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Failure to Imagine

Failure to Imagine
COMPILED BY THE KNOWLEDGE STAFF

I was a young chief warrant officer 2 when I had my Class C accident. Over the last few years, I have often contemplated the factors that led up to it. Much like other Army aviation accidents, there was a series of events (i.e., a domino effect) that got us to the final product. For my accident, the factor that sticks out the most was our crew’s failure to imagine.

Our mission was to conduct readiness level progression mission training. I was a young pilot in the unit and was receiving my instruction from a junior instructor pilot. The first hour of training went by without any problems. We had a medic on board and with only an hour remaining, decided to conduct dummy hoist training. We landed, conducted the checks on the hoist per the -10 checklist and took off to an area to conduct the training.

We set up at a 150-foot hover and prepared. My IP was on the controls. I was “inside,” monitoring the instruments. The medic opened the cabin door, got into position and hoisted the 200-pound lead dummy off the cabin floor. He announced he was booming-out the dummy, then did it and lowered the dummy. Everything was going as planned when we heard a loud pop. I looked at the instruments and then my IP. What was that? Our medic announced over the intercom system that we had just lost the hoist out the door. We landed to check the damage and locate the hoist. We called our flight operations, then flew the aircraft back to our staging area and shut it down.

Factors that contributed to this accident included a hasty installation of the hoist in the airframe, not having a technical inspector check the hoist after its installation, not pre-flighting the hoist to check for security and, finally, not briefing flight operations about our intentions to conduct hoist operations. When you look at the totality of the circumstances, you can ask yourself how did this happen? I can tell you that it occurs often. The little mistakes may not be a problem until you combine them with other activities. You can see what happens next!

For me, I have tried to learn from my accident and apply those lessons learned to all my future missions. I use the Army’s five-step risk management process to mitigate the risks that are inherent to the missions I fly. The first step in that process is to identify those hazards. The second step is to assess those hazards. The third step is to develop controls and make risk decisions for those hazards. Step four is to implement the controls. The fifth step is to supervise and evaluate those controls. Because this is a continuous process, we must always strive to improve it to reduce the risk.

Hindsight is always 20/20. I look at the events leading up to this accident and can tell you I failed to imagine something like that could happen to me. From experience, I can say this has probably happened to you. Our challenge, your challenge, is to manage those risks related not only to your operations, but to your lives as well. Be better than me. Don’t imagine that it can’t happen to you!
 
  • 1 October 2014
  • Author: Army Safety
  • Number of views: 10328
  • Comments: 0
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