SAR Accident Case Study

[Flying Pig]

http://flash.aopa.org/asf/acs_rescue/acs-rescue.cfm

Although its a helicopter, there are several lessons to be learned from this crash.  Many of the lessons arent even touched on in this presentation.   I would encourage anyone involved in SAR at any level or area of expertise to read the full NTSB report.  Sadly it is also a classic example of having all of the tools to survive at your finger tips but not knowing how to use them.

Dude, did you happen to read the NTSB report on the crash of the Missouri Highway Patrol copter that killed Trooper Schellenberger?

Yes. Not nearly the same scenario. The MHP troop simply ran out of gas on a clear VFR day and then obviously didnt auto correctly

[manfredvonrichthofen]

ICs And GBDs and AOBDs not having adequate field experience might work if they actually let those in the field with the experience make the calls without an or else threat.

Luckily, I haven't had that sort of issue around here. But I have had it elsewhere enough times to know it can be a problem anywhere.

[Flying Pig]

When I posted it I didnt realize you had to be an AOPA member to view it.  For those who dont have log-in for AOPA this was in regards to the NM State Police Agusta 109 that crashed in the mountains in 2009 in IMC conditions.  The full NTSB report is available on line. 

[bflynn]

ICs And GBDs and AOBDs not having adequate field experience might work if they actually let those in the field with the experience make the calls without an or else threat.

"I'm in charge, so I must know it all already. "  It's way too common in CAP.

Leadership should never be about the leader.

[manfredvonrichthofen]

Exactly, a chief cant be a chief if he doesn't have indians, or at least he won't be chief for long if he doesn't listen to his Indians... He may still be chief, but his Indians will walk away.

[ol'fido]

http://flash.aopa.org/asf/acs_rescue/acs-rescue.cfm

Although its a helicopter, there are several lessons to be learned from this crash.  Many of the lessons arent even touched on in this presentation.   I would encourage anyone involved in SAR at any level or area of expertise to read the full NTSB report.  Sadly it is also a classic example of having all of the tools to survive at your finger tips but not knowing how to use them.

Dude, did you happen to read the NTSB report on the crash of the Missouri Highway Patrol copter that killed Trooper Schellenberger?

Yes. Not nearly the same scenario. The MHP troop simply ran out of gas on a clear VFR day and then obviously didnt auto correctly

Wasn't trying to compare them. Just thought you might be interested. Sorry for the confusion.

[Flying Pig]

No problem.  Yeah I did read it.  Its about as cut and dry as it gets.  Experienced pilot literally runs out of gas and then fails at the auto.  Sad deal. 

[wuzafuzz]

When I posted it I didnt realize you had to be an AOPA member to view it.  For those who dont have log-in for AOPA this was in regards to the NM State Police Agusta 109 that crashed in the mountains in 2009 in IMC conditions.  The full NTSB report is available on line.

That video was part of the safety meeting at my squadron last night.  Good case study.  Thanks for sharing.

[sardak]

Here is a related incident in which a Maryland State Police helo crashed in IMC while transporting two patients from an MVA. Five POB and the only survivor was one of the two patients. The helo crashed 3.2 miles from the threshold of runway 19R at Andrews Air Force Base while on the ILS approach, being tracked by radar and ADS-B, and in voice contact with ATC. The controller had turned down the pilot's request for a radar (ASR) approach. It took two hours to find the crash site. The NTSB blasted pretty much everyone and everything including the SAR effort.

Two of the NTBS findings, particularly relevant to this thread:

- The incident commander's lack of aviation knowledge diminished the effectiveness of search and rescue activities.

- Had two Maryland State Police aviation employees not pursued their own search effort, locating the accident site would likely have taken several more hours than it did.

Here is the report on this incident: http://www.ntsb.gov/doclib/reports/2009/AAR0907.pdf

and the docket, which includes the documents the NTSB reviewed, photos, analyses, pilot logs, interviews, etc: http://dms.ntsb.gov/pubdms/search/projList.cfm?ntsbnum=MIA08MA203

The report for the incident Flying Pig started the thread with: http://www.ntsb.gov/doclib/reports/2011/AAR1104.pdf

and its docket, which includes the AFRCC mission log: http://dms.ntsb.gov/pubdms/search/projList.cfm?ntsbnum=CEN09PA348

Mike

[Radial Interceptor]

Why should being a pilot be a prerequisite for being on wing command staff?

It's all about BTDT. It gives you a lot of insight into what's going on out in the field. On my last SAREX, I saw how pilot skills were helpful in performing as an MO. As an aside, that's why aircraft carrier and aviation squadron CO billets are filled by pilots and NFOs.

I don't buy that for a second. Knowing how to plan an air sortie is totally separate from knowing how fast the aircraft has to be going to achieve lift. You don't need to be a pilot to understand an aircraft's capabilities or to say "fly here" - you just need the right training.

I guess the ground pounders like me who don't have the coin to join the sun god club can throw out any hope of doing more than being ground pounders then? That's too bad, I thought I had lots of potential.

And, as Eclipse said, there's lots of pilots who couldn't manage their way out of a paper bag.

Now, going back to your original comment about non-pilot cc, cv, and cs - that's still total bunk. Again, all they need is training on how the aircraft is managed; knowing how to turn it on is optional. Leave that to your DOO.

As an IC, I have (by requirement) held the ladder positions leading up to it (MP, followed by AOBD, followed by PSC, followed by OSC).  I hated it when an IC "told me how to do it."  This doesn't mean that I objected to guidance, commander's intent, or mentorship.  And if my plan or decision were overruled by the IC's experience, that happens, too.  But if you want me to be the AOBD, then trust me to assign pilots, planes, and tasks in the way that I see fit, which will accomplish the mission requirements which you laid out.  The IC doesn't need to be bothered with tactical assignments.  The IC even has an OSC to do his worrying for him, while the IC deals with the wing commander, other agencies, logistical issues, and generally holding everything together.

With all that said, I'm not a ground-pounder.  I used to be a Marine, but it's not the same--these are volunteers, not all in shape, some younger than 18, and not always ideally equipped.  As an IC, do I make the tactical decisions, to send which team where?  Tell them how to search?  No, I have a GBD to make those decisions.  And either he trusts the GTL (which he assigned!) or he doesn't.  And I'll let the OSC monitor their overall effectiveness--just as I let the OSC monitor the effectiveness of the air sorties as well.

It's the IC's job to ratchet DOWN the level of risk we're willing to accept ("No, John, I appreciate your enthusiasm and confidence, but..."), and it is certainly NOT the IC's job to order anyone (ground team, pilot in command, etc) to just "get it done anyway."  I will never question that single resource leader's decision to back down.

But then there's the issue of an IC not having the appropriate (or ANY) staff, and they must perform all the staff functions themselves.  I rarely have a GBD.  I have to trust that the GTL knows what he's talking about.  As a result, if anything, it makes me ratchet the risk even lower, because I'd rather be more conservative.  Spaceman says, "Knowing how to plan an air sortie is totally separate from knowing how fast the aircraft has to be going to achieve lift.  You don't need to be a pilot to say "fly here" - you just need the right training."  If that's so, the opposite must be true:  "Knowing how to plan a ground search is totally separate from knowing how to turn on a Little L-PER.  You don't need to be a GTL to say "search here."  You just need the right training."  The equivalent is me telling a GTL "just search the side of that mountain, okay?  Get it done," and ignore the fact that it's a high-angle search, middle of winter, with three hours of daylight left.  What, the GTL says no?  He refuses to take his team up today, when there's still daylight left?  NOT a team player.  I'll report him for this!

[manfredvonrichthofen]

You can tell the GTL to search the side of that mountain, no problem, but let him decide how it will be searched. If he isn't comfortable taking his team up, maybe let him get a good vantage point and. Heck the area for 20 minutes with his binoculars. The area is still searched, maybe not as good as if it had boots on it, but it isn't getting passed up completely. GTLs SHOULD be good at risk management as well. If not I wouldn't want them on the ground.

[Cliff_Chambliss]

IC, Mission Satff, Pilot/Observer/Scanner we all need to be on the same tem.  There are times when I wish those people I have to deal with were as perfect as I think I am, and at the same thime they were thinking the same of me.  The issue is one of communication, and (reaching back to classes many eons ago) for effective communications to take place there must be a common foundation.  In other words, we must speak the common language.
  I tell students there are two rules of aviation they must never forget:
1.  Don't do anything that will cause you to bust your butt.
2.  Don't let anyone tell you to do something that will cause you to bust your butt.
There is nothing wrong in saying unable, either to an ATC Facility or to a mission assignment, however I stress that anytime the "unable" is used, you must provide a reason why and as much as possible offer an alternative, and do this in a non confrontational way.

Communiation:  After every sortee every event every mission, prepare an after action report of what went right, what went wrong, and what could be improved and how the improvements could be implemented.  Maybe no else cares, but these reports could be made into a Squadron Lessons Learned Book and in time as members become familiar with the book move up the food chain, spread to other units, the ideas will spread.  Not the magic bullet but a way.  And if several units had books and met to consolidate ideas,  well real change is possible from the worker bee up. 

[Cliff_Chambliss]

As an aside: 

Another chilling example,  read "Shades of Blue, A study in failed leadership" 

This is a report prepared by a student at the USAF Air War College examining in detail the personnel and leadership failures that led up to the B-52 Crash at Fairchild AFB (video available on utube) some years ago.  while the report deals with real events and real USAF People, you can readily see some disturbing parallels with the Civil Air Patrol.

[Flying Pig]

That is an EXCELLENT study.  In the CHP aircrew school we spend just about an entire day on that case.  There is also a book called Rogue Pilot that outlines several case studies.  There is a chapter in it on CAP also.  I still have not been able to find a copy.  All the ones Ie found online are almost $100!!!

Cliff, pretty wild.  The guy has loads of complaints, nobody will fly with him, etc etc, and in response they make him the unit Stan/Eval and safety officer!  Amazing huh.

[RADIOMAN015]

When I posted it I didnt realize you had to be an AOPA member to view it.  For those who dont have log-in for AOPA this was in regards to the NM State Police Agusta 109 that crashed in the mountains in 2009 in IMC conditions.  The full NTSB report is available on line.

You can find the report right here:
http://www.ntsb.gov/doclib/reports/2011/AAR1104.pdf
RM

[sardak]

^^^The link was posted just a few posts before yours with a link to other NTSB documents for this accident and a similar one.

Mike

[NCRblues]

As an aside: 

Another chilling example,  read "Shades of Blue, A study in failed leadership" 

This is a report prepared by a student at the USAF Air War College examining in detail the personnel and leadership failures that led up to the B-52 Crash at Fairchild AFB (video available on utube) some years ago.  while the report deals with real events and real USAF People, you can readily see some disturbing parallels with the Civil Air Patrol.

So, I just was reading "darker shades of blue; A case study in failed leadership" and my god, does it nail on the head most of problems in my wing and most of the problems I see at the National level.

I highly recommend giving it a good read and thinking about it.

[Cliff_Chambliss]

That is an EXCELLENT study.  In the CHP aircrew school we spend just about an entire day on that case.  There is also a book called Rogue Pilot that outlines several case studies.  There is a chapter in it on CAP also.  I still have not been able to find a copy.  All the ones Ie found online are almost $100!!!

Cliff, pretty wild.  The guy has loads of complaints, nobody will fly with him, etc etc, and in response they make him the unit Stan/Eval and safety officer!  Amazing huh.

I searched for Rogue Pilot and could not find anything.  However, I did find several copies of Rogue Aviator on Amazon for less than $20.00. 

Also checked archive.org (which is a great site of non-copyrighted publications, films, radio, etc) and all I could find was a 1936 film "Death in the Air"  That wasted about 45 minutes.  A group of ex WWI Pilots are tasked with finding Pilot X, who is a physcopath out shooting down civilian airliners.  B&W, old Cliches, a pretty girl, playboy pilot, lots of flying, not a bad old film.

[Flying Pig]

http://www.amazon.com/Darker-Shades-Blue-Rogue-Pilot/dp/0070349274


I havnt searched for it in a while, I see the price has gone down a little.  I was off slightly on the title.  Darker Shades of Blue, Rogue Pilot

[NCRblues]

http://www.uscg.mil/safety/docs/CRM/Darker_Shades_of_Blue.pdf

This is what I just read, and with a lot less B-52s has some very real and very scary parallels with CAP "command" and "leadership".