Accident report for Jalalabad C-130J crash released

[On_The_Top_Bunk]

Report here Accident report for Jalalabad C-130J crash released (http://www.c-130.net/c-130-news-article291.html)

Very sad that something so simple could cause this.

Could have so easily happened to Voyager with the loose camera.

[212man]

Would the lack of a controls 'full and free' type-check be due to the engines running operation resulting in an 'abbreviated' checklist? Seems a curious omission - or is that normal for C130 ops? Also, would the yoke's longitudinal position not have felt unnatural during the initial take off roll?

[JAVELINBOY]

I wondered about how they felt the control yoke and failed to notice it was out of position due to the box, could it be they adjusted their seats during their stop and simply readjusted to what was the wrong position in relation to the yoke position?

[StopStart]

A full and free check of the controls after an ERO isn't actually included in the RAF's "Crew Change Pre-taxy checks" however airmanship and habit always dictated that one would do a "round the box" with the flight controls either before taxy or on the way out.

As for the control column position, the only thing I can surmise is that they used the box to deflect the controls to a neutral position as the elevators droop slightly at rest.

http://i1113.photobucket.com/albums/k512/stickybloke/45C50B83-B9C0-46CB-88C9-D72052122996.jpg

As a result the control column wouldn't be in a particularly unusual position. At rotate, the box would've slipped further downwards as the control column was pulled aft, preventing a check-forward of the column with the inevitable tragic results.

[212man]

s "Crew Change Pre-taxy checks" however airmanship and habit always dictated that one would do a "round the box" with the flight controls either before taxy or on the way out.
Quite - I was being polite....

[Brain Potter]

How terribly sad.

However, I am not so sure that the cause rests entirely with a crew lacking in "airmanship". I know next to nothing about C-130 operations, but would guess that the idea of using an NVG case as a defacto control lock was not conceived in response to unique circumstances presented by this particular flight. If elevator droop during loading is a real and known problem, it should have been reported and addressed with an approved technical and/or procedural solution. Did supervisory personnel know of the problem and tolerate (or even advocate) the workround?

Employing unapproved workrounds with safety barriers that rely principally on "airmanship" invites the holes in the Swiss cheese to line-up.

[StopStart]

Evening Potter! The elevators getting in the way during loading is actually fairly rare and only becomes an issue with outsize loads. I can't really think of more than two or three occasions where I encountered it during my 16 years on the thing.
This is something that can be simply contained by an extra "Flight controls..........P Checked" in the ERO pre-taxy checks. I'm guessing this crew were perhaps working relatively hard - awkward load, in the dark, time pressures perhaps, Captain and Co busy punching things into the CNI/FMC and having to hold the controls back was just taking one of them out of the loop. As you say, airmanship and management clearly apart came and the holes lined up.
Terribly sad indeed; a busy crew trying to do their best but sadly, and fatally, they let their guard down

[ancientaviator62]

When loading high frame heavy drop loads into the RAF C130we would sometimes need someone in the cockpit holding the elevators up until the load was over the threshold. But it was always done by someone and not 'jammed' in position.

[Just This Once...]

After an incident where the elevators were damaged during a night strip engine running offload (mover having to work with nonstandard kit) there was a recommendation for a control check following cargo ops to be added to the RAF checklist. Unfortunately the chain of command comment was that the movers shouldn't drive into the elevators and there was no change to the FRCs. Shortly afterwards there was a major scrape of a tailplane in AFG, requiring a replacement to be fitted (not an easy or quick task), thankfully during the day.

The cheese holes have been lining-up on this for years and having made the recommendation years ago I still grumble every time I see heavy equipment being operated close to primary flying controls with no mandated flying control check beyond 'airmanship'.

[squib66]

Saw the link to this illustrated report on Twitter
C-130J Control Restriction Accident, Jalalabad (http://aerossurance.com/?p=5360)
http://aerossurance.com/wp-content/uploads/2016/04/c130j-crash-site.jpg


It does say that "The investigators say they could not determine if a flight controls check would have alerted the pilots to the obstruction."http://aerossurance.com/wp-content/uploads/2016/04/c130j-nvg-case.jpg

[StopStart]

That's a very odd thing for the report to say. I'd stick my neck out and say that a check categorically would've alerted the pilots to the restriction.

[WIDN62]

I am sorry, but I must be missing something here.
If the case in those photos is the same as the one in the accident, I fail to see how it could have been missed. The control column is well back from its normal position and whether or not a "full and free" was carried out, surely anyone familiar with any model of C130 should notice the CC position long before getting airborne - whether or not they could see the case whilst wearing goggles.

[squib66]

That's a very odd thing for the report to say. I'd stick my neck out and say that a check categorically would've alerted the pilots to the restriction.

I agree so they must have their reasons.

I fail to see how it could have been missed. The control column is well back from its normal position and whether or not a "full and free" was carried out, surely anyone familiar with any model of C130 should notice the CC position long before getting airborne - whether or not they could see the case whilst wearing goggles.

Again I agree.

Do you think they would have been as coy if they had a flight deck survivor?

[Double Back]

The conclusion:
I find by the preponderance of the evidence that the cause of the mishap was pilot error due to the
combination of the MP’s decision to place the hard-shell NVG case forward of the yoke blocking
the flight controls, the distractions experienced by the MP and MCP during the course of the ERO,
and the misidentification of the malfunction once airborne resulting in the destruction of the
aircraft and cargo and the loss of fourteen lives.

Woow, this is like an airline investigation conclusion from 1950's, when nearly all was contributed to the infamous "pilot error". A bloody shameful conclusion, very hard to the relatives and friends, and the instructors of these poor guys.

To name a few, which moron in the organisation has erased or never introduced the need for a flight control check after an ERO of over one hour? 5 seconds during taxy out too much?

Misidentification once airborne??? those few seconds??? Who would not think of a wrong trim setting when the plane rotates by it selves and keeps on pitching up?

The decision to select an AMAX T/O was not "wrong", it was unnecessary at best. It did not CONTRIBUTE to the accident, it is highly speculative that the higher rotation speed would have triggered an abort. It would have added just a few secs during the T/O.

We are reinventing the wheel again, over and over again.

Non mil but 18.000 hrs heavy metal driver.

[PersonFromPorlock]

Double Back (http://www.pprune.org/members/54542-double-back)
Woow, this is like an airline investigation conclusion from 1950's, when nearly all was contributed to the infamous "pilot error". A bloody shameful conclusion, very hard to the relatives and friends, and the instructors of these poor guys.The virtue of 'pilot error' (or 'crew error', as I prefer) as an explanation for accidents is that if it isn't that, then you are just flying around waiting for the airplane to kill you. I will agree that organizational error can be a strong contributor to crew error, but the crew are the people at the sharp end.

[GlobalNav]

In addition to that, I fail to imagine how the pilot's feet readily reached the rudder pedals with the NVG case between the column and the pedals without awareness that it is there!

I don't want to ignore the possibility of organizational contributors but confess that other than callous disregard for, and failure to enforce, obviously safe operating practices, wonder what organizational contribution could override the pilot's good judgment.

Sometimes what looks like a spade really is a spade.

[Double Back]

Anyone who has been trained in simple ME planes during N-1 ops knows how after a few minutes Yr "life engine" leg starts trembling and later shaking. Keeping the Yoke pulled full aft for an hour is close to impossible.

If You have never sat in a C-130, You can't question if they could not reach the pedals. The PF had been taxiing and braking, so he must have been in contact with them.

Sure, pilots are mostly the last link of an accident chain, that does not mean the other links go free. The pilots are mostly the result of an organisation's procedures, training, doctrine, and more. If they fail, the organisation has failed.

Some difference here with commercial pilots and military pilots. The first ones may have had a long career spanning several companies. Maybe pop and mom charter or flight schools where they may have learned wrong things.

Most of the time military pilots started from scratch and stayed with the military their whole career.

[Uncle Ginsters]

A very sad mishap.

All too many times on both sides of the pond it's the crew that suck up the pressure of other agencies' genuine delays or just pure ineptitude.

Sadly, I think it is true to say that there will always be circumstances that you can't legislate for in every checklist.

Too often, it's a good dose of airmanship that may save the day (or night, at the end of a long day) - the glove over the throttles, or dropped HUD as we use - as a blanket, unmissable reminder that "something" is different.

I don't think "pilot error" is a suitable conclusion, but they let themselves get into that situation, with no 'out'. That, I believe, is something we can all learn from this. RIP.

[212man]

...the glove over the throttles, or dropped HUD as we use - as a blanket, unmissable reminder that "something" is different.


I agree it's not ideal but it is the logical thing to do. I wrote this on another forum:

Whenever a 'workaround' like this is done, it makes sense to also introduce a secondary warning that is unmissable and will trigger recognition of the first action needing reversing. On both the Sikorsky S76 and the S92 (helicopters) the use of fuel X-Feed is prohibited in flight, except in emergencies, but its use may sometimes be needed to correct a fuel imbalance whilst on deck. To prevent inadvertent departure with the X-Feed still selected, it was common practice to block the PF's ADI or PFD to give a glaring message that something wasn't normal. Typically on the 76 we would place the checklist over the ADI and on the S92 select the NAV display on the primary MFD (so no PFD on the PF side). One could also argue that a 'full and free' check should be a fairly basic pre-requisite before departure (for an aeroplane) and the omission of such has led to several fatal accidents where gust locks have been left in - some very recent.

[melmothtw]

This view shows better how the pedals can still be accessed with the NVG box in place...


http://i1373.photobucket.com/albums/ag380/garethjennings1/yourfile_zpsyzm8hqqh.jpg (http://s1373.photobucket.com/user/garethjennings1/media/yourfile_zpsyzm8hqqh.jpg.html)

[Double Back]

It also indicates that the capt who was Pilot Not Flying probably was focussed (NVG!) more outside than inside. The Copilot who was Pilot Flying had an unobstructed view on his instruments, so did not see anything odd.

[GlobalNav]

I stand corrected. Won't be a problem in the A400 I suppose.

[MPN11]

I related this sad story to my BIL today (former Vulcan driver) ... he was amazed that a quick check of "full and free movement" wasn't a standard check before moving the aircraft for departure.