CHIEF WARRANT OFFICER 3 AENDRI DECKER
B Company, 1st-106th Assault Helicopter Battalion
Illinois Army National Guard
Kankakee, Illinois

Author’s note: Both training and real-world missions are inherently hazardous; therefore, hazard controls must be established and strictly followed to ensure mission success. This article discusses a near-miss incident that occurred during a training event where established hazard controls were bypassed, nearly leading to a mishap. I will examine the pre-incident planning, the events of the incident and the lessons learned in the aftermath.

In July 2022, my UH-60 MEDEVAC unit participated in the Sage Eagle Training Exercise at Fort Bliss, Texas. During this joint exercise, our crew was tasked with a late-night patient pickup training mission at a military operation in urban terrain (MOUT) site. I was assigned as the pilot (PI), flying with a high-time instructor pilot (IP) as the pilot-in-command (PC), along with an experienced crew chief and flight medic. We received a mission request detailing the date, time, passengers and general location, giving us several days for prior planning, training and landing zone (LZ) reconnaissance.

Pre-mission planning began with classroom safety briefings covering flight routes, off-route procedures, communication protocols and established LZs. The crew conducted local area orientation flights during the day and at night under night vision goggles (NVG). We also practiced dust landings using a "crawl-walk-run" approach, progressing from no-dust to heavy-dust conditions.

On the day of the mission, we flew a daytime reconnaissance flight to the coordinates to select an LZ. We chose a specific site that offered light dust and ample separation from the MOUT site. The PC provided the ground units with precise coordinates and confirmed the use of a chemlight "buzzsaw" for the initial signal and an inverted "Y" for the LZ. With the Risk Common Operating Picture completed satisfactorily, we felt confident in the plan.

After sunset, all preflight preparations were completed and we departed for the LZ. We noted the minimal illumination around the MOUT site, which was typical for the area. Before arrival, we established that I would primarily fly the aircraft while the PC handled navigation and communications. However, the PC was unable to establish reliable communication with the ground elements. We considered this a minor inconvenience, as ground-to-air communication is sometimes unreliable in training environments.

Upon arrival, we observed that our selected LZ was occupied by ground vehicles and personnel. The LZ signals had been moved to a different side of the MOUT site. The crew expressed shared annoyance at the move to a less familiar location, but after a low pass, we determined the area was suitable. On short final approach, dust began to build. It was significantly heavier than at the original LZ, eventually resulting in a full brownout.

I focused on the inverted "Y" as we settled into the dust cloud. As the Black Hawk started to touch down, the chemlights — which had not been secured to the ground — began to blow in all directions. Maintaining a visual reference became extremely difficult. While the crew chief advised he still had a good visual, I reduced power and felt the tail wheel touch the ground. Immediately, the aircraft fuselage began to tilt on the roll axis. No longer comfortable with the landing, the PC called for a go-around. I echoed the call.

The PC joined me on the flight controls to maintain a level attitude, power was applied and we flew vertically out of the dust cloud. We decided to utilize an alternate landing area farther from the MOUT site but closer to our originally reconned LZ. That landing was successful, the passengers were loaded and the mission was completed without further incident.

Lessons learned

During the after-action review, our crew determined this was a near-miss. Had the landing attempt continued, the fuselage could have continued to roll, potentially resulting in a dynamic rollover. We identified several primary hazardous factors:

• Communication — We were accustomed to operating without communicating with the ground forces, despite communication being a basic requirement. If we had established communication with them, we could have confirmed the LZ location or called for the original LZ to be cleared.
• Unsecured lighting — The unsecured chemlights added to the confusion under low illumination when they began blowing away.
• Lack of rehearsal — Ground units were unaware of the requirement to secure lighting or the danger of moving an LZ.
• Environmental changes — Moving the LZ forced us into a full brownout in an area we had not reconned.

The most significant conclusion was that mission contingencies and rehearsals are crucial. A thorough pre-mission rehearsal with ground units would have aligned all participants and established better protocols for LZ movement or communication loss. While our internal cockpit communication and the decisive call for a go-around prevented a tragedy, better coordination with ground forces would have avoided the hazard entirely.

Did You Know?

The Army Safety Management Information System (ASMIS 2.0) Mishap and Near-Miss Reporting application provides a means for users to submit all classes of mishaps, as well as near misses. The tool was created to reduce the burden of reporting on safety officers and to improve decision-making by reducing the amount of data required and by providing enhanced visibility of mishaps and near misses at all levels of the Army. Check it out at https://mishap.safety.army.mil/.