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It was a routine training flight when the HH-60M MEDEVAC crew experienced a mishap with their hoist. The front-seat crew consisted of a 1,100-hour pilot in command (PC) and a 250-hour pilot (PI). In the back were a crew chief, a flight instructor (FI) and a standardization instructor (SI). During the initial run-up of the aircraft, the crew met all standards for the day’s weather and mission profile. However, rushing to get to the local training area, the crew — both front and back — failed to complete a critical step of the checklist: “mission equipment.”

For a MEDEVAC crew conducting hoist operations, the critical mission equipment step involves the power-on and power-off checks of the rescue hoist. These checks ensure the condition and security of the equipment while confirming proper operation and function. Failing to conduct these checks before the blades are turning reduces the crew's ability to perform them properly in a stable environment.

After conducting the health indicator test checks, the crew departed the ramp for the day's training area. Upon arriving about 20 minutes later, the crew landed to discuss the location of the hoist operations and determine which crew member would conduct them. While going through “buddy” checks in the rear and preparing the hoist, the SI reminded the crew that they had not conducted the hoist power-on and power-off checks. Upon hearing this, the PI on the controls set the brakes, and the PC retrieved the checklist.

The rear crew members opened the right cabin door, and the crew chief, under the inspection of the other two, started the checklist as the PC read through the power-off checks. When it was time to turn the power on, the crew chief followed the PC's instructions over comms. However, frustrated by time constraints, the PC deviated from the written checklist and started reciting the hoist power-on checks from memory.

When it came time to test the squib for the cable cut button, the PC missed the step to ensure the cable arm/test switch was in "test" and not "arm." Reciting the memorized step of “pilot hoist control panel cable cut switch, press,” the PC pressed the switch. An audible pop was heard, followed by the crew chiefs expressing their surprise over comms. The squib functioned exactly as it should, severing the hoist cable roughly 6 inches above the hook. After the rear crew members informed the pilots of what had happened, they decided to cancel that day's hoist training and return to base.

After unloading their gear, the crew helped the maintenance team tug the aircraft back into the hangar. There, the hoist spool was unwound, and the facility command staff conducted a local investigation. Investigators concluded that inattention, inexperience and command pressure were the primary contributing factors to the incident. The PC had made the decision to deviate from the checklist in violation of Army Regulation 95-1. Additionally, lacking confidence and experience, the young PI failed to speak up when noting the checklist was being performed from memory rather than being read. The PC received negative counseling for failing to meet checklist standards, and the FI and SI were subject to retraining on crew member evaluation techniques.

The overall cost of the incident was in excess of $26,000. Worse yet, the replacement part was on backorder, grounding the aircraft's hoist in a "Red X" status for over a month. This occurred while two of the six company hoist aircraft were already down for heavy maintenance. As a result, excessive flight time was logged on the remaining aircraft for training, ultimately disrupting the facility’s maintenance flow charts.

Lessons Learned

This preventable incident is a good illustration of how something as simple as deviating from a checklist can negatively affect a flight company on multiple levels, impacting maintenance personnel, training staff and the aircraft itself. Remedial training was provided to all involved, and the incident became the focus of multiple safety briefs emphasizing the importance of following checklists to ensure personnel safety.