Plan for the Heat
G3, Investigations, Reporting and Tracking
U.S. Army Combat Readiness Center
Fort Rucker, Alabama
A review of the last four H-60 Black Hawk mishaps (San Clemente Island, California; Tian Island, Saudi Arabia (Multinational Force and Observers Egypt); Mendon, New York; and Danskin Mountains, Idaho) reveals several commonalities. First, all four resulted in multiple fatalities. Second, all four resulted in the complete loss of an H-60 aircraft. Third, all four occurred while conducting training or evaluations, not in combat. In addition, all four mishaps also had at least one instructor pilot (IP) onboard with access to the flight controls (and two of the mishaps had a standardization pilot (SP) seated in the cabin area conducting evaluations). None of these four mishaps were the result of a materiel failure; all four were determined to be caused by human error. All four mishaps occurred as the result of either a deviation from regulatory guidance, procedures not being followed correctly, or exceeding a limitation or standard. And finally, all four mishaps did not have to occur — and likely would not have had one of the crewmembers spoken up and re-focused the crew through the use of good crew coordination.
All aircrew training manuals (ATMs) have a chapter dedicated to crew coordination; it’s Chapter 8. Broadly defined, crew coordination is the interaction between crewmembers necessary for the safe, efficient and effective performance of tasks. Regardless of the elements, qualities and objectives of crew coordination, there had to be a breakdown within the crew at some point to allow these four mishaps to occur. Whether it was not communicating positively or announcing actions, thereby allowing the other crewmembers to acknowledge actions, or if it was a failure in the appropriate decision-making techniques or lack of information and actions sought by or offered to the crew, the fact remains that these mishaps resulted in multiple fatalities and they did not have to occur. None of these mishaps indicated advocacy and assertion by any of the crewmembers that would have stopped or changed the outcome.
Failure to communicate and operate effectively as a crew is a very difficult challenge — and not just in aviation. Generally, though, the mistakes made in aviation are far more unforgiving. If the mission is planned (and make no mistake, training is a mission), briefed, acknowledged, and situational awareness is maintained and unexpected events are managed effectively, then it is on the path to success. This path to success must include all crewmembers advocating for compliance to the mission, standards, limitations and procedures. There is always a potential for mishaps to occur when there is a breakdown in the communication process. If the mission is not planned properly or if information is intentionally withheld from the crew, maybe to add to an evaluation scenario, there is the potential for a mishap. Similarly, if regulatory guidance and procedures are not followed and the crewmembers do not advocate for corrective action, then there is also the potential for a mishap to occur.
Historically, documented data reveals that a large percentage of aviation mishaps are the result of a breakdown in at least one or more failures or errors in the crew coordination process. If you think that sounds like a “blame-the-pilots” philosophy, then I would argue that you’ve probably been guilty of crew coordination failures at some point in your career. For that matter, we are all probably guilty of failing in one or more of the elements, qualities and objectives of crew coordination. But why are we not all fatalities? Maybe it was sheer grace, or the situation and the circumstance were benign and the failure did not result in a mishap; or maybe, just maybe, there was some form of advocacy and assertion by another crewmember that changed the potential outcome.
Regardless of the reasoning, failure of crew coordination, as explained in the ATM, is going to happen. However, it is not just one failure that leads to all mishaps; it was a lack of corrective behavior when failures are pending or inevitable that led to these four H-60 mishaps. For example, if the IP/pilot in command (PC) of a CH-47 said he/she was going to increase their airspeed to well above VNE (velocity – never exceed) to see how fast they could really go and say that they had flown faster than VNE, and no one in the crew (co-pilot, crew chief (CE) or flight engineer (FE) said anything, then they have just condoned this violation of a limitation. Once the crew allowed the IP/PC to exceed a limitation, this is an easily identifiable breakdown in the crew coordination process. Specifically, there was no assertive behavior or advocacy by any of the other crewmembers to preclude the behavior or action of the IP/PC. There is not some magic spell that IPs have to preclude mishaps. These recent mishaps prove that easily enough, as there was an IP present, at one set of the controls, in all four incidents.
The absolute question is why was there a breakdown in crew coordination and why did none of the other crewmembers intervene prior to the mishap occurring? It is a haunting question. Was it a lack of confidence in their advocating for a change or corrective action? If all of the mishaps involved rated crewmembers, then why did one allow another to deviate from regulatory guidance or to exceed a standard or limitation? Could it be that all four mishaps involved IPs and this title somehow clouded the co-pilot’s ability to assert or challenge the IP? Or could it be that two of the mishap flights occurred while there were evaluations taking place and the co-pilots did not want to interject any assertiveness that could or would have potentially resulted in a bias during the debrief of the evaluation?
It’s possible the reason lies within the training received by the crewmember. If the words “speak only when spoken to” are ever perceived or stated during training, then there is a problem. As a crewmember, you have an equal voice in the safety and efficient performance of any flight. Furthermore, you have the qualifications and expectations to execute your duties regardless of the situation. Certain situations may involve a rank disparity, but this should never hinder your ability to speak up and be assertive when the safety of the aircraft is in question.
Learning to operate as an effective crew is a continual learning process. Professional courtesy has a time and a place, but it should never preclude you from advocating right from wrong. Whatever the reason, the fact remains that when a flight is continued and the standards are known and no one speaks up or advocates an assertiveness to cancel the flight or maneuver, then there is a breakdown in crew coordination. In these four mishaps, it is this breakdown that resulted in multiple fatalities.
One more time — all of these mishaps occurred while conducting training. Luck should not be an option when conducting training. If you are a member of a crew, you have an obligation and a requirement through your interaction and communication to advocate for the safety of the flight. If you cannot find it within yourself to advocate for your life and the lives of your fellow Soldiers, then you may want to find another profession. Remember, the life you save today may save another in the future.
As a professional, you have the ability and opportunity to differentiate right from wrong, briefed risk approval from unbriefed risk, and you always have the potential to save yourself if you just advocate and communicate. Never bypass the opportunity to operate with the procedural guidance, standards or limitations of your aircraft. Set the example for others to follow by maintaining a professional atmosphere and encouraging others to communicate effectively regardless of their rank or position in the crew. Never rely on luck or place safety aside. Learn to communicate effectively!