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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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-1
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INTRODUCTION 

CRM PROGRAM GOALS AND DEFINITIONS ............................................................ 1-2 

LESSON OBJECTIVES ............................................................................................... 1-2 

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

HUMAN FACTOR CAUSES OF ACCIDENTS ............................................................. 1-4 

CRM CORE CONCEPTS ............................................................................................. 1-7 
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CRM PROGRAM GOALS AND DEFINITIONS 

The CRM program goals are: 

● Maximize operational effectiveness 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 effectively 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 lead to aircrew error. 

● Develop aircrew proficiency in CRM skills to anticipate conditions and/or 

threats and minimize their impact in order to safely and effectively meet 

mission requirements.

DEFINITION 

Cockpit/Crew Resource Management (CRM)—The effective use of all available 

resources--people, weapon systems, facilities, and equipment, and environment -- by 

individuals or crews to safely and efficiently accomplish an assigned mission or task. 

The term "CRM" will be used to refer to the training program, objectives, and key skills 

directed to this end. MAJCOMs may implement their programs as either "cockpit" or 

"crew" resource management based on their respective missions. 
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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 evaluate 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, this seminar will provide you with a framework, 

which will contribute to good aircrew coordination, enhance mission effectiveness, and 

decrease the likelihood of mishaps. 
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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 the human factor issues that are causing the 

majority of the accidents in aviation. 
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Most organizations, unfortunately, don't spend 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. 
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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 in 

aircraft. 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. 
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CRM CORE CONCEPTS 

Situational Awareness - Includes knowledge and skill objectives for identifying errors, 

preventing the loss of situational awareness, recognizing the loss of situational 

awareness, and techniques for recovering from the loss of situational awareness 

Crew / Flight Coordination - Knowledge and skills required within (internal) and outside 

the crew/flight members (external) for mission coordination, flight/mission integrity 

contracts, team-building, leadership, command authority, responsibility, behavior styles, 

assertiveness, persistence, conflict resolution, hazardous attitudes, legitimate 

avenues/methods of dissent, and solution driven statements.. 

Communication – Includes knowledge of common errors, cultural influences, and 

barriers (i.e., rank, age, experience, position, etc.). Skills will encompass listening, 

feedback, precision and efficiency of communication with all members and agencies 

(i.e., Crewmembers, Wingmen, Weather, 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-solving, evaluation of hazards, and control measures 

Task Management - Includes establishing priorities, overload, under-load, complacency, 

management of automation, available resources, checklist 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. Debrief instruction will include aircrew 

responses and outcomes to threats and errors. 
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SITUATIONAL AWARENESS

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

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

SITUATIONAL AWARENESS MODEL ........................................................................ 2-3 

MAINTAINING GOOD SITUATIONAL AWARENESS .................................................. 2-3 

CAUSES OF LOSS OF SITUATIONAL AWARENESS ................................................ 2-5 

CAUSE/SYMPTOMS OF SITUATIONAL AWARENESS LOSS ................................... 2-6 

REGAINING SITUATIONAL AWARENESS ................................................................ 2-7 
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SITUATIONAL AWARENESS

OBJECTIVES 

● Define Situational Awareness. 

● Describe the causes and symptoms of situational awareness loss. 

● Identify elements of good situational 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 task 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 contributing crewmember, and 

significantly reduce the probability of a crew-error mishap. 

Definition 

Situational awareness is defined as: 

● The accurate perception of the factors and conditions affecting the aircraft 

and the flight crew during a specific period 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 might 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 individual crewmembers. Thus, the level of 

situational awareness of the pilot in command is most important. It is up 

to the crew to provide feedback during all aspects of the flight situation. 
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Situational Awareness Model

● Each person reacts to a situation in a predictable manner, if you measure 

the ability; pre-conceived beliefs; objectives; experience and training. 

● These traits, the environment, along 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 initial 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 understands 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 sensors be sharp. To detect and 

process information effectively, you must stay in top physical 

shape. 

Crew Coordination 

The aircrew must be constantly monitoring 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 obligation to speak out if the operation 

can be improved or when a possible error has been detected. 
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Analysis 

This refers to the continuous evaluation of all aspects of the present 

situation as compared to the flight 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 cannot at the same time scan the 

environment for SA clues. 

Spatial Orientation 

You must know where you are at all times. You must also be able 

to detect even subtle changes in aircraft 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 meaning or required 

action. 

Remember the acronym ASK (Attitude, Skill, Knowledge). Use it to maintain aggressive 

skepticism. Demonstrate the willingness and ability to communicate any uneasy 

feeling. Ensure the Assertiveness of all crewmembers. 

Preventing/Minimizing Loss of SA 

Periodically using statements 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 prescription or over the counter 

drugs? 

Stress? Am I under excessive psychological pressures? 

Worried about financial matters, health problems, or 

family discord? 
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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 all crewmembers situationally aware of 

the status of the flight. 

Ensure an attitude of Teamwork pervades the 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 experience). When previous learning is 

threatened or challenged, one feels compelled to defend it. This is why an erroneous 

idea of a situation will be stubbornly adhered to even if compelling evidence is received 

that it is invalid, ineffective, or downright dangerous. To abandon a faulty theory 

requires time, effort, and courage. An individual or group under stress, 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 outside of previously learned areas, performance is 

significantly slowed, leading to task overload. 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 attention (tunnel vision). 

The Danger Zones 

The vast majority of aircraft mishaps occur 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 critical phases of flight: 
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● Takeoff & Final Approach 

● Air Refueling Operations 

● Fun Flights 

● Emergency Situations 

Ensure that SA is peaked to maximum prior 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 SITUATIONAL AWARENESS LOSS 

● Fixation 

● Ambiguity 

● Two independent sources disagree and remain unresolved. 

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

● Euphoria — feeling like everything 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 coming 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 limits, departure from SCOP, violating 

minimums, etc. 

● Unresolved discrepancies — forgotten about or ignored. 

● No one flying the aircraft — everyone involved with other tasks. 
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REGAINING SITUATIONAL AWARENESS

Often one or more crewmembers are vaguely aware that something is wrong but can't 

put their finger on what it is. It might just 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. 
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CREW / FLIGHT COORDINATION 

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

INTRODUCTION .......................................................................................................... 3-2 

FLIGHT CREW CHARACTERISTICS .......................................................................... 3-2 

AUTHORITY POWER BASES ..................................................................................... 3-4 

LEADERSHIP STYLES ................................................................................................ 3-5 

CREWMEMBER ASSERTIVENESS ............................................................................ 3-6 

CONFLICT RESOLUTION ........................................................................................... 3-7 

HAZARDOUS ATTITUDES .......................................................................................... 3-8 

BEHAVIOR STYLES .................................................................................................... 3-9 

RECOGNIZABLE, STANDARD ASSERTIVE STATEMENT ...................................... 3-13 

OUR GOAL ................................................................................................................ 3-15 
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CREW /FLIGHT COORDINATION

OBJECTIVES 

● Examine Command Authority 

● Identify leadership and responsibility 

● Describe assertiveness and conflict resolution techniques 

● Review hazardous attitudes and behavioral styles 

● Discuss legitimate avenues of expressing concern and team-building 

INTRODUCTION

This section covers command authority, leadership/responsibility, assertiveness, conflict 

resolution, hazardous attitudes, behavior styles, legitimate avenues of dissent, and 

team-building. 

FLIGHT CREW CHARACTERISTICS

Flight crew members are typically self-motivated, successful over-achievers. We are 

"controllers" doing a difficult task and doing it very well. A significant majority of flight 

crewmembers possess certain learned traits, some actually help ensure a successful 

mission and some are traps waiting to catch the unwary. 
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Pilot in Command Authority/Traits 

● Legal Authority 

Definition - Legal power to direct the actions of others 

Source - AF Instructions, UCMJ, FARs, 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 skills 
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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 authority solely on their referent or connection 

power. 

Legitimate Power

Legitimate power is based on the position held by the leader. Normally, the 

higher the position, the higher the legitimate power tends to be. A leader high in 

legitimate power induces compliance or influences others because they feel that 

this person has the right, by virtue of position in the organization, to expect that 

his suggestions will be followed. 

Expert Power

Expert power is based on the leader's possession of expertise, skill, and 

knowledge. These leaders are seen as possessing the expertise 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, information that is 

perceived as valuable to others. This power base influences others because 

they need this information or want to be "in on things." 

Referent Power

A leader high in referent power is generally liked and admired by others because 

of her personality traits. This liking for, admiration for, and identification with the 

leader allows her to influence others. 

Coercive Power

Coercive power is based on fear. A leader high in coercive power is seen as 

inducing compliance because failure to comply will lead to punishment, such as 

undesirable work assignments, reprimands, or dismissal. 

Reward Power

Reward power is based on the leader's ability 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 "connections" 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. 
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LEADERSHIP STYLES

A person in a leadership role has to balance the personal needs of his crew against 

what is required to accomplish the assigned 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 into 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 requirements of the task. Extremes along 

either axis are seldom effective in the long run. 

A 1/9 places emphasis on ensuring crewmembers 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 completed, 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. 
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A 5/5 adjusts to the tempo that others have come to adopt. He will not push for more 

even though the results obtained are less than what might have been accomplished by 

a different approach. When conflict 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 retaining 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 the 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 study, people rate some behavior assertive 

for men and aggressive for women. 
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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 commitment 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 important 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. 
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Hazardous Attitudes 

There are six hazardous attitudes that can impede our good judgment and decisionmaking abilities and often lead to Sudden Loss of Judgment. These attitudes may be 

an inherent part of our personality, or may be a short-term factor due to a particular 

situation. MEMORIZE THE ANTIDOTE for each hazardous attitude, 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 helpless, I can make a difference" 

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

DISC is a model of human behavior that helps people understand “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 tends 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 their own personal accomplishment 

or advancement 

• Likes varied and new activities 

3. Personal Development Opportunities: 

• Learning to pace yourself better and knowing when and how 

to relax 

• Awareness of the type and immediacy 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 included 
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• 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, casual relationships and working 

conditions 

3. Personal Development Opportunities: 

• Prefers more favorable, casual relationships and working 

conditions 

• Prefers more favorable, casual relationships and working 

conditions 

• Learning to develop more organized, systematic approaches 

to doing things – including following through with consistency 

in using these methods 

• Awareness about others in ways that involve more realistic 

expectations and objective views of others 

• Understanding how and 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 listener 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 from working together with others 

on projects, by being part of a collective effort to achieve 

specific results” 
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• Prefers known procedures and the stability gained from a 

defined, proven way of doing things 

• Likes sincere appreciation from 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 the reality of unexpected and 

ongoing change 

• Awareness about when to appropriately 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 variety 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 conditions around them, including 

clues about important expectations or standards 

• Often demonstrates caution, curiosity 

• May become critical of the 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 standards 
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3. Personal Development Opportunities: 

• Learning to develop a greater tolerance for conflict and 

human imperfection, including realistic approaches to 

productively preventing and minimizing both 

• Awareness of the importance of more directly 

communicating and discussing your 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 sense of true self-esteem the 

importance of who you are as a worthwhile person in your 

own right, rather than only for what you do 
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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 concerns 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 briefed 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 break 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 actions and requesting clarification as 

required. 

Advocacy - Stating what you believe to be the proper course of action under the 

circumstances. 

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

course of action until convinced otherwise by additional information. 
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"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 crewmembers to gain everyone's attention 

concerning uncomfortable situations. 

It is not a buzzword and its use must not be abused. 

Must be endorsed at all levels of command and reinforced during the course 

of everyday flight operations. 

Provides all crewmembers with a means to speak up when they 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 mind, as soon as possible after a crewmember 

voices the term "Time Out", the aircrew 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 other crewmembers with the opportunity 

to voice inputs relative to the stated concerns, the aircraft's position, potential 

hazards, and/or the upcoming maneuver or situation. 

After considering all inputs, the aircraft commander will direct the aircrew to 

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

THE AIRCRAFT COMMANDER STILL RETAINS THE FINAL DECISION 

AUTHORITY.

Assertiveness with Respect

The crewmembers should respect and support the authority of the pilot in 

command while clearly asserting their suggestions or communicating any 

problems they are aware of. 
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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 participation can flourish, making it 

clear that she expects to hear about any ideas, suggestions, or problems anyone 

on the crew might have. 
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COMMUNICATION 

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

INTRODUCTION .......................................................................................................... 4-2 

THE PROBLEM ........................................................................................................... 4-3 

TYPES OF COMMUNICATIONS ................................................................................. 4-4 

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

COMMUNICATION RESPONSIBILITIES .................................................................... 4-8 

EFFECTIVE COMMUNICATION ................................................................................ 4-9 
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AIRCREW COMMUNICATIONS

OBJECTIVES

● Recognize impact of effective 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 communication 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 mishap 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 sought after and can be very 

powerful and influential. History 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 delegate tasks without ambiguity 

while remaining alert to the workloads of other 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! 
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THE PROBLEM

Think back over some recent flights and chances are that you will find that many of your 

tensions, anxieties, and frustrations arose from situations in which 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 copied it correctly and had to 

go back to the original controller 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 assigned task only to learn that you 

had misunderstood the instructions 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, most people feel that they are pretty good 

communicators; it's just that everyone else seems to do a lousy job listening. 

When the communication process breaks down between people, it may result in 

interpersonal problems; when it breaks down in the aircraft, it may be fatal. 
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TYPES OF COMMUNICATIONS

Communication can generally be broken into three 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 the desired action. 

Effective Communication

Communication is effective only if the sender achieves the intended purpose; i.e., 

the receiver not only understands, but responds as desired. This may seem to 

be relatively simple but in actual practice communicating effectively can be very 

difficult. There are two reasons for this. 

The ability to convey appropriately our thoughts and feelings and in turn to 

receive and properly interpret the thoughts 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 effective communications will not exist. 
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COMMUNICATION PROCESS

It is worthwhile to examine the process by which we communicate. A good 

understanding of this process allows us to communicate more effectively, and to more 

readily isolate the cause when communication problems occur. 

The process of communication is commonly defined as "a person (sender) transmitting 

information (a message) to another person (receiver)." To determine if it is accurate, a 

feedback loop must be added. It is even more difficult to determine if the 

communication has been effective in achieving the desired result. 

At each stage the communication process can breakdown. Thus each one-way 

communication has a total of six possibilities for error followed by the same six pitfalls 

during the return communication or feedback. It really is amazing, considering the 

possibilities for errors that we manage to communicate at all! We will now examine 

some of these points of vulnerability and see what we can do to ensure the message 

gets through. 
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Verbal/Non-Verbal Cues 

It is surprising to most people how others 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 message may be lost due to loss of this last cue. Thus 

the tone of voice often transmits 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 filters 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 and frustration often result. If either 

person is prejudiced or biased the chance for effective communication is nil. 

Barriers

A barrier is anything that distorts, confuses, or interferes with the communication 

process. Common barriers to communication 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 terms 
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Guidelines for Providing Feedback

Feedback is the only way the sender can find out if his message was accurately 

received, and even this does not ensure the listener completely or correctly understands 

it. The following guidelines will help ensure effective use of feedback: 

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

● Focus on ideas and information rather than on giving advice. 

● Explore alternatives instead of offering answers or solutions. 

● Focus on what was said 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 making decisions based on information or 

reasons that is not communicated to the rest of the crew. It is typically done to 

prevent objections and confrontations with other members of the crew, perhaps 

following a decision to deviate from policy 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. 
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COMMUNICATION RESPONSIBILITIES 

Up to this point we have looked at the process of communication and have stressed the 

importance of "effective communication." 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 that 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 sender needs to listen also. 

Encourage Feedback 

Receiver's Responsibilities

Practice Active Listening, which 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 premature judgement. 

— Ask questions. 

Responding 

— Give feedback/confirmation of what you heard. 

— Avoid argument and criticism. 
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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 crews communicated less, but had a greater 

incidence of response uncertainty, frustration or anger, and embarrassment; along with 

a lower incidence of agreements. On the other hand, when more information was 

transferred about various aspects of the flight, fewer errors appeared. Crews who 

planned more and openly discussed 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 errors were less apparent. 

Commands are associated with a lower incidence of flying errors and seem to 

assure the proper delegation of cockpit duties. 

Acknowledgments validate that a certain piece of information has in fact been 

transferred and also serve as reinforcement 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 effective flight crew are frequent, 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 communicate all ideas and 

actions, no matter how insignificant they may seem.
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RISK MANAGEMENT (RM)/DECISION MAKING 

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

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

RISK DETECTION AND EVALUATION ...................................................................... 5-4 

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

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

POOR JUDGMENT CHAIN .......................................................................................... 5-9 
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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 management and the different decision making 

styles and the situations they are best matched with. We will then provide a model for 

structured decision making which helps the pilot in command and crew fight some of the 

common tendencies we all exhibit, especially in high stress situations. 
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Risk Management is an assessment of the likelihood for an acceptable outcome 

to a given decision or judgment. Judgment and decision making must involve 

risk assessment. Risk management should be ongoing; 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 judgments and decisions. 
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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. They may also be so 

focused on one problem that they miss or ignore 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 risk 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" considering its impact on this particular flight at this 

particular time. The more fingers not extended, the more you should consider not 

going, or removing one or more risk elements; e.g., wait for better weather or decide on 

a different route of flight. 
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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 that 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 important role in Aircrew Coordination 

Training. 

Decision Making is the act of rendering a solution 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 predominant style they tend to use more than the other. 

Neither style is better than the other, but it is critical that the proper style is matched to 

the situation. For this reason, the pilot in command should be aware of his own and his 

crewmembers' styles and should ensure in any situation that the appropriate style is 

being used, particularly in relation to the time available. 

Analytical

Analytical thinking is most useful for dealing with structured problems that can be 

systematically approached. It is thorough 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 unstructured problems. It is quick, making 

quantum leaps of insight vs. detailed analysis. This allows for unstructured 

trouble-shooting and creative problem resolution. But this intuitive process runs 

the risk of ignoring previous decisions and may fail to consider all the facts. 
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Choicing

Choicing styles are normally associated with results-oriented personalities who 

are practical, tend to choose quickly, summarize 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. However, when time is available these people 

will tend to decide quickly without 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 explore alternatives and look for long term 

effects. They must be given time, and tend to slowly shrink available options. 

This can be illustrated by an upside down funnel. The expanding style is 

appropriate and valuable during situations when there is sufficient time to 

consider alternatives. However, when time is short these people 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 consider other ideas they have come up 

with. 
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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 resources 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 environment 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 symbolized in a model. This model is 

called the synergy formula, or QPIDR Model. If decision-making is based on this 

model, a synergistic effect will be achieved 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 searching for information, data, and 

ideas. While the task is not solely the responsibility of the pilot in command, it is 

a task that tends to fall primarily on his shoulders. However, each crewmember 

shares the responsibility for making sure that each step of the 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 research 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 requires that we question, "What is going 

on?" and "What are other crew members doing?" Encourage open discussion, 

avoid preoccupation with minor details (tunnel vision) and remember to use all 

available resources. Above all, make sure someone is responsible for flying the 

aircraft during this process! 
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PI - Promote Ideas 

Some of the ideas or plans presented by various members of the crew during the 

questioning process may be in conflict. Open discussion of such conflict not only 

leads to a synergistic decision, 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 while remaining flexible and open to the 

ideas of others. All information 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 Pilot In Command. In virtually all circumstances, it is 

the duty of the crew to preserve the authority of command. A flight crew is not a 

democratic organization, nor should it be. It is a survivable entity only so long as 

all decision-making is funneled through the pilot in command. 

On the other hand, if the pilot in command does not communicate the plan or if 

the crew is not committed to it, the implementation could be ineffective. 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. 
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POOR JUDGMENT CHAIN (Error Chain)

Accidents don't just happen; they generally involve 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 crewmember has about the situational variables 

(aircraft, environment, operations, 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 information, which may then negatively influence 

judgments that follow. As the poor judgment chain grows, the crew's situational 

awareness becomes impaired and the alternatives for safe flight decrease. 

For example, an inaccurate assessment of deteriorating weather increases the 

likelihood that the false information will negatively influence other decisions that 

follow. 

If a pilot elects to fly into hazardous weather, the alternative to circumnavigate 

the weather is automatically lost. 

Break The Chain 

There are four steps we can use to break the poor judgment 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 the 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 acknowledge, use the Assertive Statement, 

"TIME OUT." 
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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, identify all hazardous situations resulting from the poor 

judgment, and take corrective actions. 

REVIEW ORIGINAL POOR JUDGMENT 

After a poor judgment chain has been broken, review each poor judgment as 

soon as possible after landing. Critically examine what they were and how you 

came to make them. This review provides feedback you need to avoid initiating 

a similar poor judgment chain in the future. Acknowledging honestly as a crew 

that a certain decision was stupid will also make it easier to be assertive about 

errors or poor judgment on future flights. 
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TASK MANAGEMENT

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

INTRODUCTION .......................................................................................................... 6-2 

HIGH WORKLOAD ...................................................................................................... 6-3 

LOW WORKLOAD ....................................................................................................... 6-6 

DISTRACTIONS .......................................................................................................... 6-7 

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

INTERNAL RESOURCES .......................................................................................... 6-13 

EXTERNAL RESOURCES ......................................................................................... 6-14 
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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 performance problems can be caused by too 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 these resources and discuss how to incorporate 

them into the aircrew coordination cycle. 

Workload varies according to the phase of a mission, from the routine of an airways flight 

to the high workload of a low visibility final approach. Either extreme can be dangerous. 

Our primary concern is the detection of and response to changes in workload 

performance. Workload becomes subjective very quickly. The challenge-response 

operating environment is complex and makes it impossible 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 measurable - the crew of an aircraft deals in 

a three-dimensional dynamic environment with ever changing challenges: 

● When should a task be accomplished? 

● Who should do the task? 

● How much attention does the task deserve? 
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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 involved in low level operations have a much 

greater percentage of mishaps during the low level portion of the flight, but still typically 

have a higher percentage of mishaps during the takeoff, approach, and landing phases of 

flight than would be expected based on the time spent 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 faster. 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-preventable error is increased! Planning becomes 

condensed and decisions are made on possibly incomplete information. We also tend to 

revert to previous habit patterns (strongly reinforced learned behavior). This may or may 

not be helpful. 

Classifications of Workload

Critical

A critical workload item is one that requires the immediate attention of the crew. If 

left unattended, it could have catastrophic results. 

Important

An important workload item is one that requires a response of action as soon as 

possible. If left unattended it could become a critical workload item. 

Routine

A routine workload item is one that is encountered in the course of the flight and is 

handled as part of normal crew responsibility. If left unattended it could become an 

important workload item. 
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Stress Versus Time

Accident Zone Model
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Protecting Against High Workload

Strength in the Critical Success Factors and Elements 

● Intimate knowledge of the business 

● Professional attitude 

● Skills to manipulate aircraft 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 increases, so does the likelihood of 

error. For this reason, two people should be monitoring critical flight 

parameters during high workload situations, if possible. 

The monitoring responsibility must be clearly stated, with specific limits and 

guidelines. The monitoring crewmember should make call-outs specified by these 

limits, along with normal call-outs required by the SCOP. 
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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 practical to maintain peak alertness by everyone all the 

time, but it may be necessary to regain a minimum 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, checking 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 are performed better under higher levels of 

workload, while complex tasks are performed better 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. 
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DISTRACTIONS

The distractions we experience come from two sources. Distractions having to do with 

the mission are referred to as operational while those from outside the mission are 

referred to as non-operational distractions. 

One Step at a Time: At any particular moment, humans are able to attend to only 

a limited range of sensory data. It is possible to concentrate on one sensory 

pattern and then on another, but not both simultaneously. If it appears that we are 

doing two things at once, we are really switching rapidly between them. 

Length of Attention: Remaining 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 more relevant cues that are available. 

Large Number of Stimuli: When a large number of stimuli are presented and a 

large number of responses are required, 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 ability 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 critical points in the mission. 

Delay: Some distractions can wait. Evaluate their importance in conjunction 

with other priorities and act accordingly. 

Delegate: When distractions interfere with the completion of your task 

consider delegating the work to other crewmembers. 

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

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

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

hazard avoidance. 
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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 centered 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 issue. This rule says that there will be no 

non-operational conversation during certain 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 understanding your aircraft. As an aid and 

reminder of procedure, it's great, but don't get 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 experiences 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 the sequence. Use your finger to keep track 

of the break and go back several steps to make sure something isn't inadvertently 

left out. You might even want to verbalize, "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 whenever there is a break/interruption in 

the sequence. Use the challenge-VERIFY-response technique and never give the 

response until you have confirmed it physically or visually. 
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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 signals" in the organs of the body. 

These may include headaches, heartburn, cramps, and/or fatigue. When stress 

becomes a problem, sleep is no longer restful and our general mental and physical 

condition is less than it should be. We have come to expect high performance 

from our fellow aircrew members and particularly 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 vulnerable to stress, we can look at some 

suggestions for coping. Remember this quote from Horace: "Adversity has the 

effect of eliciting talents which in prosperous circumstances would have lain 

dormant." Thus learning to cope with stress and making a conscious effort to use 

stress in a positive way can help you achieve a successful and productive aviation 

career. 

In today's society we have primarily psychological rather than physical stressors. 

But we haven't had time to change our reaction pattern from that of our ancestors. 

We instinctively respond to stressful situations 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 alert 
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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 crewmembers with the following stressors 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 Aviator." 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 with 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 — Dangerously 
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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 frustration, implement 

appropriate stress reduction techniques such as: 

● 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 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. 
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Available Resources

DEFINITION 

Available resources are the people, equipment, 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 cooperative action of separate agencies, which 

together have greater total effect than the sum of their individual 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 solving effort. But, when a 

challenge of some sort arises, all too often 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 Lindy, 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 experience with 

other available sources, will affect a more complete solution to any flight challenge. As 

always it is the pilot in command's responsibility to set the tone to insure that this synergy 

will take place in his or her aircraft. 
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INTERNAL RESOURCES 

● Pilot ● Boom Operator 

● Copilot ● Crew Chief 

● Flight Engineer ● Equipment Knowledge 

Crew

If monitoring the flight operation is one of our primary jobs, it is obvious that to do 

that job properly, guidelines must describe precisely how it is to be accomplished. 

Clearly identifiable, observable, and verifiable limits must be in place. Each 

crewmember must have a complete picture of the flight concept in order to 

contribute effectively to the safety and efficiency 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 accept the responsibility for 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 knowledge 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? 
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EXTERNAL RESOURCES 

Outside resources are a part of your flight concept - and good communications are 

essential to put them to use. 

Other Aircraft/Crew 

Other aircraft and crews can be of valuable 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 maintenance personnel are a valuable information source for 

technical data. They can be useful in helping 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 when 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. 
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In summary, be sure you know exactly what is available to you, 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 flier can then concentrate on the 

business of "just flying the aircraft, and not having to worry about the correct decision to 

make." As fliers, you must remember that 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 ultimate decision making authority with you in 

the cockpit. Other agencies can and do provide very valuable and timely information, but 

you must meld it into your scheme to arrive at your best judgment. 
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MISSION ANALYSIS 

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

INTRODUCTION .......................................................................................................... 7-2 

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

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

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

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

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

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

IN-FLIGHT PLANNING ................................................................................................ 7-5 

DEBRIEF ...................................................................................................................... 7-6 
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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 anticipated 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 concept, which is shared by 

everyone on the crew. The flight concept should include all elements and factors 

of the flight, including the responsibilities 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 themselves in not thoroughly planning the 

mission, and then reacting quickly and instinctively to the many unanticipated 

situations that occur during the flight. While it may seem impressive to be able to 

react over and over at a moment's notice to everything that occurs, 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. They are riding the cutting edge of their 

skills with no margin to allow for fatigue, error, or multiple problems. 

Long-term Planning

As opposed to the crew mentioned above, a crew, which starts the mission with 

thorough preflight planning, is using superior knowledge to avoid having to use 

their superior skill. In attempting to anticipate everything that might occur on that 

flight, they are reducing uncertainty and allowing themselves a margin of 
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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 unscathed due to challenges encountered during 

the mission. Once the original plan begins to break down, we must face new 

challenges and all the stress that goes with them. It is important 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 good 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 response items and will allow the necessary 

emphasis to be placed on the critical points 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! 
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MONITOR

Monitoring is the responsibility of all crewmembers. 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 other times we may feel that something 

is just not right. We call this feeling a "pinch." Often the first step toward solving 

the problem is to verbally state that "something 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 verifies it with other crewmembers. If others 

don't see the challenge or don't agree with its identification, the pilot in command 

either amends or abandons his initial identification. 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 process. The more anticipated a challenge has 

been, the more expanded our time concept becomes. 
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RESPONSE

Time Limited

When no time is available to get crew input, the pilot in command must respond 

immediately, drawing upon his training and experience to select the best course 

of action. When the initial or immediate 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. Under his direction, the flight crew 

examines every aspect of the challenge, every option available in response to 

the challenge, and then select the best option. As you recall from the previous 

discussion, QPIDR consists of inquiry or asking questions, promoting ideas and 

resolving conflict, deciding, and then reviewing the decision. 

BRIEF

Once the response is decided upon, the pilot in command must brief the plan. It is 

especially critical to brief each individual on his revised procedures, assignments and 

limits. The pilot in command should solicit 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 point of departure, an unscheduled landing, a 

change of destination, or an immediate diversion to a planned alternate. 

If the challenge causing flight concept revision involves any degradation in 

airplane system performance, the revision must include planning 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 concept, including any contingency planning. 
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After the challenge has been dealt with, all crewmembers return to monitoring to 

detect any new challenges to the revised flight 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 "aggressive 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 following 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 decision making, task management, and 

finally mission planning, we increase our chances of not only improving our 

performance, but also our ability 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 external 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 techniques used to manage threats include: 

1. Reading weather advisories 

2. Turning weather radar on early 

3. Thorough preflight 

4. Correct use of procedures to diagnose unexpected aircraft malfunctions 

5. Briefing an alternate runway in case of a late runway change 

6. Briefing the crew as to acceptable times and reasons for interruptions 

7. Considering adding extra fuel when destination airport is in question due 

to poor weather 
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COURSE REVIEW

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

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

BIBLIOGRAPHY ......................................................................................................... 8-5 
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COURSE REVIEW

OBJECTIVES

● Recall the core concepts of CRM 

● Utilize these concepts to analyze a case study 
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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 and 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 reveals 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 attitude" and fly an aircraft or operate a 

system that is not OK? 

● selectively disregard standard operating 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 protection in noise hazard areas? 

Sadly, the majority of our safety requirements 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. 
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● The first step during any abnormal situation 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 crewmembers if appropriate. 

● Positive delegation of monitoring responsibilities with specified 

identifiable limits must accomplished. 

● Conflicting information or situations - use the conservative 

response rule, then resolve any ambiguities. 

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

decision. 
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BIBLIOGRAPHY 

Adler, Mortimer J. How to Speak, How to Listen. New York: Macmillan 

Publishing Company, 1983. 

Alkov, Robert A. Pilot Error and Stress Management: U.S. Navy Experience. 

IALPA/Aer Lingus Flight Operations Symposium, 1983. 

Alkov, Robert A. Lifeline. Norfolk, 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 Evaluation (DOT/FAA/CT-82/56). Daytona 

Beach, FL: Embry-Riddle Aeronautical University (NTIS No. AD-117 508), 1982. 

Blake, Robert R., et al. Executive Achievement: Making It At The Top. New York: 

McGraw-Hill Book Company, 1986. 

Blake, Robert R., and Jane S. Mouton. Cockpit Resource Management. Text & 

Seminar Study Materials Manual. 1982. 

Blake, Robert R., and Jane S. Mouton. The New Managerial Grid. Houston, Texas: 

Gulf Publishing Company, 1978. 

Blake, Robert R., Jane S. Mouton, and United 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 Pilot's Role in Simulator 

Training (Technical Report NAVTRAEQUIPCEN 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 Training 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: Macmillan Publishing Company, 1986. 
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Cooper, C. L. Stress of Work: An Overview. Aviation Space Environment Magazine. 

56:627-32. 1985. 

deMare, George, et al. Listening: It Can 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 Owners and Pilots Association. Summary 

Proceedings Of An International Industry Government Pilot Decision Making Workshop. 

Maryland: 1985. 

Foushee, H. Clayton, "The Role of Communications, Soci-Psychological, and 

Personality Factors in the Maintenance of Crew Coordination." Aviation, Space, and 

Environmental Medicine, Nov. 1982, p. 1064. 

Geier, John The Personal Development Profile. Carlson Learning Company Mpls, MN. 

Copyright 1991 

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

Hamilton, Cheryl, and C. Parker. Communicating For Results: A Guide For Business 

And The Professions. Second Edition. California: Wadsworth Publishing Company, 

1982. 

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

Heller, William. Airline Safety - A View From The Cockpit. California:Rulorca Press, 

1986. 

Hurst, Ronald and Leslie. Pilot Error: The Human Factors. Second Edition. 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. 
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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. Columbus, 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 Stress. New York: Routledge and Kegan Paul, 

1986. 

Springer, Sally P., et al. Left Brain, Right Brain. 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. Investigation And Root Causes Of Helicopter 

Accidents (Report DOT/FAA/PM 86/28). Systems 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. 
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TOOLKIT

AIRCREW COORDINATION CYCLE (ACC) ................................................................ 9-2 

AESOP Model (RISK MANAGEMENT) ........................................................................ 9-3 

CRITICAL SUCCESS FACTORS (CSF’s) ................................................................... 9-4 

MOST CONSERVATIVE RESPONSE RULE .............................................................. 9-5 

CRITICAL SUCCESS ELEMENTS (CSE’s) ................................................................. 9-6 

I’M SAFE CHECKLIST ................................................................................................. 9-7 

STANDARD COCKPIT OPERATING PROCEDURE (SCOP) ..................................... 9-8 

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

TIMEOUT .................................................................................................................. 9-10 

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

THREAT AND ERROR MANAGEMENT (TEM) ........................................................ 9-14 

CRM SKILLS CRITERIA TRAINING/EVALUATION FORM ...................................... 9-16 
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Aircrew Coordination Cycle (ACC) 

The Aircrew Coordination Cycle (ACC) is a useful tool that can be applied throughout 

the flight. It is a systematically organized, 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

PLANNING
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AESOP Model (Risk Management) 

It's critical that aircrews identify all risks prior to and during the flight. Often risks are not 

fully appreciated for their potential to affect factors, 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 sum of the risk elements" 

• Operation — Purpose, criticality and duration, backup units, frequency of 

takeoffs and landings, and duty cycle 

• Personnel — Procedures, training, experience, complacency, physical 

stress, health, fatigue, psychological stress and workload 

After the risk or challenge is detected, its impact is qualitatively 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 existing situation. It is important 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. While 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-03
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CRITICAL SUCCESS FACTORS (CSF's) 

Intimate Knowledge

Successful flight crews have intimate knowledge of their business, including 

systems, procedures, limitations, 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 the 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. 
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Most Conservative Response Rule 

Occasionally there is a disagreement in the cockpit, which cannot be resolved due to 

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

in these situations until additional information is available. 
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CRITICAL SUCCESS ELEMENTS (CSE's)

Since the Critical Success Factors are too general to work with, we have further divided 

them into elements, which give a structure to the concept of Crew Resource 

Management and allow us to individually discuss smaller parts of the whole. 
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“I’M SAFE Checklist” 

Our situational awareness resources vary from day to day. Unfortunately, we don't have 

any external readouts telling others or ourselves when they are diminished. Therefore, it 

is important that we preflight ourselves daily. "I'M SAFE" is a simple checklist to 

determine if we are ready and fit to fly. 

● Illness 

● Medication 

● Stress 

● Alcohol 

● Fatigue 

● Eating 
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Standard Cockpit Operating Procedure (SCOP) 

A Standard Cockpit Operating Procedure (SCOP) provides a predictable environment 

for developing and reinforcing aircrew coordination 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. 
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Two-Challenge Rule 

The key to early response to incapacitation lies in the ability to establish a norm against 

which the results of incapacitation can be measured. The two-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 established parameters. 
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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 concerns 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 briefed 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 break 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 actions and requesting clarification as 

required. 

Advocacy - Stating what you believe to be the proper course of action under the 

circumstances. 

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

course of action until convinced otherwise by additional information. 
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"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 crewmembers to gain everyone's attention 

concerning uncomfortable situations. 

It is not a buzzword and its use must not be abused. 

Must be endorsed at all levels of command and reinforced during the course of 

everyday flight operations. 

Provides all crewmembers with a means to speak up when they 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 mind, as soon as possible after a crewmember 

voices the term "Time Out", the aircrew 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 other crewmembers with the opportunity 

to voice inputs relative to the stated concerns, the aircraft's position, potential 

hazards, and/or the upcoming maneuver or situation. 

After considering all inputs, the aircraft commander will direct the aircrew to 

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

THE AIRCRAFT COMMANDER STILL RETAINS THE FINAL DECISION 

AUTHORITY.
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SYNDROMES 

Excessive Professional Courtesy 

In general, we are hesitant to call attention 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 individual 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 the 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 the major differences between the aircraft and 

the need for a more extensive 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 problems they see, even 

though they may have much more experience on that type of aircraft. Sometimes the 

individual involved is aware of this effect 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 comforting 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 crew 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 which 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 perceived pressure to perform or 

by workload/stress related issues. 
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Hazardous Attitudes 

There are six hazardous attitudes that can impede our good judgment and decisionmaking abilities and often lead to Sudden Loss of Judgment. These attitudes may be 

an inherent part of our personality, or may be a short-term factor due to a particular 

situation. MEMORIZE THE ANTIDOTE for each hazardous attitude, 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 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 defined as an unconscious attempt to make available 

evidence fit a preconceived situation. It has been observed that once 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 conflicting 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 attitude which might allow a serious 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 attention to focus or become 

channelized on only one area. 

Hidden Agenda 

Sometimes a crewmember may be making suggestions 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 for 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 where 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 other crewmembers. 
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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 preventing, managing, and/or 

correcting aircrew induced errors before they lead to a mishap. This is accomplished in 

part by using data-based, proactive 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 effort to combat the mishap spike following 

Desert Storm, the ANG introduced their first ever CRM training curriculum, and AMC 

completely revised their existing 1985 era program. AMC is now taking the lead by 

preemptively introducing Threat and Error Management to our aircrews prior to suffering 

the inevitable increase in mishaps as personnel return from 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 perform their daily missions. 

Military Flight Operations Quality Assurance (MFOQA) – A flight data gathering system 

designed to capture and analyze the data generated and stored by the aircraft 

throughout the progress of the mission. Applying the information learned from this 

analysis is a proven method of identifying latent trends and thereby ascertaining ways to 

improve flight safety and increase overall operational efficiency. 

Threat and Error Management – A critical component of Human Factors/CRM Training 

designed to assist in identifying threats to mission accomplishment and effectively 

manage human error. It provides a framework to analyze data and assess errors, along 

with what factors contribute to making mistakes and how aircrews manage unpredicted 

situations. TEM helps organizations by integrating 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 attention and management if safety 

margins are to be maintained. Threats can include weather, maintenance or ground 

crew error, unfamiliar airports, automation events, unexpected missed approaches, 

systems malfunction, high terrain, ATC, high traffic density, etc. Threats can also come 

from within the crew, such as fatigue, complacent attitudes, hidden agendas, personal 
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distractions, etc. A mismanaged threat is a threat that is linked to or induces flight crew 

error. 

Error — Errors are defined as flight crew actions 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 operational events on the ground or during flight. 

The three main error categories include 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 incorrect configuration of an aircraft that; (1) 

results from flight crew error, actions, or inaction, and (2) clearly reduces safety 

margins. Examples typically include heading and altitude errors, speed unnecessarily 

high or low, unstable approach, near miss, fuel level below minimums, long landing, 

hard landing, wrong runway or taxiway, wrong airport, etc. 
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CASE STUDIES 

TABLE OF CONTENTS 

SUBJECT PAGE 

C-5 MISHAPS 

AIRCRAFT CRASHED DURING AN EMERGENCY 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, HAZARDOUS ATTITUDES, 

SUPERVISORY ERROR ................................................................................. 10-6 

IMPACTED TERRAIN DURING LOW LEVEL TRAINING 

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

STALLED AND CRASHED DURING LOW-LEVEL AIRDROPS 

P & R, LOSS OF S/A ..................................................................................... 10-14 

IN-FLIGHT STRUCTURAL FAILURE, EXPLOSIVE DECOMPRESSION 

GOOD CREW COORDINATION ................................................................... 10-17 

AIRCRAFT IMPACTED WATER 

LOSS OF S/A, HAZARDOUS ATTITUDES, ASSERTIVENESS ................... 10-19 

LANDED GEAR-UP DURING SIMULATED ENGINE OUT 

LOSS OF S/A, WORKLOAD ......................................................................... 10-23 

COLLISION WITH ANTENNA ON NIGHT LANDING APPROACH 

VISUAL ILLUSION ........................................................................................ 10-27 

DRAGGED WINGTIP ON LANDING 

KNOWLEDGE, CREW COORDINATION, HALO EFFECT .......................... 10-29 

HARD LANDING 

POOR BRIEFING, INEXPERIENCE, VISUAL ILLUSIONS .......................... 10-31 

STALLED ON FINAL 

POOR CREW COORDINATION, JUDGMENT, AWARENESS ..................... 10-33 
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KC-135 MISHAPS 

AIRCRAFT DESTROYED FOLLOWING SIMULATED ENGINE FAILURE 

JUDGMENT, WORKLOAD, POOR COMMUNICATIONS ............................ 10-35 

TAKEOFF ABORT, SHEARED/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, DISTRACTIONS, LOSS S/A ...................... 10-45 

HARD LANDING/GO-AROUND, IMPACT WITH TERRAIN 

VISUAL ILLUSION, WORKLOAD .................................................................. 10-49 

IMPACTED APPROACH LIGHTS 

KNOWLEDGE, VISUAL ILLUSIONS, COMMUNICATIONS ......................... 10-53 

DEPARTED RUNWAY, BROKE UP, BURNED 

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

A-7 MISHAPS 

COLLISION WITH GROUND 

TASK MANAGEMENT BREAKDOWN ......................................................... 10-61 

A-10 MISHAPS 

COLLISION WITH GROUND 

CHANNELIZED ATTENTION, PRIORITIES, COMPLACENCY .................... 10-63 

COLLISION WITH GROUND 

CHANNELIZED ATTENTION ........................................................................ 10-65 

F-4 MISHAPS 

COLLISION WITH GROUND 

COORDINATION, CHANNELIZED ATTENTION, ILLUSION ........................ 10-67 

CONTROL LOSS, EJECTION 

LACK OF COMMUNICATION, COORDINATION ......................................... 10-69 

LOSS OF CONTROL 

AIRSHOW AND COPILOT SYNDROME ...................................................... 10-71 
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F-15 MISHAPS 

MIDAIR COLLISION 

FLYING UNBRIEFED MANEUVERS, FATIGUE, DISCIPLINE ..................... 10-73 

COLLISION WITH GROUND 

SUPERVISION, DISCIPLINE, COMPLACENCY, 

OVER-CONFIDENCE, AND 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 INTERFERENCE ............................................................. 10-81 

COLLISION WITH GROUND DURING EGRESS 

PERCEIVED PRESSURE ............................................................................. 10-83 

F-111 MISHAPS 

COLLISION WITH GROUND 

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

RAPID FUEL DEPLETION, EJECTION DURING LANDING 

POOR CREW COORDINATION ................................................................... 10-87 

LOST CONTROL/IMPACTED TERRAIN 

CHANNELIZED ATTENTION, PRIORITIES .................................................. 10-89 

T-37 MISHAPS 

IMPACTED TERRAIN AFTER SINGLE ENGINE GO-AROUND 

CSF'S, STRESS ............................................................................................ 10-91 

T-38 MISHAPS 

FLIGHT CONTROL MALFUNCTION, EJECTION 

IMPROPER ANALYSIS, LACK OF COMMUNICATION ................................ 10-93 

CIRCLING APPROACH, COLLISION WITH GROUND 

IMPAIRED JUDGMENT ................................................................................ 10-95 
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USN/USMC MISHAPS

UH-1 MISHAPS

RAPPELLER KILLED DURING DEMO 

POOR AIRCREW COMMUNICATION .......................................................... 10-97 

FLEW INTO THE GROUND 

FAILING AVIATOR ........................................................................................ 10-99 

WIRE STRIKE AT NIGHT DURING NVG TRAINING 

COMMAND AUTHORITY ............................................................................ 10-101 

COLLISION DURING MOUNTAIN FLIGHT 

OPERATING STRATEGY ........................................................................... 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 AWARENESS ..................................................................... 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 ATTITUDES. ........................................................................ 10-121 
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AIRCRAFT CRASHED DURING AN EMERGENCY 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 April 2006, the aircraft, assigned to the 436th 

Airlift Wing and flown by a reserve crew from 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 Air Force Base, Delaware. The airplane, 

carrying 17 people, had taken off from Dover about 21 minutes earlier and reported an 

in-flight emergency (number 2 engine 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 concluded the crash was a result of human error, 

most notably the determination that the crew kept one of the functioning engines in flight 

idle while manipulating the throttle of the (dead) number 2 engine as if it was still 

running, while having the number 3 engine at idle, an error that was further amplified by 

the crew's decision to use a high flap setting 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 instructor and primary flight 

engineers failed to brief, and pilots failed to consider and use, a proper flap setting. The 

pilots’ attempt at a visual approach to runway 32 resulted in the aircraft descending well 

below a normal glidepath for an instrument-aided approach or the normal visual flight 

rules pattern altitude. The aircraft commander failed to give a complete approach 

briefing that would have included non-standard factors, configuration, landing distance 

and missed approach intentions.
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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 was observed by Wing and squadron 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 copilot 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, thereby inappropriately reinforcing the mishap pilot's 

behavior. Prior to the actual LAPES demonstration 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 entertainment 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 ground with sufficient force to fracture the 

aircraft structure at station 737. The aircraft 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 fatally injured. The aircraft was destroyed. 

NARRATIVE 

The mishap aircraft was the lead of a four-ship (two/two-ship elements) formation. The 

mission was planned and briefed as an adverse weather aerial delivery system 

(AWADS) visual route to a LAPES 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 descend to 3000 feet and then cleared at "pilots 

discretion" to 1,175 feet. Passing through 1,400 feet the mishap aircraft obtained VMC 

approximately 10 miles out from the EZ. The mishap crew acquired the EZ environment 

at approximately 7 miles. The copilot identified the LAPES panels at approximately 2 

miles. At about 1 1/2 miles out the pilot began a right turn for final EZ alignment. 

Eighteen seconds prior to impact the pilot 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 delayed drogue chute deployment until nine 

seconds prior to impact. The drogue was deployed and the mishap pilot aggressively 

pushed the nose of the aircraft down obtaining a vertical velocity of 2900 feet per 
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minute. During the descent to extraction altitude (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 feet per minute. After the aircraft impacted the ground, the 

aircraft ramp and portions of the ramp conveyors passed through or remained in two of 

the extractor chutes. One extractor parachute later inflated. The load was extracted 

and decelerated to a stop. The aircraft impacted the ground with the left and right aft 

main landing gear and the cargo ramp. The right aft gear strut failed and the right 

forward tire blew. The upper fuselage skin and empennage supporting 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 the ground and at approximately 1,680 feet the 

engines and propellers departed the aircraft. At approximately 1,800 feet, the right 

wingtip contacted a parked vehicle, which 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 seat of the jeep was killed instantly. 

At approximately 1,900 feet, the aircraft flipped over and fell to the ground 2,040 feet 

from the initial impact. During the rotation 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 components, hot electrical components and 

possible sparking. All four main fuel tanks, oil, and fuel vapors ignited 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 fatal burn injuries in the post-crash fire. The 

copilot and flight engineer were found outside the flight deck area but within a broken 

perimeter of fire and received serious burn injuries. The aircraft was destroyed by fire. 

The flight engineer, copilot and navigator were all overdue on ground training events 

some of which were grounding events. The formation as planned and flown for this 

mission did not have a lead crew in the deputy serial lead position as required by MACR 

55-130. Additionally, MACR 55-130, paragraph 29-5 states, "It is permissible to use an 

approach altitude higher than 200 feet if operational requirements 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 aircraft 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, cargo weight 34,850, fuel weight 19,000, CG 

of 25.4, airspeed 130 CAS and 70% flaps. The 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. 
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As a result of a currency discrepancy, a crewmember change was required at the last 

minute. Since both copilots had practiced for 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 negate 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 events was delayed by the mishap pilot. 

The mishap chain of events began with the mission briefing for the Monday practice. 

Significant emphasis to provide 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 perform 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 the 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 decision 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 explained 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 the maneuver really bothered the copilot that he 

would "shallow all that stuff out." Later Monday afternoon, the mishap pilot was 

overheard to say that he would make the next run-in a little steeper. The mishap pilot 

assumed that the LAPES approach would be accomplished as he intended even though 

he had not successfully performed such an extremely aggressive maneuver in the past. 

Other squadron members' confirmed the mishap 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-motivation, a desire to magnify self-image, 

reputation or career. The role of outside motivating factors 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 aircrews were praised for an outstanding 

performance. This inappropriate positive reinforcement 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 Courtesy) The copilot had only 

200.1 hours of C-130 flying time; he was dedicated, highly motivated individual, but 

lacked knowledge and experience in not only LAPES, but in the C-130 in general. 
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During the mishap sequence, the copilot relied 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 more 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 syndrome whereby the copilot and possibly other 

crewmembers were satisfied to have the pilot in complete control of the final approach. 
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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 destroyed and ten crewmembers and a survival 

specialist were fatally injured. This mishap occurred when the effects of three different 

factors combined at a critical time: the 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 written report concerning the mishap IP 

pushing the aircraft too far, not taking inputs from the crew and handling the aircraft 

aggressively in critical phases of flight. On a subsequent occasion, two students (both 

aircraft commanders) complained about the mishap IP's seeming disregard for Air Force 

and MAC directives, other crewmember's inputs and weather hazards. In response to 

these grievances, the squadron DO verbally counseled the mishap pilot, and the 

squadron CC was notified of these sessions. After the second incident, Stan/Eval 

administered a no-notice flight 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 the crash site. During this flight, the aircraft 

(same aircraft as mishap aircraft) experienced 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 navigator expressed concern to the mishap 

IP and others about flying the western low-level routes due to forecasted weather. The 

mishap IP ignored a later SIGMET broadcasted over center frequency reporting severe 

turbulence for the entire area. Interviews with other members in the Wing (all crew 

positions) almost always contained such words as: "aggressive, pushed the aircraft, 

pushed the crew, not receptive to inputs, extremely 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 time, the mission was altered to 

include low level terrain following 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 fatigue 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 integrity of a chord-wise fatigue crack at the stress point. The 
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repair increased the propagation of this fatigue crack by a factor of two and at the time 

of G over load, the fatigue crack went unstable and propagated at the speed of sound in 

the metal along the row of plugged rivet holes. 

At the time of the mishap the prevailing winds were from 240 degrees at 30 knots 

gusting to 40 knots. There were some gusts as high as 55 knots. SIGMET Hotel 

advised of severe turbulence with strong up and down drafts. Vertical gust velocities of 

1000 to 3000 feet per minute were calculated to be present at the time of the mishap. 

NARRATIVE 

The mission was scheduled for a 1630Z departure with 30 minutes planned for 

personnel delivery at a drop zone (DZ) and then low level training on two separate 

routes. Following low level training, the flight was scheduled for one hour and thirty 

minutes of aerial delivery training and then return to base. 

After take off at 1655Z the mishap aircraft reported 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 hour and fifteen minutes. At 1703Z, center 

broadcast in the clear to all aircraft, SIGMET Hotel Alpha, valid until 2036Z. The 

SIGMET advised of occasional severe turbulence below 15,00 feet with very strong up 

and down drafts reported by numerous aircraft. 

At 1822Z, a local resident observed the aircraft 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. Immediately 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 prior to the exit of the low level route. 

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

aircraft and the rescue mission. The squadron DO and CC were interviewed 

concerning complaints by two students and a permanent-party flight engineer against 

the mishap IP, The first complaint occurred when the flight engineer presented the 

squadron DO with a two-page letter and his personal testimony. He stated that on one 

mission the mishap pilot placed the aircraft in an unplanned staff buffet twice while 

demonstrating air-refueling techniques and once 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 traffic control clearances and thunderstorm 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 during training missions. He also advised the 

squadron commander of actions taken. After the second incident, squadron Stan/Eval 
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administered a no-notice evaluation 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 interviewed admitted that the 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 charge 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 mission setup, the pilot would 

attempt to maximize training for all crew positions. This meant flying both low-level 

routes at 500 feet while hoping for the winds to diminish enough for the paradrops. In 

doing this, he ignored the forecast weather, the SIGMET reporting sever turbulence in 

the area, and his navigator’s request to fly low-level routes 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/prebriefed routes. This attitude of ignoring crew inputs and 

pressing on as planned was the rule rather than 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 controlling the aircraft. He was confident and there was no 

doubt he controlled the aircraft and not the other way around. However, the description 

"aggressive," "mission hacker," and "dangerous" 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 prevent this after his inputs regarding crew 

endangerment and regulation violations were ignored. 

Flight engineers found the IP difficult 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 tried to impart too much information at a 

given time. The IP's closest friend described him as someone you either 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 intelligence 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. Poor judgment was evident by his continually 

flying into dangerous conditions and endangering crew and aircraft. There was no 
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evidence that an air of "mission 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 and therefore received no negative reinforcement for his 

behavior. On the day of the mishap, crew inputs were ignored and the IP proceeded as 

planned and flew into forecast turbulent weather conditions. 
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STALLED AND CRASHED DURING LOW-LEVEL AIRDROPS 

P & R, LOSS OF S/A

SUMMARY

The mishap aircraft was number two in a flight of eight C-130s scheduled 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. After the airdrops at the DZ, the formation 

planned to fly a low-level route to a simulated 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 flight 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 between elements. The flight proceeded 

normally until slowdown when the student pilot closed to within 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 closed on the lead and stabilized at 120 

KIAS approximately 1200 feet behind 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 its right wing, and begin its final descent. The 

mishap aircraft impacted on the DZ. 

NARRATIVE 

After formation takeoff and join-up, the instructor 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 route, 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 formation ascended to drop altitude, 1750 feet msl 

(800 feet AGL), set flaps 50 percent, and reduced 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 maneuvered the aircraft to the right to keep from overrunning 

lead. He stabilized at 120 KIAS and started to drift back to the correct formation airdrop 

position. The pilot established a position 1700 feet behind lead. He then moved 

forward to about 1200 feet in-trail, but still offset 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 this 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 movement. 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 encountered wake turbulence 

form the lead aircraft (I-:53). The turbulence moved the aircraft back out to the right. 
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He tried to maneuver to the correct position a second time by adding more left aileron 

and left rudder. During this maneuver, at approximately 1200 feet behind 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 pulled back on the yoke, increasing the pitch 

angle, without adding power. At approximately I-:25 the mishap aircraft entered the 

wake turbulence. Simultaneously, the aircraft began to yaw to the left and the rolling 

motion from lead's left wing tip vortex caused the left wing to rise. To counter the rolling 

motion, the pilot added almost full left aileron and some left rudder. The airspeed 

decayed slightly. Also, while in the wake turbulence, the aircraft started to sink. This 

sequence occurred over a period of about five seconds. 

The IP noticed the low airspeed 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 combination 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 available to initiate normal stall recovery. Right 

after calling "Stall," the engineer called, "Airspeed! You're getting into the rudders!" (I-

:17). Over the next two seconds, the nose continued to track 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. Next, 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 stall, 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 the landing gear warning horn from I-:08 to I-

:06. 

During the rapid sequence of events, the IP did not instruct the pilot to push the nose 

down to complete the stall recovery procedures. Additionally, the inexperienced copilot 

neither said to push the nose down, nor did he take action to push the nose down. 

When the aircraft yawed to the left, none of the crewmembers experienced any strong 

lateral forces. Had this been a true rudder force reversal (fin stall), the standing 

crewmembers would have had difficulty performing their duties. Aeronautical 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 entered a power-off stall 

from which recovery was not possible. The pilot recognized the 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 aircraft impacted the ground in a power-on stall 

condition, 5 to 10 degrees nose high, approximately 60 degrees right bank, at a low 

forward groundspeed of 85-95 knots. 

The first people to arrive at the crash site were two combat control team (CCT) 

members who were the ground party on the drop zone. The next two people to arrive 

were civilians who were working nearby. One CCT individual and one of the civilians 

moved the evaluator flight engineer away from the burning wreckage. The other two 
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people assisted the instructor pilot survivor. The CCT searched for other survivors 

without success. 

CONCLUSION 

The pilot had difficulty maintaining formation position and after slowdown was constantly 

flying close to the lead aircraft. The pilot stalled the aircraft. The aircrew misidentified 

the condition of the aircraft to be a fin stall. The IP failed 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 the C-130. While these efforts should be 

continued, the aerodynamic or natural stall warning characteristics of the C-130 are 

sufficient to alert trained aircrews of an approaching stall in sufficient time to react. 
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IN-FLIGHT STRUCTURAL FAILURE, EXPLOSIVE DECOMPRESSION 

GOOD CREW COORDINATION

NARRATIVE

The mishap aircraft was on a transoceanic mission, 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 inches of mercury. Flight conditions 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 pilots also stated that the aircraft pitched 

down and began a slight right turn. Both pilots 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 disconnected, the aircraft buffeting stopped, but a moderate 

level of airframe vibration continued. Aircraft control was 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 KIAS. 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 other instrument indications were observed as 

normal. The pilot stated that the aircraft did not feel left-wing heavy. The loadmaster 

scanned the right wing and reported no visible leaks. The engineer then realized the 

number 3 and 4 gauges were off scale low and pulled the number 3 and 4 circuit 

breakers. The ACM FE came forward and relieved the primary FE while the primary FE 

went into the cargo compartment to assess damages. 

Prior to the decompression, the navigator provided the aircraft commander (AC) with 

information on the closest emergency airfield relative 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 miles away. The copilot (CP) attempted to 

declare an emergency using the HF radios. 

Unable to directly contact 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 damage to components in close proximity to 

the hole. This included mission right outboard and center fairings, damage to electrical 

wiring bundles and cannon plugs, bent and torn air-conditioning ducting, and possible 

damage to the flight control cables. The air conditioning ducting had been blown 

upwards into the flight control cables, applying tension to these cables. The FE 

attempted to remove litter straps 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 damage 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. 
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The crew initiated a controllability 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 touchdown at 140 KIAS. During the 

controllability check, the AC slowed the aircraft 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 airfield to escort the 

mishap aircraft. Thirty miles from the airfield the landing gear was lowered, and the AC 

intercepted a precision approach final with ground radar monitoring. Landing was 

uneventful. Reverse thrust was not used due to the loose HF antenna. After landing 

and clearing the runway, a crewmember deplaned 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 aircraft 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, flight control cables, bleed air, oxygen, and 

throttle/condition level cables. A thorough aircraft systems knowledge and analysis was 

required to take the appropriate coordination corrective action. The board determined 

aircrew actions/coordination were both adequate. During individual interviews, both 

pilots and both engineers stated that mission oriented simulator training (MOST) 

enhanced crew coordination during this mishap. Although an explosive decompression 

and subsequent structural/systems damage occurred in this mishap, the rapid 

decompression and controllability procedures were sufficient when combined with the 

synergistic knowledge of the crew. 
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AIRCRAFT IMPACTED WATER 

LOSS OF S/A, HAZARDOUS ATTITUDES, ASSERTIVENESS 

SUMMARY 

The mishap flight was the first leg of a three-sorties, routine resupply mission carrying 

equipment, rations, mail and passengers. The mishap aircraft departed on schedule 

and proceeded along the flight-planned route. Once airborne 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 aircraft was unable to establish direct radio 

contact. 

The mishap crew requested and was given clearance to descend from flight level 220 to 

200 with further clearance to descend in VMC for landing at their first stop. Shortly 

thereafter the crew attempted to make another routine operations report, but received 

no reply due to another mission working at the 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 mishap site was approximately 

185 miles and the elapsed time to fly this distance was estimated to be 61 minutes. 

During this leg the flight path, type of descent, airspeed used and weather encountered 

could not actually be determined. 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 have been as low as 1/2 mile. 

The mishap aircraft was last seen visually passing over a peninsula at 300-500 feet, 

then it initiated a right turn towards the open sea. Shortly thereafter, observers and 

local residents heard a loud crash from the direction the aircraft had traveled. Two 

individuals rushed to the shore 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 passengers, 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 distance from the last reported 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 peninsula near the field of intended landing. 

Weather for that area was changing constantly with rain, fog, and low clouds obscuring 
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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 mainland. The turn also could have been made to place the 

aircraft in an area of perceived 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 controlling agency. Either of the latter three would also 

explain the aircraft remaining 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 visual illusion such as a false horizon or 

spatial disorientation. Aircrew attention could have been channelized outside the 

aircraft in an attempt to maintain visual contact with the surface. Conversely, attention 

could have been focused inside the aircraft because of some aircraft system 

malfunction. Any of these factors could have 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 was 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 who had only about 182 hours in 

the C-130. He did have, however, an aviation degree and a civilian pilot's license. The 

copilot may have been hesitant to take action and express his opinions based on his 

relative inexperience. The pilot was a highly motivated, mission-oriented flyer who may 

not have recognized his own limitations in this situation. 

The weather conditions were probably a factor 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 can be reconstructed by the use of two 

scenarios: The loss of a true horizon by cloud decks creating visual illusions or 

the loss of outside visual cues resulting in spatial disorientation while 

maneuvering. 

The distraction of the crew through channelized attention on inside or outside 

factors. 
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There is no evidence of problems within the aircraft that would have caused 

channelized attention, therefore, 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 Rules in the descent 

through the overcast cloud layer. The pilot operated the aircraft at low altitude in 

marginal weather conditions for an undetermined reason. Other violations include, 

overdue aircraft isochronal inspection, overdue flight physical on the copilot, aircraft 

commander was carrying a concealed weapon loaded with a full clip, and the alternate 

destination was invalid due to insufficient reserve fuel to reach the designated field. 
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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 copilot upgrade training, consisting of instrument approaches 

and visual pattern work for two students. Due 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 accomplished seven instrument approaches, nine 

visual patterns, and twelve landings. The instructor 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 copilot upgrade student got in the left seat and the 

instructor pilot got in the right seat. 

The mission proceeded normally until the last visual pattern prior to departing for return 

to base. The mishap aircrew completed a simulated 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 warning horn. The instructor pilot then pressed the landing 

gear warning horn silence switch. The instructor 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 engine 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 copilot briefed the landing and directed the 

instructor pilot to lower the flaps to 50 percent. 

As the aircraft approached midfield downwind for landing, tower directed the aircraft to 

make a left 360-degree turn. After completing 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 establish 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 the turn to final and 

final approach, the aircraft touched down 1,030 feet from the approach end of the 

runway, five feet left of centerline, and slid for 3,140 feet before coming to rest 18 feet 

left of centerline. The aircraft sustained substantial damage to the lower portion of the 

fuselage and ramp. Six crewmembers egressed the aircraft with no injuries. 

NARRATIVE 

After demonstrating a flaps-up touch-and-go landing, the instructor pilot planned for the 

left seat copilot to accomplish two simulated engine out visual patterns to the runway 

and then return to base. The instructor pilot transferred control of the aircraft to the left 

seat copilot. During the downwind leg of the first pattern, the instructor pilot simulated a 

nacelle overheat on the number 1 engine. The left seat copilot reacted properly and 

directed the engine shutdown procedure. The instructor pilot pulled the number 1 

throttle back to just above a zero torque setting and silenced the landing gear warning 
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horn. The left seat copilot briefed the approach and landing, called for flaps to 50 

percent, directed the landing gear down, and called for the before landing touch-and-go 

checklist. The crew completed the checklist prior 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. When 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 instructor pilot silenced the horn. 

Once the gear was up, flaps were brought up and the crew 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 downwind leg, the left seat copilot briefed the approach and 

landing, and called for flaps to 50 percent. Tower cleared 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 copilot's habit patterns, resulting in his failure to call for 

landing gear extension and checklist initiation. The landing gear warning horn was 

sounding during the beginning of this maneuver. Approximately 15 seconds after 

reentering the downwind leg and when approximately abeam the threshold of the 

runway, tower instructed the mishap crew to turn 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 mishap aircraft to the runway, the instructor pilot directed the 

left seat copilot to extend downwind a few seconds and to reduce the power to 

minimum. As the left seat copilot 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 flight idle, to avoid engaging 

the negative torque signal system. The throttles 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 glidepath, and on airspeed. The instructor pilot 

was concentrating on the approach, coaching the student, and mentally preparing for 

the departure back to base. The flight engineer was monitoring the runway, descent 

rate, and the engine instruments. 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 copilot 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 flight engineer thought the aircraft had a blown tire. The left 

seat copilot brought the throttles into flight idle, then ground idle, and used a very slight 

amount of reverse thrust. The landing gear warning horn began sounding upon 

retarding the throttles to flight idle; however, the crewmembers on the flight deck do not 

remember hearing it. The instructor pilot saw the landing gear handle 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 instructor pilot transmitted to 
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tower that they made a gear-up landing. Just prior to the aircraft coming to a stop, the 

instructor pilot transmitted to tower that the 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 that 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 seat copilot never retarded the 

throttles to this range because of the higher power setting required during a simulated 

engine out landing and his intention 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 landing gear warning light was illuminated for the previous 

three-engine approach as well as for the mishap approach. This condition resulted in 

the warning light's effectiveness as a warning 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 for the mishap landing, the 

following human factors developed. 

The left seat copilot, an initial phase I student, was in the seat approximately one hour 

and thirty-seven minutes prior to the mishap. He accomplished several instrument and 

visual approaches. Following a three-engine go-around the crew planned to fly a threeengine approach to a touch-and-go. The left seat copilot became task saturated during 

the critical phases of his last pattern and approach. During the downwind leg, following 

the briefing and setting of flaps, the left seat copilot was directed by the tower to 

execute a 360-degree turn into the simulated dead engine. This interrupted his 

prelanding habit pattern and his attention was directed to returning the aircraft to the 

proper downwind position. Soon 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 substantial amount of concentration. This is 

especially true when it is taken into consideration that the left seat copilot had been 

having difficulty landing on centerline on this and previous missions. Due to his 

preoccupation with flying the aircraft and aligning it with the runway, the left seat copilot 

never directed that the landing gear be lowered. 

The instructor pilot was occupied by clearing and monitoring the left seat copilot's 

progression through the 360-degree turn and instructing this relatively difficult short 

approach. The left seat copilot's inexperience was evident when he attempted to make 

an early turn which would have resulted in a steep angling final. The instructor pilot 

corrected him. When the aircraft was positioned on final, the left seat copilot found 

himself closer to the runway than he was accustomed to. Therefore, this approach 
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necessitated more attention and instruction by the instructor pilot than had been 

required on previous approaches. In addition, the instructor pilot 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 aircraft turned base until touchdown. This 

combination of events contributed to the instructor pilot not being aware that the gear 

had not been lowered or the checklist completed. 

The flight engineer was subject to the same anomalies of attention. Throughout the 

360-degree turn and base leg, the flight engineer was occupied with clearing for other 

traffic in the pattern. When the left seat copilot failed to initiate the checklist, the flight 

engineer was deprived of a cue that would have initiated his own routine associated 

with checking the landing gear configuration. During final approach, the flight engineer 

was observing the runway in order to prepare for a hard landing, if necessary. Any 

scanning of the instrumentation would not necessarily reveal an illuminated landing gear 

warning light, due to habituation. 

The C-130 flight manual indicates that the aircraft is configured for a typical three- or 

four-engine approach on downwind. The pilot may direct lowering of flaps and gear 

before initiating the applicable checklist. The 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 critique, coaching and demonstration. The 

instructor pilot had his normal sequence of events interrupted: 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 lowered or that the before landing touch-and-go checklist 

had not been completed. The instructor pilot failed to provide adequate 

supervision/instruction by not monitoring the aircraft 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 the aircraft or refer to the checklist prior to landing. 
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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 landing 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 last 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 status 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 copilot 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 navigation-training mission. (It later proved to be a faulty 

indicator). The engine was secured IAW NATOPS 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 field. 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 simulate a short field landing. 

The copilot, while continuing to monitor 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 line-up while looking past the bright approach lights to 

the dark hole where the runway was located. Approximately 2 seconds before impact 

the flight engineer, after checking 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 PIC responded instantaneously and aborted the 

landing. This prevented a more serious mishap. 

CAUSE FACTORS OF THE MISHAP 

The AMB and subsequent endorsers concluded that the cause of the mishap was 

aircrew error and supervisory error. Specifically, the pilot, while executing a landing to 

an unfamiliar airfield at night, abandoned the published ILS approach procedures in 

favor of a totally visual approach. He allowed his scan to breakdown due to lack of 

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The aircrew also suffered a breakdown of crew 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 illusions 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/semi-annual currency requirements 

for night hours do not ensure night landing proficiency for individual pilots. The 

squadron was cited because the copilot had not received night familiarization training in 

the KC-130 prior to the mishap. NATOPS was faulted for not addressing crew 

coordination during the landing 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 small 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 top of this rise. The illusion of a higher 

altitude than they actually were was created by the loss of updated visual cues. In an 

April 1974 APPROACH article entitled, "The Last Run of Flight Nine One Five," Dr. 

Robert Alkov of the Naval Safety Center described the illusion that results in the aircraft 

arcing far below the intended glideslope when there is up sloping 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 lights beyond the runway 

which would cause him to land short. 

The copilot failed at crew coordination when he stopped calling altitude to the PIC as he 

was briefed to do. He felt complacent with his highly experienced aircraft commander at 

the controls. When the PIC said he was visual, the copilot relaxed and became just a 

passenger. He should have remembered "It ain't over til it's over." 
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DRAGGED WINGTIP ON LANDING 

KNOWLEDGE, CREW COORDINATION, HALO EFFECT 

NARRATIVE

During landing rollout on an icy runway, the port wing of a KC-130F began to rise and 

the aircraft began to drift/slide toward the right 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 aircraft commander in P-3s and had recently 

become aircraft commander in the C-130. In his training, however, 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-year-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 seasoned 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) was 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 was reached and they were 

cleared to land on runway 04. Runway conditions were reported 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 long 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 afterward the right wing dipped. The MP used the yoke to 

attempt to correct the attitude. 

After 1800 feet of roll, the aircraft veered slightly to the right of centerline. The pilot put 

reverse thrust on the port engines and positive 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 the 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 the right side in the area of the prop arc. As the right 

wing lifted, the number 4 prop 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 power on the port engines and 
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reverse thrust on the remaining starboard engine. Nose wheel steering was ineffective 

and full braking action was applied without evidence that the tires were grabbing. The 

plane came to a stop on the runway approximately 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 Safety Center as caused by aircrew error. 

The pilot was faulted for failure to conduct a thorough approach briefing: inaccurate 

approach airspeeds and inadequate preparation for landing in crosswinds on a known 

icy runway. He was also listed for poor technique 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 crosswind characteristics for this aircraft. 

The aircrew were recorded as a probable cause 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 recently been obtained from the Marines. 

There are numerous small differences in these 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; threshold, touchdown, and stall 

speeds. The MFE was accustomed to give 3 speeds in the landing brief; approach, 

threshold, and touchdown. As a result, he used the speeds given on the placard, which 

resulted in a touchdown speed that was actually the stall speed (83 kts for 100% flaps). 

The crosswind component was marginal for icy 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 experience, 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 corresponding 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 when 100% flap is used. The 

MP's reaction time may have been impaired by stress from family problems that he 

encountered recently. 
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HARD LANDING 

POOR BRIEFING, INEXPERIENCE, 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 the pilot at the controls (PAC) at the time of impact. He 

was relatively inexperienced with 391 total flight hours, 196 in type. He had flown 25 

hours in the past 30 days. He had never landed on an unimproved surface. The only 

time he had ever been to the airfield before was as a copilot observing a landing from 

the left seat, 5 months prior. 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 displaced 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 flying 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 training, the squadron operations department must often 

conduct training flights on very short notice. 

The aircraft commander (AC) was a 27-year-old O-3 with 1096 total hours flight time, 

911 in type, 34 in the past 30 days. 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 the visual illusion caused by upsloping terrain. The AC 

did not understand how an upsloping runway could affect an approach profile due to the 

visual illusion. The PAC took the controls on downwind immediately after strapping in 

after he changed seats with another copilot who had just completed 4 touch-and-go 

landings. He made a long and wide crosswind turn from the 180 and pulled back power 

to 3000 inch-lbs. He ended up deep in the approach with a strong headwind, and was 

forced to add power to re-intercept the glideslope. The glideslope was intercepted at 

400-500 feet above MSL, one mile out. 

 

The PAC then reduced power and dropped flaps to 100%. He set up a 500-600 fpm 

descent rate and slowed to 180 kts. He left power at 3000 inch-lbs and slowed to 

threshold speed of 108 kts as briefed. Near 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 right 
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rear landing gear strut had broken through into the cargo bay. The FE went aft to 

inspect, then came forward and asked the AC, who was flying the aircraft, to come aft to 

inspect the damage. He turned over the right seat controls to the copilot, who was 

seated in the rear and went aft. The new copilot declared an emergency and climbed to 

orbit at 5000 feet. The AC returned and replaced the PAC in the left seat. The AC 

discussed the situation with the 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 landing gear emergencies and emergency egress 

procedures in accordance with 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-level fly-over was made to allow the crash crew to assess the 

damage. The AC then executed a smooth landing, stopping the aircraft with reverse 

thrust. He set the left parking brake and the crew egressed the aircraft. 

CAUSE FACTORS OF THE MISHAP 

The aircraft mishap board and subsequent endorsers concluded that the mishap was 

caused by failure of the pilot in command to recognize an unsafe situation and take 

positive corrective action. Aircrew error was assigned the pilots because they persisted 

in accepting a low approach. The PAC was not proficient in EAF landings. The AC was 

not a WTI or NATOPS instructor, but was flying an EAF training evolution in violation of 

squadron SOP. Supervisory error was assigned to the AC because the PAC was 

inadequately briefed; and to the squadron for improperly scheduling a flight and for not 

establishing the requirement to use displaced threshold during training flights. 

CONCLUSIONS 

This squadron detachment has a high turnover of personnel, with inadequate pass 

down of information on the problems unique to the area and the characteristics of local 

airfields. 
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STALLED ON FINAL 

POOR CREW COORDINATION, JUDGMENT, AWARENESS

NARRATIVE

An LC-130R, on an authorized cargo/passenger logistics flight, crashed at a remote 

Antarctic field camp during landing approach to a skiway. On final, the mishap pilot 

(MP), who was a flight instructor sitting in the right seat, took the 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°-45° turn. The aircraft descended rapidly and 

impacted the ground right wing down and nose low. On impact it rolled inverted and 

broke in two. The cargo section was engulfed in flames. Two passengers were killed, 

while one passenger suffered an open dislocation of the ankle and fractured lower left 

leg. The pilot, copilot, five crewmembers, 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 experienced LCDR with 4480 total flight hours, 2942 

in type, 2217 in model. He was considered to be a mechanical pilot. Although he 

possessed an exceptional knowledge of aircraft systems, NATOPS, and the nuances of 

antarctic flying, he had a cavalier reputation of flying 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 authoritarian and inflexible as an instructor 

pilot. Because of his domineering and condescending attitude in the cockpit, several 

flight crew personnel requested 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 pilot 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 experience 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 aircraft his own way. The MP would not compromise or accept 

suggestions on his flying style. The MCP remarked that he "felt a little burned out 

because of the no-win situation 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 approach profile at speeds below those of squadron and NATOPS 

standards. Other crewmembers considered the 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, facilities and supervisory error. The MP was 

faulted for improper approach selection, failure to wave off, loss of situational 

awareness, failing to maintain a safe margin above stall speed, and NATOPS violation 
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for performing an in-close, low altitude, low airspeed, high angle-of-bank maneuver. 

Both pilots were named for lack of effective 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 station members failed to maintain critical 

information flow. Facilities were cited for a lack of skiway markers and electronic 

NAVAIDS. Supervisory error was mentioned for failure to standardize 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. 
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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 practiced 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 broke up, caught fire and was destroyed. Five of 

the seven crewmembers were fatalities; two crewmembers were uninjured. The aircraft 

was airworthy for the entire duration 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 that an adequate and complete 

analysis was accomplished before allowing this maneuver to be performed for training 

student pilots. Test flights conducted prior to approval of this maneuver were flown and 

all recommendations regarding precautionary 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 directional control is 

stabilized." 

NARRATIVE 

A KC-135 aircraft launched on a normal training mission and after an uneventful 

refueling and celestial navigation 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 crew requested and received a 

clearance from tower for a VFR closed pattern. When the aircraft was on downwind the 

instructor pilot briefed the crew that this would be a VFR four-engine approach and 

touch-and-go landing. He also briefed that they would be doing a simulated engine 

failure, takeoff continued during the takeoff portion of the touch-and-go. 

Training records indicate that this was the student pilot's first simulated engine failure, 

takeoff continued maneuver in 20 days and his first ever from the left seat. There is no 

indication that the instructor had demonstrated the maneuver in flight prior to this 

attempt. However, he had performed this maneuver several times in the Cockpit 

Procedural Trainer (CPT). The training received in the CPT teaches the student to look 

into the cockpit to determine which engine is failed. This response is contradictory to 

what is taught in the aircraft, which is to look outside. Visual cues should be the only 

method used to determine control inputs while on the ground. The student pilot had a 

tendency to "under-control" the rudder during the previous engine failure takeoff 

continued maneuvers, which he had previously accomplished from the right seat. In 

addition, previous instructors stated that he tended to rotate before the aircraft was 

under control while performing this maneuver. 
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The aircraft touched down in the center of the runway and bounced two or three times. 

Following the touchdown, the 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. After the power was advanced and stabilized at 

touch and go EPR, and prior to the 6000 feet remaining marker the instructor pilot 

simulated failure of number 1 (left outboard) engine by retarding the throttle to idle. At 

that moment the student pilot rotated the aircraft sufficiently to lift the nose wheel off the 

runway and simultaneously applied full left rudder. The absence of nose wheel skid 

marks indicated the nose wheel never returned to the runway surface. One second 

after incorrect control input were completed the aircraft was two feet right of centerline, 

slightly nose up, right wing low and beginning an rapidly increasing 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 vertical fin stalls. If the instructor pilot does 

not initiate positive counteraction by the time the rudder reaches full left, recovery is 

virtually impossible because the yawing moment 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 seconds 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 centerline. The sideslip angle increased from 8 

to 16 degrees and the vertical fin stalled. The violent left yaw and roll rate continued to 

increase until the outboard number 1 engine nacelle contacted the runway. The 

number 1 engine departed the aircraft prior to the aircraft leaving the runway. Elapsed 

time for incorrect control inputs is now six seconds. The nose section impacted the 

ground approximately 70 feet from the edge of the runway. The initial impact was on 

the left side of the fuselage just forward of the crew entry hatch. The aircraft pivoted on 

its nose after initial impact, as the tail continued in a counter-clockwise rotation. This 

impact caused the cockpit compartment 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 input, thereby distracting the instructor pilot. 

2. Lack of cautiousness on the part of the instructor pilot since the student is older, 

previously experienced, and knowledgeable. 

3. Pressure to get all the training required by the mission profile. 
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4. The instructor's self-image that he can salvage the maneuver. 

5. The student pilot suddenly induces a surprise factor into the cockpit environment 

not anticipated, such as steering with ailerons, premature 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 when 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 the loss of thrust from the number 1 engine 

coupled with the simultaneous rotation and application of full left rudder. If the 

instructor pilot does not initiate 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, takeoff continued on the runway was authorized 

without an adequate analysis of this critical maneuver during touch-and-go 

landings. 

3. In response to the simulated number 1 engine failure, the student pilot applied 

incorrect inputs by rotating prematurely and applying full left rudder. 

4. The instructor pilot did not counteract the student pilot's incorrect inputs in time to 

stop an increasing yaw rate. 
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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 takeoff on a wet runway at a gross weight of 

252,221 pounds. Approximately 1800 feet down the runway, the pilot initiated an abort 

due to a noise in the nose gear area and low EPR on number 3 engine. Upon initiating 

abort procedures, the aircraft deviated to the right and departed the right side of the 

runway at approximately 3120 feet from the takeoff threshold. 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 investigation concluded that neither material 

malfunction nor maintenance error contributed 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 currency 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 wheel scrubbing on the wet runway during the turn 

to centerline alignment. The instructor pilot stated that the pilot used approximately 79 

percent RPM throughout the turn to centerline. Throughout the takeoff roll the pilot was 

distracted by a noise in the nose gear area; however, the instructor pilot felt the noise 

was nothing abnormal and dismissed it as the rough runway. The source of the noise in 

all probability was over controlling of nose wheel steering since a post mishap 

inspection determined that there was no preexisting malfunction in the nose wheel 

assembly. 

The pilot and copilot stated that a sustained left rudder deflection was not used during 

the takeoff roll. The pilot also 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 was 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 not notify the pilot that the 

engine would not produce an EPR 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 misinterpreted the number 1 EPR gauge as reading 2.70 when in fact it 

was reading 2.80. The EPR gauge was inspected and found to be accurate. The 

instructor pilot also confirmed that all engines 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 other throttles early in the takeoff roll. The instructor 

pilot did not notify the pilots of the throttle position. 

The pilot continued to be distracted by the 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. The 
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aircraft at this point had traveled to approximately 1800 feet on the 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 remained 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 idle position to the speed 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 near full forward position 

approximately 15 seconds after the abort and before the instructor pilot discovered it 

and notified the crew. The pilot eventually retarded the number 1 throttle but the aircraft 

had already departed the runway 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 the final stopping point 

and the right main landing gear collapsed as the aircraft crossed an old access road. 

The aircraft came to a stop approximately 50 feet after the right main gear collapsed. 

An attempt to cut off all throttles 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. Approximately 5 seconds elapsed before number 1 

throttle was discovered to be near the full 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 under some pressure to perform well since a 

senior staff member was observing the flight crew for the first time. 

CONCLUSION - FINDINGS 

1. During the takeoff roll on a wet runway, the pilot was distracted by a noise from 

the nose gear area. While making the final power adjustments, 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 accomplish bold print abort procedures; he did not 

retard no. 1 throttle, raise the speed brakes and apply both brakes. 

3. The pilot, instructor pilot and copilot failed to detect the incorrect abort procedure 

in time to take proper corrective action. 
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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 approach in IMC conditions. 

The pilot, who was also squadron operations officer, failed to adequately plan the 

mission and follow prescribed instrument procedures. The mission consisted, in part, of 

a series of practice instrument approaches at a field, which was below published 

minimums. Following the second missed approach and while proceeding inbound for a 

third practice approach the aircraft descended below radar coverage. The aircraft 

subsequently crashed in a remote area 31⁄2 miles north of the final approach course and 

83⁄4 miles northwest of the field. All occupants of the aircraft were killed. 

NARRATIVE 

The crew departed at 0900 and flew at 13,000 feet to an airport for practice instrument 

approaches. Upon arrival at the VORTAC the crew did not request ceiling and visibility 

information prior to the approach. After holding at the VORTAC the crew was cleared 

for an approach to the airport. They were instructed 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 without specific clearance to another IAF. 

They flew a DME arc until intercepting the final approach course. The crew told ARTCC 

that they planned to fly a total 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 clearance, 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 inbound 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 passed 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 aircraft ascended above 7000 feet on the 

centerline of the final approach course heading outbound. Radar plots indicate the crew 

flew the course outbound during the missed approach, rather 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 replied: "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 three three six." The 

crew contacted FSS, calling inbound for the approach. They were given and replied 

with the altimeter setting. At 1029 the aircraft was tracking inbound on the centerline at 

14 DME. The aircraft remained on centerline and descended below 7000 feet and out 
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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 control on it. You have to do it with your 

own radio there." Witnesses at the airport 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 made 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 establish 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 north of the course at 14 DME and at 9100 

feet. The aircraft made a right turn and rolled out at 900 feet tracking 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 information. This has been 

verified by subsequent FAA flight checks. Furthermore, the glide slope, navigation 

runway, and DME flags would have been in view. 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 aircraft descended below radar coverage. The 

last know position of the aircraft was at 7100 feet tracking 053 degrees, approximately 

31⁄2 miles north of the course and about 8 3/4 miles northwest of the field. 

HUMAN FACTORS CONSIDERATIONS 

The pilot was nearing the end of this PCS tour. This mission presented him with the 

opportunity to fly a memorable end of tour flight. The single significant medical finding 

relates to this end of tour or "finis-flight" attitude. His mission planning completely 

ignored weather, and he consistently exercised poor judgment during mission planning 

and throughout the flight. As the operations officer, most senior individual and aircraft 

commander, he was the prime mover in this flight. He was responsible for maintaining 

crew discipline and ensuring established procedures were followed. This disregard for 

discipline and procedures is typical of one who decides to fly his "finis-flight" in a grand 

or daring manner. All experts contacted believe "finis-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 mishap flight, completing one 

approach and landing. The copilot had not flown at all 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. 
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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 maneuvering for a third instrument 

approach. 

5. The crew positioned the aircraft outside 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. 
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LOST WATER INJECTION, CRASHED AFTER TAKEOFF 

WORKLOAD PERFORMANCE, DISTRACTIONS, 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 caused 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 approximately the 1000 foot remaining 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 consistent with steps 

common with a minor water augmentation problem. 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 controls and after rotation the aircraft banked 

sharply left. To avoid contact with the runway, 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 time the aircraft had insufficient thrust 

for sustained flight and a mishap became unavoidable. 

In all likelihood during the takeoff roll the pilot channelized his attention on dealing with 

water loss. Witness statements indicated white smoke from the number 3 engine 

occurred at a point on the runway after decision speed was obtained. Analysis 

concluded that failure of inboard water at this 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 after 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 degrees at 16 knots; however, surface winds of 230 degrees 

(magnetic) at 16 gusting to 24 knots were recorded during the takeoff roll. Although 

crosswinds may have contributed to the unstable takeoff, the limits for the aircraft were 

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The aircraft was observed to abruptly pitch up and start a roll to the right. The board 

concluded that the aircraft commander 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 approaching initial buffet and loss of lateral 

control authority. The drop of the left wing followed by an over correction that lowered 

the right wing was consistent with post mishap weapons systems trainer analysis 

profiles. These profiles indicated that once the roll to the right was initiated in this flight 

regime, the roll could not be stopped until the aircraft reached approximately 15 degrees 

of bank. The board felt that the aircraft commander attempted to lower the pitch to gain 

airspeed leading to the right wing and the number 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 seconds. A water injection malfunction was 

determined as the most likely source of degraded performance. While all maintenance 

actions to resolve discrepancies were appropriate and no repeat discrepancies 

occurred, the number of times to the water system required maintenance increased the 

susceptibility to future discrepancies. 

HUMAN FACTORS CONSIDERATIONS 

The takeoff profile was such that there was little margin for degraded aircraft or pilot 

performance. Additionally, in the final stages of the mishap, optimum pilot technique 

and awareness was essential for any possibility of a successful recovery. 

"Awareness demands attention and implies a grasp 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 malfunction that occurred during 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 handle 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 speed occurring in a very demanding takeoff 

environment, i.e., weight, 30-degree flaps, significant 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 aircraft commander had to make an accurate decision. 

Physiological factors had minimum influence on this mishap; however, significant 

psychological factors were present. These included distractions, channelized attention, 

the influence of stress on fine motor skills, and the tendency to continue on a 

preplanned course of action without consideration of other possible viable alternatives. 
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CONCLUSIONS - FINDINGS 

1. During the takeoff roll the aircraft experienced a degradation 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 inboard engines after decision speed but prior to liftoff. The 

malfunction which degraded the 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 rotation to gain additional airspeed. 

2. Due to distraction created by degraded takeoff thrust, the aircraft commander did 

not maintain adequate crosswind 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 aileron inputs and entered the initial buffet 

regime. 
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HARD LANDING/GO-AROUND, IMPACT WITH TERRAIN 

VISUAL ILLUSION, WORKLOAD

SUMMARY

After completing an air refueling 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 mishap aircraft then continued down the runway 

and climbed out. At the runway departure end the aircraft began a right turn and 

continued a shallow climb. The aircraft flew about three 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 the TTF office for one hour. At 

one hour after primary takeoff the crew is fully 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 recalled crew subsequently returned to their 

aircraft, completed preflight and launched. After air refueling the mishap aircraft 

returned to base, flying an en route descent 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 threshold. Continuing the progression of this convex 

glide path would indicate 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 glide 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 and 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 smaller than most KC-135 

crew are used to. There are problems induced 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 runways there is a tendency to 

be non-critical about touchdown point and complacent about stopping distance. In this 
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mishap this illusion resulted in a perceived need to land early on the runway, hence the 

pushover maneuver. The narrower width also has a well-known tendency to cause a 

perception of being higher than actual. These smaller dimensions work in concert to 

reinforce the perception of being higher and farther. 

As a result of this apparent perception, the crew made the decision to go around rather 

than to land. This would have been an acceptable decision if they had re-established 

themselves on a normal glide path, adjusted the aim point accordingly and landed 

normally. With the descent rate established, 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 recovery. 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 strut Overwing fitting shear bolt failed (this 

would require a 7G vertical force which 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 centerline and engine scrape marks indicated that 

the engine rotated then bounced and tumbled randomly 1700 feet past the aircraft 

touchdown point. Upon engine separation from the aircraft damage to 1.25-inch 

hydraulic lines would have resulted in virtually 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 fuel line to the engine. Witnesses stated that the right 

engine became engulfed in flames upon touchdown. 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 controls, non-optimum pilot techniques and speed 

deviations from optimum were all determined to be contributing factors to the nonoptimum climb. Average climb speed was calculated as 118 KCAS. In-flight minimum 

control speed in their configuration would 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 departure from its previously 

controlled condition, started rocking then rolled left wing low, followed by a sudden 

descent (170 feet in 3.5 seconds at 2900 FPM). The aircraft impacted the trees, left 

wing down, at the top of a 280-foot ridge. The general wreckage scatter 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 were 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 mistaken impression that 

they had more time, distance and altitude with which to correct back to the desired glide 
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path than they actually had. Thus, when the 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 almost 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 typically 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 maintain 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 copilot had a CCTS (TAPR) identified problem with 

landings. 

The decision to not land and go around was probably a result of the perceived landing 

distance problem with the 8500-foot runway. The 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 was available (abort on the runway). 

Upon becoming airborne, the crew had a task saturation problem due to degraded 

performance and multiple serious emergencies that would have been an extremely 

demanding situation for any crew. With an inexperienced 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 control given the circumstances was not an 

unexpected result once the engine sheared off. 
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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 completion 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 visual acquisition, the aircraft impacted three approach lighting 

structures and the crest of a ground upslope 200 feet short of the runway threshold. 

The aircraft continued onto the runway sliding 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 south side of the runway and the aircraft 

was subsequently destroyed by fire. 

NARRATIVE 

The mission progressed normally from takeoff through air refueling. Prior to descent the 

pilot briefed the TACAN penetration and precision radar final approach. A weather 

update was received indicating that the weather was below approach minimums. As a 

result the aircraft requested and received a clearance 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 RVR had risen to 2600 feet and cleared the aircraft to 6000 

feet then to 1700. The radar final controller established contact with the aircraft at 8 

miles from touchdown. The aircraft was properly configured for a precision approach 

with gear down and 50 degrees of flaps. The 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 descent 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 approaches at the pilot's home base. 

In a post-mishap interview, the pilot displayed 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 subsequent glide path advisories: "Slightly below," 

approximately 3/4 mile from runway threshold 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 lighting and the pilot became preoccupied with crosswind 

control. In response to several questions relating to the visual environment the pilot 

could only recall looking "real hard" at the lights. Neither pilot saw the green runway 
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threshold lighting; however, the embedded portion of the threshold lights was obscured 

by a low snow bank. The remaining approach/runway lights, including free-standing 

threshold lights, were operating and viewable from all approach angles. Once the pilot 

had allowed the excessive descent in poor visibility, 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 were on. The pilot's disorientation was 

further complicated by his perception that the runway began at the last row of red lights 

in the approach centerline light sequence. As the aircraft approached the red approach 

lights, which the pilot correlated with runway threshold, he raised the nose of the aircraft 

2-3 degrees in preparation for the landing flare. The pilot 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 copilot 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 lights on a lighting structure 368 feet prior to and 3.8 

feet below runway threshold height. The aircraft then struck another set of lights 284 

feet from the threshold. The major impact 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 airborne and settled to runway approximately 

275 feet beyond runway threshold and 7 feet left of centerline. The aircraft began to 

yaw and skid to right. The pilot attempted to go around, but was unable to move 

number 3 throttle and believed it to be in interlock. As the aircraft exited the runway the 

copilot retarded the throttles to idle. The aircraft then experienced a rapid nose right 

yawing motion like a jack-knife and the right outboard wing contacted an embankment 

and failed just outboard of the right wing junction. 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 allowed to continue unabated. Four of the five 

classic component of channelized 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 criterion was a significant factor. By the pilot's testimony, it 

was the worst weather in which he had ever flown an approach. 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 significant factor in that the pilot clearly did not follow 

prescribed procedures and techniques for transitioning slowly, as visual cues improved, 

from instrument to visual flight. 
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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 infer that he should be able to land. The 

pilot's anxiety and desire to land caused him to fixate on the approach lights. In his 

testimony the pilot related that his visual cues at some point suddenly stopped 

improving. By then, fear of not acquiring an acceptable 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 glide path vertical velocity 

and failed to stabilize the aircraft on the precision radar glide path. Just prior to 

decision height, he allowed the rate of decent to become excessive. 

2. At decision height the pilot's attention became channelized 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 from which the pilots were unable to 

correctly interpret approach and runway lighting through darkness and snow. 
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DEPARTED RUNWAY, BROKE UP, BURNED 

P & R

SUMMARY

A KC-135 aircraft returning from an air refueling mission at home base made a hard 

landing and bounced back into the air momentarily. The aircraft rolled and yawed while 

the aircraft commander attempted to regain control; he applied power to the aircraft but 

an asymmetric condition developed due to power on the number 4 engine not being 

fully advanced. The right wing contacted the runway and shortly thereafter the aircraft 

departed the runway. All four engines and their mounts were torn from the aircraft. The 

aircraft came to rest with the nose on the ground and the tail in the air. Passengers 

safely exited the aircraft moments before the aft body exploded and became engulfed in 

flames. Six crewmembers were fatally injured by fire and smoke and ten passengers 

successfully egressed. 

NARRATIVE 

The mishap crew's flight duty began with a minimum interval takeoff briefing. The 

aircraft departed in a two-ship KC-135A MITO/cell and conducted air refueling 

operations with two B-52G's. The mishap aircraft 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 activity 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 aircraft 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. The mishap aircraft arrived over the 

landing threshold at an altitude of approximately 240 feet AGL instead of the normal 

threshold crossing height of 48 feet. The initial touchdown occurred 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 approximately 25 feet. The aircraft re-contacted the runway 4,424 

feet down the runway (7,376 feet remaining) 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 and yawing back to the right. The aircraft 

commander was able to maintain essentially a wings-level bank attitude. However, after 

power was applied, an asymmetrical 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 nose 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 right wing tip and outboard aileron contacted the 

runway at this time, which was approximately six seconds after initial touchdown. Full 
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left aileron was applied as the aircraft continued to the right with the right wing tip still in 

contact with the runway. 

During the time the aircraft departed the paved 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 right 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 continued its left roll to 

where the left wing tip again contacted the ground and the bottom of the number 1 

engine scraped across a paved access road with enough force to fail the gear box angle 

drive on the bottom of the engine. 

The number 1 engine became inoperative, 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 rate of climb capability existed at this 

time. With the left wing tip in firm contact 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 the aircraft to the 

left, which severely crumpled the left side of the forward fuselage. Additionally, all four 

engines with their forward and aft mounts were 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 aircraft initially came to rest with the nose on the ground and 

the tail high in the air. Passenger egress started immediately via the aft emergency 

escape hatch. The ten passengers were observed egressing from the aircraft and were 

transported to the base hospital. Seconds after passenger egress, the aft body tank 

exploded and the tail section 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 aircraft 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 psychological factors were stressors for the 

aircraft commander. He was recently married and had just purchased a house. These 

factors reflect increased stress due to adjusting 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 than required under the terms of 
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his waiver. With substandard correction the 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 landing problems throughout his career. 

There is evidence to support the claim that the mishap aircraft commander would allow 

deviations from standard operating procedures and flying regulations. 

CONCLUSIONS - FINDINGS 

The basic cause of this mishap was pilot error. 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 found to indicate that any member of the crew attempted 

to influence the aircraft commander to make a go-around. The pilot probably would not 

attempt to interfere with the aircraft commander's approach and landing. 

Following two firm touchdowns and high bounces the crew attempted a bounce 

recovery. The rapid departure from the runway 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 the aircraft came to a stop the crew was 

incapacitated. 

1. The mishap unit's internal review process was not effective in identifying the 

mishap aircraft commander's landing problem as severe or recurring. 

2. Although squadron supervision identified landing problems and despite several 

marginal flights with instructors, they considered the mishap aircraft commander 

qualified and safe and allowed 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 pilots delayed the bounce recovery until after 

the second bounce. 

5. During the bounce recovery, the pilots failed to advance the number 4 throttle, 

which led to an asymmetric thrust situation. They also failed to apply correct 

flight control inputs. 
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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) was 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 waiting 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 four-ship resulted in his flying 

toward rising terrain. Bank angle at impact indicated the pilot was pulling sufficient G to 

impair his peripheral vision, which may have contributed to his failure to see the rising 

terrain as he attempted to retain sight of the flight. The right wing hit a ridge 10 feet 

below the crest, and the rest of the aircraft impacted 750 feet beyond. 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 1539 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 aggressor background. He had demonstrated a 

history of sound judgment and decision-making and all supervisors 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 this 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 down and he failed to clear his flight path. It was also 

determined that the MP failed to see the rising 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 masked speed rush cues of an impending ground 

impact. 

CONCLUSIONS 

This very responsible, very capable pilot channelized his attention solely 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 fatally injured on ground 

impact. 
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COLLISION WITH GROUND 

CHANNELIZED ATTENTION, PRIORITIES, COMPLACENCY

NARRATIVE

The mishap pilot (MP) was the instructor for a two-ship A-10 Replacement Training Unit 

(RTU) surface attack sortie. Prior to the 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 ridgeline, clipping the right wing and the tail. 

Realizing the aircraft was out of control, the mishap pilot ejected, 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 expected from a wingman. He allowed his 

technique to distract him from his responsibility of instructor/chase in his attempt to fly a 

precise formation; situational 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 combination of channelized 

attention, geographic mis-orientation, complacency and task prioritization. 

Reconstruction and testimony from the MP suggest channelized attention was the most 

significant factor in the MP's failure to acquire the ridgeline in the three miles prior to 

impact. The MP stated that he monitored the student throughout his reposition 

maneuver to wedge formation. In his attempt to fly precise formation, the MP 

channelized his attention on the student. 

An explanation for the MP's lack of concern with his flight path is geographic misorientation. This would account for the MP's perception that the flight 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 the student's flight path in relation to the high terrain. The 

MP was not aware of the ridge line in his flight path, and his mis-orientation led to a lack 

of concern with the high terrain. The possibility 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 prioritization. The MP failed to allot adequate 

time to terrain clearance tasks in his attempt to fly precise formation and monitor the 

student. 
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CONCLUSIONS 

This conscientious, well motivated instructor 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. 
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COLLISION WITH GROUND 

CHANNELIZED ATTENTION

NARRATIVE

The flight was briefed as a four-ship surface attack mission with a planned low altitude 

tactical navigation route to a range for standard 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 mishap and the mission was briefed 

on the day of the mishap. Following the MP's last strafe pass, the MP made a normal 

pull off and began a left turn out. The aircraft impacted the ground approximately 16 

degrees nose down in a 45-degree 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 trained, and in good health. Airborne Tape Recordings (AVTR) 

revealed that the amount and length of commentary 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 were that the MP wanted to see number 2's 

firing burst and was looking back as he apexed in his pulloff, channelizing his attention 

and did not recognize a high sink rate developing as he maintained 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 engrossed with watching his number 2's 

performance that he forgot to fly his own aircraft and flew into the ground. 
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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 Mishap Crew (MC) was to 

increase their spacing to 4 NM in preparation 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 with 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 "reducing 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 the low level, using visual references, the MP apparently 

became comfortable in a position 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 taking spacing. The MP would have been forced to fixate on lead 

to maintain a visual when getting further back in trail. Keeping lead at the same 

reference point on the windscreen during the deceleration and spacing 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 the ground. The MC instrument cross check 

and crew coordination broke down. 

The Mishap Weapon Systems Operator (MWSO) 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 most likely channelized his attention on refining 

the radar for the delivery. 

The mishap occurred on the last day of an Operational Readiness Exercise (ORE). The 

flight lead briefed not to let their guard down. The MC could have been fatigued. 

CAUSE FACTORS OF THE MISHAP 

The aircraft mishap board's findings as modified by subsequent endorsers were that the 

crew caused the mishap. The MC's attention 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 altitude control at low altitude. 
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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 visual references, which he incorrectly 

perceived to be nearly level with the lead aircraft. During the spacing maneuver and 

descent to final run-in altitude, the MP most likely continued to use visual references 

from the lead aircraft for azimuth and elevation information. Using visual reference 

exclusively, the MP would have experienced a visual illusion perceiving that he was 

nearly level with the lead aircraft while in fact he was lower than lead and descending. 

The MP most likely channelized his attention on the lead aircraft while the MWSO 

channelized his attention on the radar. Neither crewmember properly monitored flight 

instruments. A breakdown in crew coordination occurred, which allowed the aircraft to 

descend below the planned run-in altitude and the MAJCOM-directed minimum night 

weapon delivery altitude. Neither crewmember attempted to recover the aircraft or 

initiate ejection. 

CONCLUSIONS 

The MC did not properly coordinate their responsibilities during a very critical phase of 

flight. Both crewmembers channelized their attention and this precluded either from 

recognizing their shallow descent into the ground. 
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CONTROL LOSS, EJECTION 

LACK OF COMMUNICATION, COORDINATION

NARRATIVE

Mishap aircraft and crew were deployed to provide mission support (adversary air) for 

C-130 Low Altitude Air Threat Awareness Training (LOWAT). The mishap aircraft was 

configured with a centerline fuel 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 impacted the ground seven minutes after takeoff. 

HUMAN FACTOR ANALYSIS 

The mishap pilot (MP) as a 27-year-old with 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 participation in unit activities. 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 had been counseled for losing his LOWAT 

currency 3 times and landing currency 4 times in the previous 12 months. 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 LOWAT sorties in the previous 4 months for an 

indicated total of 5 LOWAT sorties. The MP was not current/qualified for the mission; 

however, this was not evident to the training officer. Based on the 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 Operator (MWSO) was a 39-year-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 falsely recorded training events, most likely in 

an effort to prevent more confrontation with his supervisors over a low level of 

participation in his flight 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 with C-130s previously and was scheduled on 

this deployment in an attempt to get his sortie count up. The MC allowed the aircraft to 

slow below minimum Dash One recommended minimum maneuvering airspeed and 

started a decent. Improper crew coordination and channelized attention accounted for 

the ignored indications of a slow airspeed and excessive decent rate. The MP, having 

recognized and reacted to the altitude loss, improperly applied flight controls and power 
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resulting in a stalled aircraft. The stall developed 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 flight training records led to his being scheduled to fly a mission 

for which he was not qualified. During a basic flight maneuver, 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 reaction to stop the descent rate resulted in the aircraft being 

stalled and subsequently departing controlled flight. 
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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-speed 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 before making their first high-speed pass (estimated 

650 KIAS, 150 feet AGL). During the transition turn for a slow-speed pass, the tower 

informed the MC that a part had fallen off their aircraft. The MC configured the aircraft 

and flew the slow-speed pass as low as 50 feet AGL and as slow 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 high-speed pass, the aircraft was maneuvered 

(overshooting centerline) into a position from which recovery 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 wing-training officer with 1,270 hours total 

flying time, 1,000 hours in type. Normally, 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 another 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 putting 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 errors. 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 available. Squadron supervisors had come to consider 

this airshow mission as commonplace and had not briefed the MC. 

The guidance from USAFE required the following: weather required 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 units); altitude minimum was 

500 feet (150 feet and 50 feet flown). 

Although the MC violated the USAFE airshow restrictions, there is no indication they 

were aware of them. They were, however, aware of the standard restrictions that they 
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violated, including the restriction 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 modified by subsequent endorsers were that the 

pilot's lack of discipline and the lack of proper guidance by the supervisors caused the 

mishap. The MP was also named causal for demanding more from the aircraft than it 

was aerodynamically capable of attaining. In addition, the inexperienced MWSO most 

likely did not provide any input as the mishap 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 the aircrew with sufficient information or 

guidance to perform their mission. The MP displayed uncharacteristic behavior and 

lack of discipline by electing to fly an aircraft with a suspected malfunction and by 

violating known directives. The MP aggressively maneuvered below a reasonably safe 

speed at low altitude. That maneuvering caused the loss of control of the aircraft. The 

MWSO apparently did not attempt to prevent the MP from continuing the airshow or 

from exceeding the capabilities of the aircraft. There were communications breakdowns 

at all levels. 
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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 part of his TX syllabus RTU program. 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 extensively 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. Start, 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 hold 350 KIAS and start a climb and that they 

would do a scissors exercise from this point without 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 resulting impact killed the IP instantly; rendered 

MP number 2's aircraft uncontrollable from which 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-old 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 "best 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 Eval visit. During his off time he was 

pursuing a masters degree, was 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 symptoms the day before and had taken himself off 

the flying schedule. The investigation board determined the IP had less than 13 hours 

sleep during the previous 48 hours. 

Both pilots violated known directives. The IP exceeded guidance in the syllabus by 

using more power than called for in the maneuvers 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 who did not know what to expect 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 the 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 underlying competitive personality. 
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CAUSE FACTORS 

Supervision was faulted for loading down the 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 commitment, fatigue, and illness. The IP was faulted for breech 

of discipline due to the numerous violations of the syllabus. The MP number 2 was also 

faulted for judgment in that he also had a responsibility for stopping the final 

engagement, but allowed the scissor to progress below controllable airspeed. 

CONCLUSION

All members of a formation, regardless of position, are responsible for the safe conduct 

of every mission flown. Pilots are not super 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 reasons to follow the rules than to break them. 
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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 alert 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 for practice approaches. He was informed by 

the center controller that only the VOR was available at one of his requested bases due 

to other equipment being NOTAMED out of service. The pilot changed his request to 

stop at only the other base prior to continuing to his destination. Following completion 

of his MOA work, he proceeded to the intermediate 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 rushed, made a number of procedural errors, 

missed the approach, and was asked for his intentions by the controlling agency. The 

pilot, now clearly in the clouds, asked for a turn to remain VFR. The aircraft then 

impacted a hill approximately 2220 feet MSL while still on centerline 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 qualified for the mishap mission, a 

relatively undemanding one. During the investigation, the MP was discovered to have 

been receiving contact lens therapy from private 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 have had difficulty reading his approach plate, 

especially in darkened weather conditions. The pilot changed his original flight plan to 

induce a series of practice approaches at an intermediate base, but failed to check 

NOTAMS or weather as required. Flight planning was a factor. The pilot was violating 

longstanding directives regarding wear of contact lenses, was in the "red" for overdue 

annual survival training and was not wearing mandatory cold weather flying clothing. 

He changed his planned route of flight without coordinating with operations and 

indicated intent to fly VFR in violation of command and Air Force directives. He 

exhibited an air of complacency by not reviewing a relatively complex approach he was 

obviously not familiar with and electing not to continue immediately to his planned 

destination despite being advised of poor weather there. In an attempt to fly the 

approach anyway, he became task saturated, was unaware of his close proximity to 

high terrain, and impacted rapidly rising terrain. 
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CAUSE FACTORS 

Complacency, inadequate planning, discipline, lack of situational awareness, 

overconfidence, and a feeling of invulnerability all combined on this day in an error 

chain that led to this pilot's death and the destruction of his aircraft. Also faulted was an 

inadequate program to make pilots aware of hazards at local divert fields and an 

inaccurate depiction of the location of the mountain the MP hit. 

CONCLUSION 

This pilot had a long chain of discipline problems, complacency, and overconfidence on 

this flight. Similar tendencies had been previously 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, and 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. 
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UNAUTHORIZED FLY-BY, AIRCRAFT BREAKUP

SUPERVISION, DISCIPLINE, COMPLACENCY

NARRATIVE

The mishap pilot and his aircraft were sitting alert when he was scrambled on a routine 

practice intercept mission. During the mission, 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 flight. Prior to starting his 

engines, he spoke with the local supervisor of flying, advising him 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 align 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 afterburner engaged. The aircraft suddenly and 

violently broke up, burst into flames, and crashed, killing the pilot. 

HUMAN FACTORS ANALYSIS 

The pilot was 24 years old, on his first operational 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 problems. He was flying regularly and was 

qualified for the mission. Crew rest and duty day were not factors. 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 occurrence 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 proper configuration into the ACP, a conflict would have 

developed within the overload warning system (OWS) as it received signals from the 

aircraft fuel gauge of more fuel on board the aircraft 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 overload. The wings then failed at 

approximately 8.5Gs due to the high speed and high fuel weight. 

CAUSE FACTORS OF THE MISHAP 

The mishap was a result of improper wing level operations supervision, the pilot's 

preoccupation, complacency, or carelessness shown in regards to the impending high 

task fly-by, improper local supervision, lack of knowledge on the OWS, and lack of 

understanding by the mishap pilot of the relationship of low altitude, high speed, and 
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high weight to severely reduced G required 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 blood was spilled prior to the writing. Supervisors must 

supervise at all times. The reason supervisors exist is to aid young inexperienced pilots 

when they get into trouble. But, most of all, supervisors keep inexperienced pilots out of 

trouble until they can gain the experience necessary to keep themselves out of trouble. 

The regs are written for a reason -follow them. 
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COLLISION WITH GROUND IN NIGHT GCA PATTERN 

LOSS OF S/A

NARRATIVE

An F-16 pilot's instrument crosscheck broke down while descending to an assigned 

altitude during a night GCA due to low flying proficiency and an unknown distraction. 

Unrecognized spatial disorientation prevented the pilot from resuming his crosscheck 

and initiating a recovery until immediately prior to impacting the ground. A ground radar 

low altitude alert system was set to provide warning 200 feet below the normal IFR 

setting in order to avoid false alarms from day VFR traffic in the same area. Due to the 

descent gradient and incomplete radar coverage in the mishap sector, the mishap 

aircraft disappeared from the GCA radar screen prior to activating 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 relatively low UE time (181.6) and poor flying 

continuity (6/10 sorties in the last 60/90 days) indicated a likelihood of low flying 

proficiency. Supervisors were aware of the 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 deferred to the mishap pilot's judgment and 

allowed him to fly his first sortie in over three weeks on a night air refueling mission with 

hazy weather. 

CAUSE FACTORS OF THE MISHAP 

The mishap pilot's unrecognized spatial disorientation, which allowed him to continue 

his descent after his crosscheck broke down, was a cause of this mishap. Possible 

reasons listed for the unrecognized spatial disorientation were temporal distortion, loss 

of situational awareness, lack of visual cues or low flying/event proficiency. Supervision 

was not considered causal since the mishap pilot was basically his own supervisor. The 

mishap pilot's crosscheck breakdown was not considered causal since it was a fairly 

common occurrence that would normally be detected and overcome well prior to ground 

impact. The ground radar low altitude alert system setting discrepancy and lack of a 

radar altimeter were not considered causal; while either might have prevented the 

mishap, they did not cause the deviation from desired flight 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 broke down during a descent in the GCA pattern 

and the mishap pilot did not detect and correct the breakdown in a timely manner. 
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Warning systems (GCA radar low altitude alert 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 operational at the time of the mishap, and did not provide a 

warning. 
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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 fuel master switch to the closed position, closing the main 

fuel shutoff valve. The engine flamed out, the mishap pilot was unable 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 delayed 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 directed to open the air 

refueling door (depressurizing external fuel tanks) and activate tank inerting (reducing 

internal fuel tank pressures) IAW the landing gear up landing procedure as a precaution 

in case the nose gear collapsed on landing. The mishap pilot attempted to activate both 

switches without visually confirming 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 tank 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 interference while attempting to move the tank 

inerting switch to tank inerting. The mishap pilot's delay in completing applicable 

portions of the landing gear up landing checklist since he considered the problem to be 

with the indication system was not causal, but did place the pilot in a position where he 

had to accomplish the checklist while simultaneously flying the straight-in approach. 

The pilot's decision to activate the required switches without visual confirmation was 

probably a technique to avoid task saturation while continuing the approach. 

CONCLUSIONS 

The mishap pilot attempted to complete required 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 fuel master switch operational ground check 

habit pattern and inadvertently closed the main fuel shut-off valve instead of activating 

the adjacent tank inerting switch. 
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COLLISION WITH GROUND 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. After 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 deviate 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 revised egress route/plan. The mishap pilot 

allowed his aircraft to enter IMC in the vicinity of high terrain, then elected to press 

ahead in hopes of regaining VMC instead of route aborting to a pre-briefed altitude 

which would maintain terrain clearance. The 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 clearance. 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 factors. 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 pilot's failure to modify course to maintain 

VMC during the egress while attempting to regain visual contact with his element lead. 

However, while not a desired outcome, going IMC did not cause the mishap. Failure to 

follow established weather route abort procedures by initiating a climb to the pre-briefed 

route abort altitude caused the mishap. Peer 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-flight supervisors might 

have helped the mishap pilot avoid his fatal error, but they chose to follow briefed min 

comm procedures to avoid saturating available frequencies, reasonably assuming that 

all attacking pilots would recognize and act on the need to deviate from course to 

maintain VMC during the egress. 
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CONCLUSIONS 

The mishap pilot mis-prioritized tasks during 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 (flight leads) might have built their flight 

member's situational awareness and been a more tactically effective force had they 

elected to make a directive modified egress radio call, but it was not reasonable for 

them to anticipate the mishap pilot's dangerous mistakes during the egress. 
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COLLISION WITH GROUND 

DISCIPLINE, JUDGMENT, LOSS OF S/A

NARRATIVE

The scheduled mission was a night, three-ship, flight lead upgrade sortie for a young F111 pilot and his WSO. One aircraft aborted prior to takeoff, but otherwise the mission 

went as briefed until the night range work. The plan was to use TFR for 400 feet AGL 

level passes. The mishap crew had TFR system problems (aircraft had history of TFR 

problems) and called off "dry" on the second pass. On the third pass, the RCO 

observed the aircraft descending below 400 feet and transmitted, "Pull up, pull up, pull 

up" but the crew did not respond and flew into the ground. Both were fatalities. 

HUMAN FACTORS ANALYSIS 

The mishap pilot was a 28-year-old Captain with 1333 total hours and 385 in the F-111. 

The mishap WSO was a 27-year-old Captain with 919 hours total with 800 hours in the 

F-111. The pilot's history was 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 the opposite in personality. He was considered quiet 

and passive, but still a competent WSO. Investigation revealed the crew elected to 

hand fly the last pass at 400 feet AGL, in direct 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. Regulations require passes at MEA without the 

use of TFR. In spite of the lack of TFR, the crew did not use available aids such as the 

altimeter, radar altimeter and VVI to maintain their situational awareness. It is most 

likely that the MP was looking outside for visual cues on the range and did not perceive 

the shallow descent to ground impact. The 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 the cause factors of this 

mishap. Hand flying below MEA was a conscious decision to violate 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 discipline and judgment and finally the lack of 

awareness that led to flying a good aircraft into the ground. 
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RAPID FUEL DEPLETION, EJECTION 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. Approximately four minutes later, the AC shut off the 

affected engine and on short final the IWSO finally pushed the fire pushbutton. The AC 

configured the aircraft late and crossed the runway threshold excessively fast in idle 

power. Due to excessive demands on the hydraulic system, the aircraft pitched down 

striking the nosegear first and porpoising into 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 with 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 perceived 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 before running out of fuel 

that he failed to accomplish important emergency and landing checklists. The IWSO 

concentrated exclusively on the 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 subsequent endorsers were 

that logistics, channelized attention, situational awareness, task management, task 

saturation, habit continuation and crew coordination were factors in this mishap. 

Logistics, channelized attention and failure to accomplish required checklists were the 

primary cause factors. 

CONCLUSIONS 

This mishap is a good example of why a checklist can be so important during an 

emergency. It allows the crew to methodically solve an aircraft malfunction during a 

high stress situation. Unfortunately, the crew took too long to do one checklist (fuel 

depletion) to the detriment of other important checklists (land/single engine). Rushing 
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the approach, not monitoring aircraft performance and forcing the landing even though it 

should have been taken around put this flyable aircraft in an out-of-control situation. 
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LOST CONTROL/IMPACTED TERRAIN 

CHANNELIZED ATTENTION, PRIORITIES

NARRATIVE

During the low level, target egress phase of a mission, an F-111 began maneuvering to 

defeat ground threats. Aft wing sweep, continuous max performance turns at or near 

stall warning and an insufficient power setting caused the aircraft to bleed off more than 

250 knots. The crew initiated a left rolling ridge crossing at a low airspeed and departed 

controlled flight while attempting to roll out and pull up for the next ridge. The crew 

ejected out of the envelope and 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 flown together many times. A review of 

AVTR tapes revealed that the crew was concentrating solely on the threats and their 

reaction to them. Their concentration was so channelized that they failed to recognize 

the decaying aircraft energy state. Habit patterns developed in the European flying 

environment may also have contributed to the mishap. Restrictions on afterburner use 

in Europe and the crew's technique of routinely pulling to the stall warning at sea level 

density altitudes could have led the crew to overestimate their energy state. The right 

seater, an IWSO, failed in his primary task as an in-flight supervisor when he didn't 

monitor aircraft performance. He was so intent on directing the 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 subsequent endorsers were 

that channelized attention, misperception of low level visual cues and task prioritization 

caused this mishap. The MP failed to recognize a 175-knot loss of airspeed in a 28-

second period prior to departing controlled flight. He was so intent on performing threat 

reactions that he didn't notice the aft wing 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 monitoring aircraft control. Finally, the MP 

attempted a nose-low ridge crossing with insufficient 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 primary flight duty: 

MAINTAIN AIRCRAFT CONTROL. 
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IMPACTED TERRAIN AFTER SINGLE ENGINE GO-AROUND 

CSF'S, STRESS

NARRATIVE

The mission was a cross-country navigation-training 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 maneuvered the aircraft 

to accomplish a single-engine overhead pattern and landing. On the downwind leg, she 

angled toward the runway resulting in an overshooting 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 runway. The IP and student 

ejected and were fatally injured. The aircraft impacted the ground and was destroyed. 

HUMAN FACTORS ANALYSIS 

The IP was relatively inexperienced with 530 total flight hours. She was considered to 

be below average in flying skills, but was fully qualified. She had recently experienced 

several medical problems and was scheduled to undergo surgery several weeks after 

the mishap date. Outwardly, she appeared to be happy and well adjusted, but was 

most likely under significant internal stress. The student pilot had approximately 66 

hours of flying time and was described as below 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 spacing. She made a 

timely decision to initiate what appeared to be a successful go-around then apparently 

decided to attempt a landing near midfield. This decision was reversed at low airspeed 

and altitude. She reestablished level flight then 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 illuminated for an undetermined reason. The IP accomplished 

appropriate emergency procedures and attempted to land via a single-engine pattern. 

She flew an angling downwind that resulted in an overshooting final turn. She then 

inappropriately discontinued her go-around and made a second attempt at landing. For 

an unknown reason, she discontinued that attempt at low airspeed and altitude and was 

unable to accomplish a successful go-around. 
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CONCLUSION 

The IP was faced with a serious emergency immediately after takeoff. Her initial 

reaction was correct but, the improperly flown 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. 
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FLIGHT CONTROL MALFUNCTION, EJECTION 

IMPROPER ANALYSIS, LACK OF COMMUNICATION

NARRATIVE

The mishap occurred during an undergraduate pilot training formation sortie. A solo 

student was flying the mishap aircraft. On takeoff the aircraft pitched up, then, as flaps 

were retracted, pitched down. The formation continued to the working area where after 

coordinating with the Supervisor Of Flying (SOF), the student 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 informed the IP that during takeoff the aircraft 

pitched up then down. The IP responded by asking, "Is that what happened, did it pitch 

up when you retracted the flaps?" The student 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 there would be any control 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 supervisory error caused this mishap. 

The T-38 flight control system incorporates an interconnect device between the flaps 

and horizontal tail which compensates for the change in tail position required when flaps 

are extended or retracted. Maintenance technicians failed to connect the interconnect 

cable during maintenance accomplished immediately 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 analyze 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 misanalysis of the problem 

and inaccurate direction provided by the SOF. 
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CIRCLING APPROACH, COLLISION 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 precision 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. There 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 undergraduate pilot training (UPT) student with 152 

hours of flying time. There were no deficiencies found in the student's training and 

since the IP was flying at the time of the mishap, the student's performance in UPT was 

not considered a factor. The IP was relatively inexperienced but fully qualified. His 

flying skills were average to slightly below average. He was described as "very sharp" 

with outstanding book knowledge. His approach to flying was an attempt to capitalize 

on his superior mind by mentally constructing a series of preplanned responses to 

situations. This made him more mechanical and slowed his development in aircraft 

"feel" and "air-sense." 

A circling approach is flow infrequently and allows little time to establish a course and 

glide path. The pilot is much more likely 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 the time of the mishap were limited 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 identified the IP as causing this mishap. He 

misjudged the base turn of the circling approach and overshot to a degree that 

interception of the final approach course could only take place well inside the desired 

roll out point. He then failed to initiate a go-around. Possible factors include impaired 

judgment due to fatigue and lack of recent food intake, overconfidence in his ability to 

complete the approach due to previous success 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 angle of attack until there was insufficient 

altitude to recover. 
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CONCLUSION 

This IP was confronted with a poorly flown circling approach. Several factors probably 

induced him to attempt to salvage the pattern and complete the landing: the low fuel, 

personal pride, etc. Because his judgment was impaired and/or due to his limited air 

sense and feel for the aircraft, he was late to recognize the hazardous situation develop. 
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RAPPELLER KILLED DURING DEMO 

POOR AIRCREW COORDINATION 

NARRATIVE

During a rappelling demonstration one rappeller 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 rappelling 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 prior to the mishap. The Crew Chief (CC) 

had a total of 475 hours in the UH-1N, with 7 prior rappelling missions. The HAC gave 

the CC final authority for all cabin 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 ground safely. Once they were 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 one 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 the ICS. The copilot at the controls (PAC) 

transitioned to forward flight at the direction of the PIC. The SIO, RM, and CC still had 

tension on all ropes. All four rappellers were still attached to the ropes. The two aft 

rappellers were taken airborne as they applied their rappel brakes 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. The 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 aircraft landed and assumed the role of medical 

evacuation aircraft, transporting the two injured to the naval hospital. The fatally injured 

man died of blood loss during surgery 4 hours later. 

The focus of such missions is on speed since these demonstrations are for recruiting 

purposes. The idea is to impress viewers with 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 tactical image without literally violating safety procedures is 

high. 
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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 pilot informed of mission progress. The PIC, 

CC, and SIO were also faulted for maintaining a perceived sense of urgency during the 

mission. The squadron and battalion were both blamed for supervisory error in failing to 

comply with the ASH manual and SOP. The battalion was further cited for failure to 

revise the SOP containing an unsafe practice. The squadron was mentioned for 

assigning a PIC who was unqualified as an instructor to conduct an instructional flight. 

Supervisory error was also assigned to the division 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 the RM, SIO, and CC were not clearly delineated in the brief. 

The lack of standardized terminology exacerbated 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 said he heard. The perceived 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 replacement of the instructor pilot with the 

less experienced HAC. The mission continued without the full complement of gunner's 

belts for everyone. The rigging used in the rappel was nonstandard. All four 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. This also enhanced the appearance of speed in the rappel. 

However, this left them in a position from which it was more difficult to apply brakes. All 

three members of the cabin crew turned their attention inside to release snap links 

before ensuring the rappellers were free of the ropes. Finally, the pilot's cursory glance 

to the rear and order to go evidenced urgency. 
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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 having problems with interpersonal relationships, not getting 

along well with his superiors and peers. A loner, he exhibited all the symptoms of a 

failing aviator. Two weeks prior to the mishap, 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 crisis. 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 the pilot of another 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 alternated at the controls. 

High angle of bank maneuvers, descending below 100 feet at high airspeeds, were 

employed. Gusty winds at better 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 could 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 the mishap were aircrew error and supervisory 

error. The aircrew was assigned blame for failure to maintain safe indicated airspeed, 

using incorrect control inputs, and engaging in unauthorized, unbriefed maneuvers. The 
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base CO was assigned supervisory error for failure 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 safe flying conduct of his flight crews. The 

mishap pilot's referring flight surgeon was also assigned supervisory error for failing to 

take appropriate action with a failing naval aviator. The CO of the local Naval Hospital 

was also named for failing to provide the flight surgeon with the opportunity to routinely 

interact with the pilots assigned to the base. 

CONCLUSIONS 

There is a serious deficiency in the way aviators with psychiatric problems are handled 

in the Navy. This mishap is not the first example of this mishandling. Aviators are very 

reluctant to go to a flight surgeon with problems of a psychiatric nature. When they do, 

no one knows how to handle them. Navy medicine is only prepared to deal with 

psychologically healthy aviators. The rare aviator with problems of this nature is not 

always referred to a flight surgeon psychiatrist, but frequently is sent to clinical 

psychologists or others who have no aviation medicine background. Typically, these 

specialists do not inform the individual's command for fear of breaching the trust implicit 

in the doctor-patient relationship, and because they do not feel the problem is a serious 

one for aviators. Normally they refer these patients to stress management training or 

therapy without any follow-up. The situation is a very delicate 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 assigned to fly their aircraft. 
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WIRE STRIKE AT NIGHT DURING NVG TRAINING 

COMMAND AUTHORITY

NARRATIVE

A UH-1N struck power lines while conducting a Night Vision Goggle (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 proficiency, particularly at 

night on NVGs. He had been under pressure due to his collateral duties in the 

squadron. He was known for his harsh treatment of subordinates. Three weeks prior to 

the mishap he had a run-in with his mishap crew chief in which he implied that the crew 

chief was trying to sabotage his controls when 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-old 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 prior 4 months, fatigue was becoming evident 

among squadron members. The detachment was bivouacked in the "boonies" while 

their squadron mates were enjoying shore leave in a foreign country. 

The mishap crew briefed a two-helo section NVG mission in support of a night training 

exercise. The mishap aircraft did not have an OMEGA navigation system installed. 

The wingman's responsibility to assist in navigation to ensure the flight 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 interfere 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 lost and the wing had to call 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 the first flight, the MP strode over to the 

wing aircraft and verbally reprimanded the two junior wing pilots and their crew chief for 

violating radio discipline. The wing pilots noted 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 coordination. Specific aircrew duties and 

responsibilities were not discussed IAW SOP. The section took off a second time. The 
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section proceeded to get lost. The wing copilot told the wing pilot (WP) that they were 

flying "off the top of the map." After watching the lead make two course 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 discipline...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 started a climb and simultaneously saw sparks 

from the impact of the lead with wires. 

CAUSE FACTORS OF THE MISHAP 

The aircraft mishap board and subsequent endorsers concluded that the cause factors 

were: (1) aircrew error - mishap crew -loss of situational awareness; (2) aircrew error - 

mishap pilot - PIC failed to exhibit proper judgment and aeronautical leadership; (3) 

aircrew error - mishap wingman -lack of crew coordination; (4) aircrew error - mishap 

wingman - loss of situational awareness; (5) supervisory error - type commander - lack 

of adequate self-contained navigational equipment; (6) supervisory error - Model 

manager - failure to include RMI alignment in pre-takeoff checklist. 

CONCLUSIONS 

Communications is a two-way process involving a sender-communicator and a willing 

listener. Aircrew who are not open to criticism of their flying and navigating are not 

professionals. Aviation has no place for non-professional behavior. Lack of crew rest 

and stress could have led the MP to react 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. 
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COLLISION DURING MOUNTAIN FLIGHT 

OPERATING STRATEGY 

NARRATIVE

A UH-1 was on a search-training mission in mountainous terrain. Rotor RPM was lost, 

and the anti-torque system became ineffective during an approach 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, with 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 type. He was not trained in mountain 

flying operations. 

The crew was assigned a mission to take a seven-person search team to a site in the 

mountains and drop them off. The search team was going to look for an aircraft that 

had crashed several months earlier. The HAC, copilot, crew 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 data. 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 another landing site at an altitude of 11,800 feet MSL, 

where the three members of the 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 search team. Returning to the landing site, 

the copilot told the crew chief to drop a smoke grenade to determine the wind direction. 

The smoke indicated the wind was generally from the west and the velocity was light. 

The copilot began an approach to the west 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, the HAC took the controls 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 initiated, but the aircraft 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 collective to gain RPM as the aircraft spun 

toward lower terrain. 
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When the HAC realized the aircraft was going to hit the trees regardless of his flight 

control inputs, he decelerated to dissipate forward airspeed and pulled all remaining 

collective pitch to cushion the impact. The aircraft hit several trees during the descent, 

severing the tail boom. Continuing to turn, the aircraft hit two trees about 2 1/2 to 3 feet 

in diameter and 60 to 70 feet tall. 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 injuries, and the other two sustained bruises and 

abrasions. 

CAUSE FACTORS OF THE MISHAP

The HAC did not re-compute landing data after significant changes had occurred that he 

knew would affect aircraft performance capabilities. On the second insertion, there was 

one more passenger with his survival equipment, as well as 50 additional pounds of fuel 

on board. The air temperature at the high altitude-landing site had increased during the 

1 1/2 hours between insertions. Regulations require re-computation of performance 

data when load and/or environmental conditions change significantly. 

The HAC attempted a second approach to a pinnacle after the copilot had aborted the 

first approach because of inadequate engine power. The second approach was 

attempted without re-computing aircraft performance 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 altitude, caused him to become hypoxic and 

make what was for him uncharacteristic errors 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 established training program for mountain qualification, there is 

inadequate regulatory guidance 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 qualification. Neither is there a requirement for an 

aviator to demonstrate proficiency in planning or performing a flight into mountainous 

terrain to an instructor pilot/standardization instructor pilot during the Annual Aviator 

Proficiency and Readiness Test evaluation period. 
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FLEW INTO SEA AT NIGHT 

DISTRACTION 

NARRATIVE

A CH-46 impacted the ocean after a pre-dawn takeoff from spot 2 on an LPH, following 

a passenger pickup. The aircraft never gained more than 90 feet of altitude. It made a 

wings-level descent into the water. The entire flight lasted 12 seconds. After water 

entry, it rolled left and sank immediately. The pilot, crew chief, and 13 passengers were 

killed. Twelve of these passengers drowned without sustaining 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 flight 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 misrepresentation on the part of unknown parties, he 

had never finished his initial Carrier Qualifications (CQ). Prior to the mishap, he had 

been in bed only 6 hours, but he didn't sleep well, 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 reflection of the overhead console 

lights. It was later determined that neither pilot had adequate instrument training, 

specifically ITO training. The tower cleared the helo to lift off and switch radio channels 

to the center frequency. Immediately after liftoff the pilot, to the copilot's surprise, 

looked down and changed frequencies. The copilot was still looking up the frequency 

on his kneeboard, intending to switch it himself, when he realized impact was imminent. 

He attempted to grab the controls, but was too late. 
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CAUSE FACTORS OF THE MISHAP 

The mishap was closed out as due to aircrew error because of a lack of crew 

coordination (aircrew performing inappropriate duties) and a loss of situational 

awareness. Also, the pilot did not employ proper flight techniques for existing 

meteorological conditions. Undetermined personnel were assigned error in that a 

misrepresentation of qualifications had taken place. The squadron was assigned 

supervisory error due to their failure to determine the qualifications requirements of 

assigned aircrew. The squadron was also blamed for failure to channelize commonly 

used shipboard frequencies and failing to ensure 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 supervisors to get into a situation they could not 

handle. The lack of a procedure for determining 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 Garrett (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 crashworthy cabin and seats would have saved 

the pilot, crew chief and the passenger acting as first mechanic. 
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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 were lost at sea. Eight passengers 

survived. Two obtained broken bones; the rest suffered various contusions, abrasions 

and lacerations. 

HUMAN FACTORS ANALYSIS 

The mishap helicopter aircraft commander (MHAC) was a 27-year-old 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. Less 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 Designated Naval Aviator for one year, and had joined the 

squadron 10 months before as the 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 expressed concern the day 

before and the day of the mishap to roommates and the 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, although it was a dark night with no horizon. At 

the time of takeoff, the Air Boss noted that the MA's red dome light was still on. He 

decided to wait until the MA was safely airborne before informing the aircrew. Takeoff 

and initial climbout were observed to be shallower than the other two helos. About 5 

seconds after takeoff the Air Boss cleared the 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 continued, and about 28 seconds after takeoff, the MA impacted 

the water about 350 yards abeam the ship. 
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CAUSE FACTORS OF THE MISHAP 

The conclusion of the Aircraft Mishap Board and subsequent endorsers was that the 

mishap was caused by pilot and copilot error, spatial mis-orientation and a lack of crew 

coordination. 

CONCLUSIONS 

The probable mishap scenario occurred as follows. Takeoff was behind schedule, two 

other helos were circling, awaiting their departure. The MHAC probably wanted to get 

on with the mission, since they had been preparing 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 could not see outside the cockpit since the 

canopy was reflecting red light. He then glanced quickly up to the dome light switch at 

the same time that the ship's tower called him. The MCP probably also looked up at 

that moment to turn the switch off. The MHAC then checked his 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 aircraft's lighting configuration to back up the 

MHAC on the flight instruments. The MHAC let himself get distracted at a critical phase 

of flight, at night, at low altitude. Poor instrument procedures in what was, in fact, an 

instrument takeoff, complicated by poor crew coordination, led to spatial mis-orientation 

and controlled flight into the water. 

If proper crew coordination had been utilized, communication between the MHAC an the 

MCP would have been established to ensure completion of the takeoff checklist. The 

MCP would not have let the MHAC hurry him. But the personalities of these pilots 

blocked this kind of communication. The MCP was reticent, building confidence, aiming 

to please the MHAC, so he wouldn't have complained that he was being rushed. He 

should have been backing up the MHAC on instruments and waited to get the light 

switches after they had established a positive rate of climb. The crew chief and 

observer could have interrupted the chain of events by warning the pilots of their low 

altitude. 
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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 had 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 total of 5 downs. Immediately upon completion 

of flight training, he was given a 6-month non-flying assignment, 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-minute brief and a 4.6-hour training flight on 

mountain procedures. 

The H2P was a 25-year-old Marine 1st LT who had 506 hours of total flight time, 380 

hours in type. He was a bachelor and had just returned from a disappointing liberty 

weekend, filled with various annoying hassles. He had not eaten in the 12 hours prior to 

the mishap. 

In following immediately behind the lead aircraft, the pilot put himself in the most likely 

position to encounter wake and rotor turbulence. 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. Practicing combat conditions, the aircraft would 

have to minimize time close to the ground, 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 the 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 trees go by the cockpit. Visual illusions and loss of normal 

perceptions are always present in mountain flying. The clear 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 closing speed compared to on flat, level ground. 

CAUSE FACTORS OF THE MISHAP 

The mishap is being closed out as due to aircrew error. The pilot used poor judgment in 

attempting to approach and land without due regard to the lead aircraft's wake/rotor 

turbulence. The copilot showed a lack of crew coordination in failing to alert the pilot 
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that the aircraft was entering 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 probably had little to do with the outcome of 

the mishap. Perceived pressure to perform, a lack of crew coordination, and visual 

illusions were the big factors here. 
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FLEW INTO SEA AT NIGHT 

SITUATIONAL AWARENESS

NARRATIVE

A CH-46E on a night flight flew into the sea and crashed. The pilot had just enough 

time to take one last breath of air prior to the cockpit filling with water. Disoriented as to 

up and down in the dark, he inflated his LPU under 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 was 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 inadvertently 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 below 500 feet and within 5 miles of the beach. Spotting a 

fixed wing aircraft flying directly 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 aircraft. 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 coordination, loss of situational 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 copilot and crew chief were also looking out 

the window and no one noticed the helo slowly losing altitude until water impact. This is 

a classic case of lack of crew coordination, where no one is "minding the store." 

Coupled with a loss of situational awareness at night, this is a dangerous combination. 
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FLEW INTO GROUND AT NIGHT 

FAILING AVIATOR 

NARRATIVE 

A CH-46E en route to a night vision goggle training area impacted mountainous terrain 

at night. Three aircrew members were killed instantly on impact. 

HUMAN FACTORS ANALYSIS 

The pilot in command was a 37-year-old Marine reserve Major with almost 3100 total 

flight hours, 2519 in type. Although the wing policy was to place 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 injuries indicates he was wearing night vision goggles, however. 

He was known to be under a significant amount of stress. During the week before the 

mishap he demonstrated symptoms of depression, anger, fatigue, indecision and 

difficulty concentrating and remembering details. 

Two years prior to the mishap he was removed as maintenance officer by his squadron 

CO and received a damaging fitness report. 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. Three months prior to the mishap 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 the 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 account and financial investments. Much of his marital 

discord stemmed from his relationship with his 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 the days immediately prior to the mishap he gave a great 

deal of thought and emotion towards the decision of a divorce. Two days prior to the 

mishap he picked up his wife to drive to their tax accountant in order to go over and sign 

their tax return. They got into the first 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 demonstrated outbursts of anger. During the 

brief for his last mission he neglected crew coordination, IFR procedures, navigation 

responsibilities and incorrectly briefed emergency procedures. It was apparent that he 

was preoccupied, significantly impairing his mental performance. He had a 13.5-hour 
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duty day at the time of the mishap and had worked 15 hours the day before. The 

copilot, a 33-year-old Marine Captain, was probably at the controls at the time of the 

mishap. He had 1827 total flight hours, 300 in type. He was 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 marriage. His only previous night vision goggle 

experience was flown the month before for 1.5 hours. He was 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 factors. 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 insist on course rules compliance and for 

waiver of the six-month probation period 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 time of the mishap. His briefing 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. 
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CRASHED ON SHIP/NIGHT SINGLE ENGINE LANDING 

STRENGTH OF AN IDEA 

NARRATIVE

A CH-46E carrying four crew and sixteen passengers experienced a single-engine 

failure due to oil starvation shortly after takeoff from an LHA at night. While executing a 

precautionary approach to the ship, the aircraft 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 with 1450 total flight hours, 1228 in type. 

He was using Night Vision Goggles (NVGs) at the time of the mishap. The copilot was 

a 26-year-old 1st LT with 844 hours 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 unsatisfactory performance on a similar mission two 

days prior. The 23-year-old crew chief has a reputation for being one of the top crew 

chiefs in the squadron. However, he was tired, having slept only 3 hours during the 36 

before the mishap. The enlisted berthing area was not conducive to daytime sleep for 

crewmembers who have to fly night missions. Announcements over the ship's intercom 

system, bell ringing, and daytime air operations, plus the fact that all hands were turned 

out at 0600 for field day, regardless if they were aircrew who had flown the night before, 

kept them from getting adequate rest. 

Crew chiefs had been working 12-18 hours per day, since a third of the maintenance 

department was assigned to various ship details. 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 occurred in the latter part of the deployment. 

Multiple errors were made due to the shortage 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 work 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 causing an inability 

to provide oil to the #1 engine. Since both 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 detected 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 observer, all concurred that the gauge had 

malfunctioned and opted to continue with the mission. Once airborne, the crew was 
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immediately notified of the engine problem by the air boss, 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 execute 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 listed 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, abetted by all other crew 

members, continued to operate an engine with a zero oil pressure indication. The pilot 

was faulted for failure to maintain single-engine airspeed and for performing a prohibited 

maneuver. The pilot and copilot were named for failure to execute single engine 

emergency procedures and for a breakdown of crew coordination. The crew chief was 

blamed for inadequate crew rest, failure to conduct a daily preflight, and inadequate 

troubleshooting procedures. The CDI was assigned maintenance personnel error for 

failure to properly inspect zonal area of maintenance action. The squadron 

maintenance department was included for failure to follow prescribed maintenance 

procedures as specified by OPNAVINST 4790.2D. The squadron CO was criticized for 

having no established system for monitoring and reacting to lack of adequate rest 

experienced by aircrew members scheduled 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 supervisory 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. 
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FLEW INTO SEA AT THE 90 

P & R 

NARRATIVE 

A CH-46E impacted the water during night deck 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 flight hours, 1376 in CH-46's. A month prior 

to the mishap he flew night FCLPs with a new copilot 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 considered 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 last night landing on a ship 

occurred 4 1/2 years prior. He was neither current 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 facilitate working interactions with his 

copilots. Because of this, some pilots asked not to fly with him. Divorced, he has two 

young children living several thousand miles away. His mother and other relatives had 

visited him immediately prior to the mishap. 

The 25-year-old Mishap Copilot (MCP) is a Marine 1st LT with 487 total flight hours, 215 

in CH-46 helicopters. He was on his first fleet tour following the TRACOM, where he 

had a number of problems coping in the aircraft. An average copilot, he is happily 

married. He is highly motivated towards the Marine Corps. He was scheduled to give a 

class to a group of enlisted personnel immediately prior to the brief on ship operations. 

His lecture ran over time, so he missed the briefing. 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 copilots who were scheduled for night deck quals. 

The MHAC would not be required to fly requals since he was erroneously thought to be 

qualified. After landing and disembarking passengers, he turned the controls over to 

the first copilot, who completed his required 5 landings. The MCP then replaced the 

first copilot. The MHAC, sitting in the left seat took a couple of minutes 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 NATOPS checklist, never did a complete NATOPS 

brief, didn't discuss aircrew coordination, the hazard of night flying with no horizon, nor 

instrument flight procedures. 

In deteriorating weather, with rain showers 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 MHAC, a little high abeam (350 feet instead 
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of 300 feet) close and a little slow (60 knots instead of 80 knots), decreased power and 

made a shallower than normal turn (15 degrees rather than 20-25 degrees angle of 

bank). Approaching the 90-degree 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 upsloping 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 normal turn and the wind coming from 110 degrees 

true, the MHAC felt as if they were going to overshoot. He attempted to correct by 

increasing his AOB to 20-30 degrees with no change in power. At this time the crew 

chief call "sink rate". The aircraft hit the water a moment later. LAWS were not installed 

in the aircraft. 

CAUSE FACTORS OF THE MISHAP 

The AMB concluded that this 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 flight. 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 listed for scheduling a non-proficient pilot for 

night carrier landing qualifications. The operations 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 the 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 calling 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 instrument scan led him into a trap. 
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FLEW INTO SEA AT NIGHT 

DISTRACTION 

NARRATIVE 

Returning from an night FAM/NAV hop to allow 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. The 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 flight hours, 528 in type. The H2P was a 

27-year-old LT with 722 total hours, 149 in type. These pilots had crewed together for 

about a month at the time of the mishap. Both 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 flight letdown when an opportunity to 

participate in a SAR presented itself and they both became preoccupied and task over 

saturated. The HAC was probably overconfident in the H2P's capability since they had 

flown together a good bit, and had completed 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 instrument flight, while the copilot failed to 

monitor instruments and assist the pilot at the 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 concentrated on the MPD. The entire three-man 

crew developed cockpit fixation trying to locate the SAR position and get ready for the 

SAR effort. 
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FLEW INTO SEA/UNAUTHORIZED AIR SHOW 

HAZARDOUS ATTITUDES

NARRATIVE

After performing a series of low altitude aerobatic maneuvers, an SH-60B impacted the 

sea alongside a ship which was 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 fractured back and bruised heart. 

HUMAN FACTORS ANALYSIS 

The pilot was a 28-year-old LT with 2228 total flight 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 his new duty station in order to build a 

house on it. The 29-year-old LT copilot had 1896 total flight hours, 343 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 reviews, and stand downs of the squadron and 

were observed infrequently by their supervisors. 

They had both undergone jet transition in preparation for Test Pilot School (TPS). 

Though they may have had some limited experience with dive-bombing over water, it is 

highly unlikely that they were fully prepared for the problems associated with smooth 

water depth perception and illusions, target fixation, and the minimum altitude for dive 

recovery. Their radar altimeters were set for 30 and 37 feet, far too low to provide 

adequate warning for the type of maneuvers they were performing. Experienced witnesses stated that they had never seen a helicopter execute this type of maneuver, 

typical of jet aircraft in dive bombing patterns. The pilot 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 regulations, being complacent, and exercising poor 

judgment in conducting low altitude maneuvers. They misjudged 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 balances to correct warning "flags" known to 

on-scene supervisors. 
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CONCLUSIONS 

These pilots demonstrated a lack 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 question 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 authorization of their squadron CO to perform an air show. 
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NATIONAL TRANSPORTATION 

SAFETY BOARD REPORTS

TABLE OF CONTENTS 

SUBJECT PAGE

UNITED AIRLINES FLIGHT 173 ............................................................................... 11-2 

SOUTHERN AIRWAYS FLIGHT 242 ......................................................................... 11-9 

UNITED AIRLINES FLIGHT 2860 ............................................................................ 11-15 

AIR FLORIDA FLIGHT 90 ........................................................................................ 11-20 

EASTERN AIR LINES FLIGHT 401 ......................................................................... 11-27 

NORTHWEST AIRLINES FLIGHT 255 .................................................................... 11-31 

PACIFIC SOUTHWEST AIRLINES FLIGHT 182 ..................................................... 11-35 

GALAXY AIRLINES FLIGHT 203 ............................................................................. 11-39 

CONTINENTAL CONNECTION FLIGHT 3407 ........................................................ 11-46 
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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, Portland, Oregon, with an en route stop at 

Denver, Colorado. 

Flight 173 departed from Denver about 1447 with 189 persons on board, including 6 

infants, and 8 crewmembers. The flight was cleared to Portland on an Instrument 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 total amount of fuel 

required for the flight to Portland 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 destination plus 45 minutes and the company 

contingency fuel of about 20 minutes. 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 Portland was normal. 

At 1705:47, Flight 173 called Portland Approach and advised that its altitude was 

10,000 feet and its airspeed was being reduced. Portland responded 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 instructed the flight to descend and maintain 8,000 feet. 

Flight 173 acknowledged the instructions 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 captain stated that, when Flight 173 was 

descending through about 8,000 feet, the first officer, who 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 complied with both requests. However, he 

further stated that, as the landing gear extended, ". . . it was noticeably unusual and (I) 

feel it seemed to go down more rapidly. As (it is) my recollection, it was a thump, thump 

in sound and feel. I don't recall getting the red and transient gear door light. The thump 
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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 right . . . . " Flight attendant and passenger 

statements also indicate that there was a loud noise and a severe jolt 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 maintain about a hundred and seventy 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 replied, "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 seventy 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 flight crew discussed and accomplished all of 

the emergency and precautionary actions available to them to assure themselves that 

all landing gear was locked in the full down position. The flight engineer checked the 

visual indicators on top of both wings, which extend above the wing surface when the 

landing gear is down-and-locked. 

The captain stated that during this same time period, the first flight attendant came 

forward and he discussed the situation with her. He told her that after they ran a few 

more checks, he would let her know what he intended to do. 

About 1738, Flight 173 contacted the United Airlines Systems Line Maintenance Control 

Center in San Francisco, California, through Aeronautical Radio, Inc. According to 

recordings, at 1740:47 the captain explained 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 extended. 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 passengers 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. 
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The aircraft continued to circle under the direction of Portland Approach 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 captain and the first flight attendant concerning passenger 

preparation, crash landing procedures, and evacuation procedures. During his initial 

interview, the captain indicated 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 reasonable and that some preparations 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, "Five thousand." The first officer acknowledged the 

response. 

At 1748:38, Portland Approach advised Flight 173 that there was another aircraft in its 

vicinity. The first officer 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 fuel pump lights, the captain 

stated, "That's about right, the feed pumps are 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 aircraft 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 conversation was interrupted by a heading change 

from Portland Approach and was followed by a traffic advisory from Portland Approach. 

About 1750:20, the captain asked 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 captain replied, "yeah, give us three or four thousand pounds 

on top of zero fuel weight." The flight engineer then said, "Not enough. Fifteen minutes 

is gonna - really run us low on fuel here." At 1750:47, the flight engineer gave the 

following information for the landing 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 flight engineer to contact the company 

representative at Portland and apprise him of the situation and 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. At 
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1753:30, because of an inquiry from the company representative at Portland, the flight 

engineer told the captain, "He wants to know if we'll be landing 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 engineer reported the “ . . . approach descent check is complete." 

At 1756:53, the first officer asked, "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 the 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 discussions of giving the flight attendants 

ample time to prepare for the emergency, cockpit procedures in the event of an 

evacuation after landing, whether the brakes would have antiskid protection after 

landing, and the procedures the captain would be using during the approach and 

landing. 

At 1801:12, Portland Approach requested that the flight turn left to a heading of 195 

degrees. The first officer acknowledged 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 three 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 that...you might even get the valves open." 

At 1802:44, Portland Approach asked Flight 173 for a status report. The first officer 

replied, "Yeah, we have indication 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, five 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 number 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." 
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From 1803:38, until 1806:10, the flight crew engaged in a conversation which 

concerned (1) checking the landing gear warning horn as further evidence that the 

landing gear was fully down and locked and (2) whether automatic spoilers and antiskid 

would operate normally with the landing gear circuit breakers out. 

At 1806:19, the first flight attendant entered the cockpit. The captain asked, "How you 

doing?" She responded, "Well, I think we're ready." 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 continued 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 comment, the first officer said, "I think you just lost 

number four . . ." followed immediately 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 again 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 Approach and requested, “ . . .would like 

clearance for an approach into two eight left, 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 flight vectors for a visual approach to runway 28L. The 

flight turned toward the vector heading of 010 degrees. 

 

From 1807:27 until 1809:16, the following intra-cockpit conversation 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: "Are you getting it back?" 

1807:40 First Officer: "No number four. You got that crossfeed open?" 

1807:41 Flight Engineer: "No, I haven't got it open. Which one?" 

1807:42 Captain: "Open'em both - get some fuel in there. Got some fuel 

pressure?” Flight Engineer: "Yes, sir." 

1807:48 Captain: "Rotation. Now she's coming." 

1807:52 Captain: "Okay, watch one and two. We're showing down to zero or a 

thousand." Flight Engineer: "Yeah" Captain: "On number one?" Flight 

Engineer: "Right." 

1808:08 First Officer: "Still not getting it." 
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1808:11 Captain: "Well, open all four crossfeeds." Flight Engineer: "All four?" 

Captain: "Yeah." 

1808:14 First Officer: "Alright 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 'em running. . ." Flight Engineer: 

"Yes, sir." 

1808:45 First Officer: "Get this . . .on the ground." Flight Engineer: "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 requested that flight engineer "reset that circuit breaker 

momentarily. See if we get gear lights." The flight engineer complied with the request. 

At 1810:47, the captain requested the flight's distance from the airport. Portland 

approach responded, "I'd call it eighteen flying miles." At 1812:42, the captain made 

another request for distance. Portland Approach responded, "Twelve flying miles." The 

flight was then cleared to contact Portland tower. 

At 1813:21, the flight engineer 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 going. 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 mayday." 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 wooded section of a populated area of suburban 

Portland about 6 NM east southeast of the airport. There was no fire. The wreckage 

path was about 1,554 feet long 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. 
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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. 
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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 (N1335U) operated as a 

scheduled passenger flight from Muscle Shoals, Alabama, to Atlanta, Georgia, with an 

intermediate stop at Huntsville, Alabama. Flight 242 departed Muscle Shoals at 1521 

and landed at Huntsville about 1544. 

About 1554, Flight 242 departed Huntsville on an Instrument Flight Rules (IFR) flight 

plan for the Hartsfield-Atlanta International Airport; there were 81 passengers and 4 

crew members aboard. The flight'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 altitude was 17,000 feet. 

At 1554:35, Flight 242 established communications with Huntsville departure control 

and at 1554:39, the controller cleared the flight to climb to 17,000 feet. At 1555:14, the 

controller cleared the flight to proceed directly to the Rome VOR. According to the 

cockpit voice recorder (CVR), at 1555:58 the captain remarked, "Well the radar is full of 

it, take your pick." 

At 1556:00, the controller told Flight 242 that his radarscope was showing heavy 

precipitation and that the echoes 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 controller said, ". . . I got weather cutting 

devices on which is cutting out the precip that you're in now . . . however, it's not a solid 

mass, it . . . appears to be a little bit heavier than what you're in right now." Flight 242 

replied, "Okay, thank you." 

At 1556:37, the first officer, who 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 see." He added, "Then coming over, we had pretty 

good radar. I believe right straight ahead . . . there the next few miles 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 are your flight conditions?" Flight 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 the flight to contact Memphis Center. 
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At 1558:10, Flight 242 established communications with Memphis Air Route Traffic 

Control Center (Memphis Center). At 1558:32, the captain said, "As long as it doesn't 

get any heavier we'll be all right." The first 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 Traffic Control Center (Atlanta Center). At 1559:00, the 

captain said, "Here we go . . . hold 'em cowboy." 

At 1559:06, Flight 242 established communications with Atlanta Center (Sector 39) and 

stated that it was "out of eleven for seventeen." The controller replied, ". . . roger; 

expect Rome runway 26 profile descent." Flight 242 acknowledged the controller's 

transmission. Between 1559:18 and 1602:03, the Atlanta Center 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 captain of Flight 242 said, "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 Eastern Airlines flight, 

which had just crossed the storm area northwest 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 hazardous." At 1603, Flight 242 was told to 

contact Atlanta Center (sector 40). About 11 seconds later, the sound of light rain was 

recorded on the CVR. At 1603:20, Flight 242 established communications with Atlanta 

Center on the new frequency and said, ". . . level at seventeen." At 1603:48, the 

captain said, "Looks heavy, nothing's going through that." Six seconds later, he said, 

"See that." The first officer said, "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 you want to go around that 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 that 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 replied, "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, Atlanta Center was coordinating 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 the 
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edge of it . . . maintain 15,000." TWA-584 replied, "Maintain 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 Center cleared Flight 242 to descend to and 

maintain 14,000 feet. At 1606:46, the captain said, "Who's that?", and the first officer 

replied, "TWA." At 1606:53, the captain reported to Atlanta 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 which 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 Center made four transmissions to Flight 

242; none was acknowledged. About 1608:34, Atlanta Center said, "Southern 242, 

Atlanta." At 1608:37, the first officer said, "Got it, got it back, Bill, got it back." At 

1608:42, Flight 242 told Atlanta Center to "standby." At 1608:49, Atlanta 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 Atlanta Center, "Our left 

engine just cut out." Atlanta Center replied, ". . . roger, and lost your transponder, 

squawk 5623." At 1609:43, the first officer said, "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 other 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 southeast 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 Atlanta Center, "Want us to turn left?" The Center replied, 

". . . contact approach control 126.9 and they'll try to get you straight into Dobbins. At 

1610:36, the first officer said, "Give me - I'm familiar 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, Flight 242 replied, "269, Okay." 
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At 1610:50, the first officer said, "Ignition override, it's gotta work . . ." At 1610:52, an 

Atlanta Approach Control transmission 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 Center made three transmissions to Flight 242. About 

1612:00, Atlanta Approach 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, you read Southern 242?" 

Approach Control replied, "Southern 242, Atlanta, go ahead." Flight 242 said, "...we've 

lost both engines, how about giving us a vector to the nearest place, we're at 7,000 

feet." At 1613:17, Approach Control replied, "Roger, turn right heading 100°, will be 

vectors to Dobbins for a straight-in approach runway 11...your position is 15, correction 

20 miles west of Dobbins at this time." Concurrent with this transmission, the first officer 

said, "What's Dobbins' weather, Bill? How far is it? How far is it?" Flight 242 

transmitted, "Okay 140° heading and 20 miles." 

At 1613:35, Atlanta Approach Control directed, ". . . make a heading of 120, Southern 

242, right turn to 120°." Flight 242 replied, "Okay, right turn to 120 and . . . you got us 

our squawk, haven't you, on emergency." 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 position is 20 miles west of Dobbins." Flight 

242 replied, "Okay." 

At 1614:03, the first officer said, "Get those engines . . ." At 1614:24, Flight 242 

transmitted to Approach Control, "All right, listen, 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 Control replied, "...19 miles." Flight 242 transmitted, "Okay, 

we're out of ...5,800, 200 knots." At 1614:45, Approach Control 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 wing 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 hydraulics." At 1615:17, the first officer said "What's the 

Dobbins weather?" At 1615:18, Flight 242 asked Approach 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 down to 4,600 now." Approach 

Control responded, "Roger, and you're approximately . . . 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, " . . . ask him if there is anything between here and 

Dobbins?" The captain said, "What?" and the first officer repeated his request. At 

1616:25, Flight 242 asked Approach Control, "... is there any airport between our 
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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 it, but we're trying everything 

to get something started." Approach Control replied, "Roger, well there is Cartersville, 

you're approximately 10 miles south of Cartersville, 15 miles west of Dobbins." 

At 1616:45, Flight 242 asked Approach Control, "Can you give us a vector to 

Cartersville?" Approach Control replied, "All right, turn left, heading of 360, be 

directly...direct vector to Cartersville." Flight 242 said, "360, roger." At 1616:53, Flight 

242 asked Approach Control, "What's the runway heading?" Approach Control replied, 

"Standby." Flight 242 than asked, "And how long is it?" Approach 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." The 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, "Southern 242, the runway configuration...at 

Cartersville is...360 and running north and south and the elevation 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 recorded: "...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 commercially 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 quit shortly thereafter. He thought the 

cabin lights went out shortly after the lightning strike, but before the hail began. 

Additionally, almost simultaneous with the turbulence, he noticed that the power was 

reduced on the engines. He estimated that the turbulence lasted 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 the hail ceased; just before the right engine 

quit, he heard loud popping sounds from an area 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 fairing 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 those expressed by the passenger. 

About 1615, several witnesses in Rockmart, Georgia, saw Flight 242 flying over 

Rockmart in a westerly direction. The aircraft made a left turn and flew back toward the 

east. They heard no engine sounds and saw nothing peculiar about the aircraft. 
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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 0 
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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 members, the only persons aboard the aircraft, 

were killed, and the aircraft was destroyed. 

Flight 2860 encountered electrical system problems during its descent and approach to 

the Salt Lake City Airport. The flight requested a holding clearance, which was given by 

the approach controller and accepted by the flight crew. The flight then 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 flight entered an area near hazardous terrain. The approach 

controller recognized Flight 2860's predicament but was unable to contact the flight. 

When Flight 2860 returned to approach 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 immediately to 8,000 feet. Eleven seconds later, the 

flight reported that it was climbing 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, United 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 scheduled departure from San Francisco, an intermediate 

stop at Salt Lake City, Utah, was scheduled. 

According to the flight dispatcher, the flight crew reported for duty at 2300. The captain 

and dispatcher discussed the weather situation at Salt Lake City, and the dispatcher 

informed the captain that the flight would be dispatched with the aircraft's No. 1 AC 

electrical generator inoperative. This conformed to company minimum-equipment-list 

procedures, and the dispatcher later stated that the lack of the generator seemed to 

present no problems to the captain. However, before the flight crew left the dispatch 

office, the dispatcher received information that the generator had been repaired, and he 
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passed this information to the captain. On December 18, 1977, at 0017, Flight 2860 

departed San Francisco on an Instrument Flight Rules (IFR) flight plan for Salt Lake 

City. The flight's estimated time en route 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 Lake air route traffic control center (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 sector 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 Center controller cleared the flight to descend to 15,000 feet 

and gave the altimeter setting as 29.58 in. At 0115:42, Flight 2860 requested landing 

and weather information for Salt Lake City Airport. 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, light rain, temperature 41, altimeter 29.58." 

The approach controller continued to vector 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 the 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 problems here, we're trying 

to check our gear and stuff right now." The controller 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 gave the surface wind as 160° 

at 13 knots. Flight 2860 replied, "Roger, we got to check our gear first." At 0124:36, 

Flight 2860 indicated it would not land and the approach controller replied, "...fly runway 

heading, maintain 6,000, will vector you back around for an approach." Flight 2860 

said, "Okay...." 

The approach controller gave Flight 2860 instructions to turn right to a 330° heading and 

to maintain 6,000 feet. The flight acknowledged, and said, "Okay, we'd just as soon not 

get back in it if we can help it." The controller replied, "Okay, minimum vectoring 
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altitude is 6,000, that's the best I can do for 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 Flight 2860 responded, "Okay 'cause we're gonna 

have to get the gear down and try to find out 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 tower, 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 controller replied, "...roger, turn right, proceed 

direct to the Salt Lake VOR, hold on the, at the VOR, maintain 6,000." Flight 2860 said, 

"Okay, we'll hold north of the VOR, 6,000...right turns, okay?" 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 Flight 2860 said, "Thank you sir, we'll be back." 

After this transmission, Flight 2860 contacted United Airlines' system line maintenance 

control center in San Francisco. This contact was made through Aeronautical Radio, 

Inc. (ARINC) on frequency 130.6 mHz. Flight 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 controller at 0132:37. Flight 2860 informed 

the maintenance controller that the No. 1 electrical bus was inoperative, and the No. 3 

generator would not parallel; also, the landing gear indicator lights did not present a 

"down" indication when the landing gear was extended. The maintenance controller 

inquired whether the flight crew had attempted to reset the No. 1 bus, and the crew 

replied that they had. The controller inquired whether the No. 1 generator was providing 

normal volts and frequency, and the crew replied that it was providing "nothing, it's 

dead." 

At 0133:37, the maintenance controller told the flight crew to standby while he checked 

the electrical power source for the landing gear indicating system, and at 0135:08, the 

controller informed the flight crew "...the landing gear position indicating 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, "Okay, 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, same generator." The controller said that 

he would "check on it if you like," but Flight 2860 said, "oh, before you go... one thing, if 
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that's the only way they can get gear indicators, we're gonna go ahead and land then." 

The controller confirmed that the No. 1 28-volt DC bus powered the landing gear 

warning system. 

At 0136:28 Flight 2860 terminated communications with the maintenance controller. In 

response to a query from ARINC on whether to keep the line to maintenance control 

open, Flight 2860 replied, "Well no, I guess we're...only got one radio, so we're back to 

the tower, we're going to land, we're going to call out the equipment." Flight 2860 

terminated radio communications with ARINC at 0137:11. 

While Flight 2860 was on the ARINC frequency, the Salt Lake City tower ground 

controller, at 0136:28, called the Salt Lake City Flight Service 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 flight to contact Salt Lake 

City approach control on frequency 124.3 mHz. Between 0137:07 and 0137:22, the 

Salt Lake City approach controller attempted three times to establish radio 

communications with Flight 2860. At 0137:22, the ground controller asked the FSS 

specialist whether he had made the 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, make 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 turn back to the VOR." At 0137:44, Flight 2860 said, "Okay." 

At 0137:54 the approach controller asked, "United 2860, do you have light contact with 

the ground?" Flight 2860 replied, "Negative." At 0138:00 the 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?" Flight 2860 did not respond to that transmission or to 

succeeding transmissions from the approach controller. 

Shortly after 0135, at least seven witnesses in Kaysville, Utah, and the nearby 

community of Fruit Heights heard 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 could see nothing more of the airplane 

because it was obscured by clouds, rain, and darkness. The airplane continued 

eastward and a short time later, 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 witnesses 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. 

 
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Wreckage Information 

N80470U crashed on the southwest slope of Ed's Peak in the Wasatch Mountains about 

2.85 miles northeast of Kaysville, Utah. The crest of Ed's Peak is at 7,665 feet. Ground 

impact marks at an elevation of 7,200 feet indicate that the 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 slope 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 indication--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 mHz 
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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, Florida, from Washington National Airport, Washington, D.C. 

There were 74 passengers, including 3 infants, and 5 crew members 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 was made with snow and/or ice adhering to the 

aircraft, the aircraft crashed at 1601 EST into the barrier wall of the northbound span of 

the 14th Street Bridge, which connects the District of Columbia with Arlington County, 

Virginia, and plunged into the ice-covered Potomac River. It came to rest on the west 

side of the bridge 0.75 NM from the departure end of runway 36. Four passengers and 

one crewmember survived the crash. When the aircraft hit the bridge, it struck seven 

occupied vehicles and then tore away a section 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 during 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 takeoff during the early stage when his attention was 

called to anomalous engine instrument readings. Contributing to the accident were the 

prolonged ground delay between deicing and the receipt of ATC takeoff clearance 

during which the airplane was exposed to continual precipitation, 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 limited experience of the flight crew in jet 

transport winter operations. 

 

History of the Flight 

On January 13, 1982, Air Florida, Inc., Flight 90, a Boeing 737-222 (N62AF), was a 

scheduled passenger flight from Washington National Airport, Washington, D.C., to the 

Fort Lauderdale International Airport, Fort Lauderdale, Florida, with an intermediate stop 

at the Tampa International Airport, Tampa, Florida. Flight 90 was scheduled to depart 

Washington National Airport at 1415 EST. The Boeing-737 had arrived at gate 12, 
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Washington National Airport, as Flight 95 from Miami, Florida, at 1329. Snow was 

falling in Washington, D.C., in the morning and in various intensities when Flight 95 

landed and continued to fall throughout the early afternoon. Because of the snowfall, 

Washington National Airport was closed for snow removal from 1338 to 1453 and Flight 

90's scheduled departure was delayed. At 1359:21, Flight 90 requested and received 

an Instrument Flight Rules (IFR) clearance from clearance delivery. 

Seventy-one passengers and 3 infants were boarded on the aircraft between 1400 and 

1430; there were five crewmembers - captain, first officer, and three flight attendants. 

About 1420, American Airlines maintenance personnel began deicing the left side of the 

fuselage using a model D40D Trump vehicle (No. 5058) containing Union Carbide 

Aircraft Deicing Fluid II PM 5178. The deicing truck operator stated that the captain told 

him that he would like to start deicing just before the airport was scheduled to reopen at 

1430 so that he could get in line for departure. American maintenance personnel stated 

that they observed about one-half inch of wet snow on the aircraft before the deicing 

fluid was applied. Fluid had been applied to an area 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 from 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 section, the top part of the engine pylon, and the 

cowling were deiced with a heated solution consisting of 30 to 40 percent glycol and 60 

to 70 percent water. No final over spray was applied. The operator based the 

proportions of the solution on guidance material from the American Airlines 

maintenance manual and his knowledge that the ambient temperature was 24°F, which 

he had obtained from current weather data received at the American Airlines line 

maintenance room. The operator also stated that he started 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 remained at these critical 

points. He also stated 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 operator of the deicing vehicle was relieved from his 

deicing task, and he told his relief operator, a mechanic, that the left side of the aircraft 

had been deiced. The relief operator 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 temperature was 24°F.) The operator 

stated that he deiced/anti-iced the 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 inspected both engine intakes and the landing 

gear for snow and/or ice accumulation; he stated that none was found. The 
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deicing/anti-icing of Flight 90 was completed at 1510. At this time about 2 or 3 inches of 

wet snow as on the ground around the aircraft. Maintenance personnel involved in 

deicing/anti-icing the aircraft stated that they believed that the aircraft's trailing and 

leading edge devices were retracted. American Airlines personnel 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 jetway was retracted. Just before the jet 

way was retracted, the captain, who was sitting in the left cockpit seat, asked the Air 

Florida station manager, who was standing near the main cabin door, how much snow 

was on the aircraft. The station manager responded that there was a light dusting of 

snow on the left wing from the engine to the wingtip and that the area from the engine to 

the fuselage was clean. Snow 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 transmitted, "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 transmitted, "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 incline prevented the tug, which was not 

equipped with chains, from moving the aircraft. When a flight crewmember suggested 

to the tug operator that the aircraft's engine reverse thrust be used to push the aircraft 

back, the operator advised the crewmember that this was contrary to the policy of 

American Airlines. According to the tug operator, the aircraft's engines were started and 

both reversers were deployed. He then advised the flight crew to use only "idle power." 

Witnesses estimated that both engines were operated in reverse thrust for a period of 

30 to 90 seconds. During this time, several Air Florida and American Airlines personnel 

observed snow and/or slush being blown toward the front of the aircraft. One witness 

stated that he saw water swirling 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 ranging 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 unsuccessful in moving the aircraft back, the 

engines were shut down with the reversers deployed. The same American Airlines 

mechanic that had inspected both engine intakes 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. Air 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. 
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At 1533, while the first tug was being disconnected 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 percent of the left wing inboard of the tip from his vantage 

point, which was about 25 feet from the aircraft. Although he observed snow on the 

upper fuselage and about 75 percent of the left wing inboard of the tip from his vantage 

point, which was about 25 feet from the aircraft. 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 windshield and a light dusting of snow on the left 

wing. 

At 1535, Flight 90 was pushed back without further difficulty. After the tug was 

disconnected both engines were restarted and the 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 responded "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 twenty four can you...get...around that...Palm on 

a push back?" Flight 90 replied, "Ground Palm Ninety, we're ready to taxi out of his 

way." Ground control then transmitted, "Okay 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 transmission 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 then made some additional comment, which was not clear but 

contained the word "deiced," to which the first 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, "Tell you what, my windshield will be deiced, 

don't know about my wings." The first officer then commented, "well -- all we need is 

the inside of the wings anyway, the wingtips are gonna speed up on eighty anyway, 

they'll shuck all that other stuff." At 1547:32, the captain commented, "(Gonna) get your 

wing now." Five seconds later, the first officer asked, "D'they get yours? Did they get 

your wingtip over 'er?" The captain replied, "I got a little on mine." The first officer then 

said, "A little, this one's got about a quarter 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 officer then commented, "I don't know why that's 

different -- less it's hot air going into that right one, that must be it -- from 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 said, "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." Conversation 
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between the captain and the first officer regarding the general topic of deicing continued 

until 1554:04. 

At 1557:42, after the New York Air aircraft was cleared for takeoff, the captain and first 

officer proceeded to accomplish the pre-takeoff checklist, including verification of the 

takeoff engine pressure ratio (EPR) setting of 2.04 and indicated airspeed bug settings 

of 138 kts (V1); 140 kts (Vr) and 144 kts (V2). 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 control to "taxi into position and hold" on 

runway 36 and to "be ready for an immediate [takeoff]." 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 acknowledged, "Palm 90 cleared 

for takeoff." Also, at 1559:28, Flight 90 was told not to delay 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 checklist was completed at 1559:22. At 

1559:45, as the aircraft was turning to the runway heading, the captain said, "Your 

throttles." At 1559:46, the sound of engine 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 officer 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 responded, "Yes it is, there'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 recorded. At 1600:45, the captain said, 

"Forward, forward," and at 1600:48, "We only want five hundred." At 1600:50, the 

captain continued, "Come on, forward, forward, just barely climb." 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 heavily congested northbound span of the 14th 

Street Bridge, which connects the District of Columbia 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 departure end of runway 36. Heavy snow continued to fall and 

visibility at the airport was varying between 1/4 mile and 5/8 mile. 
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When the aircraft struck the bridge, it struck six occupied automobiles and a boom truck 

before tearing away a 41-foot section of the 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 investigators interviewed more than 200 witnesses to 

establish the sequence of events from the start of the takeoff until impact, and more 

than 100 written statements were obtained. 

Ground witnesses generally agreed that the aircraft was flying at an unusually low 

altitude with the wings level and attained a nose-high attitude of 30° to 40° before it hit 

the bridge. Four persons in a car on the 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 bridge at about the wingtip of the 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 sinking 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 guardrail. 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 straight direction into the river. The 

plane...seemed to go across the bridge at a slight angle 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 water 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 see 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 came across the bridge. I saw nothing fall 

from the airplane as it crossed the bridge." 

Between 1519 and 1524, a passenger on an arriving flight holding for gate space near 

Flight 90 saw some snow accumulated on the 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 gate. Departing and arriving flight crews and 

others who saw Flight 90 before and during takeoff stated that the aircraft had an 

unusually heavy accumulation of snow or ice on it. An airline crew taxiing parallel to, 

but in the opposite direction of, Flight 90's takeoff, saw a portion of Flight 90's takeoff 

roll and discussed the extensive amount of snow on the fuselage. The captain's 

statement to the Board included the following: "I commented to my crew, 'look at the 

junk on that airplane,'...Almost the entire length of the fuselage had a mottled area of 
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snow and what appeared to be ice...along the 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 the aircraft's rate of climb was slow as it 

left the runway. Flight crews awaiting departure 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 roll, the local controller had transmitted to an 

approaching Eastern 727, Flight 1451, "...wind is zero one zero at one one, you're 

cleared to land runway three six; the runway visual range touchdown two thousand 

eight hundred roll out one thousand six hundred." At 1600:11 Eastern Flight 1451 

acknowledged, "...cleared to land, over the 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 airport stated, "Immediately after I noticed 

the Air Florida 737, an Eastern 727 landed unbelievably close after (Air Florida) 737. I 

felt it was too close for normal conditions - 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 bridge, 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. 
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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 crashed at 2342 EST on December 29, 1972, 

approximately 18 miles west northwest 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 received fatal injuries. All other occupants 

received injuries, which ranged in severity from minor to critical. 

The flight diverted from its approach to Miami International 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 aircraft climbed to 2,000 feet mean sea level and 

followed a clearance to proceed west from the airport at that altitude. During this time, 

the crew attempted to correct the malfunction and to determine whether or not the nose 

landing gear was extended. 

The aircraft crashed into the Everglades shortly after being cleared by Miami Approach 

Control for a left turn back to Miami International Airport. Surviving passengers and 

crew members stated that the flight was routine and operated normally 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 flight instruments during the 

final four minutes of flight, and to detect an unexpected descent soon enough to prevent 

impact with the ground. Preoccupation with a malfunction of the nose landing gear 

position indicating system distracted the crew's attention from the instruments and 

allowed the descent to go unnoticed. 

As a result of the investigation of this 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, N310EA, operating as Flight 401 (EAL 401), 

was a scheduled passenger flight from the John F. Kennedy International Airport (JFK), 

Jamaica, New York, to the Miami International Airport (MIA), Miami, Florida. On 

December 29, 1972, the flight departed from JFK at 2120 with 163 passengers and 13 
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crew members on board and was cleared to MIA in accordance with an Instrument 

Flight Rules flight plan. 

The flight was uneventful until the approach to MIA. The landing gear handle was 

placed in the "down" position during the preparation for landing, 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 recycled the landing gear, but the 

green light still failed to illuminate. 

At 2334:05, EAL 401 called the MIA tower and stated, "Ah, tower this is Eastern, ah, 

four zero one, it looks like we're gonna have to circle, we don't have a light on our nose 

gear yet." 

At 2334:14, the tower advised, "Eastern four oh one heavy, roger, pull up, climb straight 

ahead to two thousand, go back to approach control, one twenty eight six." 

At 2334:21, the flight acknowledged, "Okay, going up to two thousand, one twenty eight 

six." 

At 2335:09, EAL 401 contacted 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 acknowledged the flight's transmission and instructed EAL 

401 to maintain 2,000 feet mean sea level and turn to a heading of 360° magnetic. The 

new heading was acknowledged by EAL 401 at 2335:28. 

At 2336:04, the captain instructed the first officer, who was flying the aircraft, to engage 

the autopilot. The first officer acknowledged the instruction. 

At 2336:27, MIA approach control requested, "Eastern four oh one, turn left heading 

three zero zero." EAL 401 acknowledged the request 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 instructed the second officer to enter the forward electronics 

bay, below the flight deck, to check visually the alignment of the 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 altitude was arrested by a pitchup input. 

At 2337:48, approach control requested the flight to turn left to a heading of 270° 

magnetic. EAL 401 acknowledged the request and turned to the new heading. 
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Meanwhile, the flight crew continued their attempts to free the nose gear position light 

lens from its retainer, without success. At 2338:34, the captain 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 called MIA approach control and said, "Eastern four oh one'll go 

ah, out west just a little further if we can here 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 officer discussed the faulty nose 

gear position light lens assembly and how it might have been reinserted incorrectly. 

At 2340:38, a half-second C-chord, which indicated a deviation 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 his head into the cockpit and stated, "I can't 

see it, it's pitch dark and I throw the little light, I get, ah, nothing." 

The flight crew and an Eastern Air Lines maintenance specialist who was occupying the 

forward observer seat then discussed the operation of the nose wheel well light. 

Afterward, the specialist went into the electronics 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 alphanumeric 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 stated that he had no doubt at that moment 

about the safety of the aircraft. Momentary deviations in altitude information on the 

radar display, he said, are not uncommon; 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 exclaimed, "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. 
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At 2342:12, while the aircraft was in a left bank of 28°, it crashed 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 unrestricted visibility. The 

accident occurred in darkness, 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 occupying an observer seat in the cockpit 

and the other seated in the first-class section of the cabin. 

 

The accident survivors sustained various injuries; the most prevalent were fractures of 

the ribs, spine, pelvis, and lower extremities. Fourteen persons had various degrees of 

burns. Seventeen persons received only minor injuries and did not require 

hospitalization. 

Postmortem examination of the captain revealed a tumor which emanated from the right 

side of the tentorium in the cranial cavity. The tumor displaced and thinned the adjacent 

right occipital lobe of the brain. The lesser portion of this meningioma extended 

downward into the superior portion of the right cerebellar hemisphere. The tumor 

measured 4.3 centimeters laterally, 5.7 centimeters vertically, and 4.0 centimeters in an 

anterior-posterior direction. 

 

Damage to Aircraft Other Damage 

The aircraft was destroyed None 
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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, N312RC, at Minneapolis, Minnesota, and operating as Flight 

255, flew the airplane to Saginaw, Michigan, with an en route stop at Detroit 

Metropolitan Wayne County Airport (Detroit-Metro), Romulus, Michigan, arriving at 

Saginaw about 1840 EDT. At Saginaw, N312RC became Flight 255 and was flown by 

the same flight crew that had brought the airplane in. Flight 255 was a regularly 

scheduled passenger flight between 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 Regulations (CFR), Parts 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 the airplane, a Northwest mechanic entered 

the cockpit and reviewed the airplane and cabin maintenance logbooks. He stated that 

no discrepancies were entered in either logbook. There was no record of any 

maintenance having been performed on the airplane 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 flight release package to the airplane. He was met by 

the first officer who told him that the captain 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 the agent left the airplane, he met the captain 

who had been conducting a walk around inspection of the airplane and showed him the 

signed copy of the flight release. The captain studied the release, told the agent that it 

was all right, and thanked him. 

About 2029, the final weight tabulation (weight tab) was delivered to the flight crew. 

About 2032, Flight 255 departed the gate with 149 passengers and 6 crewmembers on 

board. Flight 255 was pushed back to Spot 4. During the pushback, the flight crew 

accomplished the BEFORE (engine) START portion of the airplane checklist, and at 

2033:04, they began starting the engines. 
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At 2034:40, after the engines had been started, the ground crew disconnected the tow 

bar from the airplane and at 2034:50, the west ground controller cleared the flight to 

"taxi via the ramp, hold short of (taxiway) delta 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 controller 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 ground controller on 119.45 mHz. At 2035:48, 

the first officer repeated the taxi clearance, but he did not repeat 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 broadcast at the time of the 

accident. Examination of the Cockpit Voice Recorder (CVR) recording showed that the 

flight crew had not received information "H" before they began to taxi. However, at 

2035:18, information "H" began on the first officer's radio channel, and at 2035:55, he 

told the captain that he was leaving the airplane's No. 1 radio "to get the new ATIS." 

About 2025, the tower supervisor began coordination 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 300° at 17 knots, and that "...ILS approaches 

are in use to Runways three left (3L) and three 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 instructed 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 for takeoff. Because of the runway change, the 

first officer had to refer to the company's Runway Takeoff Weight Chart Manual to verify 

that their takeoff weight was below the allowable limits for Runway 3C. The takeoff 

weight chart showed that with 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 concurred with the first officer's evaluation. 

During the taxi out, the captain missed the turnoff at Taxiway 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, changed 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, that windshear alerts were in effect, and that the altimeter 

setting was 29.85 in Hg. The flight crew acknowledged receipt of the information. 
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At 2042:11, the local controller cleared Flight 255 to taxi into position on Runway 3C 

and to hold. He told the flight there would be a three-minute delay in order to get the 

required "in-trail separation behind traffic just departing." At 2044:04, Flight 255 was 

cleared for takeoff. 

The CVR recording showed that engine power 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 officer 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 until 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 activated. Between 2044:01 and 

2045:05.6, the CVR recording did not contain any sound of the takeoff warning system 

indicating that the airplane was not configured properly for takeoff. 

Witnesses generally agreed that Flight 255's takeoff roll was 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 retracted after liftoff. Two Northwest first officers recalled that 

the flaps and slats were extended. One first officer was in the airplane directly behind 

Flight 255 in the takeoff sequence. According to her, "the flaps were extended, which is 

normal, but I could not. . .state the actual degree of flap extension." She did not 

describe the position of the slats. The second first officer's airplane was parked on 

Taxiway "A" between the ramp and Taxiway "J". The airplane was facing Runway 3C 

and about 150 feet from it. He testified that he observed the flaps and slats as Flight 

255 rolled past his airplane and, "The slats and flaps were extended." However, he was 

unable to estimate their degree of extension. 

After Flight 255 became airborne, it began rolling 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 briefly 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 lot. The first officer of the Northwest airplane 

parked on Taxiway "A" testified that Flight 255 was intact until the left wing struck the 

light pole in the auto rental car lot. After the wing struck the pole, he saw what 

appeared to a "four-to-five foot chunk of the wing section. . . ."fall from the airplane. He 

did not see any fire on the airplane until after 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 rental car lot, and struck the side wall of the 
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roof of the auto rental facility in the second rental car lot. Witnesses stated that the 

airplane was in a 90° left-wing-down attitude when it struck the roof and that it continued 

rolling and was still rolling to the left when it impacted the ground on a road outside the 

airport boundary. The airplane continued to slide along the road, struck a railroad 

embankment, and disintegrated as it slid along the ground. Fires erupted in airplane 

components scattered along the wreckage path. Three occupied vehicles on the road 

and numerous vacant vehicles in the auto rental parking lot along the airplane's path 

were destroyed by impact forces and/or fire. 

On board Flight 255, 148 passengers and 6 crewmembers 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. 

 
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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 Airlines, Inc. Flight 182, 

a Boeing 727-214, and a Gibbs Flite Center, Inc., Cessna 172 collided in midair about 

three nautical miles northeast of Lindbergh 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 separation from the Cessna and to contact the 

Lindbergh Tower. Flight 182 contacted the tower on its 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 and continued the approach. The aircraft collided near 

2,600 feet msl and fell to the ground in a residential area. Both occupants of the 

Cessna were killed, 135 persons on board the Boeing 727 were killed, 7 persons on the 

ground were killed, and 9 persons on the ground were injured. Twenty-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 the provisions of a maintain-visual-separation 

clearance, including the requirement to inform the controller when they no longer had 

the other aircraft in sight. Contributing to the accident were the air traffic control 

procedures in effect that authorized the controllers to use visual separation procedures 

to separate two aircraft on potentially conflicting tracks when the capability was 

available to provide either lateral or vertical 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, California, on an instrument training flight. Since the flight 

was to be conducted in visual meteorological 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. 
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The Cessna proceeded to Lindbergh Field where two practice ILS approaches to 

Runway 9 were flown. Although the reported wind was calm, Runway 27 was the active 

runway at Lindbergh. About 0857, N7711G ended a second approach and began a 

climbout to the northeast. At 0859:01, the Lindbergh tower local controller cleared the 

Cessna pilot to maintain VFR conditions and to contact San Diego approach control. 

At 0859:50, the Cessna pilot contacted San Diego approach control and stated that he 

was at 1,500 feet, and "northeastbound." The approach controller told him that he was 

in radar contact and instructed him to maintain VFR conditions at or below 3,500 feet 

and to fly a heading of 070°. The Cessna pilot acknowledged and repeated the 

controller's instructions. 

Pacific Southwest Airlines Flight 182 was a regularly scheduled passenger flight 

between Sacramento and San Diego, California, with an intermediate stop in Los 

Angeles, California. The flight departed Los Angeles at 0834 on an IFR flight plan with 

128 passengers and a crew of 7 on board. The first officer was flying the aircraft. 

Company personnel familiar with the 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 company pilot occupied the forward observer 

seat in the cockpit. 

At 0853:19, Flight 182 reported to San Diego 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 acknowledged and repeated the 

approach clearance. 

At 0859:28, the approach controller advised Flight 182 that there was "traffic at twelve 

o'clock, one mile northbound." Five seconds later the flight answered, "We're looking." 

At 0859:39, the approach controller advised Flight 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 thousand four hundred." According to the CVR, at 0859:50, 

the copilot responded, "Okay, we've 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 controller 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 the controller, "Traffic 

in sight." 

At 0900:23, the approach controller cleared Flight 182 to "maintain visual separation," 

and to contact Lindbergh tower. At 0900:28, Flight 182 answered, "Okay," and three 

seconds later the approach controller advised the Cessna pilot that there was "traffic at 

six o'clock, two miles, east bound, a PSA jet inbound to Lindbergh, out of three 
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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 called for 5° flaps, and the captain asked, "Is that the one 

(we're) looking at?" The first officer answered, "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 pass(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 off to our right" and the local controller 

testified that he heard, "he's passing off to our right.") 

The CVR showed that Flight 182'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 told the local controller how far they were going to extend 

their downwind leg, the first officer asked, "Are 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, before 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 predicted 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 transmission was not acknowledged. The 

approach controller did not inform Lindbergh tower 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 proceeding in an easterly direction before the 

collision. Flight 182 was descending and overtaking 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 exploded. Segments of fragmented wreckage fell from the 

right wing and empennage of Flight 182. 
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Flight 182 began a shallow right descending turn leaving a trail of vapor-like substance 

from the right wing. A bright orange fire erupted in the vicinity of the right wing and 

increased in intensity as the aircraft descended. The aircraft remained in a right turn 

and both the bank and pitch angles increased during 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. Seven persons on the ground were killed, and 22 dwellings 

were damaged or destroyed. 

The aircraft crashed during daylight hours into 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 Natural History, San Diego, 

California, showed that the in-flight explosion and ground impact occurred at 0901:47.9 

and 0902:07, respectively. 
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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. Approximately 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 mile to the right of 

the extended runway centerline. The impact and subsequent fire killed the crew of six 

and 64 of the 65 passengers onboard. The airplane 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 failure to control and the copilot's failure to monitor the flight 

path and airspeed of the aircraft. This breakdown in crew coordination followed the 

onset of unexpected vibration shortly after takeoff. Contributing 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 Flight 203, a Lockheed Electra L-188C (N5532), 

was operating under 14 CFR 121 requirements on a flight from Reno, Nevada (RNO) to 

Minneapolis, Minnesota (MSP). The charter flight had been coordinated as a gambling 

junket for Galaxy through a broker agent. 

About 1610 on January 20, flight plans for four flights of N5532 were filed with the 

Seattle Flight Service Station. The Galaxy flights, sequentially 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 scheduled departure time had been 1530; however, 

the Galaxy Airlines flight follower told them earlier by telephone that the flight would be 

delayed until about 2000. After reporting for duty they spent about an hour to an hour 

and a half watching television in the Pacific Southwest Airlines (PSA) crew lounge. The 

incoming Galaxy charter flight with 77 passengers aboard arrived in Seattle from Las 
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Vegas, Nevada, at 2000. A PSA ramp serviceman saw the departing flight engineer 

check the fuel quantity in N5532 manually, but he did not see a crew member perform a 

walk around inspection. The airplane departed SEA at 2019 on a ferry flight to Oakland. 

The ramp serviceman said that when the airplane was airborne, the flight crew radioed 

back their thanks for the quick turnaround. The airplane arrived at Oakland at 2225. 

At Oakland, 65 passengers, returning from 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 the 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 said that the crew 

appeared to be rested. When questioned 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 the western side of runway 16R, close to the departure 

end. 

The airplane was serviced by personnel from the Reno Flying 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 assistants who connected the fuel truck and the 

ground electrical and air start units to the airplane, as well as fueled it. In addition, four 

other persons, a ground handling supervisor, and three ground handlers performed the 

remainder of the airplane's servicing while it was parked. These duties included loading 

and off loading baggage, installing and withdrawing the wheel chocks, cabin cleaning, 

lavatory and potable water servicing, driving the passenger vans between the airplane 

and the gate, starting up and later 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. Although Galaxy procedures required it, no record of Galaxy 

203's weight and balance was left at the Reno Flying Service nor was one delivered by 

mail to Galaxy's main office. Galaxy's Operations Manual required the captain to leave 

a duplicate of this form at each departing station. 

At 0021:28, while ground servicing was being carried out, the 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, cleared to the Minneapolis St. Paul Airport 

via the Reno Seven Departure, as filed. Maintain one three thousand, expect 
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one niner zero five minutes after departure. Departure frequency will be one one 

nine point two. Squawk three three zero four. 

The flight plan, which 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, cruising altitude 190. Route of flight 

Jet Route (J) 32 ABR, J70 GEP, Destination 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 backed 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 engineer supervised the refueling and checked the fuel load in each 

tank using the airplane's installed sight gauges. A total of 2,357 gallons of Jet A fuel 

was added. When the refueling was completed, the fueler unhooked the hose and 

stowed it on the fuel truck along with the electrical grounding cables. As he climbed on 

the truck, he saw the flight engineer securing the single point fueling panel. The fueler 

then drove the truck to another location. 

The engine air start cart was then moved into a position about where the fuel truck had 

been parked. The fueling supervisor said that he had connected both the air start and 

ground power units. The departing passengers arrived at the gate from Lake Tahoe in 

buses but, because the arriving passengers were still on the airplane, the buses were 

sent to the Reno Flying Service lounge and off-loaded. The buses then returned to the 

airplane to transport the deplaning passengers. When the airplane was ready, the 

departing passengers were brought to the airplane in a series of van trips. As the 

passengers were boarded, the ground handling supervisor and two other persons 

loaded 67 pieces of luggage into the aft baggage compartment. The flight engineer had 

instructed the ground handlers to load the luggage in this way 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 ground-handling supervisor removed the baggage 

belt loader from the aft cargo compartment and closed the door. He noticed the flight 

engineer finishing the engine servicing, apparently having already closed the forward 

cargo compartment. The forward cargo compartment was 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 communications with Galaxy 203. As a result, he used 

standard hand signals for this purpose. The flight crew then flashed the taxi lights on 

and off several times in apparent acknowledgment that hand signals were now being 

used. 

At this time in the cockpit, the crew was preparing for the engine start. At 0055:51 the 

captain asked, "How does the clearance read?" The first officer responded, "We're 
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cleared the Reno Seven Departure as filed." The captain then asked the first officer 

several questions concerning departure. The Cockpit Voice Recorder (CVR) indicated 

that the before start checklist 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. Fourteen 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 because the flight crew members "...were in a 

hurry when they got in, he (the captain) would 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 the captain, whom he 

described as "very conscientious" and "very punctual," was angry because he believed 

that the flight was over three hours late. He testified that "He really assumed from the 

time he left Seattle that he was running late, and when he arrived in Oakland, he was 

looking for the passengers who had not arrived 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 explained to the captain that the schedule had been 

changed, and this did put him at ease somewhat, he described the captain as still upset, 

"for professional reasons." 

Following ground servicing the ground handler supervisor signaled to the crew that they 

could commence engine starting. However, after engines one and four were started, he 

noticed that the other ground handler was unable to disconnect the air start hose. It 

was stretched taut from the power cart to the 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 stop signal. He then left his position, 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 access 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 seeing the flaps lowered during 

engine start or as the airplane taxied out of the immediate gate area. 

At approximately 0059 the first officer requested taxi instructions. Reno tower almost 

immediately thereafter cleared Galaxy 203 to taxi to runway 16R. 

The airplane, which was taxiing on two engines, numbers one and four, had been 

directed by the ground handling supervisor to make a left turn from its parked position. 
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The airplane had been parked on a westerly heading and required the left turn to take it 

southward. The airplane followed 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 switch to the control tower and perform the takeoff checklist. At 

0101:32 the first officer requested takeoff clearance. 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 first officer called "Vtwo." This call was followed by another "thunking" type sound. 

At 0103:26 the captain called for gear up. The first officer acknowledged the order. At 

0103:29 the captain asked the flight 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, "Okay pull 'em back from METO." At 0103:43 the captain 

directed the first officer to request permission from the tower to execute a turn to a left 

downwind to return to the field. Two seconds later the request was made to the Reno 

tower. At 0103:50 the flight engineer said: "RPMs 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 cleared Galaxy 203 to maintain 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 him, "Yeah," the first officer responded, "That's 

affirmative." The Reno tower controller then 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 Proximity Warning System (GPWS) sounded. At 0104:18 

the first officer said, "A hundred 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 temperature. He then drove to the Reno Flying 

Service office to sign the bills for services rendered. He reached the office about a 

minute after lift off and heard what he described as a muffled "pahboom." He said that 
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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 estimated 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 vicinity 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 looked 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 those 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 went phum, phum." He added that he had 

experienced inflight turbulence 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 feeling any vibration; he 

remembered someone saying on the airplane'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. 
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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 directly adjacent to the 

impact area was damaged. Seven recreational vehicles parked in the primary impact 

area were destroyed. 
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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, about 2217 eastern standard time, a Colgan Air, Inc., 

Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, 

was on an instrument approach to Buffalo-Niagara International 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 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 impact forces and a postcrash fire. The flight was operating under 

the provisions of 14 Code of Federal Regulations Part 121. Night visual meteorological 

conditions prevailed at the time of the accident. 

The National Transportation Safety Board determines that the probable cause of this 

accident was the captain’s inappropriate response to the activation of the stick shaker, 

which led to an aerodynamic stall from which the airplane did not recover. Contributing 

to the accident were (1) the flight 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 for 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 professionalism, fatigue, remedial training, pilot training 

records, airspeed selection procedures, stall training, Federal Aviation Administration 

(FAA) oversight, flight operational quality assurance programs, use of personal portable 

electronic devices on the flight deck, the FAA’s use of safety 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, about 2217 eastern standard time, a Colgan Air, Inc., 

Bombardier DHC-8-400 (Q400), N200WQ, operating as Continental Connection flight 

3407, was on an instrument approach to Buffalo-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 airport. 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 impact forces and a postcrash fire. The flight 
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was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121. 

Night visual meteorological conditions (VMC) prevailed at the time of the accident. 

The home base of operations for both the captain 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 standard time (PST), arriving at EWR (via 

Memphis International Airport [MEM], Memphis, 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, had been canceled because of high winds at 

EWR and the resulting ground delays at the airport. 

The company dispatch release for flight 3407 was issued at 1800 and showed an 

estimated departure time of 1910 and an estimated en route time of 53 minutes. The 

airplane to be used for flight 3407, N200WQ, arrived at EWR at 1854. A first officer 

whose flight arrived at EWR at 1853 saw, as he exited his airplane, the flight 3407 

captain and first officer walking toward the accident airplane. The airplane’s aircraft 

communications addressing and reporting system (ACARS) showed a departure 

clearance request at 1930 and pushback from the gate at 1945. According to the 

cockpit voice recorder (CVR) recording, the EWR ground controller 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 times 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 the pressure’s just too much ... I could always 

call in tomorrow at least I’m in a hotel on the company’s buck but we’ll see. I’m pretty 

tough.” The captain responded by stating that the first officer could try an over-thecounter herbal supplement, drink orange juice, or take vitamin C. 

The CVR recorded the tower controller clearing 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 sea level (msl). The flight data recorder (FDR) showed 

that, during the climb to altitude, the propeller deice and airframe 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 recorded the captain and the first 

officer engaged in an almost continuous conversation throughout that portion of the 

flight, but these conversations did not conflict with the sterile cockpit rule, which 

prohibits nonessential conversations within the cockpit during critical phases of flight. 
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About 2149:18, the CVR recorded the captain making a sound similar to a yawn. About 

1 minute later, the captain interrupted his own conversation to point out, to the first 

officer, traffic that was crossing left to right. About 2150:42, the first 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 the airspeeds for landing with the flaps at 15° 

(flaps 15) as 118 knots (reference landing speed [Vref]) and 114 knots (go-around 

speed [Vga]), and the captain acknowledged this information. About 2156:26, the first 

officer stated, “might be easier on my ears if we start going down sooner.” About 

2156:36, the captain instructed the first officer to “get discretion to twelve [thousand 

feet].” Less than 1 minute later, a controller from Cleveland Center cleared the flight to 

descend to 11,000 feet, and the first officer acknowledged the clearance. 

About 2203:38, the Cleveland Center controller instructed the flight crew to contact BUF 

approach control, and the first officer acknowledged this instruction. The first officer 

made initial contact with BUF approach control about 2203:53, stating that the flight was 

descending from 12,000 to 11,000 feet with automatic terminal information service 

(ATIS) information “romeo,” and the approach controller provided the airport altimeter 

setting and told the crew to plan an instrument landing system (ILS) approach to runway 

23. 

About 2204:16, the captain began the approach 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 airplane 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 recorded the first officer making a sound similar to a yawn. 

About 2208:41 and 2209:12, the approach controller cleared the flight crew to descend 

and maintain 5,000 and 4,000 feet, respectively, and the first officer acknowledged the 

clearances. Afterward, the captain asked the first officer about her ears, and she 

indicated that they were stuffy and popping. 

About 2210:23, the first officer asked whether ice had been accumulating on the 

windshield, and the captain replied that ice was present on his side of the windshield 

and asked whether ice was present 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 while 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 before her employment with the company. 
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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 captain.” The first officer explained that, 

before IOE, she had “never seen icing conditions ... never deiced ... never experienced 

any of that.” 

About 2212:18, the approach controller cleared the flight crew 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 the conversation that 

was unrelated to their flying duties. About 2212:44, the approach controller cleared the 

flight crew to turn left onto 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 mode became active about 1 

second later as the airplane was approaching the preselected altitude of 2,300 feet. 

The airplane reached this altitude about 2214:30; the airspeed was about 180 knots at 

the time. 

About 2215:06, the captain called for the flaps to be moved to the 5° position, and the 

CVR recorded a sound similar to flap handle movement. Afterward, the approach 

controller cleared the flight crew to turn left onto a heading of 260° and maintain 2,300 

feet until established on the localizer 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 the outer marker to 

establish the appropriate airspeed 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 thrust about 2216:02. The approach controller 

then instructed the flight crew to contact the BUF air traffic control tower (ATCT) 

controller. The first officer acknowledged this instruction, which was the last 

communication between the flight crew and air traffic control (ATC). Afterward, the CVR 

recorded sounds similar to landing gear handle deployment and landing gear 

movement, and the FDR showed that the propeller condition levers had been moved 

forward to their maximum RPM position and that pitch trim in the airplane nose-up 

direction had been applied by the autopilot. 

About 2216:21, the first officer told the captain that the gear was down; at that time, the 

airspeed was about 145 knots. Afterward, FDR data showed that additional pitch trim in 

the airplane-nose-up direction 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 set 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 control 
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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 autopilot disengaged, the airplane was at an airspeed of 131 

knots. FDR data showed that the control columns moved aft 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 power, and FDR data 

showed that engine power had increased to about 75 percent torque. 

FDR data also showed that, while engine power was 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 through wings level, the stick pusher activated 

(about 2216:34), and flaps 0 was selected. (The Q400 stick 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 officer told the captain that she had put the 

flaps up. FDR data confirmed 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 down before the airplane began to roll back to the left 

and the stick pusher activated a second time (about 2216:40). At the time, the 

airplane’s pitch angle was -1°. 

About 2216:42, the CVR recorded the captain making a grunting sound. FDR data 

showed that the roll angle had reached about 35° left wing down before the airplane 

began to roll again to the right. Afterward, the first officer asked whether she should put 

the landing gear up, and the captain stated “gear up” and an expletive. The airplane’s 

pitch and roll angles had reached about 25° airplane nose down and 100° right wing 

down, respectively, when the airplane entered a steep descent. The stick pusher 

activated a third time (about 2216:50). FDR data showed that 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 impacted a single-family home 

(where the ground fatality occurred), 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.
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APPENDIX

 TABLE OF CONTENTS 

SUBJECT PAGE 

STANDARD COCKPIT OPERATING PROCEDURES ............................................. 12-2 

LIFESTYLE KEYS TO FLIGHT DECK PERFORMANCE .......................................... 12-7 

STRESS IN AVIATION ............................................................................................. 12-13 

THE COPING RECIPE ............................................................................................. 12-15 
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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 Flying (PF) and the Pilot 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 always ensure that responsibility 

for flying the aircraft is clearly assigned as the primary duty of one of the pilots. The 

pilot flying the aircraft must not perform tasks, which detract from or compromise 

that duty. 

Perform recall (memory) emergency checklist items in a measured manner. Other 

than in a critical situation where immediate tasks are necessary to keep the crew 

and aircraft within a safe flight envelope, there 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 checklist should be read by the PNF in 

a Challenge-Response manner. The individual steps of a procedure will be 

accomplished by the designated or appropriate (by seat position) pilot accompanied 

with the specified response in the checklist. If a step can be accomplished with 

equal ease from either seat, the PNF will accomplish that task. 
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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 simulator 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” 
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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” 
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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.” 
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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).” 
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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 that four life 

style characteristics necessarily receive inordinate 

polishing, and that the aviator's continued safety is 

dependent on his ability to fully exploit all four of these in 

concert. When one of the four 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 institutional 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 creation 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 measurements 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 safe envelope he is represents 

the difference between victory and defeat in wartime, 

and survival and demise in peacetime. Because my 

specialty field deals with human frailty and its interface 

with aviation from the perspective of preventive 

medicine, I have made it my business to discover what it 

is that the Naval Aviator brings 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 parameters. Using this data he 

exercises learned skills, and must 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 repeat itself over and over as 

new information presents. The problem with this 

chalkboard comparison is that it presupposes that upon 

entry into the flight regime, the aviator's information 

slate has been neatly erased clean; that on each 

occasion of flight, all of the existing space for recording 

on that imaginary slate is, in fact, available to him; that 

only those things appropriate to aviation will find their 

way onto the slate; that the 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 specific characteristics that will 

be found in the successful, healthy Naval Aviator. It is 

my impression that these characteristics are common to 

the professional aviation community 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 imperfectly developed these 

characteristics are, the greater the risk. Having 

knowledge of what the aviator’s positive features are 

supposed to be can equip the flier 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 likely 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. Using this knowledge, the flight 

surgeon can make assessments of risk and neatly 

circumscribe periods of time when that risk becomes 

inordinate. The characteristics 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 exploiting the positive features 

of his personality and assiduously 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 far 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 features of his life style which, when 

orchestrated together, are most conducive to good 

function. Similarly, when one or more is flawed, so is 

he. Balancing these productive assets, on the other 

hand, are those features of his life style that would tend 

to disrupt his function and are of such sufficient impact 

as to warrant special steps, institutional 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. 
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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 separate 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 their appropriateness is open to 

question, though they are found there as well. These 

features are: 

1. He is in control. 

2. His male-female interface is characterized by 

emotional distance. 

3. He is a mission-oriented compartmentalizer. 

4. He is systematic and methodical. 

The first feature, being in control, 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. With 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 toward this task, where he is 

indisputably in control, since he was a toddler. He 

probably is the oldest son. He has learned to survive in 

a success oriented home environment where mastery 

and achievements were the 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. The 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 controllers. 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, they 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 that 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 availability of gasoline or diesel 

fuel is established. Radar traps are identified. Detours 

are confirmed with the Automobile Association. The 

appointed hour for departure and arrival are agreed 

upon, if only to himself. When that appointed hour 

arrives, there he is, pacing 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 availability of ladies' rest 

rooms during the day's driving 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 event 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, then, that controllers marry 

controllers. Oldest sons marry oldest daughters. If, 

between them, there are no rules 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 would 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 naturally 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 who 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 comfortable. (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). 
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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 are only tears on the pier? 

And, that Mrs. Controller will tell you that over the two 

weeks immediately preceding 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 side 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 contribute to the mission of 

flying that airplane are excluded from his conscious. 

Referring to the cerebral chalkboard that began this 

paper, it is compartmentalization that insures that the 

chalkboard is clean before entry into the cockpit. If the 

mission is "Fly My Airplane," that becomes the 

functional compartment. Excluded 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. This makes for trouble in the 

home at the hands of the equally competent but 

disinvolved controller spouse. 

The fourth feature of the heads side of the coin is 

actually a summation of the other 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 efforts. 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 surprises, the controller must 

indeed be severely flawed. Procedures manuals are 

meticulously developed to program out any surprises. 

Situations known to contain hidden surprises are either 

figured out in advance or avoided. 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 participate, 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 are 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 feelings 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 that 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 contribute 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 excluding "surprise." 

Continued flight status requires that all four of these 

features be functional and adequate 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 incidents, some of which can 

have disastrous consequences. In implicit and 

sometimes explicit recognition of these shortcomings, 

many institutionalized pressures are brought to bear to 
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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 such 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 silk 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 addressed is not the difference 

between what he actually is versus what he would like to 

see himself as, but an ironic contradiction. The 

contradiction is that he lacks spontaneity. The learned 

procedure and the systematic, preprogrammed 

approach to management of flight are explicitly geared 

to keep him out of the spontaneous arena. 

"Spontaneous," for the aviator, 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 the 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 make correct judgments, in 

effect denying him access to his training and 

experience. He thus finds himself in a spontaneous 

mode; deprived of that wherewithal that normally keeps 

him out of trouble. 

He intuitively recognizes, without any word having to be 

said, that it is the 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, current, 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, instead, 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 affectations 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 better. 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 destructive monster poised to 

strike at a time when things go well. It is complacency. 

The only requirement for its 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 side of the coin is a cyclic, 

repetitive phenomenon very closely allied to 

complacency. It is the "Familiarity Breeds Contempt 

Syndrome." It is a misperception born of increasing 

experience with a specific model aircraft. At the initial 

stage of experience in a given model, the aviator is quite 

hyper-aware of the reputation 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 aviator 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 later date. A step in the direction of 

an institutional "fix" for the problem is the 

community-wide circulation of mishap and incident 

reports that involve his aircraft type. 

The fourth defect on the tails side of the coin is the ritual 

trap. When a repetitively 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 new 
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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 cerebral disconnect, but it is not 

acceptable to omit a preflight 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), the 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 contributes 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 circumstances, 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 compartment 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 feedback 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-actualization not unique to aviation 

but possessing uniquely high price tags if aviation is 

involved. The real curiosity surrounding the concept of 

positive (or negative) maleness feedback is that the 

protagonist is usually the last to know that his behavior 

is so distinctly goal oriented, and is readily perceived as 

such by others. The classic example of a benign 

situation containing the conflicts of positive and negative 

maleness feedback inputs occurs in the occupational 

setting. It usually involves controversy between 

institutional leadership structure 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 countering effect from other 

compartments. A more notorious 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 specific flight community 

(transport/patrol, rotary wing, attack, fighter) and 

partially in response to the relative mundane or colorful 

nature of the mission, a hierarchy exists among wing 

wearers. Naval Aviators consider themselves to be the 

top. Within the aviator community, the inhabitant of the 

lower end of the spectrum are 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 rate of fuel consumption. 

In the rotary wing community, helicopters with weapons 

affixed require a more colorful 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 preponderance 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-selective and unique community of 

aviators is a master understatement. The higher an 

aviator is found on the pecking order, the more urgent 

the requirement for a functional heads and tails of the 

coin. 

THE FAILING AVIATOR

Not everything goes well at all times for the Naval 

Aviator. Where the coping mechanisms outlined at the 

beginning of this paper are overwhelmed, 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 marriages cannot survive. 

Where there is some form of mutual agreement 

between the two on the need for dissolution of the 

relationship, the aviator may have all the coping tools 

required. Where there is bitterness, 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 instrument sweeps past the red line 

heading downward. This response, a newly adopted 

behavior pattern that is the hallmark of the Failing 

Aviator, is a distinct change from what was. He has lost 

control. She calls the shots. He cannot escape the 
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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 feelings, and casting his very 

sexuality on the public highway. He can concoct no 

system to handle this. 

Instead, the emergence of the behavior pattern of the 

Failing Aviator identifies a heretofore-unknown entity. It 

is characterized by bravado, risk-taking, abandon, 

macho, and an implicit acceptance 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 latter 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 the 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 identifiable assets and liabilities. 

 If known, these can be weighted 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 mark the man. His ability to 

dissect out purely occupational from the 

nonoccupational requirements 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 presented in this paper are those 

of the author. No endorsement by the Department of 

the Navy has been given or should be inferred.

 
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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 career 

pilots. 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 the 

business 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. 
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(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.
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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 establishing 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 pressure from another source. 

The pressure that triggers 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 stand 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 chemical juices and preparing to 

defend us. The fight reaction that results in stress. 

THREE STAGES OF STRESS

Dr. Hans Selye, known as the "father of stress" for his 

extensive work and research on the subject, has 

identified three stages of stress. 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 produces 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 inevitable 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 that 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. 

 
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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 17 
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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. 

 
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