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Pilot Error After ‘Sierra Hotel [SH-T HOT] Break’ F-35C Crash

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Pilot Error After ‘Sierra Hotel [SH-T HOT] Break’ F-35C Crash

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Old 22nd Feb 2023, 04:43
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Pilot Error After ‘Sierra Hotel [SH-T HOT] Break’ F-35C Crash

Pilot Error After ‘Sierra Hotel [SH-T HOT] Break’ Resulted in South China Sea F-35C Crash, Investigation Says 21 Feb 2023 https://news.usni.org/2023/02/21/pil...stigation-says
“...The mishap pilot (MP) attempted an expedited recovery breaking overhead the carrier, an approved and common maneuver, but the MP had never performed this maneuver before, and it reduced the amount of time to configure the aircraft and conduct landing checks,” the report said. “As a result of the compressed timeline and the MP’s lack of familiarity with the maneuver, the MP lost situational awareness and failed to complete his landing checklist. Specifically, the MP remained in manual mode when he should have been (and thought he was) in an automated command mode designed to reduce pilot workload during landings.” The ramp strike followed a routine mission of just under four hours for the junior officer pilot and his wingman....

...JASON 406 entered the “groove,” or the final approach to the carrier, and was moving too slowly. “The [pilot] realized that the jet was extremely underpowered as the jet became slow and continued to descend (settle),” the investigation continued. “At this moment, [the pilot] manually pushed the throttle to military power and then went to maximum afterburner once he realized that the airplane was in a perilous state, failing to climb.”... the LSO told the pilot the speed was too low. A second later the LSO told the pilot to wave off and hit the afterburners.

Data recovered from the F-35C after the crash showed that after the turn the F-135 engine on the aircraft shifted to flight idle – the minimum throttle position for the engine – and remained there until the pilot attempted to accelerate two seconds before hitting the ramp on Vinson....

...Ultimately, investigators determined that “pilot error was the cause of the mishap. However, the error was not conducted in a reckless manner nor with malicious intent,” reads the report. A Navy spokesman told USNI News that, due to the crash, the pilot has been removed from flight status but is still in the service.

Additionally, investigators recommended that aviators stop performing Sierra Hotel Breaks, that policy require F-35C pilots to always use Approach Power Compensation Mode (APC)/Delta Flight Path (DFP) throttle assists and that heads-up displays include indicator lights showing when flight aids are activated.""

36 page mishap redacted report PDF: https://s3.documentcloud.org/documen...edacted-v2.pdf (8Mb)
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25th Feb 2023, 22:22
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There are quite a few misconceptions and areas of misunderstanding on this thread that should probably be cleared up…

What stands out to me is the usual ‘facts based’ USN mishap report that completely fails to answer the question of how the pilot got himself into an unrecoverable situation. By glossing over that, this report offers little than a summary of what happened with a few recommendations that will hopefully prevent a crash when the next guy or girl screws it up. However, no effort is made to prevent future screw ups - simply the consequences.

Before I receive a barrage of incoming spears, I will start out by stating that I am 100% guilty of participating in this activity in a previous life. I’ve seen ‘expedited recoveries’ performed excellently and safely. I have also seen more than 1 pilot almost fly into the ocean attempting them. I’ve seen countless over-stresses of F18s doing this and plenty of requirements to wave off unsafe SHBs.

To start we should move away from the terminology of ‘expedited break’ or Sierra Hotel Break - it was a ***** hot break. Period. The intent was to demonstrate ability / Naval Aviator ‘spirit’ / bring morale to those watching. Very happy for someone to tell me the risks inherent in a SHB are worth saving approximately 30s during a deck recovery cycle. Additionally, in order to execute a SHB you need to generate more of a gap between you and your interval - you can achieve the exact same timing by just executing a normal break behind the aircraft ahead of you in the pattern. Finally, if you are ‘breaking the deck’ ie. the first aircraft to land in a given cycle, you aim for the deck to go green and ready for your recovery as you enter the groove. The time spent in the pattern, getting to the point in space, is irrelevant.

So how does one fly a SHB? Great question as it’s not published. It is not a standard procedure that a pilot is taught at any point in training or when in the fleet. Is it commonplace? - absolutely. But the first time you ‘attempt’ the SHB you are on a voyage of discovery guided only by the ‘gouge’ / techniques passed informally to you by your peers. What could go wrong? What we are talking about is normalisation of deviance. CV NATOPS states how you should fly the pattern and offers no alternative guidance. Fly the SHB and you are saying “noted, but I’m going to ignore that and try something else”. Again, before you come at me, baying for blood - I’ve ignored CV NATOPS and ripped it off at 7g aft of the ship in Max AB.

Why Afterburner in the break? Because it looks and sounds cool to the audience watching on the deck. Period. Why didn’t he wave off when he thought he was off parameters? Because pilots ‘shall not’ take their own wave offs in the groove - this is the job of the LSOs. Very happy to explain why another time. Why did he fail to complete his 4 item landing checklist? Because he was task saturated in a 7g, ~600ft, max performance turn whilst looking over his shoulder at the flight deck whilst panicking on how an earth he was going to slow his F35 down. I sympathise - I’ve been there.

SHBs are informally encouraged in the fleet. LSOs used to give automatic upgrades to your landing grade if you flew a safe SHB, regardless of being off parameters that would guarantee you a poor grade had you been flying a normal pattern. Do something unsafe however and all bets are off.

So to finish with something constructive. If the USN want to avoid this happening again by addressing the route cause they have two options:
  1. Prohibit SHBs. Tricky one as it’s a grey line on what is / what isn’t and I agree with the board’s rationale on why a blanket ban creates additional problems.
  2. Write a procedure on how to fly a SHB and like everything else you do in naval aviation, train to it. This would be my recommendation for what it’s worth (absolutely nothing).
Finally thoughts to the 5 crew members who were seriously injured by this, 3 of which whom required immediate MEDIVAC. I do sympathise with the pilot but you have little defence when consciously decide to deviate from your trained standards and attempt something you’ve never done before, that has not formalised execution standards.
Old 22nd Feb 2023, 05:46
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Energy state by any means is a fairly basic requirement, be it by alpha or IAS... if we have dumbed down the driving to the point that the landing mode selections for automation are the actual cause, and not the failure to actually manage the energy state of the plane, then we should pack up our bags and turn off the lights, and go to Creech and drive smarter drones.
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Old 22nd Feb 2023, 07:22
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For sure there was a pilot helmet fire with the explanation for that awful power up sound just before the ramp strike thud in the video:
"...Data recovered from the F-35C after the crash showed that after the turn the F-135 engine on the aircraft shifted to flight idle – the minimum throttle position for the engine – and remained there until the pilot attempted to accelerate two seconds before hitting the ramp on Vinson...."

Pilots do make errors for whatever reason. The night F-35A landing crash/ejection at EGLIN AFB by a senior F-35A pilot attempting to land unwittingly 50 KNOTS too fast. What can one say. DON'T DO IT?!


Eglin F-35 Crash Blamed on Landing Speed, but Software, Helmet, Oxygen Also Faulted | Air & Space Forces Magazine (airandspaceforces.com)
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Old 22nd Feb 2023, 10:26
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Extract from front pages of Ramp Strike Report:
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THE F-35C CLASS A AVIATION MISHAP OF 24 JAN 22
"...3. I have directed my staff to execute the following recommendations:
a. To consult with the manufacturers of the F-35C and Commander, Naval Air Systems Command (NAVAIRSYSCOM) to develop the following:

(1) An intemal indication (Helmet Mounted Display and/or audio tone) to alert a pilot that the aircraft has reached on-speed Angle of Attack (AOA) in the power approach mode without Approach Power Compensation Mode (APC) Delta Flight Path (DFP) engaged. To avoid this indication during level flight, this symbology or tone should only be triggered above a given rate of descent and below a given altitude.

(2) An external indication that an F-35C is in power approach and APC/DEP is not engaged. This extemal indication will need to be visible to the Landing Signal Officers (LSO) while the aircraft is on final approach. This would provide the LSOs the opportunity to intervene earlier in a landing attempt, preventing a similar reoccurrence of an airplane approaching the ship without appropriate thrust....

...c. To collaborate with NAVAIRSYSCOM on the following:
(1) Update the F-35C Flight Manual to reflect that F-35C pilots shall fly APC/DFP when recovering aboard the carrier. The current F-35C Landing Checklist, Step 4 is: APC/DFP — As desired.

(2) Consult with manufacturer of F-35C to incorporate internal HMD and/or audio tone to alert pilot that the aircraft has reached on-speed AOA in the power approach mode without PLM engaged...."

https://s3.documentcloud.org/documen...edacted-v2.pdf (8Mb)

Then there is this in the report: YIKES!
"8. ...The investigation determined the cause of the mishap to be pilot error. The pilot entered the carrier break, bringing the throttle to Flight IDLE, allowing the aircraft to slow to approach speed. Once approach speed was achieved, the F-35C landing checklist was not fully completed by selecting Approach Power Compensation Mode (APC)/Delta Flight Path (DFP), leaving the aircraft operating in Manual Powered Approach (PA) Control Laws (CLAW).

9. During the start, middle, and in-close portions of the landing approach, the pilot applied corrections via stick inputs under the assumption that the aircraft was in either APC or DFP PA CLAW. These corrections did not engage the engine to provide additional thrust as the aircraft was still operating in Manual PA CLAW with the throttle still at Flight IDLE. The aircraft developed a rapid sink rate during the in-close portion of the landing approach and a manual engine power demand was not added until 2.6 seconds prior to impact. This late power addition was insufficient to prevent the aircraft from striking the ramp...."

Last edited by SpazSinbad; 22nd Feb 2023 at 10:47. Reason: +txt
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Old 22nd Feb 2023, 10:31
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This old info may be of interest: Semper Lightning: F-35 Flight Control System 09 Dec 2015 Dan “Dog” Canin

"...The ability to tailor the airplane’s response as a function of its configuration and flight regime is the beauty – and potential curse – of FBW. If control engineers get it right – if they define the modes properly, put the transitions in the right places, and give the pilot the right feedback – then control is intuitive. But if they make the various modes too complicated, or the feedback (visual or tactile) isn’t compelling, then modal confusion can set in and bad things can happen.

Some mode changes occur without our knowing, which is fine as long as we don’t have to change our control strategy. An example is the blend from pitch rate command at low speed to g-command at high speed. This transition is seamless from the pilot’s perspective. Other changes require us to change our technique, which is okay if we command the changes ourselves and they’re accompanied by a compelling change in symbology. Examples are the transitions from gear-up (UA) to gear-down (PA), and from CTOL to STOVL.

There are few areas, though, where a mode change is important but not obvious, which is where pilot discipline and training come in. For example, the CV airplane has three different approach modes, easily selected using buttons on the stick and throttle. Two of these modes – APC and DFP[3] – are autothrottle modes, indicated by a three-letter label on the left side of the HUD. The third mode – manual throttle – is indicated by the absence of a label…arguably not the most compelling indication that you’re responsible for the throttle. This interface will probably evolve; [yes sireebob] in the meantime, we need to be disciplined and to make doubly sure we’ve got APC engaged before we turn throttle control over to George...."

https://www.codeonemagazine.com/arti...ml?item_id=187
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Old 22nd Feb 2023, 13:05
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It’s interesting that the Navy has withheld the accident pilots name. This is not the norm at this stage after a accident.
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Old 22nd Feb 2023, 13:26
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Just proves that pilots are smarter than engineers. No matter how good the system is, a pilot will find a way of screwing it up. Been there!

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Old 22nd Feb 2023, 14:14
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There is an assertion that this maneuver had not been done before. OK, if that's true, then I ask:
If you haven't practiced it during FCLPs, or over an airfield, why are you doing it over the ship?
(The hot break and compressed timeline to get into the groove)
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Old 22nd Feb 2023, 14:14
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Reads like the military version of Asiana 214.
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Old 22nd Feb 2023, 15:32
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Mog,

Or. have the engineers made the aircraft far too complex and Pilot's become so reliant upon the machine they lose both flying skills and the ability to effectively control the aircraft systems?

"Children of the Magenta" disease now creeping into Naval Aviation?

It would be interesting to see a video of F-35 Pilots flying approaches to a Carrier (in cockpit view of both hands and the pilot's head with view ahead of the aircraft) and compare those to existing video's of F-18 and legacy aircraft to see the difference in pilot workload and involvement (call it the human/machine interface).

You might find this article relates to what appears to have happened in the F-35 Accident.

The one exception is the F-35 is single pilot and thus the absence of a second pilot eliminates the ability for a check and verify ability that is facilitated by the inclusion of a second human pilot.

The article references a Video which is excellent viewing having watched it before.

https://airfactsjournal.com/2020/09/...-magenta-line/





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Old 22nd Feb 2023, 15:34
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Does one instance of pilot error remove you from flying? Seems a bit harsh.
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Old 22nd Feb 2023, 16:16
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Originally Posted by SASless
Mog,

Or. have the engineers made the aircraft far too complex and Pilot's become so reliant upon the machine they lose both flying skills and the ability to effectively control the aircraft systems?

"Children of the Magenta" disease now creeping into Naval Aviation?

It would be interesting to see a video of F-35 Pilots flying approaches to a Carrier (in cockpit view of both hands and the pilot's head with view ahead of the aircraft) and compare those to existing video's of F-18 and legacy aircraft to see the difference in pilot workload and involvement (call it the human/machine interface).

You might find this article relates to what appears to have happened in the F-35 Accident.

The one exception is the F-35 is single pilot and thus the absence of a second pilot eliminates the ability for a check and verify ability that is facilitated by the inclusion of a second human pilot.

The article references a Video which is excellent viewing having watched it before.

https://airfactsjournal.com/2020/09/...-magenta-line/
This reads more like a basic switchology thing, followed by some fairly basic lack of SA on the pilots behalf. It would appear he did not engage APCM having screamed into a truncated break, throttled back to idle and then apparently not noticed his sink rate until too late. The difference here is that no-one on the ship could be aware that APCM wasn't engaged. Normally there are external indications to the LSO that all the gear - and the hook are down and locked. Hence the recommendations for LM and NAVAIRSYSCOM.

F/A18 are mainly single seat as well. Only the D, F and EA18G variants have a RIO.

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Old 22nd Feb 2023, 16:25
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Originally Posted by uxb99
Does one instance of pilot error remove you from flying? Seems a bit harsh.

depends - if you write off a small trainer - maybe not - if it gets into 9 figures the DEW line beckons
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Old 22nd Feb 2023, 16:27
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Or. have the engineers made the aircraft far too complex and Pilot's become so reliant upon the machine they lose both flying skills and the ability to effectively control the aircraft systems?

Indeed!

Mog
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Old 22nd Feb 2023, 17:10
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Originally Posted by Asturias56
depends - if you write off a small trainer - maybe not - if it gets into 9 figures the DEW line beckons
What at about the millions of taxpayers £/$ to get you to that standard? Assuming he/she is cleared and was a accident, would it not be good practice to give them a chance to redeem them selfs ?
Maybe with some more deck landing training?
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Old 22nd Feb 2023, 17:19
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Originally Posted by Mogwi
Just proves that pilots are smarter than engineers. No matter how good the system is, a pilot will find a way of screwing it up. Been there!

Mog
Make anything idiot proof and Mother Nature improves the idiot , Mk 2
or to be accurate , attempt to make anything idiot proof
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Old 22nd Feb 2023, 17:39
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The difference here is that no-one on the ship could be aware that APCM wasn't engaged.
In the scheme of things you sure found the absolute least important.

Perhaps the solution to your priority. problem is removing the Pilot from the situation and go Pilot-less with UAV/Drones.

Then some non-Winged Pogue could drive these thing by remote control.....but then who or what would be needed to look over that shoulder?

Did you consider why the concern about Pilots and Automation conflict exists?

The question the Board might not have asked....and answered is what effect would the Pilot correctly engaging the auto systems had on the outcome?

Is the Automation capable of accomodating pilot errors such as happened by showing up hot, high, and close aboard or would it order a Missed Approach and Go Around on its own?
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Old 22nd Feb 2023, 20:06
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When the report said "...an approved and common maneuver, but the MP had never performed this maneuver before,..." relating to the break did they mean ever or just on the F-35 over the carrier? I started teaching breaks to students at the piston training stage of pilot training and it was a normal method of arriving in the circuit (pattern) on every aircraft I flew. If you take away raw flying skills and rely on more and more automation then this is the outcome.
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Old 22nd Feb 2023, 20:13
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Originally Posted by SASless
In the scheme of things you sure found the absolute least important.

Perhaps the solution to your priority. problem is removing the Pilot from the situation and go Pilot-less with UAV/Drones.

Then some non-Winged Pogue could drive these thing by remote control.....but then who or what would be needed to look over that shoulder?

Did you consider why the concern about Pilots and Automation conflict exists?

The question the Board might not have asked....and answered is what effect would the Pilot correctly engaging the auto systems had on the outcome?

Is the Automation capable of accomodating pilot errors such as happened by showing up hot, high, and close aboard or would it order a Missed Approach and Go Around on its own?
You know what the LSOs do don't you? Why they are there - and have been since the inception of naval aviation.......
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Old 22nd Feb 2023, 20:22
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The F-35C pilot was recognising & waiting for an LSO wave off because: "...94. The MP explained that he thought the LSO[s] were going to wave off his attempt to land because he was fast at the start to in the middle of the landing attempt...." This was a bad pilot attitude. Pilot flies the aircraft not the LSOs. They advise mostly and then they COMMAND - which must be OBEYed - with the WAVE OFF being mandatory, no matter what anyone thinks.

About 'breaking into the circuit'. The F-35C pilot had not carried out an SHB (Sh-tHot Break) at the carrier. Breaking into the circuit is standard procedure and well practiced. There is always going to be a first time (and watch out for the second time) for everything. This lad's first time was not to be repeated apparently. Otherwise as the report says the F-35C pilot was a good nugget. Sad that he FRABBED it UP.
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