Four Themes in Army Aviation Mishaps
CHIEF WARRANT OFFICER 4 KYLE CLARK
G3, Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama
Since I started working at the U.S. Army Combat Readiness Center, I’ve noticed four common themes in almost every aviation mishap I’ve investigated: mission briefing officers (MBO) making common mistakes and becoming complacent with the briefing process; units having either a poor MBO training program or none at all; command teams putting too much importance on the title “instructor pilot” (IP); and “routine” missions accounting for the majority of Army aviation Class A mishaps. In hindsight, I have seen and been involved in some of these common themes in every unit I have been a part of. Sometimes, you might only have three of the four themes present, while other times you have all four. I guarantee that at least three of these themes are found in every aviation mishap. MBO mistakes
My first mishap investigation was in 2017 and involved five fatalities. While we found several contributing factors in that incident, the one that stood out was the MBO’s mistakes. The MBO was a platoon IP who briefed his friend, the unit’s standardization pilot (SP), for the mission that night, which they regularly did for each other. It was common for them to just sign each other’s risk common operating picture (RCOP) without conducting a true mission briefing using the risk management process. The MBO actually identified the hazard that set the mishap sequence in motion. However, he only verbalized it to the SP and suggested a way to mitigate the hazard without actually documenting it on the RCOP.
Since then, I have seen MBOs make the same mistake on almost every mishap I’ve investigated. Many MBOs have become complacent and do not want to be the bad guy that puts restrictions on their buddy’s flight. The MBO should be the pinnacle of one’s aviation ascent in the unit. Why do we hold a rigorous pilot in command (PC) selection board and process yet “hand wave” who gets to become an MBO? It is not something command teams should hand out just because a pilot has graduated from the IP Course or someone has attained a career track. MBOs should be few and far between in a battalion and there should not be 50-plus people on the MBO memorandum. If you are briefing someone on their mission, think of it from the standpoint that you want to ensure they return safely. Give them an honest briefing so they can make it back to their families. MBO training
From what I have observed, the MBO training process and procedures within units are severely lacking, with some being nonexistent. How do we expect an MBO to do their job correctly and help mitigate risk within our formations if we do not have a thorough and standard training regimen in place? Based on observations I and other investigators have made during investigations regarding MBO training, it can be anything from hand-wave training to five slides on a shared drive for MBOs to review. If someone is not taught how to identify and mitigate risks properly, how can we, as a command team, expect them to conduct a thorough risk assessment? Command teams often lean too heavily on senior warrant officers to develop the training program without providing any level of guidance or oversight.
When a mishap investigation team asks to see the MBO training program, more times than not we receive a deer-in-headlights response from the unit. Not only do we need to provide a thorough and rigorous training program, but there needs to be a regimented selection process in choosing the MBOs. I referenced it earlier, but I’ll say it again: we (Army aviation) send a 500-hour, 50-hour PC-time individual to become tracked (IP Course, Maintenance Test Pilot Course, etc.) and upon return to the unit, they are placed on the MBO memorandum. Units have to remember and take into account that the pilot is still building experience. No training in the Army can give the experience needed to properly mitigate risk within aviation; only real-world experience can do that. I urge every unit I visit on accident investigations to utilize only their most senior pilots as MBOs. I also suggest they provide a thorough and detailed MBO course with practical exercises, not just the check-the-block training that is happening now. Make it a chore for a pilot to find that MBO. Make every MBO be the person that makes those pilots lay out their entire plan in detail. Instructor pilots
I’ve mentioned IPs a couple of times already and I am not picking on or blaming them for accidents. However, I’ve been on six Class A mishaps with a total of 10 fatalities. Of those six, all had an IP on board. When I see an RCOP/Electronic Risk Assessment Worksheet with a risk mitigation of IP/SP on board, it tells me the exact reason they are often involved in the mishap. Units put too much emphasis on a pilot becoming or being an IP. Command teams utilize the IPs as their fallback risk mitigator on missions from training to the most complicated air assaults. Command teams need to take a step back and realize IPC does not stand for instant pilot credibility. These IPs are still pilots like the rest of us and are capable of making the same mistakes. Routine missions
If there is one word that needs to be removed from the Army aviation vocabulary, it is “routine.” During my time as an aviation mishap investigator, I have observed that a majority of our accidents occur on routine missions. Rarely does a mishap happen during an air assault or other complicated missions requiring detailed mission planning and execution. That’s because units plan those missions down to finite details, address every possible contingency and provide oversight by all levels of leadership. As soon as we say “routine,” we lose interest and develop a we-do-it-every-day mindset. If you are a leader, MBO or final mission approval authority (FMAA), you should require those crews to plan routine flights with the same level of scrutiny they would more complicated missions. Require them to present all of their planning products and walk through their mission with the MBOs. Have MBOs ask them about contingencies. Look into who is on the mission and their weaknesses and strengths. Take “routine” out of your vocabulary and mindset. Conclusion
In closing, it simply comes down to this: If you want your crews to return from their flights every time, leaders (MBO/FMAA), senior warrant officers and commanders must be engaged, know their personnel and hold them accountable to the published standard. Army aviation has been making these same mistakes throughout its history. Leaders need to focus on the culture within their units or we will continue to see these mistakes kill our Soldiers.