Aviation Mishap Story Time 6

Aftermath

[Ed. note: Prior pieces in this series found at AMST Intro, AMST 1, AMST 2, AMST 3, AMST 4, and AMST 5.]

I began this series with a brief look at Bud Holland’s actions vìs a vìs the Fairchild AFB crash. The reconstruction of how that all happened, right down to Holland’s illicit parking habits, came from a post-crash investigation, likely more than one. In the military, there are typically two different investigations that happen post-crash: the Safety Investigation attempts to determine accident cause from an aviation safety perspective, free from any possibility of legal consequence, while the Judge Advocate General (JAG) Manual investigation attempts to determine the accident’s cause specifically for possible, follow-on legal determinations. Frequently, these investigations can converge: for example, what if the accident was caused by a faulty component made by a particular sub-contractor? That causal finding is relevant for both safety and legal reasons.

I can talk about this now with the perspective of 20+ intervening years, which has included some relevant experiences: (1) I was a member of an AMB in one of the deadliest aviation training accidents in Marine Corps history (more on that later); and (2) while becoming a judge advocate, I served on the prosecution team for this other deadliest Marine Corps aviation accident in Aviano, IT (I’ll get to that one, too). When you’re in flight training, however, suffice it to say that they don’t exactly spend a lot of time talking about surviving mishaps, or what a mishap board is like. Most of crew coordination and safety training is listening to, or looking at, stupid things that people did and got killed doing and then being told, like with the fork in the toaster: “Don’t do that.” While true and one way of mentoring, it’s not exactly comprehensive and doesn’t cover what happens if you have a mishap and live? This is one of those stories.

More “Top Gun” Bullshit?

I had forgotten, but that ever-helpful repository of aviation knowledge, “Top Gun” does give you a couple of sniffly scenes of poor Pete “Mav” Mitchell in his summer whites all teary-eyed while he gets formally exonerated of “any wrongdoing” in front of the AMB and is returned to flying status. Then, of course, it turns out he can’t, ahem, bring himself to fire his gun after the death of his oily volleyball partner, Goose.

Talk to me, Goose.

In the NAVY! In the NAVY!

“Just Relax, Turn Your Head, and Cough…”

An Aviation Mishap Board is convened by members of the Safety and Standards Office within the squadron and someone else gets separately assigned to conduct the JAGMAN investigation. If there are parts and pieces left after a crash,¹ they’ll get collected and then sent various places for testing to try to determine just what the heck happened. I would be remiss if I did not point out that statistically speaking, about 70% of aviation mishaps involve “human factors” errors - i.e. pilot and/or co-pilot and crew fuck- aboutery. This is another way of saying that if you “check out” a perfectly good, flying $15 million aircraft and then it impacts the ground… well, the betting odds are that it was the same category that causes the other 70% of perfectly flyable aircraft planes not making it back.² This can make things difficult under the best of circumstances; it can make life strange indeed when the aircraft mishap board members, and the JAGMAN investigator, and the pilots being investigated, are all sleeping on cots in the same Quonset Hut within a few feet of each other! (Imagine if the guy investigating your stolen rental car claim was living with you during the investigation. It doesn’t matter how nice the insurance investigator is, it’s just bad for everyone.)

Before I go further, however, there’s a relevant bit of helicopter doctrine you should know about…

Welcome to the Deadman’s Curve

Helicopter pilots live and die by their aircraft’s Height-Velocity diagram, “H-V diagram, for short. The H-V diagram is also very commonly known as the “Deadman’s Curve.” Below is the H-V Diagram for the helicopter I learned on, the Bell 206 Jet Ranger. Other aircraft models and types will be slightly different, but they’ll be similar shaped. The Jet Ranger is known for having a “high inertia” rotor head compared to its mass, which means that if you lose power, the rotor head loses “rotations” (measured in %) much more slowly than heavier, commercial (or “fleet” aircraft). That’s why it makes such a good training helicopter; helicopters only drop out of the sky more quickly as you move through the pipeline out into the “real world” of flying.

The Deadman’s Curve for a Bell 206

The shaded area is where you DON’T want to be. That’s called being on the wrong side of the Deadman’s Curve. This is why whenever you watch helicopters take-off in almost any movies, you’ll see the helicopter come off of the ground, and then the nose drops and the helicopter stays close to the ground as it gains speed… that is NOT simply because we are show-offs and want to fly low and fast - that’s just a bonus! It is because that is the best flight profile to fly around the Deadman’s Curve so that if you lose an engine you’ve got enough whop-whops to auto-rotate to the ground (in theory, anyway - you also need a zone to get into and a relatively unobstructed way in.) Look at that curve and trace a line with your finger starting at 0 feet of altitude and 0 kts of airspeed and don’t let your finger touch the shaded area, you can see that you have to accelerate to 45-50 kts while still below 20 feet below to fly up and away from that big shaded area on the left and above.

If you look at the fattest part of the shaded area, you’re talking about hovering “out of ground effect” - very high hovering where you do not have the benefit of your own air cushion, called “ground effect” when you’re hovering or air taxiing close to the ground. In the -206, we would shoot practice autorotations with the throttle at flight idle all the way to the ground from 500 feet, the pattern altitude. As you can see from the H-V diagram, that’s well above the 400' feet from which you can do an autorotation with zero forward airspeed. The landing pattern is 80 kts or so, so we were plenty to the right and above the Deadman’s Curve. The fields were grass and we would do slide on and full stop landings to the grass - and never bring the power back up.

By comparison, the top of the H-V diagram for the Whiskey was 1080 feet…

…and on the day we augured in, August 11, 1994, we were in a 150’ hover-hold, as wrong a side of the Deadman’s Curve as there is.

Light Switches and Checklists

Given everyone’s proximity, it wasn’t hard to set up interviews. Bill and I wrote our statements separately - when we were finally able to scrape up some pens and paper and a place to write - and then we each read the other’s account of the accident after we wrote it as we walked over to turn them in to the aircraft mishap board, who I seem to recall had a single office with a handful of chairs in one of the few permanent structures at Camp Wilson at the time.³ I can empathize with them now, after multiple careers of interviewing people in extraordinarily uncomfortable circumstances (as a prosecutor, defense attorney, etc.). At the time, not so much.

There are also some important cultural points at play that aren’t readily apparent: in a squadron, there tend to be small “camps” - you could almost call them archetypes, really, because of the nature of a squadron - but they revolve around the competing relationships between Operations/Training, Maintenance, and Safety. The Operations folks are tasked with driving the squadron’s operations, namely, putting out a daily flight schedule. That requires aircraft, so Maintenance and Ops tend to have a slightly antagonistic relationship because sometimes Maintenance can be a kind of governor on Ops.⁴

Safety sits aside from Operations and looks over Ops’ shoulder to make sure that the squadron’s operations are being conducted safely, with due regard to the operational risks, blah blah blah. Okay, so you can see where I come down on this, but let me just say that personalities migrate to each of these places, and while they’re all necessary to a strong, functioning squadron, they don’t all get along. The Tactics guys want to do ops, shoot, and train, while the Safety guys wonder if everyone’s gotten sufficient crew rest, and the Maintenance guys are all greasy and hot and wondering why everyone keeps breaking all of the f***ing aircraft?! And while there is some movement among these different places during a given tour or career, you tend to see “Safety guys” pursuing those additional courses related to that particular vertical, while the Ops guys are trying to get courses related to the “Warfighting” vertical, and the Maintenance guys are spending time in that vertical.

I say all of that by way of background for the context of our interviews with the AMB within a day or two of the crash. Evidently, our navigation lights were in the “flashing bright” position, rather than “steady bright” - which they should have been per Squadron SOP. It’s also one of the last items on the takeoff checklist, the very last thing you do before you takeoff. The takeoff checklist sits on a placard right on the face of your panel.

AMB: Do you know why were your lights in flashing bright? Me: I was up front, so I can’t say for certain. AMB: Did you complete the takeoff checklist before you left the airfield? Me: Yes. AMB: ‘Yes,’ as in you have an independent memory of doing it? Or ‘yes’ you’re certain because you always do it? Me: The former. I have an independent memory of Captain Dunn and I doing the takeoff checklist before we left to go to the arming area. AMB: Well, can you explain why we found the lights in that position when we returned to the crash site? Me: Captain Dunn had to climb out and jump down from the right side, so perhaps he hit the switch with his boot, or elbow, while getting out. Or maybe when we safed the aircraft up afterwards he hit it. I don't know - obviously I was up front and I never went to the back cockpit after impact.

Etc.

It can get testy without anyone really meaning it to or even trying.

In the days after the crash, a few interesting pieces of info emerged. When Bill read my statement, his initial reaction was surprise: “You came onto the controls and pulled? I never felt you - at all.”

“You wanna know something weird? I never felt you either. I waited until the last possible second and then pulled for all I was worth.”

We started to refer to it as the “Hand of God” on the controls among ourselves.

The AMB found it equally unbelievable, as well, but for different reasons. They seemed to struggle because I was admitting that I violated all protocol on who is flying the aircraft by (a) coming onto the controls as (b) the guy not flying, and (c) being the co-pilot and (d) a relatively junior guy in the squadron. I tried to explain to them - none of whom had been in a crash, I should note - that as the ground rushed up it simply wasn’t possible to sit there and allow one’s self to be smashed to pieces if for some reason Bill mistimed his pull.

When Bill and I talked after our interviews, he mentioned that they had brought it up to him and his impression was that they thought I was “confabulating” - that I was making it up and that I hadn’t actually touched the controls at all. Bill telling them that he never felt me on the controls seemed to help them justify the belief because if I’d come on the controls, Bill certainly would have felt that….right?

The other atypical - ahem, unbelievable part of our story - was our claim that we had a dual engine failure. The Cobra is a twin-engine aircraft, and one-engine alone should be sufficient for us to have flown away safely. Given what I’ve mentioned above about 70% of the time it’s pilot error, I would say confidently that in the early days of the AMB the distinct impression we got was that the AMB believed we had a single-engine failure, panicked, and smashed ourselves right into the ground with a perfectly flyable aircraft.

And then a series of events changed everything…

Deus Ex Machina to the Rescue!

Leading up to the deployment to 29 Palms for CAX 9/10-94, in addition to getting my PQM qual and some “X”s towards Attack Helo Commander, I had started the syllabus for becoming a Post-Maintenance Functional Check pilot, known colloquially as an “FCP” or a “tester” - someone who tests the aircraft after they’ve had maintenance done on them and then certified the aircraft safe for flight for other pilots. I had finished most of the flying and written portions of the syllabus and now at CAX was doing some OJT with ground turns and “riding along” with other testers during their full-card or other tests each day.

Bill was out doing a full-card and taxiing back in as I was in one of our squadron’s rental vans with the CO on our way over to the airfield for some reason. I may have had a night flight, but the road over to the airfield allowed us to have a pretty good look at Bill air taxiing back in when his aircraft suddenly shot a fireball out one of the exhausts and then the engine quit. We were in a perfect position to both see and hear it happen.

POW! Then, Whoosh from the flame out the back, then beeewwwww, as the engine dropped to idle. We watched Bill’s aircraft settle a bit, but he had it all under control and brought it back into the line. Whatever else we could have said, nothing made our case better than the CO watching one of his perfectly good aircraft throw an engine right before his eyes. Or, put another way, our story had just gotten a lot less fanciful - and maybe the 70% pilot error had suddenly moved more towards the 30% “Other stuff, including mechanical.”

The CO grounded all of our aircraft and let the ground unit commander know that it wasn’t safe to fly his Cobras. Within a couple of days Saint gathered us all together to explain that absent some definitive Fleet-wide grounding, like had occurred with the blades, that the Ground Commander didn’t give a flying fuck and wanted Cobras flying support ASAFP. And he didn’t say it, but we all understood it, if he made this a “wings on the desk” kind of issue, he would be fired and someone else would come in who would tell us to get back to flying and quit whining.

So we got back to flying…

…But we had discussions about where to take up hover holds, how to minimize time in the shaded area of the Deadman’s Curve while still flying the missions, and suddenly all of the Cobra pilots had a personal interest in our mishap.

Then the engineering investigation (EI) report came out saying that it had found something: a brazed bellows, vice a welded bellows, in one of our P3 bleed air valves had some cracking and it appeared to be an issue with some of these bellows that were made by a particular sub-contractor or only on certain series of T700 engines, blah blah blah, the bottom line was - there was a mechanical flaw in one of the engines on our aircraft - the one that had crashed. While it wasn’t a complete vindication, it was at least a quasi-vindication that we had some kind of mechanical failure and it may have involved faulty outputs from this brazed bellows.

The mishap investigation continued apace, but just a few days later the CO signed off on my test papers.

Wordsworth once referred to “…that best portion of a good man’s life, His little, nameless, unremembered, acts Of kindness and of love”⁵ and the older I get, the more kindly disposed I am to the CO for signing off on that qual. I was a relatively new PQM, maybe 8 months in the squadron, not yet a Captain, facing an aircraft mishap investigation, and by that single act the CO signalled to everyone in the squadron, particularly to the Marines I had to face every day, that the AMB was essentially irrelevant to him. He absolutely could have done the cautious and expedient thing and would have been within his rights. He could have said he needed more time, not signed off on my paperwork, etc., etc., and that decision would have been beyond review of and justifiable to anyone.

Within 10 days of our crash, Bill and I were on the schedule for night autorotations on NVGs. The CO signed off on that flight schedule and never said a word to us. The squadron also had a Sidearm anti-radiation missile to test during that deployment and because I had gotten 2nd place in the test on the Sidewinder - the air-to-air version of that missile - I got to fire it with the CO riding up front.

1. Not always the case as some happen over the ocean (and I have thoughts on that one, too - the fatal crash of my friend, Clark “Swab” Cox.)

2. This is just as true of rental cars as it is of multi-million dollar aircraft; you don’t bring one back and see how long before they stop renting you cars.

3. I don’t know if it’s been built up, but when we were there in 1994, you had to go to bathroom “squad bay style.” IYKYK.

4. I’ve written before about how helicopter Maintenance involves the dismal science of logistics, so additional context and explanation is available there.

5. “Lines Composed a Few Miles above Tintern Abbey, On Revisiting the Banks of the Wye during a Tour. July 13, 1798,” is more commonly known as “Tintern Abbey,” by William Wordsworth. The full text of one of the Romantic Era’s most famous poems is available here.