, 1982

SYNOPSIS

On January 13, 1982, Air Florida Flight 90, a Boeing 737-222 (N62AF) was a scheduled flight to Fort Lauderdale, Flor ida, from Washington National Airport, Washington, D.C. There were 74 passengers, including 3 infant s, and 5 crew member s on board. The flight's scheduled departure time was delayed about 1 hour 45 minutes due to a moderate to heavy snowfall which necessitated the temporary closing of the airport.

Following takeoff from runway 36, which wa s made with snow and/or ice adhering to the aircraft, the aircraft crashed at 1601 EST into the barrier wa ll of the northbound span of the 14th Street Bridge, whic h connects the District of Co lumbia with Arlington County, Virginia, and plunged into the ice-covered Poto mac River. It came to rest on the west side of the bridge 0.75 NM fr om the departure end of runway 36. Four passengers and

one crewmember survived the crash. When t he aircraft hit the bridge, it struck seven occupied vehicles and then tore away a sect ion of the bridge wall and bridge railing. Four persons in the vehicles were killed; four were injured.

The National Transportation Safety Board determines that the probable cause of this accident was the flight crew's failure to use engine anti-ice dur ing ground operation and takeoff, their decision to take off with snow/ice on the airfoil surfaces of the aircraft, and the captain's failure to reject the takeo ff during the early stage when his attention was called to anomalous engine inst rument readings. Contributing to the accident were the prolonged ground delay between deicing and the receipt of ATC takeoff clearance during which the airplane wa s exposed to continual precip itation, the known inherent pitchup characteristics of the B-737 aircraft when the leading edge is contaminated with even small amounts of snow or ice, and the limit ed experience of the flight crew in jet transport winter operations.

History of the Flight

On January 13, 1982, Air Florida, Inc., Fli ght 90, a Boeing 737- 222 (N62AF), was a scheduled passenger flight from Washington National Airport, Washington, D.C., to the

Fort Lauderdale International Ai rport, Fort Lauderdale, Flori da, with an intermediate stop at the Tampa International Ai rport, Tampa, Florida. Fli ght 90 was scheduled to depart Washington National Airport at 1415 EST. The Boeing-737 had arrived at gate 12,KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-21 01 OCT 10 Washington National Airport, as Flight 95 from Miami, Florida, at 1329. Snow was falling in Washington, D.C., in the morning and in various intensit ies when Flight 95 landed and continued to fall throughout the ear ly afternoon. Because of the snowfall, Washington National Airport was closed fo r snow removal from 1338 to 1453 and Flight 90's scheduled departure was delayed. At 1359:21, Flight 90 re quested and received an Instrument Flight Rules (IFR) clearance from clear ance delivery.

Seventy-one passengers and 3 infants were boarded on the aircra ft between 1400 and 1430; there were five crewmembers - captain, first officer, and three flight attendants. About 1420, American Airlines maintenance personnel began de icing the left side of the fuselage using a model D40D Trump vehicl e (No. 5058) containing Union Carbide Aircraft Deicing Fluid II PM 5178. The deicing tr uck operator stated t hat the captain told

him that he would like to st art deicing just before the air port was scheduled to reopen at 1430 so that he could get in line for departure . American maintenanc e personnel stated that they observed about one-ha lf inch of wet snow on the aircraft before the deicing fluid was applied. Fluid had been applied to an ar ea of about 10 feet when the captain terminated the operation because the airport was not going to reopen at 1430. At that time, the flight crew also informed the Air Florida maintenance representative that 11 other aircraft had departure priority and that there were 5 or 6 aircraft, which had departure priority before Flight 90 could push back fr om the gate.

Between 1445 and 1450, the captain requested that the deicing operation be resumed.

The left side of the aircraft was deiced first. According to the operator of the deicing vehicle, the wing, the fuselage, the tail sectio n, the top part of t he engine pylon, and the cowling were deiced with a heated solution cons isting of 30 to 40 percent glycol and 60 to 70 percent water. No final over sp ray was applied. The operator based the proportions of the solution on guidance ma terial from the American Airlines

maintenance manual and his kn owledge that the ambient te mperature was 24°F, which

he had obtained from current weather data received at t he American Airlines line maintenance room. The operat or also stated that he star ted spraying at the front section of the aircraft and progressed toward the tail using caution in the areas of the hinge points and control surface to assure that no ice or snow remai ned at these critical points. He also stat ed that it was snowing heavily as the deicing/anti-icing substance was applied to the left side of the aircraft.

Between 1445 and 1500, the operat or of the deicing vehicl e was relieved from his deicing task, and he told his relief operator, a me chanic, that the left side of the aircraft

had been deiced. The relief o perator proceeded to deice the right side of the aircraft with heated water followed by a finish anti-ice coat of 20 to 30 percent glycol and 70 to 80 percent water, also heated. He based these proportions on information that the ambient temperature was 28°F. (The actual temperatur e was 24°F.) The operator

stated that he deiced/anti-iced t he right side of the aircraft in the following sequence: the rudder, the stabilizer and elevator, the aft fuselage section, the upper forward fuselage, the wing section (leading edge to trailing edge), the top of the engine, the wingtip, and the nose. Afterwards, he insp ected both engine intakes and the landing gear for snow and/or ice accumulation; he stated that none was found. TheKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-22 01 OCT 10 deicing/anti-icing of Flight 90 wa s completed at 1510. At this time about 2 or 3 inches of wet snow as on the ground around the aircra ft. Maintenance personnel involved in deicing/anti-icing the aircraft st ated that they believed that the aircraft's trailing and leading edge devices were retr acted. American Airlines pers onnel stated that no covers or plugs were installed over the engines or airframe openings during deicing operations.

At 1515, the aircraft was closed up and the jetw ay was retracted. Just before the jet way was retracted, the captain, who was si tting in the left cockpit seat, asked the Air Florida station manager, who was standing near the main ca bin door, how much snow was on the aircraft. The station manager re sponded that there wa s a light dusting of snow on the left wing from the engine to the wi ngtip and that the ar ea from the engine to the fuselage was clean. S now continued to fall heavily.

A tug was standing by to push Flight 90 back from gate 12. The operator of the tug stated that a flight crewmember told him that the tower would call and advise them when push back could start. At 1516:45, Flight 90 transmi tted, "Ground Palm Ninety/ like to get in sequence, we're ready." Ground control replied, "Are you ready to push?" Flight 90 replied, "Affirmative," at 1516:37 . At 1517:01, Ground control transmitted, "Okay, push approved for Palm Ninety -- better still, just hold it right where you are Palm Ninety, I'll call you back." At 1523:37, Ground control trans mitted, "Okay Palm Ninety, push approved."

At 1525, the tug attempted to push Flight 90 back. However, a combination of ice, snow, and glycol on the ramp and a slight incli ne prevented the tug, which was not equipped with chains, from movi ng the aircraft. When a flight crewmember suggested to the tug operator th at the aircraft's engine reverse thrust be used to push the aircraft back, the operator advised the crewmember t hat this was contrary to the policy of American Airlines. According to the tug operat or, the aircraft's engi nes were started and both reversers were deployed. He then advised t he flight crew to use only "idle power."

Witnesses estimated that both engines were oper ated in reverse thrust for a period of 30 to 90 seconds. During this time, severa l Air Florida and American Airlines personnel observed snow and/or slush being blown toward the front of the ai rcraft. One witness

stated that he saw water swirli ng at the base of the left (No. 1) engine inlet. Several Air Florida personnel stated that they saw an area of snow on the ground melted around the left engine for a radius rangi ng from 6 to 15 feet. No one observed a similar melted area under the right (No. 2) engine.

When the use of reverse thrust proved unsu ccessful in moving the aircraft back, the engines were shut down with the reverser s deployed. The same American Airlines mechanic that had inspected both engine inta kes upon completion of the deicing/antiicing operation performed another general examination of both engines. He stated that

he saw no ice or snow at that time. Ai r Florida and American Airlines personnel standing near the aircraft after the aircraft's engines were shut down stated that they did not see any water, slush, snow, or ice on the wings.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-23 01 OCT 10 At 1533, while the first tug was being disco nnected from the towbar and a second tug was being brought into position, an assistant station manager for Air Florida who was inside the passenger terminal between gates 11 and 12 stated that he could see the upper fuselage and about 75 perc ent of the left wing inboard of the tip from his vantage point, which was about 25 feet from the aircraft. Alt hough he observed snow on the upper fuselage and about 75 perc ent of the left wing inboard of the tip from his vantage point, which was about 25 feet from the airc raft. Although he observed snow on top of the fuselage, he said it did not appear to be heavy or thick. He saw snow on the nose and radome up to the bottom of the windshiel d and a light dusting of snow on the left wing.

At 1535, Flight 90 was pushe d back without further difficulty. After the tug was disconnected both engines were restarted and t he thrust reversers were stowed. The aircraft was ready to taxi away from the gate at 1538. At 1538:16 while accomplishing after-start checklist items, the captain res ponded "off" to the first officer's callout of

checklist item "anti-ice." At 1538:22 the ground controller said: "Okay and the American that's towing there...let's...six twen ty four can you...get...around that...Palm on a push back?" Flight 90 replie d, "Ground Palm Ninet y, we're ready to taxi out of his way." Ground control then transmitted, "Oka y Palm Ninety, Roger, just pull up over behind that...TWA and hold right there. You' ll be falling in line behind a...Apple...DC Nine." Flight 90 acknowledged this transmi ssion at 1538:47. Flight 90 then fell in

behind the New York Air DC-9. Nine air carrier aircraft and seven general aviation aircraft were awaiting departure when Flight 90 pushed back.

At 1540:15, the Cockpit Voice Recorder (CVR) recorded a comment by the captain, "...go over to the hanger and get deiced," to which the first officer replied "yeah, definitely." The captain t hen made some additional comment, which was not clear but contained the word "deiced," to which the fi rst officer again replied "yeah--that's about it." At 1540:42, the first officer continued to say, "it's been a while since we've been deiced." At 1546:21, the captain said, "Te ll you what, my windshield will be deiced, don't know about my wings." The first offi cer then commented, "wel l -- all we need is

the inside of the win gs anyway, the wingtips are gon na speed up on eighty anyway, they'll shuck all that other st uff." At 1547:32, the captain commented, "(Gonna) get your wing now." Five seconds later, the first offi cer asked, "D'they get yours? Did they get your wingtip over 'er?" The ca ptain replied, "I got a little on mine." The first officer then said, "A little, this one's got about a quarte r to half an inch on it all the way."

At 1548:59, the first officer asked, "See this difference in that left engine and right one?" The captain replied, "Yeah." The first offi cer then commented, "I don't know why that's different -- less it's hot air going into that right one, t hat must be it -- fr om his exhaust -- it was doing that at the chocks awhile ago...ah." At 1551:54, the captain said, "Don't do that -- Apple, I need to get the other wing done."

At 1553:21, the first officer sa id, "Boy...this is a losing battle here on trying to deice those things, it (gives) you a false feeling of security that's all that does." ConversationKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-24 01 OCT 10 between the captain and the firs t officer regarding the general topic of deicing continued

until 1554:04.

At 1557:42, after the New York Air aircraft wa s cleared for takeoff, the captain and first officer proceeded to accomplish the pre-takeo ff checklist, including verification of the takeoff engine pressure ratio (EPR) setting of 2.04 and indicated airspeed bug settings of 138 kts (V 1 ); 140 kts (V
r ) and 144 kts (V

2 ). Between 1558:26 and 1558:37, the first officer asked, "Slush (sic) runway, do you want me to do anything special for this or just go for it?" (The first officer was the pilot flying the aircraft.) The captain responded, "Unless you got anything special you'd like to do." The first officer replied, "Unless just take off the nosegear early like a soft field takeoff or something; I'll take the nosegear off and then we'll let it fly off."

At 1558:55, Flight 90 was cleared by local c ontrol to "taxi into position and hold" on runway 36 and to "be ready for an immediate [tak eoff]." Before Flight 90 started to taxi, the flight crew replied, "... position and hold," at 1558:58. As the aircraft was taxied, the

tower transmitted the takeoff clearance and the pilot acknowledg ed, "Palm 90 cleared for takeoff." Also, at 1559:28, Flight 90 was told not to del ay the departure since landing traffic was 21⁄2 miles out for runway 36; the last radio transmission from Flight 90 was the reply, "Okay" at 1559:46.

The CVR indicated that the pre-takeoff c hecklist was completed at 1559:22. At 1559:45, as the aircraft was turning to t he runway heading, the captain said, "Your throttles." At 1559:46, the sound of engi ne spoolup was recorded, and the captain stated, "Holler if you need the wipers..." At 1559:56, the captain commented, "Real cold, real cold," and at 1559:58, the first office r remarked, "God, look at that thing, that don't seem right, does it?" Between 1600 :05 and 1600:10, the first officer stated, "...that's not right...," to which the captain re sponded, "Yes it is, ther e's eighty." The first officer reiterated, "Naw, I don't think that's right." About 9 seconds later the first officer added, "...maybe it is," but then 2 seconds later, after the captain called, "hundred and twenty," the first officer said, "I don't know."

Eight seconds after the captain called "Vee one" and 2 seconds after he called "Vee two," the sound of the stickshaker was re corded. At 1600:45, the captain said, "Forward, forward," and at 1600:48, "We only want five hundr ed." At 1600:50, the captain continued, "Come on, forw ard, forward, just barely c limb." At 1601:00, the first officer said, "Larry, we're going down, Larry," to which the captain responded, "I know

it."

About 1601, the aircraft struck the heavil y congested northbound span of the 14th Street Bridge, wh ich connects the District of Columb ia with Arlington County, Virginia, and plunged into the ice-covered Potomac River . It came to rest on the west end of the bridge 0.75 NM from the departu re end of runway 36. Heavy snow continued to fall and visibility at the airport was vary ing between 1/4 mile and 5/8 mile.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-25 01 OCT 10 When the aircraft struck the brid ge, it struck six occupied automobiles and a boom truck before tearing away a 41-foot section of t he bridge wall and 97 feet of the bridge railings. As a result of the crash, 70 passengers, including 3 infants, and 4 crew members were killed. Four passengers and one crewmember were injured seriously. Four persons in vehicles on the bridge were killed; four were injured, one seriously.

At 1603, the duty officer at the airport fire station notified Crash/Fire/Rescue (CFR) equipment based on his monitoring of a radio transmission between Washington National Tower and the operations officer that an aircraft was possibly off the end of runway 36. Safety Board investigator s interviewed more than 200 witnesses to establish the sequence of events from the start of the takeoff until impact, and more

than 100 written statem ents were obtained.

Ground witnesses generally agreed that the airc raft was flying at an unusually low altitude with the wings level and attained a nos e-high attitude of 30° to 40° before it hit the bridge. Four persons in a car on t he bridge within several hundred feet from the point of impact claimed that large sheets of ice fell on their car.

A driver whose car was on the br idge at about the wingtip of t he aircraft stated, "I heard screaming jet engines... The nose was up and the tail was down. It was like the pilot was still trying to climb but the plane was sinki ng fast. I was in the center left lane... about 5 or 6 cars lengths from where (the red car) was. I saw the tail of the plane tear across the top of the cars, smashing some tops and ripping off other.... I saw it spin...(the red car)...around and then hit the guardrai l. All the time it was going across the bridge it was sinking but the nose was pretty well up.... I got the impression that the plane was swinging around a little and going in a st raight direction into the river. The plane...seemed to go across the br idge at a slight angl e and the dragging tail seemed to straighten out. It leveled out a little. Once the tail was across the bridge the plane seemed to continue sinking very fast but I don' t recall the nose pointing down. If it was, it wasn't pointing down much. The plane seemed to hit the wa ter intact in a combination sinking/plowing action. I saw the cockpit go under the ice. I got the impression it was skimming under the ice and water...I did not s ee the airplane break apart. It seemed to plow under the ice. I did not see any ice on the aircraft or any ice fall off the aircraft. I do not remember any wing dip as the plane ca me across the bridge. I saw nothing fall from the airplane as it crossed the bridge."

Between 1519 and 1 524, a passenger on an arriving fli ght holding for gate space near Flight 90 saw some snow accumulated on t he top and right side of the fuselage and photographed Flight 90. No witnesses saw the flight crew leave the aircraft to inspect for snow/ice accumulation while at the gat e. Departing and arriving flight crews and others who saw Flight 90 bef ore and during takeoff stated that the aircraft had an unusually heavy accumulation of s now or ice on it. An airli ne crew taxiin g parallel to, but in the opposite direction of, Flight 90's takeoff, saw a portion of Flight 90's takeoff

roll and discussed the extensiv e amount of snow on the fuselage. The captain's

statement to the Board include d the following: "I commented to my crew, 'look at the junk on that airplane,'...Almos t the entire length of the fuse lage had a mottled area ofKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-26 01 OCT 10 snow and what appeared to be ice...along t he top and upper side of the fuselage above the passenger cabin windows..." None of the witnesses at the airport could positively identify the rotation or liftoff point of Flight 90; however, they testified that it was beyond the intersection of runways 15 and 36, and that t he aircraft's rate of climb was slow as it left the runway. Flight crews awaiting de parture were able to observe only about the first 2,000 feet of the aircraft's takeoff roll because of the heavy snowfall and restricted visibility.

At 1600:03, as Flight 90 was on the takeoff ro ll, the local controller had transmitted to an approaching Eastern 727, Flig ht 1451, "...wind is zero one zero at one one, you're cleared to land runway three six; the r unway visual range touchdown two thousand eight hundred roll ou t one thousand six hundr ed." At 1600:11 East ern Flight 1451 acknowledged, "...cleared to land, over t he lights." At 1600:56, the local controller transmitted, "Eastern fourteen fifty-one, turn left at the next taxiway, advise when you clear the runway, no delay clearing."

During witness interviews, one witness in the ai rport stated, "Immediately after I noticed the Air Florida 737, an Easter n 727 landed unbelievably close a fter (Air Florida) 737. I

felt it was too close for normal condi tions - let alone very hard snow."

Injuries to Persons

Injuries Crew Passengers Others Total

Fatal 4 70 4** 78

Serious 1 4 1 6

Minor 0 0 3 3

None 0 0 0 0

Total 5 74 8 87

*Including three infants **Persons in vehicles on the bridge.

Damage

The aircraft was destroyed by impact with the br idge, ice, and water. Seven vehicles in the northbound span of the 14th Street Bridge were destroyed. A section of the bridge sidewall barrier structure and bridge railing were torn away.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-27 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ EASTERN AIR LINES FLIGHT 401 L-1011, N310EA MIAMI, FLORIDA DECEMBER 29, 1972

SYNOPSIS

An Eastern Air Lines Lockheed L-1011 cras hed at 2342 EST on December 29, 1972, approximately 18 miles west north west of Miami International Airport, Miami, Florida. The aircraft was destroyed. There were 163 passengers and a crew of 13 aboard the aircraft; 94 passengers and 5 crewmembers rece ived fatal injuries. All other occupants received injuries, which ranged in severity from minor to critical.

The flight diverted from it s approach to Miami Internati onal Airport because the nose landing gear position indicating system of the aircraft did not indicate that the nose gear was locked in the down position. The airc raft climbed to 2,000 feet mean sea level and followed a clearance to proceed west from the airport at that al titude. During this time, the crew attempted to correct the malfunction and to determi ne whether or not the nose landing gear was extended.

The aircraft crashed into the Everglades sh ortly after being cleared by Miami Approach

Control for a left turn back to Miami Inter national Airport. Surviving passengers and

crew members stated that t he flight was rout ine and operated norma lly before impact with the ground.

The National Transportation Safety Board determines that the probable cause of this

accident was the failure of the flight crew to monitor the f light instruments during the final four minutes of flight, and to det ect an unexpected descent soon enough to prevent impact with the ground. Preoccupation with a malfunction of the nose landing gear position indicating system di stracted the crew's attenti on from the instruments and allowed the descent to go unnoticed.

As a result of the investigation of th is accident, the Safety Board has made

recommendations to the Administrator of the Federal Aviation Administration.

History of the Flight

Eastern Air Lines, Inc., Lockheed L-1011, N310 EA, operating as Fli ght 401 (EAL 401), was a scheduled passenger flight from the John F. Kennedy International Airport (JFK), Jamaica, New York, to the Miami Internati onal Airport (MIA), Miami, Florida. On December 29, 1972, the flight departed from JFK at 2 120 with 163 passengers and 13KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-28 01 OCT 10 crew members on board and was cleared to MIA in accordance with an Instrument Flight Rules f light plan.

The flight was uneventful until the approach to MIA. The landing gear handle was placed in the "down" positi on during the preparation for l anding, and the green light,

which would have indicated to the flight crew that the nose landing gear was fully extended and locked, failed to illuminate. The captain recycl ed the landing gear, but the green light still failed to illuminate.

At 2334:05, EAL 401 calle d the MIA tower and stated, "Ah, tower this is Eastern, ah, four zero one, it looks like we're gonna have to circle, we do n't have a light on our nose gear yet."

At 2334:14, the tower advised, "E astern four oh one heavy, roge r, pull up, climb straight ahead to two thousand, go back to approach control, one twenty eight six."

At 2334:21, the flight acknow ledged, "Okay, going up to two thousand, one twenty eight

six."

At 2335:09, EAL 401 contacte d MIA approach control and reported, "All right, ah, approach control, Eastern four zero one, we 're right over the airport here and climbing to two thousand feet, in fact, we've just reached two thousand feet and we've got to get a green light on our nose gear."

At 2335:20, approach control a cknowledged the flight's tr ansmission and instructed EAL 401 to maintain 2,000 feet mean sea level a nd turn to a heading of 360° magnetic. The new heading was acknowledged by EAL 401 at 2335:28.

At 2336:04, the captain instruct ed the first officer, who was flying the aircraft, to engage the autopilot. The firs t officer acknowledged the instruction.

At 2336:27, MIA approach contro l requested, "Eastern four oh one, turn left heading

three zero zero." EAL 401 ack nowledged the reques t and complied.

The first officer successfully removed the nose gear light lens assembly, but it jammed when he attempted to replace it.

At 2337:08, the captain instru cted the second officer to enter the forward electronics bay, below the flight deck, to check visually the alignment of t he nose gear indices.

At 2337:24, a downward vertical acceleration transient of 0.04 g caused the aircraft to descend 100 feet; the loss in altit ude was arrested by a pitchup input.

At 2337:48, approach control reques ted the flight to turn le ft to a heading of 270° magnetic. EAL 401 acknowl edged the request and turned to the new heading.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-29 01 OCT 10 Meanwhile, the flight crew c ontinued their attempts to free the nose gear position light lens from its retainer, without success. At 2338:34, the captai n again directed the second officer to descend into the forward electronics bay and check the alignment of the nose gear indices.

At 2338:46, EAL 401 calle d MIA approach control and said , "Eastern four oh one'll go ah, out west just a little further if we can he re and, ah, see if we can get this light to come on here." MIA approach control granted the request.

From 2338:56 until 2341:05, the captain and the first offi cer discussed the faulty nose gear position light lens assembly and how it might have been reinserted incorrectly.

At 2340:38, a half-second C-chor d, which indicated a deviati on of 250 feet from the selected altitude, sounded in the cockpit. No crew member commented on the C-chord. No pitch change to correct for the loss of altitude was recorded.

Shortly after 2341, the second officer raised hi s head into the cockpit and stated, "I can't see it, it's pitch dark and I throw t he little light, I get, ah, nothing."

The flight crew and an Eastern Air Lines ma intenance specialist who was occupying the

forward observer seat then discussed the operation of the nose wheel well light. Afterward, the specialist went into the elec tronics bay to assist the second officer.

At 2341:40, MIA approach control asked, "Eastern, ah, four oh one how are things comin' along out there?"

This query was made a few seconds after the MIA controller noted an altitude reading of 900 feet in the EAL 401 alp hanumeric data block on his radar display. The controller

testified that he contacted EAL 401 because the flight was nearing the airspace boundary within his jurisdiction. He further st ated that he had no doubt at that moment about the safety of the aircraft. Moment ary deviations in altitude information on the radar display, he said, are not uncomm on; and more than one scan on the display would be required to verify a deviation requiring controller action.

At 2341:44, EAL 401 replied to the controller' s query with, "Okay, we'd like to turn around and come, come back in," and at 2341: 47, approach control granted the request with, "Eastern four oh one turn left heading one eight zero." EAL 401 acknowledged

and started the turn.

At 2342:05, the first officer said , "We did something to the altitude." The captain's reply was, "What?" At 2342:07, the first officer asked, "We're still at two thousand, right?" and the captain immediately exclaim ed, "Hey, what's happening here?"

At 2342:10, the first of six radio altimeter warning "beep" sounds began; they ceased immediately before the sound of the initial ground impact.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-30 01 OCT 10 At 2342:12, while the aircraft wa s in a left bank of 28°, it cr ashed into the Everglades at a point 18.7 statute miles west northwest of MIA (latitude 25°52' N., longitude 80°36' W.). The aircraft was destroyed by the impact.

Local weather at the time of the accident was clear, with un restricted visibility. The

accident occurred in dark ness, and there was no moon. Two ground witnesses had observed the aircraft shortly before impact to be at an altitude that appeared low.

Injuries to Persons

Injuries Crew Passengers Others

Fatal 5 94 0

Nonfatal 10* 67 0

None 0 0 0

*Includes two nonrevenue passengers, one occ upying an observer seat in the cockpit

and the other seated in the first- class section of the cabin.

The accident survivors sustained various inju ries; the most prevalen t were fractures of the ribs, spine, pelvis, and lower extremities. Fourteen persons ha d various degrees of burns. Seventeen persons received only minor injuries and did not require hospitalization.

Postmortem examination of the captain re vealed a tumor which emanated from the right

side of the tentorium in the cr anial cavity. The tumor displaced and thinned the adjacent right occipital lobe of the brain. The le sser portion of this meningioma extended downward into the superior portion of the right cerebellar hemisphere. The tumor

measured 4.3 centimeters latera lly, 5.7 centimeters vertically , and 4.0 centimeters in an anterior-posterior direction.

Damage to Aircraft Other Damage

The aircraft was destroyed NoneKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-31 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ NORTHWEST AIRLINES FLIGHT 255 McDONNELL DOUGLAS DC-9-82, N312RC

DETROIT METROPOLITAN WAYNE COUNTY AIRPORT ROMULUS, MICHIGAN AUGUST 16, 1987

History of the Flight

On August 16, 1987, a Northwest Airlines (Northwest) flight crew picked up a McDonnell Douglas DC-9-82 airplane, N 312RC, at Minneapolis , Minnesota, and oper ating as Flight 255, flew the airplane to Saginaw, Mich igan, with an en rout e stop at Detroit Metropolitan Wayne County Airport (Detroit-Me tro), Romulus, Michigan, arriving at Saginaw about 1840 EDT. At Saginaw, N312RC became Fli ght 255 and was flown by the same flight crew that had brought the airplane in. Flight 255 was a regularly scheduled passenger flight betw een Saginaw and Santa Ana, California, with en route stops at Detroit and Phoenix, Arizona. The flight was to be conducted in accordance with the provisions of 14 Code of Federal R egulations (CFR), Part s 91 and 121. About 1853, Flight 255 departed Saginaw and about 1942 arrived at its gate at Detroit-Metro. Except for taxiing past and having to make a 180° turn to return to its assigned gate, the flight to Detroit was uneventful.

After the disembarking passengers had left t he airplane, a Northwest mechanic entered the cockpit and reviewed the airplane and c abin maintenance logbooks. He stated that no discrepancies were entered in either logbook. There was no record of any maintenance having been performed on the airp lane while it was at Detroit-Metro.

About 10 to 15 minutes before the flight was due to depart the gate, a company transportation agent brought the fli ght release package to the airplane. He was met by

the first officer who told him that the ca ptain was not on board. The first officer inspected the package that contained the dispatch documents, signed the release, and returned the signed copy to the agent. As t he agent left the airplane, he met the captain who had been conducting a walk around inspection of the ai rplane and showed him the signed copy of the flight releas e. The captain studied the rel ease, told the agent that it was all right, and thanked him.

About 2029, the final weight t abulation (weight tab) was delivered to the flight crew. About 2032, Flight 255 dep arted the gate with 149 pas sengers and 6 crewmembers on board. Flight 255 was pushed back to Spot 4. During the pushback, the flight crew accomplished the BEFORE (engine) START por tion of the airplane checklist, and at 2033:04, they began star ting the engines.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-32 01 OCT 10 At 2034:40, after the engines had been started, t he ground crew disconnected the tow bar from the airplane and at 2034:50, the we st ground controller cleared the flight to "taxi via the ramp, hold short of (taxiway) de lta and expect runway three center (3C)(for takeoff)...." The controller also informed the flight crew that Automatic Terminal Information Service (ATIS) Hotel ("H") was now current and asked them if they had the information. The flight crew repeated the taxi instructions and stated that they had the ATIS information. At 2035:43, the ground c ontroller cleared Flight 255 to continue taxiing, to exit the ramp at Taxiway Charlie (C), to taxi to Runway 3C, and to change radio frequencies and then contact the gr ound controller on 119.45 mHz. At 2035:48, the first officer repeated the taxi clearanc e, but he did not re peat the new radio frequency nor did he tune the radio to the new frequency. Thereafter, the first officer told the captain, "Charlie for three center, right."

ATIS "H" had been transcribed at 2028:35 and was being broad cast at the time of the

accident. Examination of the Cockpit Voice Recorder (CVR) recording showed that the flight crew had not re ceived information "H" before they began to taxi. However, at 2035:18, information "H" began on the first offi cer's radio channel, and at 2035:55, he told the captain that he was leaving the ai rplane's No. 1 radio "to get the new ATIS."

About 2025, the tower supervisor began coordi nation to change Detroit-Metro from a Runway 21 configuration to a Runway 3 configuration. The change was completed at 2028. ATIS "H" was the first ATIS transcription to contain and broadcast this information. It also described the ceiling and visibility and stated in part that the temperature was 88° F, that the wind was 3 00° at 17 knots, and that "...ILS approaches are in use to Runways three left (3L) and thr ee right (3R) departing Runway three. . .low

level windshear advisories are in effect..."

The takeoff performance data in the flight crew's dispatch package was based on using either Runway 21L or 21R; however, the flight had been instru cted by the ground controller to taxi to Runway 3C, the shortest of the three available runways. The final takeoff weight for the airplane was 144,047 pounds. At 2037:08, the captain asked the first officer if they could use Runway 3C fo r takeoff. Because of the runway change, the first officer had to refer to the company's R unway Takeoff Weight Chart Manual to verify that their takeoff weight wa s below the allowable limits for Runway 3C. The takeoff weight chart showed that wit h the flaps set at 11°, the maximum allowable takeoff weights for Runway 3C at 85°F and 90° F were 147,500 pounds and 145,100 pounds, respectively. After consulting the manual, the first officer told the captain Runway 3C could be used for takeoff and the captain concu rred with the first officer's evaluation.

During the taxi out, the captai n missed the turnoff at Taxiwa y C. When the first officer contacted ground control, the ground controller redirected them to taxi to Runway 3C and again requested that they change radio frequencies to 119.45 mHz. The first officer repeated the new frequency, ch anged over, and contacted the east ground controller. The east ground controller gave the flight a new taxi route to Runway 3C, told them that ATIS "H" was still current, t hat windshear alerts were in effect, and that the altimeter setting was 29.85 in Hg. The flight crew acknowledged receipt of the information.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-33 01 OCT 10 At 2042:11, the local controller cleared Flight 255 to taxi in to position on Runway 3C and to hold. He told the flight there woul d be a three-minute delay in order to get the required "in-trail separation beh ind traffic just departing." At 2044:04, Flight 255 was

cleared for takeoff.

The CVR recording showed that engine powe r began increasing at 2044:21, that the flight crew could not engage the Autothrottle system at first but, at 2044:38, they did engage the system and that the first office r called 100 knots at 2044:45.6. At 2044:57.7, the first officer called "Rotate, " and at 2045:05.1, the stall warning stick shaker activated and continued operating unt il the CVR recording ended. At 2045:09.1, 2045:11.4, 2045:14.3, and 2045:17.1, the aural tone and voice warnings of the supplemental Stall Recognition System (SSRS) also acti vated. Between 2044:01 and 2045:05.6, the CVR recording di d not contain any sound of the takeoff warning system indicating that the airplane was no t configured properly for takeoff.

Witnesses generally agreed that Flight 255's takeoff roll wa s longer than that normally made by similar airplanes. They stated that the flight began its rotation about 1,200 to 1,500 feet from the departure end of the runway, agreed that it rotated to a higher pitch angle than other DC-9's and agreed that the tail of the airplane came close to striking the runway.

Only a few witnesses recalled any details about the position of the airplane's leading edge wing slats, trailing edge wing flaps, or landing gear. Most of these witnesses said that the landing gear was retr acted after liftoff. Two Northwes t first officers recalled that the flaps and slats were extended. One first officer was in the airp lane directly behind Flight 255 in the takeoff sequence. According to her, "the flaps were extended, which is normal, but I could not. . .state the act ual degree of flap extension." She did not describe the position of the sl ats. The second first offi cer's airplane was parked on Taxiway "A" between the ramp and Taxiway "J". The airpla ne was facing Runway 3C

and about 150 feet from it. He testified that he observed t he flaps and slats as Flight 255 rolled past his airplane and, "The slats and flaps were ex tended." However, he was unable to estimate their degree of extension.

After Flight 255 became airborne, it began ro lling to the left and right. Witnesses estimated that the bank angles during the rolls varied from 15° to 90°. Some witnesses stated that the airplane wings leveled brie fly and then banked to the left just before the left wing hit a light pole in a rental car lot. Most witnesses did not see fire on the airplane until it was over the rental car lo t. The first officer of the Northwest airplane parked on Taxiway "A" testifi ed that Flight 255 was intact until the left wing struck the light pole in the auto rental car lot. Af ter the wing struck the pole, he saw what appeared to a "four-to-five foot chunk of the win g section. . . ."fall fr om the airplane. He did not see any fire on the airplane until a fter it struck the light pole and then he saw "an orange flame. . ." emanating from the left wingtip section.

After impacting the light pole, Flight 255 continued to roll to the left, continued across the car lot, struck a light pole in a second rent al car lot, and struck the side wall of theKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-34 01 OCT 10 roof of the auto rental facili ty in the second rental car lot. Witnesses stated that the airplane was in a 90° left-wing-down attitude w hen it struck the roof and that it continued rolling and was still rolling to the left w hen it impacted the groun d on a road outside the airport boundary. The airplane continued to slide along t he road, struck a railroad embankment, and disintegrated as it slid al ong the ground. Fires erupted in airplane components scattered along the wr eckage path. Three occupi ed vehicles on the road

and numerous vacant vehicles in the auto rent al parking lot along the airplane's path were destroyed by impact forces and/or fire.

On board Flight 255, 148 passengers and 6 crew members were killed; 1 passenger, a 4-year-old child, was injured seriously. On the ground, two persons were killed, 1 person was injured seriously, and 4 persons suffered minor injuries.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-35 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD (NTSB) WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ PACIFIC SOUTHWEST AIRLINES FLIGHT 182 BOEING 727-214, N533PS, FLIGHT 182 GIBBS FLITE CENTER, INC. CESSNA 172, N7711G SAN DIEGO, CALIFORNIA SEPTEMBER 25, 1978

SYNOPSIS

About 0901:47 PST, on September 25, 1978, Pacific Southwest Ai rlines, Inc. Flight 182, a Boeing 727-214, and a Gibbs Flite Center, Inc., Cess na 172 collided in midair about

three nautical miles northeast of Lindb ergh Field, San Diego, California.

The Cessna was under the control of San Diego Approach Control and was climbing on a northeast heading. Flight 182 was making a visual approach to Runway 27 at Lindbergh Field and had been advised of the location of the Cessna by the approach controller. The flight crew told the approach controller that they had the traffic in sight and were instructed to maintain visual sepa ration from the Cessna and to contact the Lindbergh Tower. Flight 182 contacted the tower on it s downwind leg and was again advised of the Cessna's position. The flight crew did not have the Cessna in sight; they thought they had passed it an d continued the approach. The aircraft collided near 2,600 feet msl and fell to the ground in a re sidential area. Both occupants of the Cessna were killed, 135 persons on board t he Boeing 727 were killed, 7 persons on the ground were killed, and 9 persons on the ground were injured. Tw enty-two dwellings were damaged or destroyed. The weather was clear and the visibility was 10 miles.

The NTSB determined that the probable cause of the accident was the failure of the flight crew of Flight 182 to comply with th e provisions of a maintain-visual-separation clearance, including the require ment to inform the controlle r when they no longer had the other aircraft in sight. Contributing to the accident were the air traffic control procedures in effect that aut horized the controllers to use visual separation procedures to separate two aircraft on potentially conf licting tracks when the capability was available to provide either lateral or vert ical radar separation to either aircraft.

History of the Flights

About 0816 PST on September 25, 1978, a Gibbs Flite Center Cessna 172, N7711G, departed Montgomery Field, Califo rnia, on an instrument traini ng flight. Since the flight was to be conducted in visual meteorologica l conditions, no flight plan was filed and none was required. A flight instructor occupied the right seat, and another certificated pilot, who was receiving instrument training, occupied the left seat.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-36 01 OCT 10 The Cessna proceeded to Lindbergh Field w here two practice ILS approaches to Runway 9 were flown. Although the report ed wind was calm, Runway 27 was the active runway at Lindbergh. About 0857, N 7711G ended a second approach and began a

climbout to the northeast. At 0859:01, the Lindber gh tower local controller cleared the Cessna pilot to maintain VFR conditions an d to contact San Diego approach control.

At 0859:50, the Cessna pilot contacted San Die go approach control and stated that he was at 1,500 feet, and "northeastbound." The appr oach controller told him that he was

in radar contact and instructed him to mainta in VFR conditions at or below 3,500 feet and to fly a heading of 070°. The Cess na pilot acknowled ged and repeated the

controller's instructions.

Pacific Southwest Airlines Flight 182 was a regularly scheduled passenger flight between Sacramento and San Diego, Californi a, with an intermediate stop in Los Angeles, California. The f light departed Los Angeles at 0834 on an IFR flight plan with 128 passengers and a crew of 7 on board. The first officer was flyi ng the aircraft. Company personnel familiar with t he pilots' voices identified the captain as the person conducting almost all air-to- ground communications. The cockpit voice recorded (CVR) established the fact that a deadheading co mpany pilot occupied the forward observer seat in the cockpit.

At 0853:19, Flight 182 reported to San Di ego approach control at 11,000 feet and was cleared to descend to 7,000 feet . At 0857, Flight 182 reported that it was leaving 9,500 feet for 7,000 feet and that the airport was in sight. The approach controller cleared the flight for a visual approach to Runway 27. Flight 182 acknow ledged and repeated the approach clearance.

At 0859:28, the approach controller advised Flight 182 that t here was "traffic at twelve o'clock, one mile northbound." Five seconds la ter the flight answered, "We're looking."

At 0859:39, the approach controller advised F light 182, "Additional traffic's twelve o'clock, three miles, just north of the field, northeast bound, a Cessna one seventy-two climbing VFR out of one thous and four hundred." Accordi ng to the CVR, at 0859:50, the copilot responded, "Okay, we'v e got that other twelve."

At 0900:15, about 15 seconds after instructing the Cessna pilot to maintain VFR at or below 3,500 feet and to fly 070°, the approach c ontroller advised Flight 182 that "traffic's at twelve o'clock, three miles, out of one thousand seven hundred." At 0900:21, the first officer said, "Got 'em", and one second later the captain informed t he controller, "Traffic in sight."

At 0900:23, the approach controlle r cleared Flight 182 to "m aintain visual separation," and to contact Lindbergh tower. At 0900:28, Flight 182 answered, "Okay," and three seconds later the approach controller advised t he Cessna pilot that there was "traffic at six o'clock, two miles, eas t bound, a PSA jet inbound to Lindbergh, out of threeKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-37 01 OCT 10 thousand two hundred, has you in sight." The Cessna pilot acknowledged, "One one gold, roger."

At 0900:34, Flight 182 reported to Lindbergh tower that they were on the downwind leg for landing. The tower acknowledged the transmission and informed Flight 182 that there was "traffic, twelve o'clock, one mile, a Cessna."

At 0900:41, the first officer ca lled for 5° flaps, and the capt ain asked, "Is that the one (we're) looking at?" The first officer ans wered, "Yeah, but I don't see him now." According to the CVR, at 0900:44, Flight 182 told the local controller, "Okay, we had it there a minute ago," and six seconds later, "I think he's pa ss(ed) off to our right." The local controller acknowledged the transmission. (According to the ATC transcript, the 0900:50 transmission was "think he's passing o ff to our right" and the local controller testified that he heard, "he's passing off to our right.")

The CVR showed that Flight 18 2's flight crew continued to discuss the location of the traffic. At 0900:52, the captain said, "He was right over there a minute ago." The first officer answered, "Yeah."

At 0901:11, after the captain to ld the local controller how fa r they were going to extend their downwind leg, the first officer asked, "A re we clear of that Cessna?" The flight engineer said, "Suppose to be." The captain said, "I guess" and the forward jump seat occupant said, "I hope."

At 0901:21, the captain said, "Oh yeah, befo re we turned downwind, I saw him about one o'clock, probably behind us now." At 0901: 31, the first officer called, "Gear down."

At 0901:38, the first officer said, "There's one underneath. " And then one second later, he said, "I was looking at that inbound there."

At 0901:28, the conflict alert warning began in the San Diego Approach Control Facility indicating to the controllers that the predict ed flight paths of Flight 182 and the Cessna would enter the computer's prescribed warning parameters. At 0901:47, the approach controller advised the Cessna pilot of "traffic in your vicinity, a PSA jet has you in sight, he's descending for Lindbergh." The trans mission was not acknowledged. The approach controller did not inform Lindbergh towe r of the conflict alert involving Flight 182 and the Cessna because he believed Flight 182's flight crew had the Cessna in sight. The aircraft collided at 0901:47.

According to witnesses, both aircraft were pr oceeding in an easterly direction before the collision. Flight 182 was descending and ov ertaking the Cessna, which was climbing in a wing level attitude. Just before impact, Flight 182 banked to the right slightly and the Cessna pitched nose up and collided with the right wing of Flight 182. The Cessna broke up immediately and expl oded. Segments of fragment ed wreckage fell from the right wing and empennage of Flight 182.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-38 01 OCT 10 Flight 182 began a shallo w right descending turn leaving a trail of vapor-like substance from the right wing. A bri ght orange fire erupted in the vicinity of the right wing and increased in intensity as the aircraft descended. The aircraft remain ed in a right turn and both the bank and pitch angles increased dur ing the descent to about 50° at impact.

Both aircraft were destroyed by the collision, in-flight and post-impact fires, and impact.

There were no survivors. Se ven persons on the ground were killed, and 22 dwellings were damaged or destroyed.

The aircraft crashed during daylight hours in to a residential area about three miles northeast of Lindbergh Field. The coordinates of the wreckage sites were 32° 45'N, 117° 08'W. Seismological data recorded at the Museum of Na tural History, San Diego, California, showed that t he in-flight explosion and gr ound impact occurred at 0901:47.9 and 0902:07, respectively.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-39 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ GALAXY AIRLINES FLIGHT 203

LOCKHEED ELECTRA-L-188C N5532 RENO, NEVADA JANUARY 21, 1985

SYNOPSIS

About 0102:30 Pacific standard time on January 21, 1985, Galaxy Airlines Flight 203, a Lockheed Electra (N5532) charter flight en route to Minneapolis, Minnesota, departed runway 16R of the Reno-Cannon International Airport. Appr oximately one minute later, the crew requested a turn to a left downwind to return to the airport because of a vibration in the airplane. In accordance with the request, the tower controller cleared the flight to make a left turn to a downwind traffic pattern. The airplane crashed at 0104 into an area 11⁄2 miles from the departure end of runway 16R, and 3/4 m ile to the right of the extended runway c enterline. The impact and subsequent fire killed the crew of six and 64 of the 65 passengers onboard. The airp lane was destroyed. The sky was clear and the visibility was 12 miles at the time of the accident.

The National Transportation Safety Board determines that the probable cause of this accident was the captain's failur e to control and the copilot's fa ilure to monitor the flight path and airspeed of the aircra ft. This breakdown in crew coordination followed the onset of unexpected vibration sh ortly after takeoff. Contribut ing to the accident was the failure of ground handlers to properly close an air start access door, which led to the

vibration.

History of the Flight

On January 21, 1985, Galaxy Airlines Fli ght 203, a Lockheed Electra L-188C (N5532), was operating under 14 CFR 121 requirements on a flight fr om Reno, Nevada (RNO) to Minneapolis, Minnesota (MSP). The charter flight had been coordi nated as a gambling junket for Galaxy th rough a broker agent.

About 1610 on January 20, flig ht plans for four flights of N5532 were filed with the Seattle Flight Service Stati on. The Galaxy flights, s equentially numbered 201 to 204, were from Seattle to Oakland, Oakland to Reno, Reno to Minneapolis, and Minneapolis to Seattle. The flight crew of Galaxy 203 began their duty period when they reported for duty at about 1815 at the Seattle-Tacoma International Airport (SEA), Seattle, Washington. The crew's original sc heduled departure time had been 1530; however, the Galaxy Airlines flight fo llower told them earlier by tel ephone that the flight would be delayed until about 2000. After reporting fo r duty they spent about an hour to an hour and a half watching television in the Pacific S outhwest Airlines (PSA) crew lounge. The incoming Galaxy charter fli ght with 77 passengers aboard arrived in Seattle from LasKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-40 01 OCT 10 Vegas, Nevada, at 2 000. A PSA ramp serviceman sa w the departing flight engineer check the fuel quantity in N 5532 manually, but he did not s ee a crew member perform a walk around inspection. The airplane depart ed SEA at 2019 on a ferry flight to Oakland. The ramp serviceman said that when the airplane was airbor ne, the flight crew radioed back their thanks for the quick turnaround. T he airplane arrived at Oakland at 2225.

At Oakland, 65 passengers, returning fr om the Super Bowl football game, were boarded. During the stopover at Oakland, a boarding passenger visited the cockpit and spent about 20 minutes talking to the captain. The passenger remembered commenting that the cockpit looked "worn"; however, the captain assured him that, for its age, the airplane did not have many hours on it. The passenger noted, in addition, that the crew appeared to be in a hurry and, in his words, "pushed it" from Oakland to

Reno. He remembered that t he captain had told him that they (the crew) had to go to Minneapolis, and be back in Seattle by 7:00 on January 21. He sa id that the crew appeared to be rested. When qu estioned about whether there were unusual vibrations during the flight, the passenger answered no; however, he did not remember the landing in Reno since he may have been asleep at the time. After it landed in Reno, N5532 was parked at a gate on t he western side of runway 16R, close to the departure

end.

The airplane was serviced by personnel from the Reno Flyi ng Service and a broker agent, who, as part of his responsibilities to Galaxy Airlines, met Galaxy airplanes and oversaw both passenger handling and airplane servicing. A total of seven individuals from the Reno Flying Service performed ground service duties on N5532. They included a fueling supervisor and two assi stants who connected the fuel truck and the ground electrical and air start units to the airplane, as well as fueled i t. In addition, four other persons, a ground handl ing supervisor, and three gr ound handlers performed the remainder of the airplane's se rvicing while it was parked. These duties included loading and off loading baggage, instal ling and withdrawing the wheel chocks, cabin cleaning, lavatory and potable water servicing, drivin g the passenger vans between the airplane and the gate, starting up and late r disconnecting the air start and ground electrical units, and providing ground directions to the flight crew for airplane parking and initial movement from the gate. Al though Galaxy procedures required it, no record of Galaxy 203's weight and balance was le ft at the Reno Flying Service nor was one delivered by mail to Galaxy's main office. Galaxy's Oper ations Manual required the captain to leave a duplicate of this form at each departing station.

At 0021:28, while ground servic ing was being carried out, th e crew contacted the Reno tower stating, "Reno clearance, ah, Galaxy two oh three is IFR to Minneapolis, uh, with

the information."

The tower controller then issued the following clearance:

Galaxy two oh three, Reno Clearance, clear ed to the Minneapolis St. Paul Airport via the Reno Seven Departure, as filed. Maintain one three thousand, expectKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-41 01 OCT 10 one niner zero five minutes after depar ture. Departure frequency will be one one nine point two. Squawk th ree three zero four.

The flight plan, whic h had been filed earlier in the day with the Seattle Flight Service Station (FSS), contained the following information:

Aircraft N5532, Galaxy Flight 203, L188/A, true air speed 320 knots, departure point RNO, proposed departure time 0820Z, crui sing altitude 190. Route of flight Jet Route (J) 32 ABR, J70 GEP, Destinat ion MSP, estimated time en route 4 hours; fuel on board 6 hours: alternate airport DLH: number aboard 102.

During ground servicing, a fuel truck was ba cked into a point about 5 feet behind the trailing edge of the right wing. The rear of the truck was located about 10 feet from the fuselage. The flight engine er supervised the refueling and checked the fuel load in each tank using the airplane's inst alled sight gauges. A total of 2,357 gallons of Jet A fuel was added. When the refueling was comp leted, the fueler unhooked the hose and

stowed it on the fuel truck along with the electrical groundi ng cables. As he climbed on the truck, he saw the flight en gineer securing the single point fueling panel. The fueler

then drove the truck to another location.

The engine air start cart was then moved in to a position about where the fuel truck had been parked. The fueling supervisor said th at he had connected bot h the air start and ground power units. The departi ng passengers arrived at the gate from Lake Tahoe in buses but, because the arriving passengers were still on the airpl ane, the buses were sent to the Reno Flying Serv ice lounge and off-loaded. The buses then returned to the airplane to transport the deplaning passen gers. When the airplane was ready, the departing passengers were brought to the airpl ane in a series of van trips. As the passengers were boarded, t he ground handling supervisor and two other persons loaded 67 pieces of luggage into the aft bag gage compartment. The flight engineer had instructed the ground handlers to load the luggage in this wa y since the forward bin contained crew bags and galley stores. The luggage was not weighed before it was loaded on the airplane. Sixty-five passengers were boarded in groups. During the latter part of the passenger loading, the groun d-handling supervisor removed the baggage

belt loader from the aft car go compartment and closed the door . He noticed the flight engineer finishing the engine se rvicing, apparently having al ready closed the forward cargo compartment. The fo rward cargo compartment wa s closed when the groundhandling supervisor made his pre-departure check. He then took his position at the left front of the aircraft for the engine start. Although he ordinarily communicated with the flight crew by means of a headset connected to the aircraft, he was unable, after several attempts, to establish such communication s with Galaxy 203. As a result, he used standard hand signals for this purpose. The f light crew then flashed the taxi lights on and off several times in apparent acknowl edgment that hand signals were now being

used.

At this time in the cockpit, the crew wa s preparing for the engine start. At 0055:51 the captain asked, "How does t he clearance read?" The first officer responded, "We'reKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-42 01 OCT 10 cleared the Reno Seven Departure as filed." The captain then asked the first officer several questions concerning departure. The Cockpit Voic e Recorder (CVR) indicated

that the before start checkl ist was not completed properly. There was no verbal response by the captain to the flight engineer' s check items. Ten checklist items were then skipped and six items were called for in incorrect order. F ourteen more items, required at intermediate stations, were not called out. No predeparture briefing, which was also required, was recorded on the CVR. A reason for this was later suggested by the president of Galaxy who testified that be cause the flight crew members "...were in a hurry when they got in, he (the captain) wo uld have immediately got the clearance and probably did the departure briefing at that time." Galaxy's broker agent at Reno similarly described the captain as in a hurry. He testified that t he captain, whom he described as "very conscientious" and "very punctual," was angry because he believed that the flight wa s over three hours late. He testifi ed that "He really assumed from the

time he left Seattle that he was running late, and when he a rrived in Oakland, he was looking for the passengers who had not arri ved from the Super Bowl Game. So when they did arrive, he boarded them as quickly as possible and got them on their way to

Reno."

Although the broker agent ex plained to the captain t hat the schedule had been changed, and this did put him at ease somew hat, he described the captain as still upset, "for professiona l reasons."

Following ground servicing the gr ound handler supervisor signaled to the crew that they could commence engine starting. However, a fter engines one and four were started, he noticed that the other ground ha ndler was unable to disconnect the air start hose. It was stretched taut from the power cart to t he airplane's air start access panel, located on the underside of the right wing leading edge, close to the fillet area. He gave the flight crew an emergency st op signal. He then left his pos ition, disconnected the hose, and returned to his previous position. He testified that although he thought he did, he could not remember closing the air start a ccess door. This door is about 81⁄2 by 11 inches in size. After the ground-handling supervisor disconnected the hose, the other ground handler picked it up and folded it onto the air start cart. She said that she did

not close the access door nor did she see it being closed; instead, after stowing the hose, she drove the tractor and pulled the air start cart away from the airplane. The power cart was pulled away from the airplane by the fueling supervisor.

According to Galaxy's policy, it was the captain's prerogative to extend the landing flaps to the full down position when taxiing close to parked aircraft. At 0058:42 the captain

called for the first officer confirmed full flaps after the number four engine had been started. However, no one on the ground remembered seei ng the flaps lowered during engine start or as the airplane ta xied out of the i mmediate gate area.

At approximately 0059 the first officer request ed taxi instructions. Reno tower almost immediately thereafter cleared Galaxy 203 to taxi to runway 16R.

The airplane, which was ta xiing on two engines, num bers one and four, had been directed by the ground handling supervisor to make a left turn from its parked position.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-43 01 OCT 10 The airplane had been parked on a westerly headi ng and required the left turn to take it southward. The airplane follo wed the taxi lane eastward to the parallel taxiway, then turned left again and taxied northward about a hundred yards to runway 16R.

At 0100:34 the captain said, "Okay, start 'em up." At 0100:45 the captain called for alternate flaps, and the call out was repeated by the first officer. At 0101:27 the captain

told the first officer to swit ch to the control tower and perform the takeoff checklist. At 0101:32 the first officer requested takeoff clear ance. Four seconds later Galaxy 203 was given clearance to take off from runway 16R.

At 0102:44 the sound of engine power increase could be heard on the CVR. At 0103:01 a sound similar to a glare shield rattle or Nosewheel shake was heard. Four seconds later, the captain said, "My yoke."

At 0103:19 the first officer called out "V-one." Almost simultaneously a sound

characterized as a "thunk" was heard. Four seconds later, the fi rst officer called "Vtwo." This call was followed by another "thunking" type sound.

At 0103:26 the captain called fo r gear up. The first officer acknowledged the order. At 0103:29 the captain asked the f light engineer, “What is it, Mark?" He responded, "I don't know. I don't know, Al."

At 0103:37 the flight engineer said, "That's METO." Three seconds later the captain ordered the flight engineer, "O kay pull 'em back from METO." At 0103:43 the captain

directed the first officer to r equest permission from the tower to execute a turn to a left

downwind to return to the field. Two se conds later the request was made to the Reno

tower. At 0103:50 the f light engineer said: "R PMs look stable, horsepower look good." At 0103:55 the captain told the first officer to "Tell 'em we have a heavy vibration." The

first officer so informed the tower at 0103:58.

At 0104:00 the tower cl eared Galaxy 203 to ma intain VFR conditions and to enter a left downwind to runway 16 right. The controller also asked, "Do you need the equipment?" Two seconds later, after the captain told hi m, "Yeah," the first offi cer responded, "That's

affirmative." The Reno tower controller t hen asked Galaxy for the number of people on board and fuel remaining. At 0104:13 the first officer replied, "Sixty-eight and we got full

fuel." At 0104:14 the Ground Pr oximity Warning System (GPW S) sounded. At 0104:18 the first officer said, "A hundr ed knots." He repeated this three seconds later. At 0104:24 the captain called for maximum power. Six seconds later the sounds of impact were recorded. The Cockpit Voice Recorder terminated at the time.

The broker agent said that he remained at his position at the gate and watched the aircraft taxi to the takeoff end of runway 16R. He said that to him the airplane appeared to have lifted off "earlier than usual," but he felt that it was acceptable because of the relatively light load and the cold temper ature. He then drove to the Reno Flying Service office to sign the bills for servic es rendered. He reac hed the office about a

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CRM-IT-11-SG 11-44 01 OCT 10 he did not think about it. On his way home he passed an ambulance, the significance of

which he did not know at the time.

The tower controller said that after he issued the takeoff clearance to Galaxy 203, the airplane stopped on the runway for 10 to 15 seconds before it started its takeoff roll. He said that the takeoff roll appeared normal, and the airplane lifted off about 4,000 feet down the runway. The controller estimat ed that the airplane was about one to two hundred feet above the ground when it passed over the departure end of runway 16R. Other witnesses who were in the airport vici nity said the aircraft reached a maximum

altitude of 200 to 250 feet. The controller said that it was about over the end of the runway when the radio transmission was made requesting the return to the airport. He said that he cleared the flight to return to the runway and looked away from the airplane

to write down some information and when he l ooked up again, he could no longer see it. As he was looking for the airplane, he saw a fireball at about ground level.

The lone survivor among thos e onboard the aircraft described the takeoff as "smooth," but then he felt the airplane stop its climb. It then hit turbulence with two specific "thumps" and as he said, "...the airplane w ent phum, phum." He added that he had experienced inflight turbulenc e similar to this before, but in a storm and at a high altitude. He also described the "thumps" as coming from the right side of the airplane. The airplane then began a right turn. He knew that it was a right turn because the starts became visible through the window to his left. He did not recall feeli ng any vibration; he remembered someone saying on the airpl ane's public address system, "We're going down." The airplane then made ground contact.

Ground witnesses generally agreed that the airplane was not on fire before impact and described hearing noises that were similar to metallic "bangs" or the sounds caused by the rotors of a large helicopter. Another witness characterized the sounds as "a propeller surging in and out..."

The accident occurred during darkness, at 39°27'55" north latitude and 119°46'56" west longitude.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-45 01 OCT 10 Injuries to Persons

Cockpit Cabin Injuries Crew Crew Passengers Other Total

Fatal 3 3 64 0 70

Serious 0 0 1 0 1

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 3 3 65 0 71

Damage

The airplane was destroyed by impact and fire. A furniture store direct ly adjacent to the impact area was damaged. Seven recreational vehicles parked in the primary impact area were destroyed.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-46 01 OCT 10 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

═════════════════════ ══════════════════ ════════════════ CONTINENTAL CONNECTION FLIGHT 3407 BOMBARDIER DHC-8-400, N200WQ

CLARENCE CENTER, NEW YORK FEBRUARY 12, 2009

SYNOPSIS On February 12, 2009, abou t 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400, N200W Q, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara Internat ional Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport. The 2 pilo ts, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a postcr ash fire. The flight was operating under the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed at t he time of the accident.

The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate res ponse to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not reco ver. Contributing to the accident were (1) the f light crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures fo r airspeed selection and management during approaches in icing conditions.

The safety issues discussed in this report focus on strategies to prevent flight crew monitoring failures, pilot pr ofessionalism, fatigue, remedial training, pilot training records, airspeed selection procedures, stall training, Federal Aviation Administration (FAA) oversight, flight operat ional quality assurance program s, use of personal portable electronic devices on the flight deck, the FAA’s use of safe ty alerts for operators to transmit safety-critical information, and weather information provided to pilots. Safety recommendations concerning these issues are addressed to the FAA.

History of the Flight

On February 12, 2009, abou t 2217 eastern standard time, a Colgan Air, Inc., Bombardier DHC-8-400 (Q400), N200WQ, operating as Contin ental Connection flight 3407, was on an instrument approach to Buffa lo-Niagara International Airport (BUF), Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles (nm) northeast of the air port. The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impac t forces and a postcrash fire. The flightKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-47 01 OCT 10 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. Night visual meteorological conditions (VMC ) prevailed at the ti me of the accident.

The home base of operations for both the c aptain and the first officer was Liberty International Airport (EWR), Newark, New Jersey. On February 11, 2009, the captain had completed a 2-day trip sequence, with the final flight of the trip arriving at EWR at 1544. Also that day, the first officer began her commute from her home near Seattle, Washington, to EWR at 1951 Pacific standar d time (PST), arriving at EWR (via Memphis International Airport [MEM], Memphi s, Tennessee) on the day of the accident at 0623. The captain and the first officer were both observed in Colgan’s crew room on February 12 before their scheduled report time of 1330. The flight crew’s first two scheduled flights of the day, from EWR to Greater Rochester International Airport (ROC), Rochester, New York, and back, h ad been canceled because of high winds at EWR and the resulting ground delays at the airport.

The company dispatch release for fli ght 3407 was issued at 1800 and showed an estimated departure time of 1910 and an estima ted en route time of 53 minutes. The airplane to be used for flight 3407, N200WQ, arrived at EWR at 18 54. A first officer whose flight arrived at EW R at 1853 saw, as he exited hi s airplane, the flight 3407 captain and first officer walkin g toward the accident airplane. The airplane’s aircraft communications addressing and reporting system (ACARS) showed a departure clearance request at 1930 and pus hback from the gate at 1945. According to the cockpit voice recorder (CVR) recording, the EWR ground contro ller provided taxi instructions for the flight at 2030:28, which the first officer acknowledged.

About 2041:35, the first officer stated, “I’m ready to be in the hotel room,” to which the captain replied, “I feel bad for you.” She continued, “this is one of those ti mes that if I

felt like this when I was at home there’ s no way I would have come all the way out

here.” She then stated, “if I call in sick now I’ve got to put myself in a hotel until I feel better ... we’ll see how... it feels flying. If t he pressure’s just too much ... I could always

call in tomorrow at least I’m in a hotel on t he company’s buck but we’ll see. I’m pretty tough.” The captain responded by stating t hat the first officer could try an over-thecounter herbal supplement, drink or ange juice, or take vitamin C.

The CVR recorded the tower controller cleari ng the airplane for takeoff about 2118:23. The first officer acknowledged the clearance, and the captain stated, “alright cleared for takeoff it’s mine.” According to the dispatch release, the intended cruise altitude for the flight was 16,000 feet mean se a level (msl). The flight data recorder (FDR) showed that, during the climb to alti tude, the propeller deice and ai rframe deice equipment were turned on (the pitot static deicing equipment had been turned on before takeoff) and the autopilot was engaged.

The airplane reached its cruising altitude of 16,000 feet about 2134:44. The cruise portion of flight was routine and uneventful. The CVR reco rded the captain and the first officer engaged in an almost continuous conv ersation throughout that portion of the flight, but these conversations did not c onflict with the sterile cockpit rule, which prohibits nonessential conversations within t he cockpit during critical phases of flight.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-48 01 OCT 10 About 2149:18, the CVR recorded the captai n making a sound similar to a yawn. About 1 minute later, the captain in terrupted his own conversation to point out, to the first officer, traffic that was crossing left to righ t. About 2150:42, the firs t officer reported the winds to be from 250° at 15 knots gusting to 23 knots; afterward, the captain stated that runway 23 would be used for the landing.

About 2153:40, the first officer briefed th e airspeeds for landing with the flaps at 15° (flaps 15) as 118 knots (re ference landing speed [Vref]) and 114 knots (go-around speed [Vga]), and the captain acknowledged th is information. About 2156:26, the first officer stated, “might be easier on my ears if we start going dow n sooner.” About 2156:36, the captain instructed the first office r to “get discretion to twelve [thousand feet].” Less than 1 minute later, a controller from Cleveland Center cl eared the flight to descend to 11,000 feet, and the first of ficer acknowledged the clearance.

About 2203:38, the Cleve land Center controller instructed the flight crew to contact BUF approach control, and the first officer acknowl edged this instruction. The first officer made initial contact with BUF app roach control about 2203:53, st ating that the flight was descending from 12,000 to 11,000 feet wit h automatic terminal information service (ATIS) information “romeo,” and the approach controller prov ided the airport altimeter setting and told the crew to plan an instrum ent landing system (ILS) approach to runway

23.

About 2204:16, the captain began the appr oach briefing. About 2205:01, the approach controller cleared the flight crew to descend and maintain 6,000 feet, and the first officer acknowledged the clearance. About 30 seconds later, the captain continued the approach briefing, during which he repeated the airspeeds for a flaps 15 landing. FDR data showed that the airpla ne descended through 10,000 feet about 2206:37. From that point on, the flight crew was required to observe the sterile cockpit rule.

About 2207:14, the CVR recor ded the first officer making a sound similar to a yawn. About 2208:41 and 2209:12, the approach controller cleared t he flight crew to descend and maintain 5,000 and 4,000 feet, respectively , and the first officer acknowledged the clearances. Afterward, the captain aske d the first officer about her ears, and she indicated that they were stuffy and popping.

About 2210:23, the first officer ask ed whether ice had been accumulating on the windshield, and the captain replied that ic e was present on his side of the windshield and asked whether ice was pres ent on her windshield side. The first officer responded, “lots of ice.” The captain then stated, “that ’s the most I’ve seen—most ice I’ve seen on the leading edges in a long time. In a wh ile anyway I should say.” About 10 seconds later, the captain and the first officer began a conversation that was unrelated to their flying duties. During that conversation, the first officer indicated that she had accumulated more actual flight time in icing conditions on her first day of initial operating experience (IOE) with Colgan than she had bef ore her employment with the company.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-49 01 OCT 10 She also stated that, when other company first officers were “complaining” about not yet having upgraded to captain, she was thinking that she “wouldn’t mind going through a winter in the northeast before [upgrading] to c aptain.” The first o fficer explained that, before IOE, she had “never seen icing cond itions ... never deiced ... never experienced any of that.”

About 2212:18, the approach co ntroller cleared the flight cr ew to descend and maintain 2,300 feet, and the first officer acknowledged the clearance. Afterward, the captain and the first officer performed flight-related duties but also continued t he conversation that was unrelated to their flying duties. About 2212:44, the approach controller cleared the flight crew to turn left ont o a heading of 330°. About 2213:25 and 2213:36, the captain called for the descent and approach checklists , respectively, which the first officer performed. About 2214:09, the approach controller cleared the flight crew to turn left onto a heading of 310°, and the autopilot’s altitude hold m ode became active about 1 second later as the airplane was approaching the preselected altit ude of 2,300 feet. The airplane reached this altitude about 2214:30; the airspeed wa s about 180 knots at

the time.

About 2215:06, the capt ain called for the flaps to be mov ed to the 5° position, and the CVR recorded a sound similar to flap ha ndle movement. Afterward, the approach controller cleared the flight cr ew to turn left onto a heading of 260° and maintain 2,300

feet until established on the loca lizer for the ILS approach to runway 23. The first officer acknowledged the clearance.

The captain began to slow the airplane less than 3 miles from t he outer marker to establish the appropriate airs peed before landing. According to FDR data, the engine power levers were reduced to about 42° (flight idle was 35°) about 2216:00, and both engines’ torque values were at minimum thru st about 2216:02. The approach controller then instructed the flight crew to contact the BUF air tr affic control tower (ATCT)

controller. The first officer acknowled ged this instruction, which was the last communication between the flight crew and air traffic control (A TC). Afterward, the CVR recorded sounds similar to landing gear handle deployment and landing gear movement, and the FDR showed that the pr opeller condition levers had been moved

forward to their maximum RPM position and that pitch trim in the airplane nose-up direction had been app lied by the autopilot.

About 2216:21, the first officer told the capt ain that the gear was dow n; at that time, the airspeed was about 145 knots. Afte rward, FDR data showed that additional pitch trim in the airplane-nose-up directi on had been applied by the autopilot and that an “ice detected” message appeared on the engine display in the cockpit. About the same time, the captain called for the flaps to be se t to 15° and for the before landing checklist.

The CVR then recorded a sound similar to flap handle movement, and FDR data showed that the flaps had been selected to 10°. FDR data also showed that the airspeed at the time was about 135 knots.

At 2216:27.4, the CVR recorded a sound similar to the stick shaker. (The stick shaker warns a pilot of an impending wing aerodynamic stall through vibrations on the controlKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-11-SG 11-50 01 OCT 10 column, providing tactile and aural cues.) The CVR also recorded a sound similar to the autopilot disconnect horn, which repeated until the end of the recording. FDR data showed that, when the autopilo t disengaged, the airplane wa s at an airspeed of 131

knots. FDR data showed that the control columns moved a ft at 2216:27.8 and that the engine power levers were advanced to about 70° (rating detent was 80°) 1 second later.

The CVR then recorded a sound similar to increased engine po wer, and FDR data showed that engine power had increased to about 75 percent torque.

FDR data also showed that, wh ile engine power wa s increasing, the airplane pitched up; rolled to the left, reaching a roll angle of 45° left wing down; and then rolled to the right. As the airplane rolled to the right th rough wings level, the stick pusher activated (about 2216:34), and flaps 0 was selected. (The Q400 sti ck pusher applies an airplanenose-down control column input to decrease the wing angle-of-attack [AOA] after an aerodynamic stall.) About 2216:37, the first o fficer told the captai n that she had put the flaps up. FDR data confirm ed that the flaps had begun to retract by 2216:38; at that time, the airplane’s airspeed was about 100 knots. FDR data also showed that the roll angle reached 105° right wing do wn before the airplane began to roll back to the left and the stick pusher activated a second ti me (about 2216:40). At the time, the airplane’s pitch angle was -1°.

About 2216:42, the CVR reco rded the captain making a grunting sound. FDR data showed that the roll angle ha d reached about 35° left wing down before the airplane began to roll again to the right. Afterward, t he first officer asked whether she should put the landing gear up, and the ca ptain stated “gear up” and an ex pletive. The airplane’s pitch and roll angles had reac hed about 25° airplane nose down and 100° right wing down, respectively, when the airplane en tered a steep descent. The stick pusher activated a third time (about 2216:50). FDR data showed t hat the flaps were fully

retracted about 2216:52. About the same time , the CVR recorded the captain stating, “we’re down,” and a sound of a thump. The airplane im pacted a single-family home (where the ground fatality occurr ed), and a postcrash fire ensued. The CVR recording

ended about 2216:54.

Injuries to Persons

Injuries Flight Cabin Crew Crew Passengers Other Total

Fatal 2 2 45 1 50

Serious 0 0 0 0 0

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 2 2 45 1 50

Damage

The airplane was destroyed by impact forces and a postcrash fire.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-1 01 OCT 10 

## APPENDIX

TABLE OF CONTENTS

SUBJECT PAGE

STANDARD COCKPIT OPERATIN G PROCEDURES ............................................. 12-2

LIFESTYLE KEYS TO FLIGHT DE CK PERFORMA NCE .......................................... 12-7

STRESS IN AVIATION ............................................................................................. 12-13

THE COPING RECIPE ............................................................................................. 12-15KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-2 01 OCT 10 

### STANDARD COCKPIT OPERATING PROCEDURES

No matter what the size of your unit, a written SCOP is critical to a professional, effective, and safe operation. If there is not now a crew coordination section in your squadron SOP, use the following minimum crew procedures as a guide in developing an SCOP pertinent to your operation.

This basic SCOP is presented by phase of flight for a normal flight. Additionally, sound crew procedures always include:

• Command-Response calls by the Pilot Fl ying (PF) and the Pilo t Not Flying (PNF) any time configuration changes in landing gear are made (if so equipped).

• In an emergency, follow these priority steps:

FLY THE AIRCRAFT . The pilot in command must a lways ensure that responsibility for flying the aircraft is clearly assigned as t he primary duty of one of the pilots. The pilot flying the aircraft must not perform ta sks, which detract from or compromise that duty.

Perform recall (memory) emergency checklis t items in a measured manner. Other

than in a critical situation where immedi ate tasks are necessary to keep the crew and aircraft within a safe flight envelope, ther e is time to get confirmation from the other crew member(s) before making major systems configuration changes such as shutting an engine down or turning off a generator.

Non-recall items on the emergency/abnormal che cklist should be read by the PNF in a Challenge-Response manner. The indi vidual steps of a procedure will be accomplished by the designated or appropriate (by seat position) pilot accompanied with the specified response in the che cklist. If a step can be accomplished with equal ease from either seat, t he PNF will accomplish that task.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-3 01 OCT 10 FLIGHT PHASE PF PNF

All Phases Requiring a

Checklist The crew will execute the checklist in a flow pattern manner, if so trained, with a challenge/response follow-up. If not trained in flow pattern, the crew will execute the checklists in a conventional challenge/response manner. All emergency/abnormal checklists will be called for by the PF and executed in a challenge/ response manner following accomplishment of any appropriate recall items.

Takeoff

! Abort

! Briefing while holding

! Airspeeds

— Initial movement of PNF's airspeed indicator In the first briefing session before the simu lator flight, the crew will explicitly

define:

1. Which pilot commands an abort. 2. Which pilot performs an abort maneuver.

Brief:

! Initial Heading

! Initial Altitude

! Airspeed Limit (if applicable)

! Clearance Limit

! Emergency Return Plan

Visually confirm PF's Call: "AIRSPEED ALIVE"

indicator active.

Climb

! At Positive Rate of Climb (vertical speed indicates positive rate and altimeter is increasing:

! At 3,000 feet AGL

! Altimeter

! At 1,000 feet below an assigned altitude:

! Upon reaching assigned

altitude: Call, "POSITIVE RATE"

Only after PNF's call, then call, "GEAR UP."

Call “GEAR IS UP” when indicated

Call for Climb Checklist Complete Climb Checklist

Call, "ALTIMETER SET ____" Call, "(Altitude) ALTIMETER ____”

Call, “Altitude for Assigned Attitude.”

Call, “Altitude”KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-4 01 OCT 10 FLIGHT PHASE PF PNF

Cruise

! Altitude deviation " 100

feet:

! Course deviation of " 1/2

Dot after established on

course: Call, “(Amount of Deviation)”

Call, “(Amount of Course Deviation)”

Descent

! At 1,000 feet before an assigned altitude:

! Upon reaching the assigned altitude:

! Altimeter

! At appropriate workload

time: Call, “ALTIMETER SET (Current Altimeter Setting)”

Brief on approach to be used:

! Field Elevation

! Appropriate Minimum Sector Altitude (s)

! Approach to be executed

! Inbound leg to FAF, procedure turn direction, and

altitude

! Timing required

! DH/MDA

! MAP (non precision)

! Special Procedures (DME step-down, arc, etc.)

! Type of approach lights in use (and radio keying procedures if required)

! Missed Approach

Procedures Call, “(Altitude) for (Assigned Altitude)”

Call, “(Altitude)”

Call, “ALTIMETER”

Approach

! Each pilot will call initial convergence of their respective flight director’s

course deflection bar and glideslope raw data

indicator Call, “LOCALIZER ALIVE” Call, “LOCALIZER ALIVE”KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-5 01 OCT 10 FLIGHT PHASE PF PNF

Approach (cont)

! Each pilot will call both localizer and glideslope capture for his respective flight director.

! At FAF: — Precision Approach:

— Non-precision Approach:

— Landing Checklist

! At 1,000 feet above

minimum

! At 500 feet above

minimum

! At 100 feet above

minimum

! Deviations:

" One Dot (GS/LOC)

" 10 knots from approach

! At minimums — Precision (DH):

— Non-precision

$ At MDA: Call “LOCALIZER (GLIDESLOPE) CAPTURE”

Call, “OUTER MARKER.”

Call, “FINAL FIX.”

Call, “Landing Checklist.”

Make appropriate call, “GO

AROUND” or “LAND”

Acknowledge, “(Time or distance) TO GO.” Call, “LOCALIZER (GLIDESLPE) CAPTURE

Visually crosscheck that altimeters agree and call, “ALTIMETERS CHECK, NO FLAGS” after checking both PF’s and PNF’s flight

instruments and the comparator warning.

Call, “ALTIMETER CHECK.” (Same as Precision.) “NO FLAGS.” (Same as Precision)

Start Time Hack.

Call “Landing Checklist Complete.”

Call, “1,000 ABOVE

MINIMUM.”

Call, “500 ABOVE MINIMUM.”

Call, “100 ABOVE MINIMUM.”

Call, “ONE DOT (high/low or left/right) AND (increasing, holding, decreasing).”

Call “APPROACH (plus/minus) AND (increasing, holding, decreasing).

Call, “MINIMUMS.”

Call, “MDA, (time or distance)

TO GO.”KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-6 01 OCT 10 FLIGHT PHASE PF PNF

Approach (cont)

$ At MAP:

$ At point on approach where PNF sights runway

or visual references:

$ Missed Approach

— At positive climb rate:

— To ATC: Make appropriate call, “GO

AROUND” or “LAND.”

Announce intentions “ROGER, I’LL GO VISUAL”

or “ROGER I”LL STAY ON

INSTRUMENTS.”

Call, “GEAR UP.” Call, “MISSED APPROACH

POINT.”

Call, “I HAVE THE RUNWAY (or visual reference) AHEAD (or RIGHT or LEFT).

When PF announces

transition to PNF transitions to

instruments and continues

altitude and deviation calls as appropriate.

Call, “GEAR IS UP,” when

indicators so indicate.

Announce, “MISSED

APPROACH HEADING IS (assigned heading) AND LEVEL OFF IS (assigned altitude).”

“(Call Sign) IS MISSED

APPROACH CLIMBING TO (Assigned Altitude).”KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-7 01 OCT 10 THE LIFESTYLE KEYS TO FLIGHT DECK PERFORMANCE

OF THE NAVAL AVIATOR -- ANOTHER WINDOW

Frank E. Dully, Jr.

ABSTRACT

This paper presents the views of a Naval Flight Surgeon on the coping mechanisms that the Naval Aviator brings to his occupation. It develops the theme t hat four life style characteristics nece ssarily receive inordinate polishing, and that the avia tor's continued safety is dependent on his ability to fully exploit all four of these in

concert. When one of the f our is flawed, he is in jeopardy. Also identified in the paper are five built-in defects present in the healthy aviator that require that he be protected from these, both by his own recurring awareness and by concerted in stitutional measures. Implicit in the complexity of modern military aircraft is that they are designed for the aviator whose described characteristics are forever uncompromised. The engineer is wrong who believes that the capabilities of the aviator who will fly his cr eation are static, or that these capabilities are always tweaked to the maximum.

IT WOULD APPEAR to this flight surgeon that cockpit information systems and other forms of aircraft performance measurement s are designed for use primarily by an uncluttered mind, capable of assimilation and interpretation with uncommon accuracy in order to make the judgments and take the appropriate actions that will sustain safe flight. In tactical military aviation, where the capabilities of the machine have already outdistanced the physiological capabilities of the man, the feedback loop that keeps the pilot informed of how close to the edge of that sa fe envelope he is represents

the difference between victor y and defeat in wartime,

and survival and demise in peacetime. Because my specialty field deals with hum an frailty and its interface with aviation from the per spective of preventive medicine, I have made it my business to discover what it

is that the Naval Aviator br ings to this occupational environment. I am dismayed to find that his airplane frequently requires him to be what I would compare to a blank slate or cerebral chalkboard. On this gray-matter slate is to be sequentially recorded and erased appropriate flight data paramet ers. Using this data he exercises learned skills, and mu st demonstrate a certain stage presence. His task is to correctly select pertinent information and guarantee its flow. Then he must act on it, with this cycle to then r epeat itself over and over as new information presents. The problem with this chalkboard comparison is t hat it presuppos es that upon entry into the flight regime, the aviator's information slate has been neatly eras ed clean; that on each occasion of flight, all of the existing space for recording on that imaginary slate is, in fa ct, available to him; that only those things appropriate to aviation will find their way onto the slate; that t he information displayed there is usable; it tells him what he needs to know, in a way

that is both articulate and concise, and that he be able to use it.

The catch, of course, is that the aviator in this loop is nothing like a clean chalkboard. He is neither your average man (or woman), nor is he or she the unfettered information system that the slateboard would appear to represent, though at certain times he functions beautifully in this mode.

There are certain, very specif ic characteristics that will be found in the successful, healthy Naval Aviator. It is my impression that these characteristics are common to the professional aviation co mmunity as a whole, but tweaked to a higher degree in tailhook aviation. These characteristics are present to a less predictable degree in general aviation. In all aviation communities, however, the more imper fectly developed these characteristics are, the greater the risk. Having knowledge of what the aviato r’s positive features are supposed to be can equip the f lier or his flight surgeon with a yardstick against which to measure predicted and predictable performance. Similarly, having an awareness of the coexisting negative features resident in the typical aviator equip him to stay out of areas where his performance is lik ely to be substandard. What is being described here, then, is the person on the upper end of the performance spectrum for whom the engineer is designing aircraft, and for whom "the system," Naval Aviation, or a commercial airline company, is structured. Usi ng this knowledge, the flight surgeon can make assessments of risk and neatly circumscribe periods of ti me when that risk becomes

inordinate. The characte ristics to be outlined here summate into an equation of sorts that describes the aviator's ability to cope. When all goes smoothly, when the aviator is maximally expl oiting the posit ive features of his personality and assiduous ly avoiding those areas where his weaknesses would trap him, then and only

then does the cerebral chalkboard function as advertised. The design engineer needs to appreciate that this person for whom he is designing is not always the same person. Events fa r removed from the cockpit can either degrade or improve his efficiency quite substantially. The performance available may be exceeded by the performance required. Using the Naval Aviator as a model, there are

identifiable featur es of his life style which, when orchestrated together, ar e most conducive to good function. Similarly, when one or more is flawed, so is he. Balancing these produc tive assets, on the other hand, are those featur es of his life styl e that would tend to disrupt his function and ar e of such sufficient impact as to warrant special steps, in stitutional if possible, to protect the flier from their influence. These features can be likened to characteristics of first the "heads," and

then the "tails" side of a coin.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-8 01 OCT 10 THE HEADS SIDE OF THE COIN

Examining the life style keys shows that not unlike a coin, the good features are on one side and the not-so-good features are on the other. The "heads" side of the coin shows four separ ate but clearly interrelated features, which complement each other. They are most visible in the cockpit. They are, however, present and

functional at all other times of the day, both at work and

at home. In the business of aviation, they combine smoothly to produce a safe and aggressive aviator. Sadly, in the home thei r appropriateness is open to question, though they are found there as well. These

features are:

1. He is in control.

2. His male-female interf ace is characterized by

emotional distance.

3. He is a mission-ori ented compartmentalizer. 4. He is systematic and methodical.

The first feature, being in cont rol, is the cardinal feature of the healthy aviator. It is the one that consumes the majority of his energies. If he is visualized in the mind’s eye as being in his airplane, he can be seen there in all his controlling splendor. Wi th feet on the rudders, one

hand on the stick and the other on the throttle, his aircraft is precisely responsive to his measured control inputs. He has gravitated to ward this task, where he is indisputably in control, si nce he was a toddler. He probably is the oldest son. He has learned to survive in

a success oriented home env ironment where mastery

and achievements were t he order of the day. Recognition for achievement was prominent by its absence, though criticism for minor failings was easily

obtainable. The circle of friends he chose varied with his age so that by the mid to late teens, he selectively co-mingled with other over-achievers who had also set very high standards for themselves. Priorities were set. Competitiveness ran high. T he thrill of controlling your own destiny through your own efforts came in small

doses on athletic fields. This group of young men will become the professionals of their adult world: the physicians, engineers, and aviators in the community. Progressively important and demanding challenges

were seized. Great satisfaction came from successes that followed in increasingly more complex tasks. There was a surprising amount of comfort to be derived from interfacing with other contro llers. One can, of course, always trust another controller; he won't let you down. There are rules of engagement to be followed. Everyone knows what they are. The controlling features that mark his performance in the cockpit are not restricted to the cockpit, t hey are everywhere. As a parent he can sometimes be seen treating his children the same way he treats his airplane: measured input - measured response, forthwith!

The fairly classic scenario t hat shows the adult controller "doing his thing" is not original. It happens in almost every household. It has to do with a family automobile trip. The "preflight" trip planning is extensive, though the vehicle is made by GM and not Lockheed. Maps are pored over. The availab ility of gasoline or diesel

fuel is established. Radar tr aps are identified. Detours

are confirmed with the Auto mobile Association. The appointed hour for departure and arrival are agreed upon, if only to himself. When that appointed hour arrives, there he is, paci ng smartly around the car, awaiting family assemblage. The only flaw in the planning will have been one that he has relegated to being a minor concern: the av ailability of ladies' rest rooms during the day's drivi ng marathon. He is in control. There will be no surprises. It will be a good day.

Taking the same scenario and twisting it a bit can be enlightening, because in the ev ent that Mr. Controller, for whatever reason, failed to do his pre-trip planning, the family is alerted to an upcoming "bad day: Father is not good company on the trip . It has been agreed that he "...is in a bad mood." The bad mood, in fact, is the

fate of the controller who thinks he should be in control of a situation, but is not.

Controllers are comfortable with other controllers. Aircraft squadron ready rooms are a case in point. It should come as no surprise, t hen, that cont rollers marry controllers. Oldest sons marry oldest daughters. If, between them, there are no ru les to establish whose turn it is to be in control, the relationship will not survive.

As a youngster, the budding controller makes a terrifying discovery. He has a grievous shortcoming in his makeup that defies control. Feelings. There are feelings within him that woul d control him. How can you have feelings and control, too? It will be one or the other. Something must be done.

The second feature of the heads side of the coin shows

what is to be done. It flows nat urally from the first: the controller's male/female interface is marked by

calculated emotional distance. This, too, has its origins in early childhood where it is obvious to all that the boy w ho clings to his parents is an embarrassment. Big boys don't cry! Dependency feelings are unmasculine. By the time the boy has experienced the first pangs of puppy-love, he has added

a sinister dimension in the whole concept of feelings: He learns that he who shows his feelings risks being manipulated at the hands of another. As if this were insufficient, he also discovers that feelings parasitize energy. They detract from the mission. Feelings are dynamite. The less to do with them, the better. At risk

is control. Results: The feelings get buried, compartmentalized at a safe distance so they do not have to be dealt with. As long as they are kept in their private, locked, hidden compartment where the controller can carefully meter their visibility on an "as required" basis, things are co mfortable. (The spouse or girlfriend decides that because the visibility of feelings she wants to see is so low -- tenderness, love, etc. -- that therefore they do not exist, is an underwritten risk).KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-9 01 OCT 10 When a controller is placed in a situation where his feelings will be exposed, he will respond in a universal manner. He absents himself. Consider the feelings attendant to the aircraft carrier’s deployment. Does it strike anyone as curious that there are never any tears on the ship? That there ar e only tears on the pier? And, that Mrs. Controller will tell you that over the two weeks immediately precedi ng deployment things at home become increasingly distant. Not intimate, not sharing the upcoming departure but distant. Why? Because two weeks before deployment he began to systematically and gradually withdraw his emotional iron from the fire -- imperceptibly, he thought. (Not so.) Some of the greatest domestic rows in the Naval Aviator's marriage will occur in the two weeks prior to carrier deployment. He has elected not to deal with those feelings. They are loaded.

The third feature of the heads si de of the coin is that the Naval Aviator is a mission-oriented compartmentalizer. Visualizing him, again, in his cockpit, compartmentalization offers a system to exclude

distractions such that while he is charged with accountability for that multi -million dollar national asset, those things that do not c ontribute to the mission of flying that airplane are excluded from his conscious. Referring to the cerebral chalkboard that began this paper, it is compartmentalizat ion that insures that the chalkboard is clean before entry into the cockpit. If the mission is "Fly My Airplane," that becomes the functional compartment. Ex cluded are all the unrelated compartments: an overdrawn back account, a fight with the spouse, an impending major purchase, a clandestine evening meeting, etc. Similarly, when functioning in one of these other compartments, that problem-solving mission is also undistracted; attention is

zeroed onto that task. Among special compartments are deployment, combat, get-home-itis, and sexuality; a myriad of commonplace compartments exist, including wash the car, mow the lawn, in-basket/ out-basket, and the evening news. Controllers dislike interruptions and are commonly quite intense in mission accomplishment, sometimes without regard for the relative importance or unimportance of the task. Th is makes for trouble in the

home at the hands of t he equally competent but disinvolved controller spouse.

The fourth feature of the heads side of the coin is actually a summation of the ot her three. The controller, hell-bent to accomplish a mission, unencumbered by distractions, and reinforced by his successes, believes he has found a system or method to insure the

continued success of his effort s. By being methodical, and having learned to worship the god of checklists, he precludes the occurrence of the one thing he is least comfortable with: surprises. There shall be no surprises. If there are surp rises, the controller must indeed be severely flawed. Procedures manuals are meticulously developed to program out any surprises.

Situations known to contai n hidden surprises are either figured out in advance or av oided. In the case of feelings, which by their spontaneous nature can defy the dictum of no surprises, it is far easier to avoid provocations than to attempt to handle them after the fact. It is noteworthy that the spouse quite commonly would launch an attack for the purpose of getting in the open some of these mysterious feelings, only to find her partner unwilling to participat e, electing to leave the matter unresolved -- a form of control in itself. Though both members of a team may be quite like each other in handling life problems, there ar e notable differences that become difficult. Using the carrier deployment example again, it is not uncommon that at the completion of the deployment when some semblance of normality has returned to the family constellation, she wants to talk.

She wants to share her feeli ngs with him now that she no longer needs to deal with them. She would simply like him to listen, to know , to share. He does not engage in discussions for the purpose of sharing, he engages in discussion to identify and solve problems. She is likely to address a short-fused audience.

Working smoothly in concert with each other, these four

features of the heads side of the coin are the hallmark of the aviator who approaches his occupation with the greatest chance of success. When any one is flawed, so is he. To be able to use his learned skills and apply the "stage presence" perspective, he must:

1. Be comfortable t hat all significant compartments of his life are amenable to his control and that no major or significant threat exist that would compromise this requirement.

2. Keep sufficient distance between himself and others of the opposite sex so that feelings and

emotional involvement are on his terms and

amenable to control.

3. Be expert at precluding distraction by compartmentalizing out of his conscious those things, which do not cont ribute to a specific mission compartment.

4. Be methodical and systematic to effect a form of preprogrammed approach to task accomplishment which, for him, is time proven, for the purpose of ex cluding "surprise."

Continued flight stat us requires that a ll four of these features be functional and adequat e in the life situation. Temporary termination of flight status when these coping methods are inadequate for the need is appropriate.

THE TAILS SIDE OF THE COIN

Not all the built-in features of the healthy Naval Aviator are conducive to his safety and survival. The flip side of

the coin shows the existence of five defects which, if left to themselves, would tend to trap the unwary into

foreseeable untoward incident s, some of which can have disastrous consequenc es. In implicit and sometimes explicit recogniti on of these shortcomings, many institutionalized pressu res are brought to bear toKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-10 01 OCT 10 protect the Naval Aviator from himself in these areas.

These defects are:

1. Limited spontaneity 2. Complacency 3. The "familiarity breeds contempt syndrome" 4. The ritual trap 5. The "positive maleness feedback" requirement

The first defect on the tails side of the coin distresses the Naval Aviator when it is pointed out. This is

because the existence of su ch a defect is anathema to the image he would like to project. Recalling Clark Gable and Errol Flynn in the 1939 movie epic, "The Dawn Patrol," or more recently, "The Great Waldo Pepper," it is more or less expected that the normal or average happy-go-lucky aviator has no deep attachments, is likely to be a semi-alcoholic skirt-chaser, and is an incompletely bridled adventurer who often borders on the psychopathic. For him, ending up in a smoking hole holds no horror, and he frequently does. The symbolism of the white s ilk scarf in the slipstream

embodies this attitude. This frankly ignores that today's Naval Aviator is a complex weapons platform operator who is in every respect a professional. He is neither an impulsive Waldo Pepper nor a psychopathic Gable or Flynn. The defect to be addr essed is not the difference between what he actually is versus what he would like to see himself as, but an ironi c contradiction. The

contradiction is that he lacks spontaneity. The learned procedure and the system atic, preprogrammed approach to management of fli ght are explicitly geared to keep him out of the spontaneous arena. "Spontaneous," for the aviato r, is often better equated with "impulsive." As his experiences in the airplane multiply, he becomes equipped with more and more

wherewithal from which to draw in the decision-making process. Spontaneity would deny or abort this learned

process.

One of the reasons that t he compartment labeled, as "get-home-itis" is so dangerous is that in this scenario of compartmentalization gone awry, the fixation on getting home impedes his ability to ma ke correct judgments, in effect denying him access to his training and experience. He thus fi nds himself in a spontaneous mode; deprived of t hat wherewithal that normally keeps

him out of trouble.

He intuitively recognizes, without any word having to be said, that it is t he spontaneity of emotions that constitute their major threat to his continuing control.

In a hedge to protect the fledgling aviator from his spontaneity, there exists the time-honored institution of "hanger flying." Through the sharing of experiences, a relatively inexperienced aviator can, in effect, have a preprogrammed response to a future crisis or scenario, thus avoiding the happenstance of having no experience or training from which to draw, and responding spontaneously.

The U.S. Navy institution known as the "Plan Of The Day," for the wing-wearing community, is a document not merely outlining events and information, but also is a vehicle for use to keep the training, or reprogramming

current. Therein will be found a daily feature known as the Emergency-Of-The-Day, specifically designed to keep the flyer refreshed, cu rrent, programmed, and out of the spontaneous mode.

The charming and socially adept aviator who can command an adoring audience with his wit at a cocktail party, rather than being the classic example of spontaneity at its best, is, in stead, reprogramming at its best. The behavior pattern he exhibits is the result of very carefully studied effort at collecting the best stories he has heard, the social affe ctations he thinks are most becoming and the appearances of savvy and aplomb acquired from his experiences and preserved for use in just such situations. He thinks he is a model of spontaneity. His spouse knows be tter. In his airplane, it spells trouble.

The second defect on the tails side of the coin is probably the best known, and as such needs little amplification. It is the des tructive monster poised to strike at a time when things go well. It is complacency. The only requirement for it s presence is a sense of security. It is not necessary that the aviator-victim be a competent and skilled performer. It is only necessary that he think so.

The third defect on the tails si de of the coin is a cyclic, repetitive phenomenon very closely allied to complacency. It is the "F amiliarity Breeds Contempt Syndrome." It is a misper ception born of increasing experience with a specific m odel aircraft. At the initial stage of experience in a given model, the aviator is quite hyper-aware of the reputati on of the plane, of the bad things it has done to others in the past, and that this

man-machine interface can be a tenuous one with unhappy results. As his proficiency increases, his perspective changes. "This airplane only eats other people, less smart than myself." This is most clearly visible in the military aviato r in the early stages of his career as he progresses up the ladder of increasing aircraft complexity, culminating with the model he will ultimately fly in the fleet, and spanning a 24-month period. His first entrees to each were accompanied by transitory realizations that this airplane kills. Soon, however, he has issued himself a private waiver from inclusion in this group of mortals. For some, the inappropriateness of this judgement will be vividly brought home at a late r date. A step in the direction of

an institutional "fix" fo r the problem is the community-wide circulation of mishap and incident reports that involve his aircraft type.

The fourth defect on the tails si de of the coin is the ritual trap. When a repetitivel y performed task no longer requires conscious attention to make it happen, the task can be completed by rote, with no conscious attention at all, with a cerebral disconnect. The perpetrator need not even be aware that his task is complete. He certainly will not have any cognitive awareness of newKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-11 01 OCT 10 information that the ritual should have uncovered. This is the trap awaiting the aviator who has performed thousands of essentially identical preflight examinations of his type of aircraft and who can now do it with his eyes closed -- literally. This is the trap ready to be sprung in response to the ground controller's ritual challenge to "check wheels down and locked." This is the trap set for the husband whose ritual goodbye kiss as he goes out the door to work has become devoid of meaning. People whom, for whatever reason; fail to perform the prescribed ritual (or cannot recall whether it was performed) come away feeling guilty because the

ritual was not done. That the ritual was meant to accomplish something has been lost. Witness: It is acceptable in the business of aviation to perform a preflight check with a cerebr al disconnect, but it is not acceptable to omit a pref light check -- even though one is the equivalent of the other.

The fifth and last defect on the tails side of the coin is

the most involved of the five, and has the greatest potential for mischief. On the surface it appears benign, and for some aviators will always be so. But for most aviators, at least once in their lives (and probably more often than that), t he defect that is a "requirement for positive maleness feedback" will have to be recognized for what it is and dealt with head-on. It is as if every compartment of the healthy aviator's multi-compartmented life c ontributes a measurable quantity of positive maleness feedback, indicating to him that his coping skills are at least adequate for the need. On an imaginary cerebral totalizer instrument, the aviator always has a readout relative to his performance

as a mate. This totalizer instrument has painted on its imaginary face a red line, below which the reading indicates an insufficient amount of positive maleness

feedback. Under most ci rcumstances, the healthy

aviator knows his totalizer instrument reads well into the higher numbers. When adverse impact on the totalizer results from scenarios involving negative maleness feedback from another compar tment and thereby nullify or balance the negative input. The peculiar significance of this phenomenon in aviation is that if the stresses are

such that the aviator is unable to muster sufficient positive maleness feedba ck to counter negative maleness feedback, he is at risk for flying dangerously, for risk taking, in an ineffective and inappropriate but unoriginal attempt to prove himself better than his coping ability at the time would suggest. This is a form of mandatory self-actualizat ion not unique to aviation but possessing uniquely high pric e tags if aviation is

involved. The real curios ity surrounding the concept of positive (or negative) mal eness feedback is that the protagonist is usually the last to know that his behavior is so distinctly goal orient ed, and is readily perceived as such by others. The classic example of a benign situation containing the conf licts of positive and negative maleness feedback inputs occurs in the occupational setting. It usually involves controversy between institutional leadership stru cture over him. In short, things do not go well for the aviator. Pending his getting a handle on the problem, negative maleness feedback can become significant, causing the needles on the imaginary totalizer to fall towards the red line. In response to this, specific other constructive actions will take place as he seeks a c ountering effect from other compartments. A more notor ious occurrence in such a

scenario involves an increase in the level of sexual activity for the duration of the occupational crisis that can seem inexplicable to the partner, and doubly so when crisis resolution is complete and the need no longer exists for that level of bedroom activity.

THE PECKING ORDER

Partially in response to Training Command grades required for entry into a s pecific flight community (transport/patrol, rotary wing, attack, fighter) and partially in response to the relative mundane or colorful nature of the mission, a hi erarchy exists among wing

wearers. Naval Aviators c onsider themselves to be the top. Within the aviator co mmunity, the inhabitant of the lower end of the spectrum ar e pilots of multi-engine, multi-place propeller driven aircraft. At the upper end are pilots of single-seat jet aircraft. The presence or

absence of a tailhook is considered a hallmark of excellence. Aircraft speed increases as one proceeds up the spectrum, as does the ra te of fuel consumption. In the rotary wing community, helicopters with weapons affixed require a more colorf ul aviator than the rest. A carrier qualified aviator will be higher on the spectrum

than one who is shore based. The higher up on the pecking order one goes, the greater the preponder ance of oldest sons to be found, beginning at the low end with 50% or less and culminating at the high end with 80% or better. To state

that this is a self-selec tive and unique community of

aviators is a master under statement. The higher an aviator is found on the pecki ng order, the more urgent the requirement for a func tional heads and tails of the

coin.

THE FAILING AVIATOR

Not everything goes well at all times for the Naval Aviator. Where the copi ng mechanisms outlined at the beginning of this paper are ov erwhelmed, the entity of the Failing Aviator presents. The most common cause of the failing aviator is a failing marriage. The spouse of the Naval Aviator is presented with unique hardships

and burdens not to be found in any other occupation, and for some, will have to face these alone, and on a repetitive basis. Some ma rriages cannot survive.

Where there is some fo rm of mutual agreement

between the two on the need for dissolution of the relationship, the aviator ma y have all the coping tools required. Where there is bi tterness, the impact of the negative maleness feedback commonly overwhelms the available resources and the "Failing Aviator," in desperation, trolls for new methods to recoup his perceived ego losses. The indicator needle on his

cerebral totalizer instrum ent sweeps past the red line heading downward. This response, a newly adopted behavior pattern that is t he hallmark of the Failing Aviator, is a distinct change fr om what was. He has lost

control. She calls the s hots. He cannot escape theKC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-12 01 OCT 10 impact of the overwhelming negative maleness feedback bluntly delivered in his home. It defies compartmentalization. It cannot be sequestered out of

his conscience. He ruminates over it. What used to be

"safe" emotional distance is no longer safe as, in his view, she runs amok over his sensitivities, tromping through his once protected fee lings, and casting his very sexuality on the public highway. He can concoct no system to handle this.

Instead, the emergence of t he behavior pattern of the Failing Aviator identifies a her etofore-unknown entity. It is characterized by br avado, risk-taking, abandon, macho, and an implicit accept ance of physical pain. He

sets out to show the world that he is a man. He acts like an 18-year-old wild man, a classic of youthful exuberance, sowing wild oats and meeting artificial challenges, except he is not eighteen, he's twice that. The end result is an automobile accident, public disgrace, and finally an aircraft accident. He is clearly

identifiable before the latte r occurs. The trail of carousing, alcohol excess, the snappy sports car, the speeding and DWI tickets, the injuries accumulated in the process, and the sexual promiscuity point out that

the aircraft accident is on t he way, if he survives the auto accident. The process may last six months.

The curiosity is that for one who at one time possessed

and used the heads and tails side of the coin that is his best asset, clearly one of these are in the running for the duration of the Failing Aviator. The cure is to

reestablish dominance of his old coping methods. They may not immediately solve the family problem that is the genesis of the entity, but neither can the Failing Aviator. If he is made aware that this newly adopted behavior pattern is goal oriented and meant to be destructive, he will stop it. This does not require psychotherapy. Anyone (except the spouse) can do it, as long as the one who does it is respected in the eyes of the victim. In recent years over ten percent of Naval Aviators involved in accidents were the Failing Aviator.

CONCLUSION

The healthy aviator's armamentarium meant to keep him healthy contains clearly identif iable assets and liabilities. If known, these can be we ighted against the impact of the environment in which they are to function, giving a prediction of coping success or failure. For some aviators, certain stressful situations will provoke an identifiable maladaptive coping style, which requires and is amenable to interruption. It is the whole man who enters the cockpit to undertake flight; into that arena are brought all the frailties that ma rk the man. His ability to dissect out purely o ccupational from the nonoccupational requirement s of the task is the cornerstone on which his aircraft is designed. This cornerstone is not always made of granite that the engineer would require.

NOTE: The opinions present ed in this paper are those

of the author. No endorsem ent by the Department of the Navy has been given or should be inferred.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-13 01 OCT 10 

### STRESS IN AVIATION

BY RICHARD O. REINHART, M.D.

Stress has a tremendous influence on our personal and professional lives, but despite its (usually) negative connotation, it actually can be a positive force. Certainly, stress is inherent in flying. The results of stress, though, have been likened to the price paid to be a racehorse instead of a plow horse. Thus, the variety of stress that is particular to flying, in addition to the ability of a pilot to cope with such stress, is precisely what makes him or her a bad, good or excellent aviator.

But just what is stress? Stress can be defined as any activity that requires us to cope, and putting this energy to our advantage enables us to be that

"race horse" mentioned before. If stress become unmanageable, though, it changes to distress -- anxiety, oppression, affliction, unhappiness -- and frequently is disabling because of its debilitating effects on the human body.

Some studies, in fact, have found that 50 to 70 percent of all visits to the family doctor are related to the negative effects of stress. Such distress produces as many symptoms or "body signals" as there are organs in the body and functions of these organs. Symptoms such as headaches and gastrointestinal problems (heartburn, belching, cramps) lead the list, with general fatigue a close second. When stress becomes a problem, sleep isn't restful, and your general mental and physical

condition is less than it should be.

Nevertheless, no one can be free of stress, and that statement is especially pertinent for careerpilots. Additionally, pilots, like doctors, are goaloriented, which can compound the problems of stressful situations. It has been observed by senior aviators that "any pilot who does not privately consider himself to be the best in thebusiness is in the wrong business." This selfimposed high standard produces stress, but this stress can also hone the pilot's proficiency. If we add to those high expectations the fact that the career pilot is a very visible professional in that he or she is monitored from many perspectives, such as company flight standards, the FAA, peers, medical examiners and the press, the extra pressure of already being "on guard" only heightens any sensitivity to stress. Furthermore, job security, financial obligations, lifestyles, etc., all have become serious issues facing pilots since deregulation. Another pressure is the periodic medical examination, particularly when the pilot feels he or she has no control of his

FAA medical when he walks into the doctor's office. (The pilot does not have control, but many are not aware of the options available). And consider the tension that is "triggered" by the following: "on reserve," "grounded," "retirement," "commuting," "checkride." Are these subjects distressful to you? Are you feeling as well as you did before deregulation? Could you be under enough stress that you are "distressed"?

Let's assume that, like many of your colleagues, your life could be less distressful. What can you do about it? First, don't use the powerful tool of denial, which many people use to protect them from reality. All too often, pilots deny that they are vulnerable. In addition, they frequently have unrealistic expectations of themselves and those close to them. Therefore, the illusions created by a person's ego usually have to be dealt with before

the stress can be identified and controlled.

Another priority for any attempt to control stress is to realize and accept that your life is a little hectic and then admit that you, alone, are not omnipotent in dealing with all stressful situations. Once this conflict is resolved, you are ready to take the next step -- to take action -- in resolving the stressful situation(s). The following suggestions are some specific actions that you can take to keep your life in proper perspective and to cope with those stresses that interfere with a smooth lifestyle.

(1) Prioritize your time, activities and work obligations. One way to control the pace is to make a three-column list of (a) things you have to do, (b) things you want to do, and (c) things you neither have to nor want to do. Then, do not concern yourself with anything in column c.

(2) Talk out your worries with someone who can help sort out the priorities. For the best results, this person should be a professional but also someone you can

trust.

(3) Balance work and recreation. By prioritizing your time, you can find time to get away from the job.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-14 01 OCT 10 (4) Accept what you can't change, and give in once in a while.

(5) Get the facts about situations that concern you, and don't rely on hearsay from peers.

(6) Don't self-medicate. In addition, don't "drown your sorrows" with alcohol. This drug has the power to make things

appear better, but the unresolved stress goes merrily on.

Finally, after you have identified your priorities and have begun to take action, "let go." If you are doing all you can, then worrying about or being obsessed with the outcome isn't going to help. It has been said that "worry is imagination misplaced." Worse yet, worrying means that the effects of stress are still being felt.

Remember that few people are able to deal with stress by themselves. Seeking professional help whereby you can talk to competent counselors, therefore, may be necessary. Beware the myth that claims that a pilot's medical certification is in jeopardy when he begins to see such counselors. The FAA does not ground you for seeking help in such matters. In fact, you are not fit for flight if you are having difficulty coping, and furthermore, it is

your responsibility to seek whatever help is necessary to resolve your stress. Trying to get by on your own can only lead to your becoming a

"human factor."

The truth is that a counselor can be very effective in identifying your particular forms of stress as well as those stresses that are so deep in your mind that even you aren't aware of their existence. Tests, interviews and surveys all are valuable in assisting you and your counselor in finding hidden problems, which can then be dealt with.

Stress is a real phenomenon and something that everyone experiences in relatively equal amounts.

But how we cope with our stress is a major factor in living a healthful, productive and satisfying life. Horace, the ancient Roman poet, said, "Adversity (stress) has the effect of eliciting talents which in prosperous circumstances would have lain dormant." I encourage you to accept the fact that stress will be with you; coping with it and making a conscious effort to use stress in a positive way will help you achieve a successful and productive career.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-15 01 OCT 10 

### THE COPING RECIPE

Choose the stress-reduction technique that's right for you.

Stress is something most of us try to avoid, but some stress can actually be good for us. Without it we'd lack the energy and enthusiasm that pushes us to grow and

learn. The trick is estab lishing a healthy level of stress and maintaining that level.

While some stress is good, too much can be dangerous to your health -- even fatal. It's important to know how to cope with excess stress that can pile up and threaten your healthy stress level.

STRESS: A PHYSICAL REACTION

Stress is not pressure from the outside, as some people think. It's the physical reaction within your body that prepares you to meet pressu re from another source. The pressure that trigger s the stress response is a

stressor.

For example, a husband may be waiting for his wife who is late coming home from work. He may say to himself that she's probably late because she's working overtime or doing errands she couldn' t get done earlier. Those reactions are positive and will produce little or no stress.

However, if his reaction is worry or anger, he will undoubtedly be stressed. And if the wife walks in the door with a perfectly understandable reason for being late, the husband will st and there stirred up and prepared for the worst.

We all continually face many similar stressors. When these stressors threaten us, our bodies rush to protect us by turning on the chemic al juices and preparing to defend us. The fight reaction that results in stress.

THREE STAGES OF STRESS

Dr. Hans Selye, known as t he "father of stress" for his extensive work and research on the subject, has identified three stages of st ress. The first stage is alarm, in which the body gears up for a fight. The heart beats faster, blood pressure rises, digestion slows down, and adrenaline produc es a sudden burst of

energy.

The second stage is adaptation. This is the negotiation phase when the person works through the crisis. When this is done successfully, the body functions slow down,

relax and return to normal.

If relaxation doesn't occur after the alarm stage, the body remains physically geared up and moves into the third stage, exhaustion.

In this stage, if the body isn't given the chance to recover and rid itself of harmful by-products, an imbalance occurs. Over time, resistance is lowered, and illness is likely.

CHOOSING COPING TECHNIQUES

Because stress is an inevitabl e part of life, it makes sense to develop coping techniques that work. Everyone should have a variety of coping techniques. There are many -- from the practical to the creative and avant-garde.

Following are some basic, common-sense techniques:

Organize yourself. Take better control of the ways you're spending your time and energy.

Change your environment. Control what and who is surrounding you to get rid of stressors and gain support for yourself.

Build up your strength. If you're in good physical condition, you'll be better able to stand up against your

stressors.

Listen to your body. It will let you know when you're pushing too hard. When t hat stomach sours or headaches, slow down and enjoy life.

Find ways to laugh each day. Laughing is one of the purest and most total releases of tensions.

Develop a supportive network of caring people around you. Research indicates that if you do, you'll live longer and be healthier.

Learn to relax. Use relaxation techniques for 20 minutes each day. You'll be prepared for clearer thinking and decision-making.KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-16 01 OCT 10 THE LIFE-EVENT TEST

You can also explore the stress in your life by finding out how many changes you've faced recently. Below is a list of some events that commonly occur in life. Check the left-hand column if the event has happened to you during the past 12 months.

Life Event Points

_____Death of spouse 100
_____Divorce 73 _____Marital separation 65 _____Jail Term 63 _____Death of close family member 63 _____Personal injury or illness 53 _____Marriage 50 _____Fired at work 47 _____Marital reconciliation 45 _____Retirement 45 _____Change in family member's health 44 _____Pregnancy 40 _____Sex difficulties 39 _____Additions to family 39 _____Business readjustment 39 _____Change in financial status 38 _____Death of close friend 37 _____Change to different line of work 36 _____Change in number of marital arguments 35 _____Mortgage or loan for major purchase 31 _____Foreclosure of mortgage or loan 30 _____Change in work responsibilities 29 _____Son or daughter leaving home 29
_____Trouble with in-laws 29 _____Outstanding personal achievement 28 _____Spouse begins or stops work 26 _____Starting or finishing school 26 _____Change in living conditions 25 _____Revision of personal habits 24
_____Trouble with boss 23 _____Change in work hours, conditions 20 _____Change in residence 20 _____Change in schools 20 _____Change in recreational habits 19 _____Change in church activities 19 _____Change in social activities 18 _____Mortgage or loan for lesser purchase 17KC-10 Aircrew Training System Crew Resource Management Initial Training

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CRM-IT-12-SG 12-17 01 OCT 10 Life Event (continued) Points

_____Change in sleeping habits 16 _____Change in number of family gatherings 15 _____Change in eating habits 15
_____Vacation 13 _____Christmas season 12 _____Minor violations of the law 11

Total Score_______________

Now add up the point values of all the items checked. If your score is 300 or more, statistically you stand an almost 80% chance of getting sick in the near future. If your score is 150 to 299, the chances are about 50%. At less than 150, about 30%.

This scale seems to suggest that change in one's life requires an effort to adapt and then an effort to regain stability. Probably this process saps energy that the body would ordinarily use in maintaining itself; so reserves of energy are depleted, and susceptibility to illness increases.KC-10 Aircrew Training System Crew Resource Management Initial Training

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