Public release on Dover C-5 crash

[C-141/C-5]

AF PROCEDURES for first!!! WHY IS THE ENGINEER NOT READING THE CHECKLIST AND THE PNF IS????????????????????? My answer i get "THIS IS HOW IT 'S ALWAYS DONE IT'S THE C-5 WORLD" In my world Horrible answer to the question!!! Fix what is broke don't fall in the mindset that this is how we always do it!!! If there is a better way fix it!!!

DON'T BLAME AMP!!

Do you not feel the yaw with 1 engine out??? You would if the other side was pushed up! TRIM SETTINGS ARE TAUGHT! THIS WAS JUST BAD STUFF ALL AROUND!!

in the c-5 you are taught trim settings with one engine out! I highly

 

[Rez O. Lewshun]

First of all, let me make it very clear that I bear no ill will towards this crew and I wish them the best. Better pilots than me have made mistakes and any of us can screw it up given a particular set of circumstances. Having said that, I notice that the tone of this discussion is much more patient and understanding than if it had been a civilian crew that erred. For example, take the SWA incident at MDW or the recent SkyWest accident. Look how toxic those threads were. IMO, neither of those are significantly different from this C5 incident. All three crews were given less than perfect circumstances and neither had good outcomes. Yet, the military crew seems to have been given a pass on the typical FlightInfo post-flight critique/bashfest. That's a good thing. In a perfect world we would give ALL flight crews the benefit of the doubt and try to imagine walking in their shoes during the incident. There are exceptions that deserve severe critiscism. The Pinnacle fiasco comes to mind, but there are plenty of others that don't deserve the lambasting that goes on. Let's try and extend that courtesy to all crews in future discussions of accidents. As someone else noted, let's use sombody else's mistake as an opportunity to learn. Good job on keeping this thread professional.

Caveman-

Great post. Consider some reasons why....

• The military crews have comaradiere whereas the airline/civilian crews have very little. In addition, the military guys are serving country whereas the airline guys are serving the dollar. Hence the MIL service is more noble.

• Also, the MIL guys are the best. They have to be to defend the USA. And as a taxpayer, I only want the best. However, the point is the CIV guys, especially the ones at the NON-major airlines are constantly wondering if they are good enough. The fear that they aren't can always be in the back of thier minds. A negative trait to make one feel better is to drag another down.

• The current state of the airline industry with its massive cuts in pay/work rules/benefits/retirement and low faith in the future, it is difficult to feel good about being a pilot in the airlines. Many people define themsleves by thier job title, social status and/or income. With the current industry state that definition can be pretty low.

• Also, since there are so many organizations in the USAF (Navy/USMC, too) it would be difficult to group accidents together and point at the USAF itself. For example, the C-5 community has an accident, then the F-15, then the C-17 community. Each jet operates in a different realm so to speak, so it is rare (not impossible though) to say look the AF has a problem! In addition no ne says the DOD can't fly jets! But look at FedEx. They have had a few accidents lately (past 5-ish years) and they get grouped together as one organization, even though there are three plus aircraft types. (FedEx is a great organization with a great safety record!)

• Finally, divide and conquer. Old School management has taught us to be advisarial if not paranoid of our fellow employees. Notice the SWA guys don't really bash. (There maybe an exception?) they live in an entirley different dynamic and culture.

With low comaradiere, infighting, organization structure, self definition of career worth and a "fear" it is no wonder we easily get into cat fights and insults. (and not just about accidents either!) We seem to fight about everything! It is the truth and rather embarrassing.

My armchair physco analysis might be off, but there are reasons why your post is accurate. Any thoughts anyone? (thread hi-jack? Hope not. )

I hope you don't mind me springboarding off your post.

With that said, I wish the airline crews took themselves to the next level.

 

[Hagar17]

AF PROCEDURES for first!!! WHY IS THE ENGINEER NOT READING THE CHECKLIST AND THE PNF IS????????????????????? My answer i get "THIS IS HOW IT 'S ALWAYS DONE IT'S THE C-5 WORLD" In my world Horrible answer to the question!!! Fix what is broke don't fall in the mindset that this is how we always do it!!! If there is a better way fix it!!!

DON'T BLAME AMP!!

Do you not feel the yaw with 1 engine out??? You would if the other side was pushed up! TRIM SETTINGS ARE TAUGHT! THIS WAS JUST BAD STUFF ALL AROUND!!

in the c-5 you are taught trim settings with one engine out! I highly

C-141/C-5:

I don't think the PNF reading the Precautionary Engine Shutdown was a factor in this incident. They should have had the engine shutdown long before they started the approach.

However, I do agree with you in that, in flight, the FE should read any and all EP checklists.

Why is it then that the PNF reads the Emergency/Precautionary Sutdown checklists? I believe it is because the engineer has so many items that he accomplishes silently, that is, without a challenge and response, that it is easier for the PNF to run the front-seater items and wait for the engineer to report his checklist items are complete with the reponse "engineer report check complete, fuel remaining xxx." The pilots can continue with aviating, navigating, and communicating while they wait on the eng to finish.

Just my $.02. I don't think a pilot reading the checklist caused this accident, and I don't see it being a detrement to flying safety when we do it every day in the pattern or every quarter in the sim.

Hag

 

[C-141/C-5]

This crew I think got alerted at 1:00am for a 5:15am T/O. It's not a canned local where you have your checklist ready opened to the page. This is early in the morning with all the factors working against you (Sleep, night, ect).

I agree this SHOULD not be the reason why this happened, but instead of fumbling around looking for the checklist, trying to find the correct page, and being heads down. Another ACTIVE eye could of prevented what happened.

From day one we are taught to use all resources available and CRM. Why do we then get trapped in the mentality that the engineer is too stupid to read the checklist.

NEWS FLASH: the engineers reads most checklists already and generally they are more accurate at doing it because they are NOT FLYING THE PLANE.

MOST AIRPLANES WITH ENGINEERS USE THEM FOR EMERGENCY CHECKLIST

 

[Hagar17]

This crew I think got alerted at 1:00am for a 5:15am T/O. It's not a canned local where you have your checklist ready opened to the page. This is early in the morning with all the factors working against you (Sleep, night, ect).

I agree this SHOULD not be the reason why this happened, but instead of fumbling around looking for the checklist, trying to find the correct page, and being heads down. Another ACTIVE eye could of prevented what happened.

From day one we are taught to use all resources available and CRM. Why do we then get trapped in the mentality that the engineer is too stupid to read the checklist.

NEWS FLASH: the engineers reads most checklists already and generally they are more accurate at doing it because they are NOT FLYING THE PLANE.

MOST AIRPLANES WITH ENGINEERS USE THEM FOR EMERGENCY CHECKLIST

Hey chief, enough with the NEWS FLASH and the CAPS already, ok? I know more about this accident than you can imagine.

A good C-5 driver has his checklist turned to the EP page all of the time. I split mine into two parts, Normal Procedures, EPs, and AR in one binder, all of the rest in the other.

Who read the checklist had nothing to do with this accident. What are you going to do in a two man cockpit?

Hag

 

[C-141/C-5]

This is the attitude I expected from the C-5 community. Unwilling to change for the better.

I'll be just fine in a 2 man cockpit, but we aren't in one are we. USE ALL AVAILABLE RESOURCES CHIEF

 

[C-141/C-5]

Sorry for the slight hostility, but its frustrating to see good people getting hurt and the AF getting a bad rap for this incident.

I do realize there was a ton of other factors ie: IP being pencil whipped, bad checklist discipline, human factors, etc.

I just truly believe in using the engineer so the pilots can maintain aircraft control.

 

[Hagar17]

This is the attitude I expected from the C-5 community. Unwilling to change for the better.

I'll be just fine in a 2 man cockpit, but we aren't in one are we. USE ALL AVAILABLE RESOURCES CHIEF

Re-read my first post.

"However, I do agree with you in that, in flight, the FE should read any and all EP checklists."

Now, SWITCH TO DECAF!!

BTW, that's what I expect to see from the C-141 community, all 2500 hrs total time of it.

Hag

 

[OrionFE]

When I was an FE in the navy, as in the AF, the copilot read all checklists. However, we had several procedures that were burried in the book and not on the laminated checklist. During the complex EP's the FE would have the book opened up in his lap while executing the procedure. I sat on a committee that for over a year studied different checklists from both civilian and military. We had a lot of reserve pilots who were airline pilots on the committee. We came up with a more efficient way of operating and utilizing the normal and emegency checklists. When submitted for approval, it was rejected by the young active duty folks, because we have always done it that way and that is that. When looking at several other operators from around the world (same plane), I always thought the way we did it was pretty bizzare. One thing in relation to this accident, when we shut an engine down, the power lever was pushed all the way forward and out of the way of the operating engines.

Now on the 747, the FO reads the before start, after start, and parking checklist while the FE reads the rest. For in-flight EP's, the FE grabs the QRH (Quick Reference Handbook), the Captain normally relinquishes controls to the FO and the FE and Captain run through the procedure. The Capt. can back up and observe the FE as he works his panel. During the approach and landing phase the FE is all the way forward backing up the pilots. It is mentioned throughout the AOM for the FE to be alert for any missed ques or callouts by the pilots and make the callout if needed and be alert for flap settings, speed breaks, etc...For an engine shutdown, after it is secured the thrust lever is aligned with the rest. Doesn't hurt to move that thing around the rest of them.

In the navy, if there were an extra pilot and FE on-board, they were normally included in on the procedures and all briefs and stayed in the cockpit for the landing. It is amazing still, in a three-man cockpit, mistakes like this are still made all the time. Read through the NTSB files at all the gear-up, good airplanes flown into terrain, etc...

 

[TankerDriver]

AF PROCEDURES for first!!! WHY IS THE ENGINEER NOT READING THE CHECKLIST AND THE PNF IS????????????????????? My answer i get "THIS IS HOW IT 'S ALWAYS DONE IT'S THE C-5 WORLD" In my world Horrible answer to the question!!! Fix what is broke don't fall in the mindset that this is how we always do it!!! If there is a better way fix it!!!

DON'T BLAME AMP!!

Do you not feel the yaw with 1 engine out??? You would if the other side was pushed up! TRIM SETTINGS ARE TAUGHT! THIS WAS JUST BAD STUFF ALL AROUND!!

in the c-5 you are taught trim settings with one engine out! I highly

As much as I agree with you about the Air Force dragging their feet adopting new (better) procedures with just about everything (this takes money - something we never seem to have), after reading the report, I don't think checklist discepline was a primary factor in the crash. From day one in pilot training, what do we hear? "Maintain aircraft control, analyze the situation, take the proper coordinated action [crew aircraft] and land as soon as conditions permit.". Fly the airplane. In situations like these, it's crucial that someone is flying the aircraft and only flying the aircraft. 9 times out of 10, this will keep you alive. Sounds like such a simple task, but there were a chain of events that lead to distraction of the PF. I honestly believe the emergency return to land was rushed. This is just my opinion, but there is no reason why a 4 engine aircraft needs to hang an immediate U-turn to come back around and land. Especially heavy weight like that. The aircraft is flyable with 3 good engines. Heck, our -1 [KC135R] says at weights below 200,000lb [max TO - 322,500lb] the aircraft can maintain level flight with one engine!! The book even recommends pulling the asymmetric engine to idle and fly the pattern with 2 engines. The 135 is really a two engine jet at lighter weights. They analyzed the problem as a reverser unlock and successfully shut that engine down with no further issues. Why not do the immediate action items, climb away from the ground, go into a holding pattern, slap the autopilot on and let it do it's thing to get rid of some work load? Then talk about the situation, go through EVERYTHING in the book. We all know one emergency checklist in the expanded -1 can lead to several other checklists to run through (heavy weight landing considerations, egress procedures, etc...). I just can't see them going through absolutely everything in the time it took to go around a radar pattern to a final approach. In a large aircraft with so many redundancies, there are very few situations that'd require getting the jet on the ground ASAP. Smoke in the cockpit comes to mind. Fuselage fire is another. An engine failure? Not at all. I don't think having the FE run checklists would have been much different, although I see your point that the PNF could have watched his PF's back better with airspeed control. Honestly, I don't think that's an excuse though. The PNF should know his/her duties and that is to back up the pilot flying. If they had their head in the book on final approach, that's UNSAT and probably could have been avoided with my view above.

I'm familiar with using procedures that are still here because "this is how we've always done it". A lot of our procedures were carried over from the old SAC A-model days. The AF likes to put band-aid on top of band-aid on top of hand-aid on an oozing wound that just won't go away to avoid bureacratic ass pain and more importantly, spending money. Unfortunately, it takes death and/or hull loss to change anything and they're really not alone because the FAA is the same way.

 

[metrodriver]

According to the article there was an instructor and more than one FE. What did these people do during this flight? How about using them to read the checklists and going to the manuals finding the right pages, and being an extra set of eyes. The released article just screams poor CRM (or is that a concept the airforce doesn't know about yet?).

 

[TrafficInSight]

(or is that a concept the airforce doesn't know about yet?).

I really don't think it's fair to say that since the rest of the world has problems with CRM at times.

 

[michael707767]

When I was an FE in the navy, as in the AF, the copilot read all checklists.

In my plane in the Air Force (E-3) the engineer read all the checklists, emergency or normal.

 

[Rogue5]

C-5 Crash At Dover AFB in April Blamed On Crew Error

World News & Analysis

C-5 Crash At Dover AFB in April Blamed On Crew Error
Aviation Week & Space Technology
06/19/2006, page 28

David Hughes
Washington


An experienced crew gets complacent returning to home base on a clear day

Printed headline: C-5 Crew Error Crash

A U.S. Air Force accident investigation board has concluded that the cause of a C-5B crash near Dover AFB, Del., on Apr. 3 was a series of primarily pilot errors that resulted in the aircraft stalling into the ground.

All 14 crewmembers from the USAF Reserve's 512th Military Airlift Wing and three passengers survived. Some were seriously injured. The aircraft crashed and broke into two large pieces about 2,000 ft. short of the runway during an emergency return to Dover.

The aircraft weighed 742,000 lb. and was bound for Ramstein Air Base, Germany, with 105,000 lb. of cargo when the crew decided to shut down the No. 2 engine after a "thrust reverser not locked" light illuminated. If a thrust reverser deploys in flight with the engine running, it would be a serious hazard.

The pilots then canceled the instrument flight rules clearance, for reasons not in the report, and requested a visual approach to Dover's runway 32--3,300 ft. longer than the instrument landing system-equipped runway 19.

The pilot was in the right seat and was certified as a C-5 flight instructor. He was chosen by the pilots to fly the emergency return so he could log the sortie. During the descent, he pulled throttles for the remaining operating engines 1, 3 and 4 to idle. When later advancing the throttles, he mistakenly advanced throttle 1, 2 and 4, leaving No. 3 at idle (29% fan speed) for the duration of the flight. In effect, the pilot used above-idle thrust on just two of the three functioning engines until ground impact. This error and corresponding engine-instrument indications were missed by the pilot in the left seat (a C-5 flight examiner), the pilot in the jump seat and the flight engineers who monitor engine performance.

The accident board found the cause of the mishap was the pilots' and flight engineers' failure to use the fully operational No. 3 engine, the instructor and primary flight engineer's failure to brief the approach and the pilot's failure to use 62.5% or 40% flaps for the approach. Col. Raymond Torres, president of the accident investigation board, says the Air Force directs pilots of heavy-weight aircraft (above 632,000 lb.) to use 40% flaps on an engine-out approach--not 100% flaps.

While flying with the landing gear extended at 500 ft. above ground about 4 mi. from the runway, the pilots selected 100% flaps--an action not normally taken on a three-engine approach until landing is assured. Normal glidepath at this point should have put the aircraft at about 1,200 ft. The investigation board said the 100% flap selection was premature, based on the heavy weight, speed, altitude and position of the aircraft relative to the runway. The crew's call for a visual approach and descent below the normal glidepath was another cause of the accident, the board says.

After selection of 100% flaps, the aircraft continued to descend. The target approach speed for 100% flaps was 146 kt., with minimum control airspeed at 133 kt. But the pilot was unable to maintain the target airspeed, and the aircraft slowed to 127 kt. Descending through 150 ft., the crew selected 40% flaps (apparently to reduce drag), causing an immediate stall due to loss of lift. The 127-kt. speed was 40 kt. below the target speed for 40% flaps. The accident board noted that even without this change in flap setting, the plane would have stalled and crashed short of the runway.

The aircraft impacted the ground in a "very nose-high attitude" of 18-21-deg. angle of attack. The tail struck the ground first, even before the main landing gear, with a 10g force as the empennage broke off. Then, the nose slammed down with 30g of force, breaking the fuselage into two major sections.

There was no post-crash fire or explosion, despite the aircraft carrying 250,000 lb. of jet fuel. The C-5 had nitrogen in the airspace above the JP8 fuel in the tanks. The main and auxiliary tanks ultimately ruptured, and more than 1,000 gallons of fuel spilled on the ground. There was no spark to set it on fire.

The board says the crew was complacent and failed to realize the potential risk of a heavy-weight, full-flap approach and landing. Torres says simulator sessions showed if any of three errors (flying below the normal glidepath, using less than the available thrust on the three running engines or selecting the 100% flap setting) had been corrected, the aircraft could have landed safely.

For example, simulator sessions showed that using the No. 3 engine as late as 300 ft. above the ground resulted in a safe landing. The accident aircraft stalled at 150 ft. Another scenario showed that using a 62.5% or 40% flap setting and the related approach speed without using the No. 3 engine above idle led to a safe landing. And a third scenario showed that flying an ILS or tactical air navigation approach to the runways at the base at the right altitudes would have worked even without the No. 3 engine above idle and flaps at 100%.

Torres says that crew performance in this accident did not meet the Air Force's professional standards, but he does not know if any disciplinary action will be taken against crewmembers.

The C-5 in the accident was recently fitted with the avionics modernization program system, which worked properly during the flight.

Wally Magathan, a former C-5 aircraft commander and flight instructor, contributed to this article.

 

[Fury220]

^Wow...doesn't look too good for those guys.


Thank GOD everyone is alive.

 

[dojetdriver]

I really don't think it's fair to say that since the rest of the world has problems with CRM at times.

True. But a few (notice I said a few) mil type guys walk around with their chests stuck out, bragging about how great the military training is compared to the civilian training and that only the top gun-best of the best-super pilots can cut it in the military. And how good they are compared to civ pilots, how with a mil pilot you getting a "known quantity" blah blah blah.

I feel bad for these guys, shiite happens to everybody, and sometimes it happens to you. Everybofy screws up, myself included.

But if any of these guys go to interview for a major, are they a mil super pilot top gun "known quantity"?

They just proved that mil training and flying is subject to the same foibles and problems that civ training is.

Sorry if nobody agrees. I doubt this is the only mil accident ever to happen from a lack of CRM.

 

[Big Beer Belly]

Just an observation from a former AF guy. There are lots of references to "PNF" and the Air Force being "behind the times" on this thread. FWIW, most airlines have replaced "PNF" with "PM" (PILOT MONITORING) to further emphasize the engaged role of the pilot not directly at the controls. The title itself emphasizes the importance of the "non-flying" pilot in monitoring for satisfactory performance.

I think the report speaks for itself. I took the following from it:

1. Never get SLOW in an engine-out/thrust deficient situation.

2. Properly identify which engine is malfunctioning.

3. Comply with Standard Operating Procedures in an emergency (i.e., use recommended flap settings for the situation).

Most emergency procedures (especially those in military aircraft) have UNFORTUNATELY been written in blood. DO NOT DISREGARD the Dash-1 Notes, Warnings, and Cautions ... someone has most likely paid for them with his life.

This is truly an occupation characterized by hours and hours of boredom with rare seconds punctuated by terror. I take it as another reminder to occasionally hit the books and brush up on the EP's between annual re-qual events. You just never know when your life/career may depend on your successful handling of an emergency.

BBB

 

[dojetdriver]

Just an observation from a former AF guy. There are lots of references to "PNF" and the Air Force being "behind the times" on this thread. FWIW, most airlines have replaced "PNF" with "PM" (PILOT MONITORING) to further emphasize the engaged role of the pilot not directly at the controls. The title itself emphasizes the importance of the "non-flying" pilot in monitoring for satisfactory performance.

I think the report speaks for itself. I took the following from it:

1. Never get SLOW in an engine-out/thrust deficient situation.

2. Properly identify which engine is malfunctioning.

3. Comply with Standard Operating Procedures in an emergency (i.e., use recommended flap settings for the situation).

Most emergency procedures (especially those in military aircraft) have UNFORTUNATELY been written in blood. DO NOT DISREGARD the Dash-1 Notes, Warnings, and Cautions ... someone has most likely paid for them with his life.

This is truly an occupation characterized by hours and hours of boredom with rare seconds punctuated by terror. I take it as another reminder to occasionally hit the books and brush up on the EP's between annual re-qual events. You just never know when your life/career may depend on your successful handling of an emergency.

BBB

4. Use some CRM

 

[JohnnyP]

World News & Analysis

The pilot was in the right seat and was certified as a C-5 flight instructor. He was chosen by the pilots to fly the emergency return so he could log the sortie.

Im out of the loop here, but what does that statement refer to, "so he could log the sortie"? During an actual emergency, were they concerned about how/and who was going to log this in a certain manner? Maybe im just missing something here. Is the PF not the "chosen one" when flying in this situation?

 

[CHQ Pilot]

This accident goes way beyond what the AF has released in press releases. There is so much more with many lessons to be learned. Unfortunately the public won't have access to the majority of it. It is not a simple case of a throttle swap and bad CRM. There are many more facets that lead up to the accident. I have a feeling it will be used for many years as a teaching tool in the military.

The crew, since it was a Rerserve crew, probably had an extensive civillian background in addition to their military experience.