C-5 accident at Dover AFB
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http://www.newszap.com/articles/2006...ware/dsn02.txt
Published: Jun 13, 2006 - 11:02:18 pm EDT
'Cavalier' crew draws blame; Retired generals say familiarity led to complacency
By Jenny Maher, Delaware State News
DOVER - When retired Air Force Brig. Gen. Richard Bundy learned Tuesday about the human errors that caused the April 3 C-5 crash at Dover Air Force Base, all he could do was shake his head in disbelief.
During an afternoon press conference at the base, Col. Raymond Torres, president of the Accident Investigation Board, announced that the crash resulted from several mistakes made by the pilots and flight engineers.
Those mistakes included using an incorrect flap setting, failing to use a fully operational engine and attempting to land at an incorrect altitude.
Mr. Bundy, who flew C-5s for three years and served as commander of Dover Air Force Base's 436th Airlift Wing, found the findings unsettling.
"I'm kind of shocked," he said after reviewing the report. "I don't know how this highly experienced crew could do that."
Col. Torres blamed the errors on complacency and a lack of situational awareness.
He compared it to the way drivers get careless when they're in familiar territory.
"We're all used to driving to our home, condo or apartment, and accidents often occur because we get close to (home)," he said.
"We're used to rounding that corner and not quite stopping at that stop sign. We're used to whatever the neighborhood traffic pattern is."
Retired Brig. Gen. Michael J. Quarnaccio agreed that the aircrew could have been overly confident and complacent because they were flying close to home.
"I hate to say this, but maybe they had a cavalier attitude," he said. "When you're in your own backyard, you're familiar with what you're doing and that could lead to that attitude."
Mr. Quarnaccio is a retired commander of Dover Air Force Base's 512th Airlift Wing with eight years of C-5 piloting experience.
He said it's not only hard to understand how experienced pilots and flight engineers could make such glaring mistakes, but how the other crew members could miss the errors.
"I was shocked that there were so many people in the airplane and nobody caught it," he said.
"How do you fly an airplane with two engines? The whole crew should've been looking at all that stuff."
There were 13 crew members and four passengers aboard the C-5 when it crashed.
The three pilots had more than 10,000 hours of C-5 flight experience, Col. Torres said, and the two flight engineers had more than 12,000 hours of C-5 flight experience.
George Talley, of Felton, a retired C-5 pilot with Dover Air Force Base's 512th Operations Unit, said he wonders if the air crew's mistakes could have been caused by inexperience with new C-5 cockpit instrumentation.
The aircraft was one of a dozen C-5s to recently receive a cockpit instrument modernization.
However, the Accident Investigation Board concluded that the types of errors that led to the crash would not have been impacted by the cockpit changes.
Despite their findings, Mr. Talley remains skeptical.
"That's easy for them to say," he quipped.
Mr. Talley said he knows some of the crew members and is confident in their expertise.
He was disappointed to learn about their mistakes, although he feared that human error had been a factor.
"When I first heard the eyewitness accounts, I thought, 'Uh-oh, it sounds like (the pilots) stalled the airplanes,' and it turned out that is what happened," he said.
"I was hoping I was wrong."
Retired Navy Chief Petty Officer Paul W. Kath, a passenger aboard the ill-fated C-5, was also upset by the Accident Investigation Board's findings.
Until this week, he assumed the crash had been caused by mechanical problems.
However, after learning about the mistakes, he said he felt no resentment toward the crew members.
In fact, he praised them for helping the passengers to safety after the crash, even though there were puddles of fuel surrounding the plane, creating a major fire hazard.
"I'm saddened there was human error," he said during a phone interview from his Hawaii home.
"But I still hold the crew in high esteem. They did a lot of things in a very short and scary time period to get us off the plane."
Post comments on this issue at newszapforums.com/forum4
Staff writer Jenny Maher can be reached at 741-8233 or [email protected]
Published: Jun 13, 2006 - 11:02:18 pm EDT
'Cavalier' crew draws blame; Retired generals say familiarity led to complacency
By Jenny Maher, Delaware State News
DOVER - When retired Air Force Brig. Gen. Richard Bundy learned Tuesday about the human errors that caused the April 3 C-5 crash at Dover Air Force Base, all he could do was shake his head in disbelief.
During an afternoon press conference at the base, Col. Raymond Torres, president of the Accident Investigation Board, announced that the crash resulted from several mistakes made by the pilots and flight engineers.
Those mistakes included using an incorrect flap setting, failing to use a fully operational engine and attempting to land at an incorrect altitude.
Mr. Bundy, who flew C-5s for three years and served as commander of Dover Air Force Base's 436th Airlift Wing, found the findings unsettling.
"I'm kind of shocked," he said after reviewing the report. "I don't know how this highly experienced crew could do that."
Col. Torres blamed the errors on complacency and a lack of situational awareness.
He compared it to the way drivers get careless when they're in familiar territory.
"We're all used to driving to our home, condo or apartment, and accidents often occur because we get close to (home)," he said.
"We're used to rounding that corner and not quite stopping at that stop sign. We're used to whatever the neighborhood traffic pattern is."
Retired Brig. Gen. Michael J. Quarnaccio agreed that the aircrew could have been overly confident and complacent because they were flying close to home.
"I hate to say this, but maybe they had a cavalier attitude," he said. "When you're in your own backyard, you're familiar with what you're doing and that could lead to that attitude."
Mr. Quarnaccio is a retired commander of Dover Air Force Base's 512th Airlift Wing with eight years of C-5 piloting experience.
He said it's not only hard to understand how experienced pilots and flight engineers could make such glaring mistakes, but how the other crew members could miss the errors.
"I was shocked that there were so many people in the airplane and nobody caught it," he said.
"How do you fly an airplane with two engines? The whole crew should've been looking at all that stuff."
There were 13 crew members and four passengers aboard the C-5 when it crashed.
The three pilots had more than 10,000 hours of C-5 flight experience, Col. Torres said, and the two flight engineers had more than 12,000 hours of C-5 flight experience.
George Talley, of Felton, a retired C-5 pilot with Dover Air Force Base's 512th Operations Unit, said he wonders if the air crew's mistakes could have been caused by inexperience with new C-5 cockpit instrumentation.
The aircraft was one of a dozen C-5s to recently receive a cockpit instrument modernization.
However, the Accident Investigation Board concluded that the types of errors that led to the crash would not have been impacted by the cockpit changes.
Despite their findings, Mr. Talley remains skeptical.
"That's easy for them to say," he quipped.
Mr. Talley said he knows some of the crew members and is confident in their expertise.
He was disappointed to learn about their mistakes, although he feared that human error had been a factor.
"When I first heard the eyewitness accounts, I thought, 'Uh-oh, it sounds like (the pilots) stalled the airplanes,' and it turned out that is what happened," he said.
"I was hoping I was wrong."
Retired Navy Chief Petty Officer Paul W. Kath, a passenger aboard the ill-fated C-5, was also upset by the Accident Investigation Board's findings.
Until this week, he assumed the crash had been caused by mechanical problems.
However, after learning about the mistakes, he said he felt no resentment toward the crew members.
In fact, he praised them for helping the passengers to safety after the crash, even though there were puddles of fuel surrounding the plane, creating a major fire hazard.
"I'm saddened there was human error," he said during a phone interview from his Hawaii home.
"But I still hold the crew in high esteem. They did a lot of things in a very short and scary time period to get us off the plane."
Post comments on this issue at newszapforums.com/forum4
Staff writer Jenny Maher can be reached at 741-8233 or [email protected]
He said it's not only hard to understand how experienced pilots and flight engineers could make such glaring mistakes, but how the other crew members could miss the errors
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Funny how eager the accident board was to discount the glass cockpit transition issue.
Earlier in the year the aircraft commander was named Company Grade Officer of the Year for the 512th Airlift Wing:
http://www.512aw.afrc.af.mil/news/st...p?id=123018150
Earlier in the year the aircraft commander was named Company Grade Officer of the Year for the 512th Airlift Wing:
http://www.512aw.afrc.af.mil/news/st...p?id=123018150
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Thank God no one was killed.
Good area to point out in the sim.
First job, fly the aircraft, airspeed, alltitude, configaration etc.
We all learn from the mistakes of others.
Just seems like its constantly reminded to us, not sure what it will take for people to learn from this bad tradegy.
I am really suprised as the F/E third man in the cockpit is the one that usually catches these mistakes/errors before its too late.
Maybe something in the final report will contribute to these errors.
Good area to point out in the sim.
First job, fly the aircraft, airspeed, alltitude, configaration etc.
We all learn from the mistakes of others.
Just seems like its constantly reminded to us, not sure what it will take for people to learn from this bad tradegy.
I am really suprised as the F/E third man in the cockpit is the one that usually catches these mistakes/errors before its too late.
Maybe something in the final report will contribute to these errors.
Last edited by Earl; 17th Jun 2006 at 22:46.
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I personally believe, Earl, that the 'I know it all, therefore don't confuse me with the facts' US AirForce attitude led, part and parcel to this very unfortunate accident.
One wonders, with the training civil crews receive in just these same sort of scenarios every 6 months, if the outcome would have been FAR different, had civil procedures been used.
USAF, too darn many 'Colonels' in charge.
Why are we not surprised...?
One wonders, with the training civil crews receive in just these same sort of scenarios every 6 months, if the outcome would have been FAR different, had civil procedures been used.
USAF, too darn many 'Colonels' in charge.
Why are we not surprised...?
411A:
I usually find your posts interesting and informative (many would disagree), but the problem here wasn't "too damn many Colonels in charge". There were two colonels on the crew, IN THE SEATS! One colonel is an airline pilot, experience and training wasn't the issue. Willingness to correct improper actions by the aircraft commander (a captain who seems to have excercised poor CRM--poor or non-existent briefings, failure to follow procedures for a well-practiced emergency situation in the sim, failure of the crew to question him was an issue). One "colonel", the Operations Group Commander has been relieved of command, by my sources.
The C-5 program includes 8 sims per year, plus quarterly local proficiency rides in the plane. Training requires 2 T/Os, 2 Approaches and 2 Landing per month. Each sim WILL include OEI and two-engine out work, we sweated the sim just like any airline guy does. Annual checks in the box.
I usually find your posts interesting and informative (many would disagree), but the problem here wasn't "too damn many Colonels in charge". There were two colonels on the crew, IN THE SEATS! One colonel is an airline pilot, experience and training wasn't the issue. Willingness to correct improper actions by the aircraft commander (a captain who seems to have excercised poor CRM--poor or non-existent briefings, failure to follow procedures for a well-practiced emergency situation in the sim, failure of the crew to question him was an issue). One "colonel", the Operations Group Commander has been relieved of command, by my sources.
The C-5 program includes 8 sims per year, plus quarterly local proficiency rides in the plane. Training requires 2 T/Os, 2 Approaches and 2 Landing per month. Each sim WILL include OEI and two-engine out work, we sweated the sim just like any airline guy does. Annual checks in the box.
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OK, Galaxy Flier, fair enough, eight sims a year...
BUT, my God, this sort of scenario is more or less standard heavy jet transport procedures, yet these guys screwed it up big time.
Quite frankly, to my way of thinking, the training standards surely could not have been up to snuff, otherwise the outcome would have been far more favorable.
Would you disagree?
OK, I can accept the fact that there are always one or two bad apples that slip through the system, but these folks all 'seemed' to be the best that there was, and yet, the end result was certainly not to be as expected.
I really do believe that the AirForce NEEDS to clamp down really hard, to keep this nonsense from happening again.
Then, we come to the new glass installed.
Could this have been distracting, to the point that there were too many heads down, wondering, "what the hell is it doing now?" all the while no one was keeping an eye out for the number of engines operating, and the altitude/sink rate/flap setting etc, to the point that it all went south?
If so, large changes in training need to be carried out, pronto.
BUT, my God, this sort of scenario is more or less standard heavy jet transport procedures, yet these guys screwed it up big time.
Quite frankly, to my way of thinking, the training standards surely could not have been up to snuff, otherwise the outcome would have been far more favorable.
Would you disagree?
OK, I can accept the fact that there are always one or two bad apples that slip through the system, but these folks all 'seemed' to be the best that there was, and yet, the end result was certainly not to be as expected.
I really do believe that the AirForce NEEDS to clamp down really hard, to keep this nonsense from happening again.
Then, we come to the new glass installed.
Could this have been distracting, to the point that there were too many heads down, wondering, "what the hell is it doing now?" all the while no one was keeping an eye out for the number of engines operating, and the altitude/sink rate/flap setting etc, to the point that it all went south?
If so, large changes in training need to be carried out, pronto.
411A
No disagreement on a standard emergency poorly executed. It was repeatedly covered in the 400+ hours I had the box. Can't speak for Dover's standards.
I would agree that the new FMS may have played a distracting role, but come on--two pilots and two FEs cannot recognize that they are not utilizing one of three engines.
Does set a bad example of airmanship
GF
No disagreement on a standard emergency poorly executed. It was repeatedly covered in the 400+ hours I had the box. Can't speak for Dover's standards.
I would agree that the new FMS may have played a distracting role, but come on--two pilots and two FEs cannot recognize that they are not utilizing one of three engines.
Does set a bad example of airmanship
GF
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All five asleep
I have a simulation, produced for the USAF on what really happened, but to put it in a nutshell, they did the Manchester thing, and shut down the wrong engine.
They were low on speed and altitude, and decided to reduce the flaps, but was too late. Nose pitched up, and the tail hit the ground and broke off.
I can email you the simulation, just yell out on
[email protected]
If you did not believe in CRM before, you will after seeing this. Three qualified pilots and two engineers, who allsat there and watched the whole sorry mess.
Regards
Col Tigwell
They were low on speed and altitude, and decided to reduce the flaps, but was too late. Nose pitched up, and the tail hit the ground and broke off.
I can email you the simulation, just yell out on
[email protected]
If you did not believe in CRM before, you will after seeing this. Three qualified pilots and two engineers, who allsat there and watched the whole sorry mess.
Regards
Col Tigwell
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'........they did the Manchester thing, and shut down the wrong engine'.
I think you may be referring to the Kegworth accident - British Midland 737. Not Manchester.
See http://en.wikipedia.org/wiki/Kegworth_air_disaster
I think you may be referring to the Kegworth accident - British Midland 737. Not Manchester.
See http://en.wikipedia.org/wiki/Kegworth_air_disaster
They did NOT shut the wrong engine down. No.2 had the thrust reverser problem and that is the engine that they shut down.
Look at your simulation again and you will see that Nos. 1, 3 and 4 throttles are forward and all three are producing N1.
Then watch the throttles come back to flight idle.
When the power comes on again it is Nos. 1, 2 and 4 throttles that go forward and that is when the disaster started. You will note that No.3 remains at flight idle.
Therefore the only engines that were responding were Nos. 1 and 4. The No.2 throttle was connected to a dead engine!
Amazingly not one of them noticed that a perfectly good engine (No. 3) had been left at flight idle!
Look at your simulation again and you will see that Nos. 1, 3 and 4 throttles are forward and all three are producing N1.
Then watch the throttles come back to flight idle.
When the power comes on again it is Nos. 1, 2 and 4 throttles that go forward and that is when the disaster started. You will note that No.3 remains at flight idle.
Therefore the only engines that were responding were Nos. 1 and 4. The No.2 throttle was connected to a dead engine!
Amazingly not one of them noticed that a perfectly good engine (No. 3) had been left at flight idle!
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Originally Posted by JW411
When the power comes on again it is Nos. 1, 2 and 4 throttles that go forward and that is when the disaster started. You will note that No.3 remains at flight idle.
Therefore the only engines that were responding were Nos. 1 and 4. The No.2 throttle was connected to a dead engine!
Amazingly not one of them noticed that a perfectly good engine (No. 3) had been left at flight idle!
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Just seen the animation from the MAAF (Mishap Analysis & Animation Faciliity) which as already pointed out shows 1,3,4 throttles advanced then after coming back to flight idle then 1,2,4 are pushed forward.
The tape starts 6 miles from the rwy so a lot of the CVR is missing and you don't hear any briefing but what was noticeable is the number of crew talking againsnt one another. A mention is made of a checkerboard, which I assume is an airspeed warning, which is not picked up until too late. One member of the crew states "I'm concerned" twice but again appears to be far to late to be oof value.
It's no wonder that the last real comment heard was "Oh sh1t"
I can't host it myself but if someone can I'm happy to e-mail that person. Its 6Megs in size.
clicker
The tape starts 6 miles from the rwy so a lot of the CVR is missing and you don't hear any briefing but what was noticeable is the number of crew talking againsnt one another. A mention is made of a checkerboard, which I assume is an airspeed warning, which is not picked up until too late. One member of the crew states "I'm concerned" twice but again appears to be far to late to be oof value.
It's no wonder that the last real comment heard was "Oh sh1t"
I can't host it myself but if someone can I'm happy to e-mail that person. Its 6Megs in size.
clicker
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clicker and all
I listened to the CVR, for some reason my player doesn't show any animation.
Every plane with more than one engine that I have ever flown, after a shutdown, you move all the throttles no matter what (exceptions: when needed to use asymetric thrust, or while flying in a situation in which you are only simulating, one is shut down).
I read another article that says the crew only had 4.5 hours of sleep...that is part of the equation.
While I understand a previous brake fire on a heavy landing plane caused one million dollars in damage, worrying about it this time was a false economy.
Training, sleep, a lack of something caused this.
of course, there for the grace of God go I.
I am glad no one was killed.Perhaps "tunnel" vision lead to this.
Any C5 drivers out there? I read an article that says some C5 pilots would have moved all throttles? thoughts?
I listened to the CVR, for some reason my player doesn't show any animation.
Every plane with more than one engine that I have ever flown, after a shutdown, you move all the throttles no matter what (exceptions: when needed to use asymetric thrust, or while flying in a situation in which you are only simulating, one is shut down).
I read another article that says the crew only had 4.5 hours of sleep...that is part of the equation.
While I understand a previous brake fire on a heavy landing plane caused one million dollars in damage, worrying about it this time was a false economy.
Training, sleep, a lack of something caused this.
of course, there for the grace of God go I.
I am glad no one was killed.Perhaps "tunnel" vision lead to this.
Any C5 drivers out there? I read an article that says some C5 pilots would have moved all throttles? thoughts?
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One thing I'm uncertain about. I noticed that it was showing 90 per cent flaps down then as the crew saw the speed dropping off they brought the flaps up.
Bearing in mind I was ground based in my aviation days, would I be right in guessing that due to the heavy weight of the aircraft this would increase the airspeed quicker and thereby increase any climbout chances?
Thanks for helping a numbskull.
Clicker
Bearing in mind I was ground based in my aviation days, would I be right in guessing that due to the heavy weight of the aircraft this would increase the airspeed quicker and thereby increase any climbout chances?
Thanks for helping a numbskull.
Clicker
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clicker
there are some times when retracting the flaps would help you climb...indeed on the older 737 if you lose an engine while making an approach, going to a reduced flap setting is one of the things you do...
HOWEVER
if you retract flaps and there is no or little margin between your current airspeed (really angle of attack) and STALL, BAM you stall.
in this case, with the information presented, unless the crew could have gotten additional thrust from number 3 engine, it might have been better to land short of the runway NOTstalled, than to try to "stretch" the approach to the runway and STALL.
there are some times when retracting the flaps would help you climb...indeed on the older 737 if you lose an engine while making an approach, going to a reduced flap setting is one of the things you do...
HOWEVER
if you retract flaps and there is no or little margin between your current airspeed (really angle of attack) and STALL, BAM you stall.
in this case, with the information presented, unless the crew could have gotten additional thrust from number 3 engine, it might have been better to land short of the runway NOTstalled, than to try to "stretch" the approach to the runway and STALL.
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I have the data recorder animation replay of this event but can't seem to attach it or paste it in here. Can someone give me a clue and I'll post it if no one has before me?
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>>...in this case, with the information presented, unless the crew could have gotten additional thrust from number 3 engine, it might have been better to land short of the runway NOTstalled, than to try to "stretch" the approach to the runway and STALL.<<
Hmmm, perhaps a better idea, jondc9, would be for the crew to actually pay attention to what the hell they were doing.
Ok, as I understand it, one engine had been shut down.
So far, so good.
Normally, on a four engine type, the one engine inop landing procedure is the same as all engines operating...at least this was true on the 4-engine (and three engine as well) types that I have flown.
Now, if the crew truly believed that another engine was either failed or not producing adequate thrust, then the two engine procedure should absolutely be used, which requires a reduced flap selection for approach/landing.
This is pretty basic stuff, it seems to me.
I truly believe the USAF had better have a really close look at their training procedures, as apparently the ones they have now (if we consider this accident) simply don't cut the mustard.
Hmmm, perhaps a better idea, jondc9, would be for the crew to actually pay attention to what the hell they were doing.
Ok, as I understand it, one engine had been shut down.
So far, so good.
Normally, on a four engine type, the one engine inop landing procedure is the same as all engines operating...at least this was true on the 4-engine (and three engine as well) types that I have flown.
Now, if the crew truly believed that another engine was either failed or not producing adequate thrust, then the two engine procedure should absolutely be used, which requires a reduced flap selection for approach/landing.
This is pretty basic stuff, it seems to me.
I truly believe the USAF had better have a really close look at their training procedures, as apparently the ones they have now (if we consider this accident) simply don't cut the mustard.
411A:
"Now, if the crew truly believed that another engine was either failed or not producing adequate thrust, then the two engine procedure should absolutely be used, which requires a reduced plap selection for approach/landing".
Have you watched and listened to the animation? You don't seem to have grasped what they actually did. I agree that it is difficult to believe that something so basic went wrong.
They (correctly) shut down No. 2 engine.
They flew the pattern using the throttles (correctly) for Nos. 1, 3 and 4 engines and set up for a three-engine approach and landing.
When they got to slowing down all throttles came back to flight idle. When power was required again the GOOD No. 3 engine was left at flight idle and whoever was applying the power pushed forward the Nos. 1, 2 and 4 throttles.
The No. 2 throttle was, of course, connected to a shut-down engine and putting that throttle forward was as much use as putting t*ts on a bull.
It is obvious to me having listened to the CVR that it never at any point occured to any of them that they were now conducting a self-inflicted 2-engined approach so therefore never considered the 2-engine out procedure.
If they had used the perfectly good No. 3 engine they would have been in the bar by now and would have probably picked up at least five medals each!
"Now, if the crew truly believed that another engine was either failed or not producing adequate thrust, then the two engine procedure should absolutely be used, which requires a reduced plap selection for approach/landing".
Have you watched and listened to the animation? You don't seem to have grasped what they actually did. I agree that it is difficult to believe that something so basic went wrong.
They (correctly) shut down No. 2 engine.
They flew the pattern using the throttles (correctly) for Nos. 1, 3 and 4 engines and set up for a three-engine approach and landing.
When they got to slowing down all throttles came back to flight idle. When power was required again the GOOD No. 3 engine was left at flight idle and whoever was applying the power pushed forward the Nos. 1, 2 and 4 throttles.
The No. 2 throttle was, of course, connected to a shut-down engine and putting that throttle forward was as much use as putting t*ts on a bull.
It is obvious to me having listened to the CVR that it never at any point occured to any of them that they were now conducting a self-inflicted 2-engined approach so therefore never considered the 2-engine out procedure.
If they had used the perfectly good No. 3 engine they would have been in the bar by now and would have probably picked up at least five medals each!