UH60 IMC Crash determined to be pilot error

[Flying Pig]

http://www.nola.com/military/index.ssf/2015/06/black_hawk_crash_caused_by_pil.html

11 killed total, 4 crew and 7 MARSOC Operators on a training mission.  The helicopter launched into IMC and 2 minutes later, 2 very seasoned, instrument rated and equipped pilots lost control of the aircraft.  When it was determined there was a spatial orientation issues, the pilots attempted to engage the auto pilot however the aircrafts parameters to engage the auto pilot were already exceeded (wow.... in a helicopter)  And yes, the UH60 is an IFR capable helicopter. 

There are a lot of issues in this event that lead to pilot attitude.  The PIC was described as an "aggressive pilot" who never turned down a challenge.  They had briefed the weather prior, and at one point the training op had been cancelled.  During run ups and taxi for the mission, comments were made about the deteriorating weather.  When the two UH60s launched, within minutes, one of the UH60s returned to base for weather, yet the lead UH60 continued and intentionally punched into IMC.  Yet nobody ever questioned the mission commander.  There are other reports beyond what I linked here that discuss a lot of the issues with interviews with the helicopter that returned.  Extreme Professional Courtesy....  everyone is so worried about offending the commander that nobody said anything.  THIS attitude is absolutely created by the commander.

In the end, it was determined both pilots were attempting to fly the helicopter at the time of the crash.

These were multi-thousand hour, highly trained pilots flying a helicopter that had the ability to get them out of IMC conditions with the push of a couple buttons.  This is a crash that will be talked about at training seminars for decades to come.

I would encourage any aircrew specifically to review this accident and keep up with the details, as well as the crash in 1994 of "Czar 52" at Fairchild Air Force base.  Beyond aircrews the lessons learned here are applicable to anywhere in CAP as well as life.  Leadership is not creating an environment where people are more concerned about offending you than they are about saving their own necks.   I dont know anything about this PICs leadership.  Nothing suggests he was a bad person, bad leader or unliked. In fact, the MARSOC units pointed out they particularly enjoyed working with this unit because their pilots had great reputations. However, its hard for me, as a professional pilot to believe this was the first time a pilot pushed the limits this far the first time.  This case study could fill the SQ PD calendar for a year and still not cover all the aspects involved.   

[docsteve]

Was this a case of an evening flight with night vision goggles into IMC without a timely transition to the panel?  The article is not clear on that, but there is some reason they had trouble controlling the aircraft by reference to instruments.  Any info on that?

[Flying Pig]

They definitely would have been on NVGs.  NVGs headed into degrading visibility can be very deceiving but that is something that is harped on in NVG training quite a bit.   There is a laundry list of procedural, and leadership flaws.   One has to wonder why they continued on when the second UH60 aborted and headed back to base and landed safely.   Surely there was radio traffic about that.  Being military I don't think we will ever be privy to any of the radio traffic or to many intimate details.   For some reason the PIC attempted to hand fly the helicopter in actual IMC. They were not on an IFR flight plan so they didn't plan on IFR flight.  Not sure if they thought they would punch out on the "other side" or what. 

I've read some interesting thoughts.  One being "train like you fight".  My thought is you don't create a real emergency trying to train for one.  In this particular case the leadership culture of the unit as far as not questioning the mission commander is what I see repeated over and over.   

[PHall]

They were from an Army Guard unit. Not a big turn over in personnel. So if you get on someone's bad side, especially if they're in charge, it can be really bad for you for years.

[Flying Pig]

It's just pretty interesting that the second helicopter turned back, which was also part of the mission yet the lead continued on punching into IMC.  Seems the drive to complete a training mission at all costs took its toll. 

[Live2Learn]

Thanks for publishing the article about this accident.  I agree, there are a book full of lessons here that are gifted to us by the deceased.  Excessive deference by the co-pilot, hubris by the commander (Pilot flying), confusion over who was pilot flying, mission focus, likely unconscious transfer of skills and habits developed in another environment that didn't mesh with their current situation...  I shared the link with several people.

Thanks again.

[Live2Learn]

They were from an Army Guard unit. Not a big turn over in personnel. So if you get on someone's bad side, especially if they're in charge, it can be really bad for you for years.

Good point, and huge flaw in NG unit culture.  "Knock it off" doesn't sound like it had real meaning in their vocabulary.  Another powerful lesson to consider as we think about this.

[Flying Pig]

Thanks for publishing the article about this accident.  I agree, there are a book full of lessons here that are gifted to us by the deceased.  Excessive deference by the co-pilot, hubris by the commander (Pilot flying), confusion over who was pilot flying, mission focus, likely unconscious transfer of skills and habits developed in another environment that didn't mesh with their current situation...  I shared the link with several people.

Thanks again.

Like what?

[Live2Learn]

Thanks for publishing the article about this accident.  I agree, there are a book full of lessons here that are gifted to us by the deceased.  Excessive deference by the co-pilot, hubris by the commander (Pilot flying), confusion over who was pilot flying, mission focus, likely unconscious transfer of skills and habits developed in another environment that didn't mesh with their current situation...  I shared the link with several people.

Thanks again.

Like what?

Maybe "likely" is too strong, and I should have said "possible"...  Good catch.

If the highly experienced ARMY Guard pilots built their competencies during missions primarily over black terrain (deserts, mountains, etc.) I speculate that may provide a different set of cues, with or without NVGs, under some environmental conditions than over black, featureless water... for which [truth in advertising] I have zip experience and have no desire to acquire any!  Negative transference of experience from one environment to another has been a factor in stall/spin accidents, as well as in other situations.  The problem of negative transfer in aviation is discussed here:  http://www.ncbi.nlm.nih.gov/pubmed/7159345.   This website goes into a little more detail as it describes some of these phenomena in a sports situation http://www.teachpe.com/sports_psychology/skill_transfer.php. 

[Flying Pig]

I can tell you NVGs over water is IFR.   It's even worse on calm clear nights when the stars reflect off the water. You feel like you are suspended in outer space. Then add real IFR on top of night/NVG it would be a real hoot.  I've done over water NVG but I'm never more than a mile or two off shore and absolutely never in even the slightest chance of IMC.  I'm in a jet ranger though, not a UH60. 

[docsteve]

The transition from VR to IR (and back again) is a learned skill.  Having spent nearly all of my instructing career in coastal areas I was able to take advantage of off-shore cloud banks, having students fly into the clouds and make a 180 out: repeat until proficient.

Of course (of course?), the most difficult and critical transition is at 200' AGL on an ILS, a clear case for never operating single-pilot IFR  to minimums.

That's the problem here: two pilots, marginal VMC to IMC, and nobody's on the gauges?  They reached for the auto-pilot instead of hand-flying?  What type of "Crew Resource Management" (CRM) was going on in that cockpit?

[PHall]

The transition from VR to IR (and back again) is a learned skill.  Having spent nearly all of my instructing career in coastal areas I was able to take advantage of off-shore cloud banks, having students fly into the clouds and make a 180 out: repeat until proficient.

Of course (of course?), the most difficult and critical transition is at 200' AGL on an ILS, a clear case for never operating single-pilot IFR  to minimums.

That's the problem here: two pilots, marginal VMC to IMC, and nobody's on the gauges?  They reached for the auto-pilot instead of hand-flying?  What type of "Crew Resource Management" (CRM) was going on in that cockpit?

Been my experience that most military helicopter pilots are not exactly "IFR proficient".

[Flying Pig]

The transition from VR to IR (and back again) is a learned skill.  Having spent nearly all of my instructing career in coastal areas I was able to take advantage of off-shore cloud banks, having students fly into the clouds and make a 180 out: repeat until proficient.

Of course (of course?), the most difficult and critical transition is at 200' AGL on an ILS, a clear case for never operating single-pilot IFR  to minimums.

That's the problem here: two pilots, marginal VMC to IMC, and nobody's on the gauges?  They reached for the auto-pilot instead of hand-flying? What type of "Crew Resource Management" (CRM) was going on in that cockpit?

Well, the issue is they tried to hand fly it.  By the time the realized they were in trouble they had exceeded the parameters to engage the auto pilot. 

[docsteve]

The transition from VR to IR (and back again) is a learned skill.  Having spent nearly all of my instructing career in coastal areas I was able to take advantage of off-shore cloud banks, having students fly into the clouds and make a 180 out: repeat until proficient.

Of course (of course?), the most difficult and critical transition is at 200' AGL on an ILS, a clear case for never operating single-pilot IFR  to minimums.

That's the problem here: two pilots, marginal VMC to IMC, and nobody's on the gauges?  They reached for the auto-pilot instead of hand-flying? What type of "Crew Resource Management" (CRM) was going on in that cockpit?

Well, the issue is they tried to hand fly it.  By the time the realized they were in trouble they had exceeded the parameters to engage the auto pilot.

Well, yes, but the point is that they were in an unusual attitude and should have executed an appropriate unusual attitude recovery (hand flying the recovery).  Reaching for the auto-pilot indicates that they (1) had already mis-handled the aircraft, (2) had lost situational awareness, and (3) failed to recognize or understand that they had already exceeded the limits of the auto-pilot.

Two pilots, no awareness, seems eerilly similar to Colgan 3407, Air France 447, Comair 5191, Indonesia 8501; the list goes on.

[TheSkyHornet]

"Human error" not "pilot error." As someone who studied this and works in aviation safety, I can't stress this enough.

In this case, the pilots may have made the error, but that doesn't address the root causes behind the error(s) made, nor the long series of events that were contributing to it, including going back to the training program. The ultimate decision that came down to it may have come from the PIC, but go back to the factors that may have caused them to act this way, or think a certain way, or believe certain things, and you learn that it's highly unlikely that this is a freak occurrence. This just happened to end in tragedy, but that doesn't mean the exact same issues aren't floating around, inherent in the entire scope of the operation; they just haven't exposed themselves yet to the public eye.

[blackrain]

I had a very simple "Command Philosophy" for my troops (and myself) that was applicable to pretty much any operation or situation.....Before you do anything ask yourself how the Accident Report/15-6 Investigation/UCMJ Action/After Action Review is going to read.

One of our CAP Squadron members is an Airbus Pilot for a major airline who highly recommends reading "Understanding Air France 447 by Bill Palmer" ......One thing we discussed ad nauseum was why they didn't just set power setting/N1 to 90 percent/level wings and 3 degrees nose up on the attitude indicator should have bought themselves some time....works for a Cessna as well as an Airbus.....of course the Captain was too busy chasing his girlfriend into the crew quarters in spite of a very violent storm showing on radar.....sad

[Live2Learn]

http://ftpcontent4.worldnow.com/wafb/WebFiles/Report.pdf

Here's the unclassified summary of the accident investigation team report.  The issues that contributed to and ultimately resulted in this accident can be traced to the mission commander's failure to comply with the mandatory weather minimums pre-briefed several times during the days and hours preceding the mission.  Secondarily, his co-pilot and the pilot/co-pilot of the other aircraft failed to hold CW4 Griffin accountable when he (a) launched into below mission minimums wx, then (b) continued as the wx deteriorated to 0-0 conditions.   IFR proficiency, transition to instruments, failure to recognize spatial disorientation, misuse of the auto pilot, etc. are secondary to CW4 Griffin's failure to follow direct orders regarding acceptable wx minimums for the mission.

As was pointed out previosly in the thread, the fundamental causal issue in this needless loss of life and resouces is likely unit culture, though the accident investigation did not address this directly.

[Flying Pig]

Thanks for the link.  That will make  for interesting reading. 

[Flying Pig]

http://www.fresnobee.com/news/local/article49184375.html

To add to this discussion.....

This just happened last night.  Very sad.  An EMS helicopter punched into IIMC.  At this point, I am still waiting to hear if anyone I worked with was on board.  I used to fly a lot of missions with the assistance of Skylife and Im friends with a couple of the nurses and pilots.  Im hesitating calling anyone at this point.  In a few hours Im sure the names will come out. 

[Cliff_Chambliss]

So what is the learning point here? 
We have all heard at one time or another that a VFR pilot entering IMC averages about 3 minutes before they lose control of the aircraft. 
Some years ago the AOPA Air Safety Foundation published a study that stated even if a pilot was instrument rated and current, entering inadvertent IMC while unprepared, had the same 3 minutes before loss of control.
In Army talk, this accident was caused by Operator Headspace Error, and was entirely preventable. 
CAP pays lip service to this type mindset with the "Knock it off" concept where any member of the crew can stop a mission/flight.  But is it really used?  Is Cadet Brightstar really going to tell LTC Greybeard "This flight is hazardous and needs to be terminated"?  Is SMWOG really going to tell the Form 5/91 Check Pilot to "Stop This, this ride is over, land now"?
There is more to CRM than just publishing buzz words in manuals and regulations.  It must be Command Emphasis for all members. 
Unfortunately for the UH60 crew and passengers CRM was not practiced or adhered to, or maybe it was and the aircrew commander just chose to ignore the advice/objections of the crew. Was this aircrew commander another LTC Bud Holland (re: "Darker Shades of Blue: A case Study of Failed Leadership"  by Tony Kern.)(http://sbfpd.org/uploads/3/0/9/6/3096011/darker_shades_of_blue.pdf)  The study of Czar 52 at Fairchild AFB If so, what then? 

[Flying Pig]

So what is the learning point here? 
We have all heard at one time or another that a VFR pilot entering IMC averages about 3 minutes before they lose control of the aircraft. 
Some years ago the AOPA Air Safety Foundation published a study that stated even if a pilot was instrument rated and current, entering inadvertent IMC while unprepared, had the same 3 minutes before loss of control.
In Army talk, this accident was caused by Operator Headspace Error, and was entirely preventable. 
CAP pays lip service to this type mindset with the "Knock it off" concept where any member of the crew can stop a mission/flight.  But is it really used?  Is Cadet Brightstar really going to tell LTC Greybeard "This flight is hazardous and needs to be terminated"?  Is SMWOG really going to tell the Form 5/91 Check Pilot to "Stop This, this ride is over, land now"?
There is more to CRM than just publishing buzz words in manuals and regulations.  It must be Command Emphasis for all members. 
Unfortunately for the UH60 crew and passengers CRM was not practiced or adhered to, or maybe it was and the aircrew commander just chose to ignore the advice/objections of the crew. Was this aircrew commander another LTC Bud Holland (re: "Darker Shades of Blue: A case Study of Failed Leadership"  by Tony Kern.)(http://sbfpd.org/uploads/3/0/9/6/3096011/darker_shades_of_blue.pdf)  The study of Czar 52 at Fairchild AFB If so, what then?

CAP is an odd animal because of how we recruit or train pilot.  In dealing with pilots who enter CAP as a time building opportunity, then if could be met with hazardous results potentially.  However, CAP also recruits high time, experienced pilots who would have no issue telling you whats up without regard to rank.  In my case, and in the case of many many CAP pilots Ive flown with, Id openly laugh at any check pilot who suggested we do something along those lines.  But Im also in the position of having built confidence as a pilot.  In my case, I dont need CAP for flying.  ON the other hand, I know CAP pilots who, without CAP would simply lose any real access to flying or being around aviation.  We all have our motivations.  Its just important to keep your mindset in check.  Are you fudging a pre-flight issue because this is the last flight you need?  Are you pushing weather because this is a funded SAREX and you get to fly for free today?   You just wrapped up mountain school and now you are being asked to fly a search grid in the Sierras at 8000' in August?  But you are a 350hr total time pilot with 11hrs of mountain time?  Just insure you live to fly another day.

I was always in a strange position in CAP because I didnt need CAP to fly.  I flew and still fly for a living.  It was always very easy for me to never sweat a flight or not think twice about canceling a funded flight because something on a pre-flight wasnt right or tell a AOBD they were incompetent and to assign me another grid or I was leaving.  Because tomorrow.... Ill just go to work and fly all day anyway.  But like most of us, Ive know CAP pilots who sacrificed family time and money they didnt have for a .5 of C182 time.  All easier said that done I know.