USMC CH-53 Mid-Air Off Hawaii Declared Pilot Error

[SASless]

Article about the Mid-Air that killed Twelve and video of wreckage on the sea bottom.


Cause of helicopter collision that killed 12 Marines off Hawaii revealed - CBS News (http://www.cbsnews.com/news/hawaii-dual-helicopter-collision-12-marines-killed-pilot-error-poor-training/)

[ryano]

Those guys went to work that day with the best intentions. They've been thoroughly let down and people should be ashamed this occurred. Their deaths were entirely preventable. It's not rocket science - poor serviceability, low flying rates, inadequate training, lack of focus and poor command will kill people. Only fools believe otherwise. Unfortunately it's the guys and girls at the pointy end, doing their best, that pay the piper. The report only proves what people knew already. My most sincere condolences to their families and friends.

[ShyTorque]

It's a sad fact that it's always easier to decree "pilot error" than "management error". Management are seldom in the aircraft crash.

[Frying Pan]

Not wishing to condone 'management error' in this tragedy. I can't see how in a mid air collision with no mechanical faults and I assume no crew not trained properly, else they would have said, how it couldn't be anything but a tragic accident. I lost 4 colleagues when 2 Seakings collided at the start of Gulf War II, the conclusion had reasons why the risk increased but again a tragedy. Formation flying at night over water is inherently risky.

[OvertHawk]

Frying Pan

As I understood the article there is very definitely the suggestion that the crew were not sufficiently current for the operation they were undertaking.

I would suggest that that comes clearly under the heading of "Not Trained Properly", if we consider that currency should be part of any adequate ongoing training programme, and therefore clearly a management failing is it not?

OH

[SASless]

This one was personal....one of the young Crewmen was a Friend's Son.

The US Military is suffering from Budget Cuts due to Congress and the President being unable to properly assess priorities on spending thus the implementation of Sequestration where none of them take the blame for the bad things that happen due to automatic across the board Budget Cuts.

Military flying can be very hazardous due to the very nature of what is being done.

To send Crews out that are not properly trained and experienced during Training is inexcusable at the Command Level.

In War Time...then perhaps that situation becomes tolerable even if not desirable.

We need to hold our Civilian and Military Leadership responsible for their actions and their In-Action.

Yes....it can be called "Pilot Error" but someone gave them the Gun, Loaded the Bullets into it, Pointed it at their Head, Cocked it....leaving only the pulling of the trigger to the victims.

Twelve Good Marines died that Night that should still be with us had the System not failed them.

[Lonewolf_50]

Not wishing to condone 'management error' in this tragedy. I can't see how in a mid air collision with no mechanical faults and I assume no crew not trained properly, else they would have said, how it couldn't be anything but a tragic accident. I lost 4 colleagues when 2 Seakings collided at the start of Gulf War II, the conclusion had reasons why the risk increased but again a tragedy. Formation flying at night over water is inherently risky.
Frying Pan, I suggest that you read the article, which mentions the matter of not being current (proficiency is another matter) on some of their training minimums. Night minimums, with and without aids, is governed by OPNAVINST 3710 and other training and standardization regulations. The larger problem that is even if you manage to get your minimums to stay current, proficiency usually takes a bit more flying. Night formation has some hazards that day formation flying does not.


Training dollars are not infrequently cut as they are more easily reached funds, unlike MilCon or APN 1 acquisition dollars. Training, however expensive, is how you keep your force proficient and professional in their craft. The monthly pilot flying rate, which was about 30 hours when I was an Ensign back in the 80's, has been drastically reduced.


This is the kind of executive level decision made up the chain of command, and in Congress, and when budgets are established and prioritized. And then, operating and maintenance funds (O&M) are raided half way through the fiscal year leaving the squadron commander and his opso holding the bag. (No, I'm not bitter ... ) The squadron is once again told to "do more with less."


This is an old and tiresome story. The politicians want to declare "we have the best trained military in the world" but they'll cut training funds in the blink of an eye. Further comments censored.

RIP and Semper Fi: sadly not the first nor the last "routine training mission" that ends with us losing comrades in arms.

[Frying Pan]

I apologise for treading on toes. Tradegies that involve insufficiently trained aircrew is inexcusable. From memory more allies died in Operation Desert Shield than Operation Desert Storm. That says too much. Why were these guys flying so close at night without the skills...so unnecessary. All those levels of command and pre flight briefings in peacetime and still they did it. Let's hope lessons are learned.

[SASless]

FP,

We are agreeing with you. Yet most of us are inclined to think under the Contributing Factors section of the Accident Report should be a very clear assertion that there were Command Failures right up to the Oval Office.

[ShyTorque]

Problem comes with senior officers, often at station, or even squadron level, not having big enough balls to stand up and risk their own careers by saying "NO!"

I saw it a number of times during my time in the armed forces.

One particular night will always stick in my mind. We had been called back into work on a Friday night, after a long week, for a "MINEVAL" (station generated exercise, latter Cold War days). We had a new Station Commander who was obviously rapidly on his way to the top (and he did), having come from a fixed wing, recently made obsolete type and was in the process of making his mark on the SH force. Our squadron commander was of the same ilk, albeit further down the chain of command.

It was obvious to me that the weather was well below limits for visual night flying (low cloud, rain, poor visibility, gusty winds). Regardless, we were soon called to a mass pre-flight briefing where it immediately became obvious that our aircraft were expected to deploy very shortly afterwards. The brief was to deploy in radio silence as a night stream to an unlit and unrecc'ed landing site at an army camp somewhere south of our secret helicopter base not far from London.

However, we were not trained or equipped to land at unlit landing sites (our aircraft were deficient in NVG searchlights or floodlighting. Our SOPs of the time required night landing sites to be pre-recc'ed or be manned by a ground party and conventional ground lighting laid out in advance.

During the briefing, nothing was mentioned about night stream procedures, except that a two minute time gap would be maintained. No mention of approach or circuit direction was made.

As this briefing went on, the hackles on the back of my neck began to rise and alarm bells began to ring in my soul. It seemed to me that basic common sense had departed when the MINEVAL siren went off.

As an OCU QHI, albeit relatively inexperienced compared to some of the old lags present, I couldn't believe that no-one more senior than I hadn't already spoken up about the obvious deficiencies of the plan. I looked around. Everyone seemed uneasy but reluctant to question the "Boss".

I finally asked the question "What is going to happen to the aircraft separation if someone has to go around from their approach to the landing site or goes IMC in transit?"

I received a blank look from the briefing officer. The briefing was concluded. I told my flight commander and crewman that we weren't going to fly under that plan. I wasn't popular among the hierarchy for some time but none of us flew to that landing site.

[SASless]

"NO!" is the most difficult word in the Pilot's Vocabulary....especially if directed towards a Senior of some sort.

That inability to articulate such a simple word....only two letters in it...one syllable.....and Pilot's will rather kill themselves than utter that word!

[Lonewolf_50]

"NO!" is the most difficult word in the Pilot's Vocabulary....especially if directed towards a Senior of some sort.

That inability to articulate such a simple word....only two letters in it...one syllable.....and Pilot's will rather kill themselves than utter that word!
SASless: sad but true.


I once did that and, in part due to the style of my saying "no," was grounded by my CO for three months and directed to take anger management training. (I kid you not). What's funny is that in the long run his directive had some embedded wisdom. That wasn't bad training as it helped me later in life in a variety of situations. The CO and I served in another squadron later and had a solid relationship.

[MightyGem]

I wasn't popular among the hierarchy for some time but none of us flew to that landing site.
Good effort, Shy! :ok:

[JohnDixson]

Updated Report Article:
https://www.marinecorpstimes.com/articles/marine-corps-ch-53-crash-hawaii-report-investigation

The details emphasize the problems pointed out here.

[212man]

Not sure that faster 53Ks will fix it, or jumping on Obama, but a familiar story.

[47B-3]

Where are the mission training full flight simulators (FFS) located for the CH-53E?
At the base ? Or on the US mainland?

[megan]

The senior ranks not taking responsibility for their decisions is not new. A young man I met when he was a high school student went on to join the RAAF, dux of his wings course, went straight to F-111, and dux of that as well. Being a computer whip the squadron had him doing IT work with little flying, though he was champing at the bit and on the back of his seniors for same. Came the day, night actually, he was put down to fly a night low level simulated attack mission, not only fly, but to brief the others, and lead the mission, despite not having flown at night for some six months, and the nav was not his usual crew member, since he was down medically. A young buck (squadrons youngest and most inexperienced) not wanting to be seen lacking and desperate for stick time. What could go wrong? Weather was crap, and the poor guy lost it during the attack and CFIT. It took his Mother to investigate and find what went on, and detailed it in a book "The Thirteenth Night". The only RAAF fatal accident not to have had an official investigation. Why is that you might well ask. Senior officers with red faces? Where was the supervisory oversight of this young man, and in particular, the authorising officer of the fatal flight? The reason those people are in place is to pace the development of the up and comers, not to let them get in over their heads.

RIP Jeremy McNess - one of our nations most dedicated and brightest.

[[email protected]]

It will be interesting to see if the families of the deceased mount a campaign to challenge that 'pilot error' declaration in the same way as the Mull Chinook crew's families did. It seems they could have a very good case.

[Lonewolf_50]

47-B: it is only comparatively recently that the Hawaii squadrons got 53E's. Kanehoe Bay was the last operating 53D squadron for some years. I'll need to ask around to be sure, but I don't think the full motion 53E sims are present. I'll get back to you.

[SASless]

More information re the Crash and possible linkage to temporary restrictions on the Unit flying while the POTUS was on Vacation near the Unit.

Report: Marines Link Obama Vacation to Deadly Helo Crash | Military.com (http://www.military.com/daily-news/2016/10/28/obama-vacation-may-have-contributed-to-deadly-marine-helo-crash.html)

[megan]

Why in the world does he need a TFR established wherever he decides to go? If anyone's going to take pot shot I don't think it would involve an aircraft.

[212man]

The article is typical Obama bashing and it's sad to see these deaths being used as such!

It even starts with this statement:
...the Secret Service put in place a series of standard security measures, including a temporary regional flight restriction...

Devine said the annual, pre-planned restriction on flights was consistent with standard Secret Service operating procedures, and units typically mitigate the impact of the restrictions by using alternative training routes or venues.

So, nothing unique to the present incumbent and not the first time the TFR was in force! A more measured approach to the questions would be; "did standard security service protocols influence the causes of the accident?", not "was it Obama's holiday that did it?"

A couple of weeks of restrictions does not create these kinds of proficiency numbers:

Two pilots were not “adequately proficient” in the use of night vision devices. One of them had only flown 2.8 hours at night in the preceding 90 days, with two of those hours coming the night before the fatal crash. The other had logged zero night hours in the previous three months and had not worn night vision goggles in the “local flying area” in over a year.

BTW, the official report is here: http://www.hqmc.marines.mil/LinkClick.aspx?fileticket=cKZnmr7HQuI%3d&tabid=16139&portalid=61&mid=88592

[SASless]

It is not Obama bashing....it is simply suggesting the Temporary Flight Restriction threw a huge wrench in the Flying Program for the unit and perhaps that played a role in the management pressures to play catch up after Obama departed.

Oddly....it ain't all about Obama and his annual vacation for some golfing.

[[email protected]]

Sadly it looks like a familiar tale of poor serviceability of the fleet (for a number of reasons including manpower), a continued push to keep the readiness levels (keeping someone's command/promotion tick boxes filled) poor morale and just not enough training - ie achieving bare currency as opposed to proper competency.

Sad waste of good guys.

[tistisnot]

Strange use by the military of the description "mishap" - which in my book is a small mistake / unlucky accident / misfortune. However ....

I note some crew members had total flight time equal to their flight time on CH53 - is that erroneous reporting, or possible? And the low total hours makes one realize their vulnerability without sufficient and regular competency training.

I spent more time offshore so easily forget the pressures within the military, but it makes me wonder if Safety Culture has been developed enough when the Aviation Safety Officer is noted as having a heated discussion on the previous day about the execution of that particular flight - and no-one took enough notice - does he not have direct access to the unit commander?

[212man]

Strange use by the military of the description "mishap" - which in my book is a small mistake / unlucky accident / misfortune. However ....


Pretty standard US terminology in their reports - MP = Mishap Pilot. I guess similar to my company's non-use of the word 'accident' as one of the definition's implies something that couldn't be controlled or predicted.

[megan]

I've always been amused by the use of the term "substantial" when describing damage to an aircraft in an accident, even though the largest piece you could fit in your pocket.

[[email protected]]

As anyone who has done helicopter formation will tell you - line astern is the worst position because judging the rate of closing is so much harder - and that's in the daytime. At night it is almost impossible - hence the advice in their training documents to minimise time spent within 15 degrees of that position.

[ClearedHot28]

It is a sad and tragic event that could have been avoided with proper funding. I knew the Major slightly that died in that accident. We had mutual friends and were both stationed on the same Air Station several years ago. I've known too many fine men and women who have died in accidents like these over the years.

I also have been in the same situation as those Marines were in with not enough money for flight time, poor leadership, and being pressured to do a flight when you shouldn't. One year I got a little over 100 hours (the minimum according to OPNAV 3710) because of funding and this was back around 2006.

Hopefully this situation with funding, equipment, and training will change but I'm not that optimistic.

[SASless]

Then add in the use of NVG's and NVG compatible lighting rather than the standard Nav Lights and you add another dimension to the difficulty.

[Thomas coupling]

Well the CO and the Brigadier General were stood down which probably means the hierarchy can sleep at night anyway:mad:

Meanwhile press on itis has its way again........:{

Poor souls.

[[email protected]]

Sasless, sorry, by night I meant, but didn't specify, being on NVG with NVG formation lights.:ok:

[Lonewolf_50]

Strange use by the military of the description "mishap" - which in my book is a small mistake / unlucky accident / misfortune. However ...

The US Navy uses an officially defined doctrinal term, Mishap, which has severity codes A, B, and C. That term covers both ground and air events.
I've investigated a few of each.
Reference: OPNAVINST 3750.7 series ; (http://www.cacclw.navy.mil/docs/aeromed/3750.7R.pdf)Chapter 3:
The following mishap severity classes, based on personnel injury and property damage, apply to all three categories of mishaps listed above. To determine mishap costs see paragraph 314.

a. Class A Severity. A Class A mishap is one in which the total cost of damage to property or aircraft or UAVs exceeds $1,000,000, or a naval aircraft is destroyed or missing, or any
fatality or permanent total disability results from the direct
involvement of naval aircraft or UAV. Loss of a UAV is not a
Class A unless the cost is $1,000,000 or greater.
b. Class B Severity. A Class B mishap is one in which the total cost of damage to property or aircraft or UAVs is more than $200,000 but less than $1,000,000, or a permanent partial disability or the hospitalization of three or more personnel
results.
c. Class C Severity. A Class C mishap is one in which the total cost of damage to property or aircraft or UAVs is $20,000 or more, but less than $200,000, or an injury requiring five or
more lost workdays results.
d. Any occurrence in which the total cost of property or aircraft or UAV damage is less than $20,000 and there are no
reportable injuries is not an aviation mishap. Report these
events as hazards. (See Chapter 4.) Your opinion on the semantics of the term is noted, but irrelevant. You are invited to read chapter three of the OPNAV instruction, which governs Navy and Marine Corps aviation safety and mishaps, for further edification.

[Gordy]

Why in the world does he need a TFR established wherever he decides to go?

Tis common practice for the POTUS and the VP. Some of the fun ones were when Dick Cheney would go fishing in his drift boat on the Snake River. His property in Jackson Hole lies on the border of two National Forests. The TFR would be a "Rolling TFR"--speed determined by the water flow and where he took lunch. I was on fire contract on those forestswith a helicopter for his last 3 years in office.

In reality the Secret Service is easy to work with. We had a discrete transponder code and direct phone and radio communication with them in the event we needed to get in and effect an initial attack on a wild fire.

[SASless]

Crab,

There are more than a few that frequent here that did not have the privilege of doing military flying or experience NVG formation or precision flying using NVG's that others got to enjoy.

Just pointing that out in case that might have been overlooked when they are considering what it must have been like that night....offshore....operating in close proximity to another aircraft with not just limited visual acuity but also a very limited field of view as well all in a different hue of lighting than normal vision.

[tistisnot]

Lonewolf 50

Thanks for allowing me the opportunity to further my military edification but the resume was sufficient. I now see Class "A" Mishap mentioned once in the preliminaries.

Your involvement in the investigations is noted, but irrelevant!

[megan]

Lonewolf, forget the classifications that applied at the time, may have been as you quote above, but the fond quote at Ellyson ('67) was it was impossible to have an accident in the TH13, providing you had the data plate.

[Lonewolf_50]

I spent more time offshore so easily forget the pressures within the military, but it makes me wonder if Safety Culture has been developed enough when the Aviation Safety Officer is noted as having a heated discussion on the previous day about the execution of that particular flight - and no-one took enough notice - does he not have direct access to the unit commander? Yes, and so do the Ops(O) and the Training(O). Who does the CO, in the end, listen to? Given the details in the article, and the relief of the CO, the chain of command seems to have found fault with his choices.


Not sure if you spent time in the military or not, but operating safely is the issue ... and if you aren't operating you are not doing your job. So it's a balancing act.
It's not either or, it's both. That would compare to your offshore experience: if you aren't operating safely, to include operating where the revenue is derived from, then you don't have a company, much less a safety culture (of whatever quality).

[SASless]

Not that there is any pressure Offshore to fly is there?

Or are there shortcuts taken that impinge upon safety either.

[tistisnot]

My, we are being defensive. Of course there are far fewer pressures offshore in comparison where the role is nowhere near as demanding as night formation NVG - everything is in the Ops Manual agreed by oil company which means PIC can simply refuse to do flight using manual as defence which should include qualification, currency and pairing. Ok, so depends on the maturity of the oil company's local management and aviation advice - and the intervention from CO and ASO equivalent to back you up if necessary.

My point about ASO was that he had a new CO to convince on 13/14 Jan about the execution of the flight. Of course CO was possibly under pressure from Brig Gen to continue operating as normal - though CO did brief his new unit not to push it. Just cruel, tragic and ironic that Sanborn relieved CO in order to, in his words, prevent a mishap.

Last thing both operator and oil company want to hear after an offshore incident, accident is "but I thought I was helping the customer" (with the short cut, failure to follow SOP etc). I was just trying to get a feel if that had permeated through to the military. I mention it 'cus an old Vietnam pilot I knew had a simple rule from moons ago - 3 things wrong prior to pulling power, cancel the mission, think again. A simplified version of how to avoid lining up the holes in the Swiss cheese.

[[email protected]]

though CO did brief his new unit not to push it And therein lies the problem - if he sees the risk he should make the decision, not push it downwards to where career and report pressures are much higher. Additionally, if the CO is a decent guy, his underlings are more likely to get the job done so as not to disappoint him.

[SASless]

Tis,

As I got older and learned more (usually by scaring the poop out of myself), I cut that Rule much closer to Zero Things wrong.

More likely, I was lowering the Standard by which I identified things that were "Wrong" by being more sensitive to Risks in general.

One thing for certain....I learned to say "NO!"....then when the argument started I explained my reasons exactly once and after that the harder I was pushed to go, the shorter my response became.

If it was a Chief Pilot or someone above my position in the Food Chain....the retort was always...."The Keys are in it Asshole....take the aircraft and have at it!"

Not once did the guy applying the pressure ever take me up on that offer.

I have seen another Pilot and Co-Pilot take the Flight...but never had any negative repercussions as a result of saying "No" as the Chief Pilot knew he was in the wrong for doing what he doing.

When you do have that Ops Manual to fall back on....makes it easy.

All through my flying Career I had plenty of help in trying to kill myself....but just like Jimmy Durante, I always objected to others getting into the act.