C-5 accident at Dover AFB

[gtale77]

Flight recorder animation

Just got the Animation from a Reserve C-5 Driver buddy. This aircraft had just recieved a cockpit Mod bringing it up to a Glass Cockpit from previously being a steam guage airplane. Only one guy on the flight deck had ever actually flown the glass cockpit in this aircraft and he was using the EP as an opportunity to impart a little knowledge. Unfortunately, he got bogged down in the systems and forgot the part about flying the airplane. Notice also on the animation, the right inboard engine is not at full power like the outboards.

An unfortunate example of getting your priorities out of order. Just luckly no one was killed.

[brain fade]

On the fleet I'm on (twinjet) it used to be SOP to pick up all (ie 2) thrust levers on S/E missed app. Now SOP is just pick up 'live' TL.
Don't know why tho.

[electricjetjock]

The teachings of the great and wise one.

411A

In the type of aircraft you flew that might have been the case. However, in modern aircraft the use of autothrottle is possible and safe, you can even do an autoland engine out!! Dang cant you pilots fly your aircraft you will no doubt reply, however if it is approved and available at the airport you are going to land at, you can do an autoland if you want. Hey that might mean I can actually monitor and manage the emergency better.

As for the moving of the dead thrust lever, if your type allows it then fine. When I fly the twin in the sim I don't as it is easy to manage the one thrust lever. When I fly the quad then if it is an outboard then again no real drama. However, when it is 2 or 3 it can be tricky when you are using manual thrust on approach and the dead lever is getting in the way of you moving the other three on approach in gusty conditions. In case you don't understand the thrust levers are close to idle, then it is easier to pick up all four. (Just did it a few weeks ago on my regulatory check - no comment from the checker as it is approved) You might have to do it anyway once you have landed to select reverse, cocking the interlocks. If your short sharp comments are how you used to brief / debrief your "lambs" in the simulator NO wonder they screwed up. You sometimes have to teach!!!

Perhaps if this poor USAF Colonel, that you seem to hate so much, the USAF not him personally,had collected all four from idle then he would have had the three remaining engines for the approach. Perhaps it is the dinosaur teaching of only using the working engines that helped cause the crash. Remember the swiss cheese model, it is a normally a COMBINATION of factors that cause an accident.

Now tell me do you zero the rudder trim on approach engine out or not?

[misd-agin]

[quote=gtale77]Just got the Animation from a Reserve C-5 Driver buddy.]

Uncle Sam's looking for you.

-----------------------------------------------------------------------


Somebody has noticed that their video is missing.

Dover Crash Video

There have been multiple emails going around containing the video animation of the C-5 crash at Dover. The animation is being sent as an attachment with the filename(s) of “animationfrom1323.wmv”, “animationfrom1323.wm”, “Dovercrash.wmv”, and possible other names or variants. This file is classified as Privileged. It is not for the general public nor is it intended to be openly available to all members of the DoD. Although the “official use only” identification label was edited from the beginning of this video, it is still a protected source and needs to be treated as such.

The sole purpose of this video is for mishap prevention purposes. It contains an interpretation gathered from Digital Flight Data Recorder (DFDR) and Cockpit Voice Recorder (CVR) data. Unauthorized possession of this video is a violation of military and federal laws. One must heed the last few frames of this video which contains the following statement:

FOR OFFICIAL USE ONLY
THIS CONTAINS PRIVILEGED, LIMITED-USE SAFETY INFORMATION. UNAUTHORIZED USE OR DISCLOSURE CAN SUBJECT YOU TO CRIMINAL PROSECUTION, TERMINATION OF EMPLOYMENT, CIVIL LIABILITY, OR OTHER ADVERSE ACTIONS. SEE AFI 91-204 FOR RESTRICTIONS.
FOR OFFICIAL USE ONLY Unauthorized recipients will delete it and advise the sender to do the same as well as notify all those who were sent the file.Although DFDR and CVR data is releasable, animation created from the derived data is not. Federal ruling has upheld that CVR transcripts may be released; however, actual voice transmissions are not.

Safety Privilege is a critical tool for mishap prevention. It gives a flight safety investigation board (SIB) the ability to expeditiously conclude the findings, causes, and make recommendations for a mishap by granting limited immunity to those involved, thereby avoiding lengthy bureaucracy. This immunity only applies to the SIB’s investigation and their report because their sole purpose is mishap prevention. Without the ability of safety privilege, SIBs may never find the root causes to certain mishaps.

When safety privilege items are compromised, the entire investigation system breaks down and the ability to continue to grant such a right in future flight mishap investigations is jeopardized. It is incumbent for all, aviators or not, to protect this and all privileged material. If safety privilege is not properly and diligently protected, it may not be available in the future.

[safetypee]

I can understand the need for the USAF to publish such a notice in a litigious or blaming society – if only to cover their embarrassment, but this is the technological age and perhaps such leaks should have been expected.
The wording of the final paragraph is unfortunate; how can the disclosure of this information cause the collapse of an investigation. Perhaps this is more an issue of not wishing to embarrass some senior commanders or senators who, based on information in previous posts, appear to lack even the basic understanding of human factors and the nature of human error.
Sensible and well considered discussion in this and other forums, even with speculation, can provide valuable insight to human behaviour and thus identify potential safety improvements from which we may all learn.
I hope that the SIB/MAAF have sufficient integrity to investigate all of the contributing factors to this accident, particularly any organisational or systematic issues, including those which could embarrass the commanders / senators, so that they or those who follow might learn from any mistakes, and for the benefit of civil and military flight safety.

[Reach]

Privilege is there to promote safety. The crew may be less open with their answers if they know everything they say to the SIB is going to end up on the internet. Remember that unlike the airline guys, they don't have a union to protect their interests.

[safetypee]

Reach, true statements - I agree, but no post-accident information is in the animation.

[Ignition Override]

Reach: I'm sure that you realize this, but for the unfamiliar (non-airline types), a union can not save your job if you really screw up or if you to distort or try to hide any facts from the company investigation etc. If you really blunder, a union will not try to stand very close to you.

For the neophytes out there, nothing in this business remains hidden for very long. This world is much smaller than people believe, and faces (along with back-stabbers) are very hard to forget.

[Reach]

Ignition Override

Thanks. I should have added that once the mishap prevention stuff is done, the lawyers get involved and the blame game starts. Its then that the crew pays if they really screwed up.

[Ignition Override]

True, and despite the many problems inside a union, there is no better organization which attempts to preserve the dignity of the profession, nor the prerogative of a Captain to refuse an aircraft. Also for the neophytes and non-airline people: when this happens and no spare aircraft is available, the better airlines allow safety to come before revenue. So far, there is no other group which can replace a union. Many Ppruners imply the need for no union, but they are evading the question, without a better solution. They choose to remain oblivious to the real problems.

Still off of the main topic, but the thousands of laymen who read Pprune might have no idea, and would never imagine how often many companies often attempt to place revenue ahead of safety; very few US (aviation) corporate leaders have any operational aviation background. This alone says quite a bit about their true interests and motivation$.
Excuse me for the wandering.

[411A]

Yeah...well, Ok

You are excused, thanks.

Sadly, this does NOT excuse the crew of the respective C-5 in question, as they REALLY did f**k up.
What to do?

Well, one thing is for sure, the USAF had better darn well get their collective house in order...or else.
And the 'or else' is NOT likely to be pleasant.

[alf5071h]

I have reviewed the animation and audio;– not admitting to retaining a copy!
It would be unwise to form conclusions on the cause of this accident from this data as it is only a very small subset of that which would be required to gain a full understanding of the situation both before and at the time of the accident. However, IMHO there are questions which can be raised based on what is present / not present in the animation. The answers to these questions, or just the questions alone could be a catalyst for thought or even initiate valuable safety activities.
The animation starts on base leg, thus what the crew had deduced after the failure, their reactions/actions, and subsequent abnormal/pre-approach briefing is not known. Similarly, there is no data on any associated human factors or organizational issues (fatigue, tiredness, training, safety culture) which could have significant input to understanding the accident.
It is not possible to identify the speakers from the audio except where it might be assumed that the pilot flying (PF) calls for checklist and actions; up to five voices can be identified. Verbatim CVR quotes are avoided as these are normally regarded as personal and private.

Before turning final, ATC gives landing clearance and the PF calls for the landing checklist. Aircraft configuration: 175kts, 38 flap, eng 1/3/4 at 65% (# 2 eng throttle at ‘Idle’, N1 at 15%, assumed to be shut down).
There is additional (extraneous) discussion on anticipating hot brakes and no necessity to aim for a gentle landing – ‘think about clearing the runway/taxi’. An interpretation of the tone of this reminder was of an ‘instructor’ or mentor briefing a student or a senior pilot to a junior – alternatively it could have been a ‘self briefing’.
Who gave this briefing?
Was this an indicator of the crew’s interaction or culture (power/distance, cockpit gradient) or alternatively a positive reminder of issues to consider – good CRM?
Was there any history of the aircraft brake performance at heavy weight that could have influenced the crew – a previous incident?
What specific advice is there for an overweight landing – use restricted flap?
Should the crew have considered / could the aircraft dump fuel?
Was the discussion distracting at this stage of the flight?

The landing checklist items were run smoothly, but quite quickly; there was an item for EGPWS.
Does this suggest that the briefing was for a non normal flap selection requiring EGPWS to be switched off, or is this a C5 specific item (QFE ops, DME/FMS input only)?

Gear was selected down and checked, ‘flaps’ were called from the checklist, the flaps move to 90 deg. Electronic audio call of ‘1000ft to go’
What flap setting is required for an approach with an engine inoperative, when is it set – full flap vice restricted flap for heavy wt – was this a conflicting combination in this situation – engine out and heavy?
What, if any, differences are there between an engine out approach and a normal approach? If different, is there a specific checklist for the differences?
How often do crews practice with an inboard engine failed?

At 900 RA (4.5nm), the throttle positions retard to idle (N1 50%), 165kts for 146 kts (Vapp). As the throttles are advanced, #2 and #3 are interchanged, thus only Eng 1&4 provide thrust, 70% N1 becoming 90% or greater for the remainder of the flight. The animation shows eng 2 at 15% N1 (shutdown) and eng 3 at 30% N1 (idle), landing checklist complete - Rad Alt 700 – thus a relatively short time for all of the above to have occurred.
Who normally manages the throttles during an approach?
What rudder trim is set with an engine inoperative or is there any rudder bias system which will / will not provide any force cue from the rudder as to which engines were in use.
Was the engineer head up? What should he be monitoring his or the crew's instruments?

Discussion:- note the significant differences between aircraft variants in the display format of engine parameters. See US Cockpits, search for ‘C5’; review the range of photos pre/post flight deck update including the engineers station; also see the C141 for comparison – a common ‘Lockheed’ flight deck?.
Of particular interest are C5 Old flt deck and New flight deck.
After the lessons learnt by civil regulators / operators from the FAA report ‘The Interfaces Between Flightcrews and Modern Flight Deck Systems’, it is surprising that so many potential error paths (design weaknesses) can be identified with in the C5 flight deck upgrade.

• The engine displays change from strip indications to dials (N.B. previous transport aircraft, C141 also has strip instruments).
• The secondary engine are displays positioned alongside the main dials without vertical correlation (recall the 737 Kegworth accident). Was the C5 engineer’s engine display changed to ‘glass/LCD’ strip or dials?
• Two sets of throttle levers; note the asymmetrical arrangement of the outboard levers.
• The inability to lock out an inoperative throttle lever – some civil aircraft have latched / combined levers and HP cocks.
• Strip airspeed and altitude appear to be on EFIS, but where are the ‘strip’ displays of AOA and Rad Alt located (assuming mechanical strip displays in the old flight deck).

How many simulators have been modified to the new flight deck standard?

The animation continues with discussion on ‘boxes’ and ‘speed’ apparently relating to the PFD, RA 6-500ft, 4-3.5nm: – “check speed now” – 148kts (for 146Vapp). The voice ‘chatter’ again appears to be ‘non normal’. The tone was explanatory, similar to an instructor or more knowledgeable pilot/crewmember explaining an aspect of the aircraft or display. Comment on the (EFIS?) ‘checkerboard’.

Supposition:- this point was probably the last chance of identifying and recovering the situation, thereafter there was insufficient height to dive to maintain speed and then raise the flaps, or speed was always too low to raise flaps. The only plausible recovery would have been the identification of the engine mix-up and applying full power.
RA 480ft, 138kts (Vapp -8), Eng 1&4 N1 95%. A call for ‘flaps 40 – no disregard’.
Was the cancellation in recognition of the low speed?
Was the focus of attention in this situation the drag / speed, but not thrust?
Was power ‘assumed’ to be max on Engs 1, (3) & 4.
What was the crew's understanding of the situation?

There were comments and discussion where the pilots were aware of the increasingly low approach. Background voices (independent discussion amongst other crewmembers?) were querying the flap setting, whether they should advise/question the pilot – they appeared to be unaware of the situation, the planned approach, SOPs, or the precise stage of flight.
At RA 210ft (Vapp –16) there is a movement of Eng 3 throttle lever to 30%, but without any noticeable change in N1.
Who moved the throttle lever, was it done consciously or subconsciously?
Did this indicate that someone had doubts about which engines were being used?

The short remainder of the animation and audio relates to being low and slow, except at 170RA (Vapp -18) there was a call from an indeterminate source to ‘get the flaps up’; flaps retracted to 40. The aircraft encountered stick shake; there was a stall warning before ‘touchdown’.


This review is not to find fault with any crewmember or make judgment on anyone’s responsibilities or actions; it is to seek a better understanding of what appears to be an accident of human error. The narrative above is provided to encourage others to explore the vast range of ‘what ifs’ and why didn’t … , and all those seemingly innocuous issues that should have been taken account of.
For those who have sought a single cause or unwittingly allocated blame in earlier posts, take time to reflect on the vast range of human factors that could have been present in this accident. Take time out for ‘Self Reflection’ – “it could happen to me”.
A detailed understanding of this accident might provide a good example of the difficulties of Threat and Error Management, whether it is conducted by an individual, the crew, operator, management, command, or even at regulatory/senate level.
An accident is a lesson to be learned. Detect and avoid, or alleviate those error provoking situations (foreseeable events) which can be identified beforehand so that whatever human capability remains can be used to counter those unforeseeable diverse events such as those apparent in this accident.

[BEagle]

"For those who have sought a single cause or unwittingly allocated blame in earlier posts, take time to reflect on the vast range of human factors that could have been present in this accident. Take time out for ‘Self Reflection’ – “it could happen to me”. ""

Oh no it b£oody couldn't!! Because the training I received, and later delivered, made damn sure that a higher level of professionalism was invariably displayed than by that bunch in the C-5.

[misd-agin]

At 900 RA (4.5nm), the throttle positions retard to idle (N1 50%), 165kts for 146 kts (Vapp). As the throttles are advanced, #2 and #3 are interchanged, thus only Eng 1&4 provide thrust, 70% N1 becoming 90% or greater for the remainder of the flight. The animation shows eng 2 at 15% N1 (shutdown) and eng 3 at 30% N1 (idle), landing checklist complete - Rad Alt 700 – thus a relatively short time for all of the above to have occurred.

**********************************************************

20 kts above Vapp, roughly 450' below normal glidepath. The answer is idle power to slow the a/c???? How about maintaining the current power setting, decrease descent rate, and trade excess airspeed to attain typical glidepath?

Three pilots, along with two experienced F/E's, and this is the result?

The FDR and CVR explained what happened. Curious as to what might have lead up to the start of the event.

Something not addressed was the short sleep all crewmembers had. Happens at times. But 1 AM brief for a post 6 AM launch? Airline crews show up 1 hr prior to fly anwhere in the world. That the military still operates this way is dumb IMO.

[misd-agin]

But 1 AM brief for a post 6 AM launch? Airline crews show up 1 hr prior to fly anwhere in the world. That the military still operates this way is dumb IMO.[/quote]

Friend flew 727's civilian and military. Civilian showtime was 1 hr prior. Military? 4 hours. "We rebuild the friggin' aircraft in the preflight..."

[alf5071h]

Oh dear! Beag’s your post (20 July) reflects the best and worst of the issues that currently plague our industry.
At best you engage the subject and express the incredulity of this accident; at worst you perhaps exhibit denial, and circum to errors of personal assessment.
Whether you like it or not, you and I are history. I suspect that we had similar, if not identical training. You twirled your 4 jets or provided airborne refreshment while I made fruitless efforts to intercept, and latterly was thankful for a top up every 20mins.

In our time the training was exceptional – in places it still is; I have spent many hours trying to understand what it was, capture those special components which provided discipline, awareness, and judgement for so many situations. Other pilots may not be so fortunate; they are not given the length or quality of our training, nor the opportunity for extensive and meaningful experiences. They, all of us to some degree, now suffer the constraints of modern commercial pressures.

I am sure that even the tiniest bit of self reflection would enable you to identify precursor situations in your career which could have developed into something just as serious as happened with the C5 (good ‘war stories’). What was the ‘special’ item from your training that closed the hole in the ‘Swiss Cheese’; or was it one of your crew that prevented all of the components of an impending accident from coming together. Then an analysis could consider contributions (or lack of) up the chain of command, facilities, personal support, safety culture, etc.

I won’t argue the point that ‘it’ wouldn’t happen to you, but I wouldn’t bet on it, particularly with my own life. You, like many other less experienced pilots, apparently fail to accept the human vulnerability to error. If it is not going to be your error then it will probably be someone else’s.
Alternatively, with acceptance of error what gems can you pass on to others? Instead of stating what you see as obvious, “Because the training I received, and later delivered, made damn sure that a higher level of professionalism was invariably displayed than by that bunch in the C-5”, please pass on this ‘wisdom’ and help us all to move towards that higher level of professionalism which aviation requires.

You will recall that:-
We do not plan or decide to commit errors.
Errors do not cause accidents - it is our failure to identify them with time to act.
Errors are only determined after an event, they are ‘labels’ - symptoms of the situation.
Errors are there to be used, to be learnt from; they are an essential ingredient of the professionalism that we all seek.

For those looking for something more positive from this discussion, try some Reason; CRM with a photocopier.

[ORAC]

I seem to recall there have been occasions where the RAF CRM has not been exemplary, Victor XL191 at Hamilton in 1986 comes to mind. Thankfully they also all walked away from that one..

[GlueBall]

C5 Crash Animation Video

Brigadier General misd-agin: "...FOR OFFICIAL USE ONLY Unauthorized recipients will delete it and advise the sender to do the same as well as notify all those who were sent the file...."

...Is that an order, Sir?

[Ignition Override]

Lots of repetition, even in the simulator, can be the first trap waiting to grab you. For example, an engine failure is expected and almost always happens at or just after V1. Why not skip the PRM approach training and (as briefed) set up an engine flame-out while dragging in the fog at Localizer minimums {about 400' agl} with gear down and flaps 40 at a very low energy state such as Vref+5?
For what it is worth, I've never been a superior pilot, nor flown a widebody jet. But partial automation on the B-757 could be a concern, with both pilots fairly new on the plane.

But does reliance on having at least two or three other experienced flightcrewmembers ('having a staff') also create a trap, even with some automation, or is automation the main focus when it is a novelty? If an aircraft can be safely flown with a basic autopilot and "heading select", especially when returning to a nearby airport, then why try to use all of the automation-especially when many crewmembers have little or no line exposure to it?
A 'classic' L-1011 with a highly-experienced crew crashed many years ago into the nighttime Florida Everglades due to the focus of all three pilots (one was FE) on a burned our lightbulb. Reportedly, nobody simply flew the plane. Did the active role as "handling pilot" seem too simple and was always assumed, at least back then? A bump against the control yoke somehow initiated a subtle, gradual descent over dark swamps-from only about 1500 or 2,000' !
The crash of the United DC-8 in Portland OR, due to overemphasis on a fairly minor problem, and no seriously stated, very clear warnings by the FE, or awareness by the Captain, led to an emergency fuel situation and a crash.
This might not pertain to the C-5 disaster, but the United crash inspired United Flight Ops to create the concepts of CRM.

The horrible nightmare at Tenerife was also excellent motivation for teaching Captains to listen to crewmembers' concerns. A television episode about the influence of human factors on the Tenerife tragedy tonight described a phenomenon whereby a pilot who instructs in a simulator and does limited line flying can have a different "mission-oriented" or "mission reset" thought process compared to those who only fly the real airplane. The Captain who was the flying pilot felt pressure to depart, and yielded to the temptation, being quite aware of rigid limitations on the crew duty period.

Did the C-5 Wing require at least one pilot to have about 100 hours (or 5 legs etc) in the glass cockp1t before being paired with a pilot who had no training on the FMC/MCP etc?
Most of these reviews of some accidents are for the benefit of the younger pilots who might not be aware of them. Most, if not all of those crewmembers were highly-experienced, often 16-20 years or more. And nowadays, the younger generation relies on the automation or other technology to save them from using (developing?) flying skills . This mindset was apparent on the first/last cruise of the Titanic.

[HotDog]

C5 crash Delaware

Accident report blames crew for C5 crash at Delaware on April 3, 2006.

http://www.delawareonline.com/apps/p...4001/-1/NEWS01