Near-miss Review:UH-72A Aircrew Coordination Failure
NAME WITHHELD BY REQUEST Background
A UH-72A crew was conducting a routine surveillance mission along the United States/Mexico border in support of U.S. Army and Customs and Border Patrol operations. The crew reported for the mission at 2200 local, performed preflight operations and mission planning, and conducted a crew brief. At about 0000, the crew took off and began flying orbits in the area of operations at 3,500 feet mean sea level utilizing night vision goggles (NVG).
About one hour into the mission, due to poor aircrew coordination, the aircraft entered into settling with power while attempting an out-of-ground effect (OGE) hover. The pilot in command (PC), who was not on the controls, experienced spatial disorientation (SD) upon taking the controls to recover the aircraft. The aircraft recovered from the emergency situation and resumed the mission. The crew conducted an after-action review (AAR) following a safe landing at the end of mission. No one was injured. Crew
The PC had 545 hours total time and 163 hours of NVG time. The pilot (PI) had 224 hours total time and 50 hours flying NVG. The crew chief had 411 hours total time and 125 hours of NVG time. Additionally, the PC had recently attended the High-Altitude Army National Guard Aviation Training Site (HAATS) in Gypsum, Colorado, and was familiar with the power management training process. Commentary
While conducting orbits, the crew chief was using the aircraft’s MX-15i infrared camera to locate surveillance targets. Once the targets were spotted, it was determined an OGE hover was required to remain on station. The PC checked the PPC, noted the aircraft’s gross weight and wind direction/speed, and determined the aircraft would have sufficient power to perform the OGE hover. The PC directed the PI, who was on the controls, to perform a deceleration and enter the OGE hover in the direction of the wind, approximately a 120 degree heading.
The first breakdown in crew coordination was the PC’s failure to adhere to the objective “cross-monitor performance.” After directing the PI to initiate the OGE hover, the PC flipped up his NVGs and announced “right-front inside” in order to complete a fuel check due to the fuel timer going off. While the PC was focused on the fuel check, the PI failed to pull in enough power to arrest the initial descent once the airspeed slowed to zero knots. The PI was focused outside and did not realize the aircraft was in a descent, and the crew chief was focused on operating the camera and coordinating with agents on the ground.
Once the PC noticed the aircraft was descending, he flipped down his goggles, focused his attention back outside and directed the PI to pull in power to arrest the descent. The PI pulled in the collective to max continuous power but failed to apply any pedal inputs, which brought the aircraft’s heading out of the headwind, thus requiring more power to stop the descent. At this time, the aircraft was settling in its own power with max continuous power being applied and a descent rate of more than 1,000 feet per minute.
The PC announced the aircraft was settling with power and told the PI to gain airspeed and conduct a flyaway into the wind direction. The PI did not respond, most likely due to task saturation, and the PC took the controls and put the aircraft in a 10 degree nose-low and 20 degree left bank to escape the emergency. Because the PC was previously head-down and not wearing the NVGs for a prolonged period of time, while attempting to recover the aircraft, he experienced SD upon quickly looking back outside and having no outside references. Upon gaining airspeed, the aircraft was able to initiate a climb and resume the mission.
The aircraft lost more than 1,500 feet in altitude during this event. Had the crew not been operating at such a high altitude, this could have been catastrophic. During the AAR, the crew noted that had the aircrew training manual NVG and OGE considerations for Task 1038, Perform Hovering Flight, been briefed during the crew brief, the crew could have anticipated the potential to settle with power as well as the possibility to experience SD. The crew also noted the failure to “cross monitor performance,” as well as “offer/direct assistance,” becoming task saturated with crew-specific tasks, and the PI’s inexperience with performing OGE hovers in an aircraft with a high gross weight and small power margin.
This event could have been avoided with a more elaborate, mission-specific crew brief, effective aircrew coordination and more experience in the cockpit (the PC and PI had less than 1,000 hours total time combined). Fuel checks are important but should be completed during a less demanding mode of flight and without impeding on the crew coordination objective of “cross monitor performance.”
It is critical for aviation safety officers and instructor pilots to familiarize aircrews with mission-specific hazards and effective aircrew coordination during aircrew calls and safety days. Flight crew experience must be evaluated closely before making the flight schedule, and PC’s need to be cognizant of the aircrew’s experiences and comfort zones before directing specific tasks, as well as make sound decisions when prioritizing which tasks need to be accomplished and in what order. Readiness Through Safety!