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C-17 down Elmendorf (Merged)

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C-17 down Elmendorf (Merged)

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Old 18th Aug 2010, 20:51
  #41 (permalink)  
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Originally Posted by Double Zero
[COLOR=#000063]if people will perform graceful displays ( warbirds for me ) well within the envelope of aircraft and pilot, I’ll pay
We had a pair of FAF Mirage do a pairs display at Waddo. They were there for ACMI and got permission from MOD FR to do a display. I don't know how they rated compared with the UK display pilots - practices and authorisations - but they put on an immaculate display.

It was more impressive as a pair of heavy metal rather than the individual 'aeros' that we do now with a GR4 hi-speed left right, lo-speed right left followed by an F3 hi-speed . . .

You need more than one aircraft to lend depth and perception.
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Old 19th Aug 2010, 02:54
  #42 (permalink)  
 
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Delaney T

I'd also note that formal Boards-of-Investigation do make errors, usually take excessive time to release conclusions, and sometimes deliberately hide results from the public.

The U.S. Navy hid the results of the last Blue Angels/F-18 fatal airshow crash (pilot error) ... until a newspaper forced them in judicial court to release the basic investigation report.
IF you knew how the US Military investigates and under its legal privilege for Safety Investigation Boards for confidentiality, you would know that that statement is incorrect.

SIB reports are confidential, not releasable to the public, they are solely to prevent accidents. A releasable, legally admissible report is written by the Accident Board, who conducts its own investigation. The SIB privilege is a long-standing (50 years or more) policy granted the military by law.

GF
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Old 19th Aug 2010, 07:25
  #43 (permalink)  
 
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DOUBLEZERO.
I so agree with you. Warbirds for me too. Duxford, the best flying in the world, graceful and above all safe. 11 Airshow crashes for me over the years. I really have had enough of spoilt days and spoilt lives.
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Old 11th Dec 2010, 07:18
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USAF Accident Report (PDF) available here.

Video of actual flight (ends before impact) can be seen here.

PAFPA reports:

Air Force releases findings on Alaska C-17 fatal mishap

by Pacific Air Forces Public Affairs 12/10/2010

12/10/2010 - JOINT BASE PEARL HARBOR-HICKAM, Hawaii -- Headquarters Pacific Air Forces today released the results of its investigation into a fatal C-17 Globemaster III aircraft mishap July 28, 2010, at Joint Base Elmendorf-Richardson, Alaska.

Gen. Gary North, Pacific Air Forces commander, directed an investigation into the incident which resulted in the deaths of the four crewmembers aboard, the destruction of the $184 million aircraft, and damage to part of the Alaska Railroad.

The accident investigation board found clear and convincing evidence the cause of the mishap was pilot error. The investigation revealed the pilot placed the aircraft outside established flight parameters and capabilities. During the mishap sortie, the pilot aggressively flew the aircraft in a manner inconsistent with established flight procedures, resulting in a stall. The pilot failed to take required stall recovery actions. Furthermore, the board concluded the co-pilot and safety observer failed to recognize or address the developing dangerous situation. As a result, the C-17 stalled at an attitude and altitude from which recovery to controlled flight was impossible.

Brig. Gen. Carlton D. Everhart II, served as the Accident Investigation Board president. General Everhart is vice commander of the 618th Air and Space Operations Center at Scott Air Force Base, Ill. The general is a command pilot with more than 4,400 flight hours in a variety of aircraft, including the C-17.

The mishap occurred as the C-17 -- tail number 00-0173 and call sign Sitka 43 -- practiced for the Arctic Thunder Air Show scheduled for the weekend of July 31 at Joint Base Elmendorf-Richardson.

For a copy of the Accident Investigation Board report, visit: Pacific Air Forces - AIB Reports. Video footage of the mishap flight is also available at that Web site. The footage has been edited to cut off just prior to the aircraft's impact, out of consideration and respect for the families of the deceased.

Last edited by Machaca; 11th Dec 2010 at 08:13.
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Old 11th Dec 2010, 08:56
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Horrendous. Pretty damning report to boot. Memories of a certain B-52...
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Old 11th Dec 2010, 09:53
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And a certain Nimrod, Co-Captain.

The Inquiry detenmined that the captain made an error of judgement in modifying one of the display manoeuvres to the extent that he stalled the aircraft at a height and attitude from which recovery was impossible. The Inquiry considered that contributory factors could have included deficiencies in the flight deck crew's training and in the method of supervision which could have allowed the captain to develop an unsafe technique without full appreciation of the consequences.
my italics

So sad that, despite all the corporate knowledge and experience among the aviation community, these events still occur. Is it too much trouble to incorporate lessons identified (I was going to say learned, but patently not in this case) into pre season training for display crews?

WRT to this report, the timescale between mishap and full publication (4 months) of a thorough investigation seems pretty damn quick; also compared to UK BoI's, the finding of pilot error seems unequivocal whereas post Mull of Kintyre our findings are subtly different.

Good thing, bad thing?
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Old 11th Dec 2010, 09:58
  #47 (permalink)  
 
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I imagine the USAF has had just about enough of these accidents now, so why not call a spade a spade...
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Old 11th Dec 2010, 10:03
  #48 (permalink)  
 
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Thats completely out of order
No, it's not. It's the only scenario I can offer whereby, a supposedly, highly trained... supposedly highly competent pilot officer... ignored flight instruction procedures and replaced them with his own untested version... that involved taking the aircraft beyond known limits and then ignoring the multitude of warnings.

It goes further than pilot and crew incompetence. Maybe the issue is just lack of ability within the USAF commanders, and severe deficiencies in their training programs, as indicated in this extract...

"Because he (the pilot) was an accomplished aviator, leadership allowed him to operate independently with little or no oversight".
If this isn't a major failure within USAF leadership and command procedures, I don't know what is. The only parallel I could imagine with this setup, is a battle commander landing a battalion of troops on a battlefield, and then allowing the officers to formulate their own individual plans of attack, because they were individually regarded as being extremely competent.
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Old 11th Dec 2010, 10:28
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The video is quite shocking in relation to how fast the situation develops.

If - to be simplictic - the right hand turn which started at 42 seconds was too aggressive for the aircraft speed/energy at the time, when was the ac fate sealed - at 45 secs, 50? It looks like its definately all over and unrecoverable at 53 seconds, if not earlier. When would you guess the stall warning went off?

Not long to realise the mistake. I assume they would have done this many times before, but this time they were a few critical knots short. Seems rather dangerous to be trying to fly so near the stall limits anyway, or where they actually far off the "approved" speeds do you think?
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Old 11th Dec 2010, 10:44
  #50 (permalink)  
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Surely it only has a close parallel to the Bob Holland incident if the pilot had been pulled up for similar occurrences before the accident flight. If this was his first transgression, although the accident had very similar causes, the failures of higher command wouldn't exist.
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Old 11th Dec 2010, 11:00
  #51 (permalink)  
 
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An individual doesnt have to fly a couple of knots slow on one occasion for this sort of accident to happen.

they were flying with various exceedences, bank being the most particular and height being the other.

Where was the supervision?
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Old 11th Dec 2010, 14:27
  #52 (permalink)  
 
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Surely it only has a close parallel to the Bob Holland incident if the pilot had been pulled up for similar occurrences before the accident flight. If this was his first transgression, although the accident had very similar causes, the failures of higher command wouldn't exist.
GG - Wrong. This pilot's abilities were lacking, largely due to a failure of higher command to ensure that this person was a team player, was able to follow instructions to the nth degree, and was training others correctly.

His personality was deficient in that he...

1. Had an arrogance that was nothing short of breathtaking. He believed that he alone, knew better than any aircraft designer, the limits of an aircraft.

2. Taught other pilots that stall warnings were an "anomaly" and could be ignored when the pilot considered that he knew better than a proven warning device...

3. Lacked basic understanding of the aeronautical theory behind a stall...

4. Lacked any sense of responsibility towards the men under his command, and the crew of his aircraft, in a peacetime environment...

5. Suffered from such arrogance and basic incompetence, that it led him to totally ignore a valid stall warning for an extended period... led to him failing to initiate correct stall recovery procedures... and led to him applying the incorrect response to that approaching stall, by maintaining control stick pressure and rudder...

The pilots commander did nothing to ensure that strict instructions (written, prescribed procedures) for climbout speed, heights, and angles of bank were to be followed as per the written word.

He was never pulled up, because of the deficiency in his leadership, that allowed his arrogance and incompetence, full rein...

The only saving grace that I see is that Brig. Gen. Everhart hasn't minced matters in the collation and summary of the accident report, and has delivered a biting report that not only stands as a monument to one man's breathtaking arrogance, incompetence, and major personality flaws... but which stands as a monument to serious flaws in USAF officer selection and training.

This pilot suffered from such major deficits in personality traits and abilities, that they should have led to him never being given any kind of officers commission... and which deficits should have led to him never being allowed to fly an aircraft, without permanent supervision...
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Old 11th Dec 2010, 17:10
  #53 (permalink)  
 
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Disregard - just read the full report.

Last edited by Ewan Whosearmy; 11th Dec 2010 at 17:43.
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Old 11th Dec 2010, 17:30
  #54 (permalink)  
 
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The report says nose down elevator imput, max engine power and no large rudder imputs.

When it stalled after the stall warning he still had full back stick and right rudder imput. He tried to roll wings level, but with little effect since the wing was stalled.

Tell me if I read the report wrong.
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Old 11th Dec 2010, 17:42
  #55 (permalink)  
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Unfortunately I cant seem to be able access the full report, only the summary, so I wouldn't know about onetrack's allegations.
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Old 11th Dec 2010, 17:57
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GG. Try Mithaca's link here: http://www.pacaf.af.mil/shared/media...101210-079.pdf
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Old 11th Dec 2010, 18:58
  #57 (permalink)  
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If - to be simplictic - the right hand turn which started at 42 seconds was too aggressive for the aircraft speed/energy at the time, when was the ac fate sealed - at 45 secs, 50?
The fate of the Aircraft was sealed the moment the USAF decided to believe this guy's own publicity. Military flying is characterized by aggresive, confident, but capable individuals. That trait is countered only by effective supervision. That didn't happen here.

It also underlines the point made when any well-respected and experienced aviator commits a fatal error, on the day, experience counts for nothing if you go beyond your ability. Good experience teaches you the limits of your ability in a more benign manner than a smoking hole.

Suffered from such arrogance and basic incompetence
If only it were that simple.
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Old 11th Dec 2010, 19:13
  #58 (permalink)  
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Thanks for that link Ewan, it makes interesting reading, certainly the command failures weren't as bad as in Bob Holland's case, but there was definitely a dire lack of over sight, and what were the rest of the team doing allowing it to continue flight after flight?
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Old 11th Dec 2010, 23:21
  #59 (permalink)  
 
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The parallels with the Bud Holland accident are amazing. It's not "Why did this happen?" but "How the **** did it happen again?"
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Old 12th Dec 2010, 00:38
  #60 (permalink)  
 
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Thanks for that link Ewan, it makes interesting reading, certainly the command failures weren't as bad as in Bob Holland's case, but there was definitely a dire lack of over sight, and what were the rest of the team doing allowing it to continue flight after flight?
Thing is, there are two sorts of accidents in this world.

There is the sort where people stand back and think "I just knew that would happen".

And the sort which no-one foresaw and was completely down to bad luck, wrong place wrong time.

The whole point of the authorisation process is to stop example one happening. This could be as simple as taking someone to one side and having a quiet chat, it could be crewing them with strong willed people. It could be a grounding.

I am guessing the jet involved had some form of CVR/FDR. I wonder how many auths would consider using the data to verify the display development process and as oversight?

Bearing in mind how many fine people we have spray themselves across the countryside with wrongly executed best intentions, I wonder if it needs to feature more highly in future, to stop the overexuberance we all have the potential for inside.

Was this a "violation for organizational gain", or one for "personal thrill seeking"?

Thats for the board to determine surely. I would lean towards the former. We shouldnt underestimate the effect of pressure on individuals that normally excel, especially when we have very high expectations. Having prizes for best, most complex display imho does little to reduce the problem, despite how popular they may be with the decent characters that put themselves forwards for the display role.

I think everyone should have a long hard think before sullying anyone on here; are we all as white as white as we make out, or have we simply been "lucky" in the past?

Last edited by VinRouge; 12th Dec 2010 at 00:57.
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