The Navy & Marine Corps Aviation Safety Magazine
The Navy & Marine Corps Aviation Safety MagazineSeptember-October 2008, Volume 53 No. 5RADM Arthur JohnsonCol. Mark W. Vanous, USMCJohn MahoneyNaval Safety CenterCommander, Naval Safety CenterDeputy CommanderHead, Communications and Marketing(757) 444-3520 (DSN 564) Dial the followingextensions any time during the greetingPublications Fax (757) 444-6791Approach StaffJack Stewartjack.stewart@navy.milAllan Amenallan.amen@navy.milCapt. Ed Langforded.langford.navy.milKimball Thompsonedward.thompson@navy.milCdr. John Klemencjohn.klemenc@navy.milCdr. Bob Standleyrobert.standley@navy.milCdr. Kevin Brookskevin.e.brooks2@navy.milCdr. Allen McCoyallen.mccoy@navy.milEditor and DistributionExt. 7257Graphics, Design & LayoutExt. 7248Aviation Safety ProgramsExt. 7225EA, Aviation Safety ProgramsExt. 7226Aircraft Operations DivisionExt. 7203Aircraft Mishap Investigation DivisionExt. 7236Aeromedical DivisionExt. 7268ORM DivisionExt. 7266AnalystsCdr. John Klemencjohn.klemenc@navy.milLeslee McPhersonleslee.mcpherson@navy.milCdr. Duke Dietzduke.dietz@navy.milMaj. Mark “Duke” Budde, USMCmark.budde@navy.milLCdr. Paul Wilsonpaul.j.wilson@navy.milLCdr. James “Moose” Haasjames.haas@navy.milLCdr. Jason “Grease” Domzaljason.domzal@navy.milMaj. Scott “Atis” Nicholsen, USMCscott.nicholsen@navy.milLt. Angela Domingosangela.r.domingos@navy.milMaj. Matt Robinson, USMCmatt.robinson@navy.milLt. David “Willy” Williamsondavid.a.williamson@navy.milLt. Brad “Frog” Loftisbradley.p.loftis@navy.milLt. Larry Tarverlarry.tarver@navy.milABCM (AW/SW) Lance Handslance.hands@navy.milACC Brian Soperbrian.soper@navy.milNATOPS/WESS Program ManagerExt. 7203MISREC/WESS/ATCExt. 7245Culture WorkshopExt. 7212FA-18A/B/C/D, F-16, F-5, T-38Ext. 7217P-3, EP-3, C-130, KC-130, C-40, C-9, E-6B, P-8Ext. 7214C-12, C-20, C-26, C-35, C-37, T-6, T-34, T-44Ext. 7206EA-6B, T-2, T-39, T-45Ext. 7224AV-8B, F-35, ARSAG, NVDExt. 7216E-2, C-2, S-3, UAVExt. 7274CH-46E, V-22, CH-53D/E, H-1, H-57, NVD, CWExt. 7233H-60, MH-53E, H-3, MFOQAExt. 7242FA-18E/F, EF-18GExt. 7208Facilities Branch, Fuels, CFR/ARFF, BASHExt. 7281ALRE/Air TerminalExt. 7279ATCExt. 7282Mishaps waste our time and resources. They take our Sailors, Marines and civilian employeesaway from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishapsruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help makesure that personnel can devote their time and energy to the mission, and that any losses are due toenemy action, not to our own errors, shortcuts or failure to manage risk. We believe there is only oneway to do any task: the way that follows the rules and takes precautions against hazards. Combat ishazardous enough; the time to learn to do a job right is before combat starts.Approach (ISSN 1094-0405) is published bimonthly by Commander, Naval Safety Center, and isan authorized publication for members of the Department of Defense. Contents are not necessarilythe official views of, or endorsed by, the U.S. Government, the Department of Defense, or the U.S.Navy. Photos and artwork are representative and do not necessarily show the people or equipmentdiscussed. We reserve the right to edit all manuscripts. Reference to commercial products doesnot imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprintedwithout permission; please credit the magazine and author. Approach is available for sale by theSuperintendent of Documents, P.O. Box 371954, Pittsburgh, PA 15250-7954. Telephone credit cardorders can be made 8 a.m. to 4 p.m. Eastern time at (202) 512-1800.Periodicals postage paid atNorfolk, Va., and additional mailing offices.Postmaster: Send address changes to Approach, Code 71B,Naval Safety Center, 375 A StreetNorfolk, VA 23511-4399Send articles and letters to the address above, or via e-mail to the editor,jack.stewart@navy.mil.C O NFeatures3. The Gear SolutionBy Maj. Carl Forsling, USMCGear problems don’t always have a NATOPS solution.6. Fly or Swim?By Lt. Timothy WriterAny big-deck ship will sacrifice time for safety.8. Training to TacticalBy Capt. Mitchell Kirkland, USMCThe crew chief yelled, “Pull up!” Then it was time to“Knock it Off.”10. Where’d Who Go?By 1stLt. Edward Lord, USMCSitting in a Hornet off the side of the runway was not theplan.14. Electrical Nightmare in the GulfBy Capt. Zachariah Anthony, USMCKnowing the electrical system may not be exciting, but it isessential.16. Helmet FireBy Ens. Aaron MetrickThis student naval-flight officer feels the heat on his second flight.18. To Tempt FateBy Capt. Ian T. Brown, USMCTwo HACs shouldn’t have been in a position where theyhad to use their superior skills.22. A Long Norwegian NightBy LCdr. Shawn PetreRelax, just once, and the unthinkable may happen.23. The 2 Stupidest ThingsBy Cdr. Joel JungemannWe all make mistakes, so why not share them?29. Almost a Fatal LiftBy AT1 (AW/NAC) Randy WituckiThe paperwork was perfect, but something smelled fishy.30. 90 Days to ContemplateBy LCdr. Thad JohnsonNever take a passive approach to training.32. The Wheel Spun FreelyBy Lt. Mathew OlsonThis P-3 crew has a gear malfunction during a combatdeparture. Should they still fly the mission?34. The High Cost of (Not Following) ProceduresBy Adria MarkowskiOur analyst looks at where the money goes in aviationmishaps, and where it shouldn’t have gone.
N T E N T SPhoto by PH1 Edward G. Martens. Modified.pg. 26September-October ThanksThanks for helping with this issue Maj. Jason Jolliff, VMFA-232Lt. David Lundy, VQ-2Lt. Tom Alpers, VR-55LCdr. Dave Larsen, HSL-51LCdr. Billy Fraser, VAQ-136Lt. Joseph Huffine, VT-4Cdr. John Minners, CNATRACapt. Stacey Colón, USMC, HMH-361LCdr. Eric Illston, VAQ-140Lt. Chris Kerns, VPU-2Maj. Brian Harrelson, VFA-125Lt. Meghan Forehand, HSC-23Ltjg. Benjamin Anderson, VP-5Lt. Chris Martyn, VAW-1211stLt. Bradley Gautreaux, VMMT-20438. Business-Class FODBy LCdr. Paul LanzilottaLook for FOD everywhere, even on cross-countries.39. From Four Engines to TwoBy Lt. Michael WintersMulti-engine malfunctions raise the issue of whether to shutdown or restart engines.41. When Competing Ideals CollideDepartments2. The Initial Approach FixAviators sharing their “There I was” stories play a key role inaviation safety.By Lt. Jason Gelfand, USCGORM Corner: The Green Light to AvoidCommunication with the skipper always was one way, and that’sBy LCdr. Daniel Kimberlynot good.What would you do if you got lased?The United States Postal Service requires all publications publish a statement of ownership,management and circulation.Date - 01 October 2008Title of Publication - ApproachPublisher - U.S.NavyUSPS Publication No. - ISSN 1094-0405Editor - Jack StewartFrequency of Issue - BimonthlyOwner - United States NavyTotal No. Copies Printed - 14,531No. Copies Distributed - 14,281No. Copies Not Distributed - 250Total Copies Distributed and Not Distributed - 14,531Issue Date for Circulation Data Above - July-August 2008Location of Office of Publication:CommanderNaval Safety Center375 A StreetNorfolk, Va. 23511-439926.36. CRM: New Guys Can Talk, Too!By AW2(AW/NAC) Joseph A. RosbroughEveryone is responsible to be assertive when something justdoesn’t feel right.44. Best Practices: A Matter of SurvivalBy Lt. John GoodenoughThis Prowler crew was ready to fly, until the safety officergave them the news.46. Bravo ZuluFront cover: Photo composite by Allan Amen for the article, “A Matter of Survival,”by Lt. John Goodenough, pg. 44.
The InitialApproach FixSince July 1955, this magazine has been the voice of naval-aviation safety—your voice. Back then, it was called“The Approach, U.S. Naval Aviation Safety Review,” and was introduced to the fleet during a time when theaviation-Class A mishap rate was 38.18 mishaps per 100,000 flight hours. We lost 225 aviators and destroyed 611aircraft that year (1955), not bad when you compare this data to the year earlier. In 1954, we had a mishap rate of50.54, and the toll was 263 aviators and 776 aircraft.Today, we are the beneficiaries of advanced technology, proactive safety programs, and continued engagedleadership. But let’s also include one more factor, one where you, the naval-aviation community, play a key role: thispublication and our cornerstone “There I was” stories.The following is a reprint of the foreword in that first issue of Approach. It was written by the Deputy Chief of NavalOperations (Air), VAdm. Thomas Combs. While published more than 53 years ago, his words still ring true.“It is with a great deal of pleasure that I address you through the medium of the first issue of the Naval AviationSafety Review.“Naval aviation has progressed very rapidly during the past few years. To realize maximum effectiveness andcombat readiness, it has been necessary to place strong emphasis on our aviation accident-prevention program.The excellent progress which has been made during the past year is most gratifying and has resulted in the savingof lives and the conservation of extremely costly equipment.“The Naval Aviation Safety Review will provide a medium through which all of us can benefit from the experiencesof others. By bringing to light the mistakes, as well as the accomplishments of others who fly, we can reduce thenumber of instances in which pilots must learn the hard way.“The accident-prevention program is an all-hands evolution, and this publication is intended for the use of all whomay contribute to the safety of our flight operations. We must all, individually and collectively, contribute to theaviation-safety program by hard work in our own particular specialty. By submitting ideas, articles, experiences,and photographs pertinent to the problems that we encounter for publication in this magazine, we can make aspecial contribution, which will help to keep the accident rate on its present downward trend.”Here is an expanded issue of Approach, showcasing more stories that keep this tradition going. Naval aviation isgrateful to every aviator who takes the time to reflect on his/her experiences, write the story, and contribute to thesafety mission. The benefits of your efforts were recognized at the beginning and are just as valuable today.Current aviation-mishap statistics can be found on the Naval Safety Center’s website at: t.htm.2Approach
The Gear SolutionBy Maj. Carl Forsling, USMCwas the MV-22B instructor on what seemed like a routine familiarizationflight at a local civilian airport. My student was an Air Force major doinghis transition training from the MH-53. In the back, I had a crew-chiefinstructor and two students doing their initial V-22 crew-chief training. Wedid the normal series of conversion-mode (helicopter-style) landing patterns, and my student was doing fine. We were ready to start the fun stuff: stretching it out to airplane-mode for some much quicker laps around the pattern. Mystudent had the controls and ready for takeoff.I turned around the forward-looking-infrared radar(FLIR) and saw my right gear fully down,with the left and nose gear still retracted.September-October 20083
“Sixty nacelle, on the go.”“Door’s closed, all set in back.”“Torques matched, gauges green, continue passing 40 knots,” I said.“Gear up.”“In transit,” I replied. “That’s taking a little while aw crap, I’ve got a landing-gear-transition-abort posting keep it in conversion,” I added.As we continued in the pattern, I broke out thechecklist for the transition abort. The abort proceduremerely described the condition and referred me to thelanding-gear-fails-to-retract procedure. That proceduretold me to keep the airspeed below the gear-transitionlimits and to command down the gear. After doingthat step, I still had an unsafe-gear indication. I turnedaround the forward-looking-infrared radar (FLIR) andsaw my right gear fully down, with the left and nosegear still retracted.The next step took me to the landing-gear-failsto-extend procedure. The scenario was getting veryinteresting. If the nosegear alone failed to come down,that was one thing; I could have mattresses stacked andtied down on the deck at homefield and just put thenose on those. Even if the nosegear was down and bothmains were up, the reverse was doable. One out of threepossibilities? That was a problem.The landing-gear-fails-to-extend procedurecalled to cycle the gear. From previousbriefings on the V-22’s landing-gear problems, we were told that multiple cycleswere approved, even though the emergency procedure (EP) just said “cycle.” These briefingshad focused on the possibility of a mechanical bindingin the gear mechanism. In the V-22, this binding historically has been a problem with the nosegear. We triednumerous recycles of the gear.Looking at the FLIR, the nose and left gear weren’teven budging. When I’d had a previous gear malfunctionon another aircraft, we could at least see movement on thenosegear doors and hot spots where the tires had tried tobust out. But, this time, we had nothing except the rightgear going from fully extended to partially retracted.4After several attempts to move the gear, we entereda 1,000-foot overhead at homeplate and declared anemergency. We now were on the radio with maintenance reps, who offered some troubleshooting guidance.We also tried several techniques not in the book, but Iwas willing to try them to avoid having to, as the Godfather said, ”Go to the mattresses.”The right main failing to retract fully had meconcerned. NATOPS says that if you can’t get a symmetrical configuration, retract the gear to land on aneven surface. Because I couldn’t fully retract all mygear, I couldn’t do that step.Maintenance recommended various combinations of circuit-breaker resets, securing and restoringthe utility-hydraulic system, primary-flight-controlsystem (PFCS) resets, and cycling the gear handle.The CB resets were for the landing-gear-controlunit (LGCU); that made sense to me. The utilityhydraulic system operates the gear, so that made alittle sense. The PFCS reset is a mechanism in whichdepressing a button tells the elements of the flightApproach
control system to go to their originally commandedpositions. In a fly-by-wire aircraft, it’s a reset of theflight controls, not the landing gear. In the V-22, this isa step in many flight-control EPs but not for landinggear EPs. This procedure is for good reason, as it hasnothing to do with the landing gear. I should have beena little more cautious before doing this step. In the end,my action had no ill-effects, but pushing a button thatresets the flight controls like a PEZ dispenser probablyisn’t the best move.After many iterations, we finally got the magic solution. We brought up the gear handle, cycled the LGCUand the emergency gear CBs, did a PFCS reset, andimmediately brought down the handle. The gear gave asatisfying three-down-and-locked indication. We landedthe bird and had the gear pinned, just as we started toburn into our feed tanks.What had happened? The safety wire holding oneend of the maintainer strut that supports one of theright gear doors had come off. This problem allowedone end of the strut to spin in its housing, graduallySeptember-October 2008unthreading it during flight. When we tried to raise thegear, the strut was unattached at the gear-door side,which allowed the strut and door to swing freely andobstruct the upward progress of the right gear. Thissituation made the gear unable to complete the upwardcycle in its 30-second time limit, and the systemdeclared an abort.The EP for landing-gear-fails-to-extend states thefirst movement of the gear handle in the event of acontrol-unit failure is not a command but resets thelogic. The next movement is the command. When werepeatedly cycled the gear, we did so with the mistaken idea we had to allow time for the gear to complete a full cycle. Because of this mistake, we alwayscaused a cycle abort as we hit the 30-second timeout.If we just had cycled the handle up and down a littlefaster, the gear would have reset, using this resetfunction. As it turned out, the final set of CB cycles,using both the LGCU and EMER GR circuit breakers, reset the logic by turning the gear controller offand on. As it turned out, both of those CBs had to bepulled to remove power from the LGCU. When wedid that step, followed immediately by bringing downthe gear handle, the gear finally got the commandthey needed. However, this circuit-breaker dancewould have been unnecessary, if we had applied thenote in the PCL as intended.Know your systems. Your PCL just gives amplifyinginformation. It’s up to the pilot to know the fundamentals underlying each system. If I’d thought more abouthow the system worked, I wouldn’t have wasted timeand possibly risked other system failures with PFCSresets. I would have known to cycle the gear faster toavoid another cycle abort.NATOPS does not cover every contingency. Therewas no NATOPS solution for the gear configurationI had, so if the final attempt hadn’t worked, and myemergency gear down had failed, I would have had noironclad solution in mind for how to land. Don’t justwork the immediate problem; also work the next one.Fortunately, through good CRM, the right bit of advice,and a little skill, things worked out OK.Maj. Forsling flies with VMMT-204.5
Fly or Swim?By Lt. Timothy WriterWitnessing a mishap, or even a near-mishap,involving a fellow aviator can be a gutwrenching experience. You get a certainfeeling of helplessness when you see, fromclose range, aircraft come within inches of disaster.Your only response in such a situation may be a gasp ofdisbelief.Detached aboard a USNS ship, I was the helicoptercontrol officer (HCO) during a vertrep to the carrier. Wewere having a busy day from a supply-ship’s standpoint.Our ship was doing conreps and vertreps to the bigdeck, as well as to other ships in the strike group.The event unfolded on an early summer morningin the Arabian Gulf, where conditions were, as always,hot, humid and hazy. This day also offered a less thandesirable wind, because of the course the carrier hadto maintain for operations. A two-bird evolution wasshared between an MH-60S from our detachment andan HH-60H from the carrier’s HS squadron. We wereabout midway through our deployment and had completed many vertreps. The HS helicopter-aircraft commander (HAC) was a former HC bubba, who had a lotof experience in the field. We actually had teamed upwith the same HS flight crew on a few previous occasions during the deployment.About two hours into the event, the HS bird refueled. Loaded with more equipment and carrying significantly more fuel than the sierra model, the hotel ismore restricted on its external-load capacity. Knowingthat, the HS HAC had been taking less than max fuelbecause of the extreme temperatures that day, as wellas a very slight tailwind that kept a lot of the sea sprayaround the delivery ship’s flight deck. I noticed that,after fueling, they had picked up and set down a coupleof loads because of inadequate power margins. A palletof soda was their last pick of the day. I watched as theylifted off the port side of the flight deck, and I turnedto focus on the next inbound helo.6Next, I heard an abrupt, “Putting this down,” overthe radio, as I turned to see the first bird backing overthe deck to lower the load on top of other pallets. Atfirst, I thought it was nothing major. Likely, it just wasanother heavy load. While the deck crew might have alittle difficulty digging it out, that was a minor consideration, compared to the safety of the aircraft. In the nextmoment, the nose of the aircraft turned right, towardthe superstructure of our ship.Before I knew it, the nose had passed, and the tailwas on its way around. The yaw rate was not extremebut built slowly to a rate slightly faster than mightbe used for a clearing turn. The tail swung by thetower well beyond the foul line. The tail-rotor clearance couldn’t have been more than a few feet from thehangar, and t
The Initial Approach Fix Since July 1955, this magazine has been the voice of naval-aviation safety—your voice. Back then, it was called “The Approach, U.S. Naval Aviation Safety Review,” and was introduced to the fleet during a time when the aviation-Class
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