Public release on Dover C-5 crash

[GasPasser]

Here's the press coverage on the AF release of it's finding in the C-5 crash investigation. I've seen the whole brief, but I'm not talking....neither should others. The AF released this info, and I'll leave it at that.



http://www.aero-news.net/index.cfm?contentBlockId=4758ce8e-7c43-43fd-9114-5da409b0bc62

Top News
on error resume next flash2Installed = (IsObject(CreateObject("ShockwaveFlash.ShockwaveFlash.2"))) flash3Installed = (IsObject(CreateObject("ShockwaveFlash.ShockwaveFlash.3"))) flash4Installed = (IsObject(CreateObject("ShockwaveFlash.ShockwaveFlash.4"))) flash5Installed = (IsObject(CreateObject("ShockwaveFlash.ShockwaveFlash.5"))) flash6Installed = (IsObject(CreateObject("ShockwaveFlash.ShockwaveFlash.6"))) if(nNoFlash) { showTableBasedFlashAd("421.gif"); } else { showFlashAd("421.swf"); }

Board Rules Human Error Caused April C-5 Galaxy Accident

Wed, 14 Jun '06
Crew Did Not Use Proper Throttle, Flap Settings

The results of an investigation into the C-5 Galaxy crash at Dover Air Force Base, Del., on April 3 found that human error was the cause, Air Mobility Command officials at Scott Air Force Base in Illinois stated Tuesday.

http://www.aero-news.net/index.cfm?contentBlockId=4758ce8e-7c43-43fd-9114-5da409b0bc62#d​

The accident investigation board determined the pilots and flight engineers did not properly configure, maneuver and power the aircraft during approach and landing.
Following a normal takeoff and initial climb the C-5 aircrew observed a Number 2 engine "Thrust Reverser Not Locked" indication light. They shut down the No. 2 engine as a precaution, and returned to Dover AFB.

http://www.aero-news.net/index.cfm?contentBlockId=4758ce8e-7c43-43fd-9114-5da409b0bc62#d​

The board determined that during the return to the base:

• 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.

As Aero-News reported, all 17 people on board the C-5 survived the crash... but three crewmembers were seriously injured when the aircraft stalled, hit a utility pole and crashed into a field about a mile short of the runway. The other passengers and crewmembers sustained minor injures and were treated and released from local hospitals.

http://www.aero-news.net/index.cfm?contentBlockId=4758ce8e-7c43-43fd-9114-5da409b0bc62#d​

The aircraft was assigned to the 436th Airlift Wing and was flown by members of the 512th Airlift Wing, a Reserve associate unit at Dover. It was bound for Ramstein Air Base, Germany, and was carrying 105,000 pounds of replenishment supplies for the US Central Command area of responsibility when it went down.
FMI: www.af.mil

 

[The_Russian]

Wow! So they must have forgot what engine had the problem during all the stress. In training do they teach moving all of the throttles regardless of the number of the engine that failed? We do that in the 1900.

 

[MarineGrunt]

What was wrong with #3 being left in idle? Or are they referring to not bringing it up to asymetric N1 when impact was immenant? What was the selected flap setting and the "proper" one for the landing?

 

[MarineGrunt]

Wow! So they must have forgot what engine had the problem during all the stress. In training do they teach moving all of the throttles regardless of the number of the engine that failed? We do that in the 1900.

A 4 engine aircraft, you have the option of moving the respective engine on the other side to idle to acheive symetric thrust. I think what this board was getting at is they did not advance #3 when impact was certain. There should be a maximum N1 setting calculated for that engine to be accelerated to so the aircraft does not go below VMCA on it's engine out climb.

 

[L-1011-500]

What was wrong with #3 being left in idle? Or are they referring to not bringing it up to asymetric N1 when impact was immenant? What was the selected flap setting and the "proper" one for the landing?

Then it becomes a heavy weight 2 engine approach.

 

[MalteseX]

What was wrong with #3 being left in idle? Or are they referring to not bringing it up to asymetric N1 when impact was immenant? What was the selected flap setting and the "proper" one for the landing?

Because then it becomes a 2-Engine heavyweight aircraft. The report cited that they continued to use the throttle of the engine that was shut down, implying that the crew mis-identified the engine they had shut down.

If they had that throttle in idle, and applied full flaps the airplane will not continue to fly.

An operating engine should not be left in idle with an engine shut down on a C-5, especially a heavyweight aircraft

 

[MalteseX]

Wow! So they must have forgot what engine had the problem during all the stress. In training do they teach moving all of the throttles regardless of the number of the engine that failed? We do that in the 1900.

Yes and no. In the simulator, they teach using all throttles.

However, when doing "engine-out" approaches and landings and touch and go's in actual aircraft, you "simulate" the engine out by putting a throttle in idle--of course you have to leave it there. Since most pilots fly many more engine-out approaches in the actual aircaft than in the simulator, this "conditions" you to leaving the throttle in idle. Happens to many crews in the C-5 when they shut down an engine--leaving the throttle in idle. Only a problem if you misidentify an the engine.

 

[MalteseX]

What was wrong with #3 being left in idle? Or are they referring to not bringing it up to asymetric N1 when impact was immenant? What was the selected flap setting and the "proper" one for the landing?

The proper flap setting for a 3 engine approach is either full flaps or 40% flaps (heavyweight approaches 40% recommended).

Proper setting for 2 engine is 40% only -- with a warning that says "do not select full flaps" (or something like that)

From the pictures on the ground, the flaps were at 40%.

So what I guess happened based on the public release report, was that full flaps were selected, and the approach was "effectively" a 2 engine approach due to throttle being in idle. Airplane wasn't performing normally , so someone puts flaps back to 40%, when speed was too low and stalls airplane.

 

[Beaker]

Two thoughts:

99% (ok, that's a guess) of the time when engines are failed for training, it's an outboard engine, to train for the most difficult adverse thrust. Use of symmetrical engines after one has failed is not an encouraged technique because of the potential to overboost or get thrust deficient during a go-around or in the traffic pattern. Fred is more underpowered than many other big aircraft.

The checklist calls for the throttle to be in idle in the airborne shut down checklists (precautionary and emer eng s/d). When practicing engine out in the aircraft, the engine is left in idle to be used when the training is done (t/o portion of the t-n-go, actual e.p., etc.). In the sim, most folks leave the dead throttle in idle to make the training just like in the airplane (where evaluations are administered).

The combination of these two factors could make it pretty easy for a pilot to make an error and not use all available throttles after losing an inboard engine.

My thoughts are with those guys. For those that haven't heard the privileged brief, but have access to it, I highly encourage you to get w/ your safety officers for lessons learned.

Fly safely

B

 

[Erlanger]

Any chance they'll put that plane back together or is it scrap?