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Lessons From The Hornet Crash

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GOONIE:
(NORFOLK VIRGINIAN-PILOT 03 JUL 12) ... Adm. John C. Harvey

"We have a high level of confidence that we know what happened. Although we were unable to identify a smoking gun, we did find a substantial body of evidence to support the findings.

The results show that the aircraft suffered two unrelated, nearly simultaneous, catastrophic engine malfunctions. The first malfunction occurred in the right engine during takeoff when the pilot received warnings in the cockpit that the engine had stalled.

The pilot followed established procedures by taking both engines out of afterburner and then placing the right engine in an "idle" position. The pilot attempted to compensate for the loss of thrust in the right engine by increasing throttle in the left engine, but the left engine failed to respond.

At this point, the aircraft was severely underpowered and began losing altitude. At approximately 100 feet altitude, the aircraft began to roll to the right, and the air crew was forced to eject.

The investigation determined the pilots followed established procedures, and it cleared the air crew of any dereliction of duties or misconduct. Our experts also have concluded the outcome would have very likely been the same for even our most experienced crew.

After we determined the extremely rare chain of events (simultaneous, but unrelated engine failures) that led to this crash, we began updating our emergency procedures and training air crews to effectively respond should they encounter a similar situation."

http://www.hrana.org/articles.asp#LessonsFromTheHornetCrash


-GOONIE (changing my signature)

GOONIE:
also worth a read from seven G blog;

Who's on the Ball - communication breakdown while landing on carrier


We've reached the midpoint of our deployment to the Mediterranean and the Arabian Gulf. After an uneventful night OPFOR hop, I'm spending my time in marshal with the typical excitement and apprehension of the upcoming night trap. I'm flying aircraft 206, a Hornet with a full-up system and no problems of note (later analysis will reveal an intermittent IFF). Also airborne and playing a vital role is aircraft 105, an F-14B.

I've commenced a normal Case III approach and, reaching platform at 5,000 feet, switch to assigned button 17 (channel B). Down in CATCC, an intermittent Mode II from my aircraft is about to produce mass confusion. With no Mode II hit from my Hornet, the "Mr. Hand" operator neglects to add 206 to the list of aircraft on the approach. I proceed on the approach. At three miles, I commence tipover on the ILS bullseye, disappointed that CATCC is unable to lock my aircraft for the ACLS approach. Meanwhile, 105 is vectored from the bolter pattern two miles in trail.

Due to the lack of IFF from my aircraft, only one other person now knows that I'm first in line, and that's my final controller. The Tomcat's final controller locks the next hit on his screen, which of course is not 105 but me in 206. At about the same time, my final controller locks the next hit on the scope, mistakenly locking the Tomcat at its tipover. Everything appears normal in my dark cockpit, when, at just outside a mile, I get indications of ACLS lock on. I report the needles slightly up and on, and CATCC concurs. Each aircraft is now flying needles intended for the other aircraft.

You can imagine the confusion on the platform when the Boss calls over the 5MC, "Tomcat, 105, one mile, Alpha." Paddles is looking at a Hornet bearing down with about 15 seconds of flying time until the trap. The arresting gear, fresnel lens, and paddles radios have all been set tier a Tomcat on channel A. Paddles desperately scrambles to reset the gear and lens for a Hornet and, in lieu of the incorrect lens setting, starts talking down the Hornet. Unfortunately, the LSO radios are never switched to channel B, so I hear nothing but silence. Here's the call to the Tomcat (on channel A): "105, three-quarters of a mile, call the ball."

The Tomcat RIO replies, "I don't think so," and deselects the ACLS. Paddles hears 105's comment (on channel A) and interprets it as a ball call. Meanwhile, in 206, I've deselected the ILS and am flying the needles instead. Engrossed in flying an on-and-on pass, I'm focused on the needles. At half a mile, I realize nobody has told me to call the ball. As I transition my scan to the ball, I'm surprised to see the lens showing what appears to be a nearly clara high pass, with the ball barely visible on the top of the lens. I make my ball call (on channel B) as I start to correct the high but receive no response. Again I call the ball--now it's coming down toward the center. Still no response from paddles. I make one last ball call, then push the throttles to mil for an in-close waveoff just as the happy lights signal me that paddles agrees with that decision.

As I clear the ship and climb away, I'm struck by the eerie symbology of needles remaining on my HUD, remarkably still showing me "on and on." Strange! Confusion sets in; I deselect the needles and continue with NORDO procedures, convinced that I must have lost my radios. In the boiler pattern abeam the ship, my radios finally crackle "206, paddles, sorry about that ... we had a little problem with the lens, we'll get you next time!"
The phones are now ringing off the hook in CATCC with everyone, including the boss and the captain of the ship, wanting to know what the heck just happened.

Back in the ready room after the flight, the story slowly unfolds, and it becomes very apparent how close tonight was to a mishap. The PLAT camera replay tells a chilling tale: I watch my Hornet settle from high above the glideslope to well below, all to the tune of blood-curdling power calls, and then finally the waveoff. In the cockpit, I heard none of it, saw a stable centered-needles approach, and took my own waveoff only because I hadn't heard a "roger ball." I remember the ball coming down but did not recognize how rapidly it was falling.
What finally broke this evil chain of events was the waveoff lights from paddles and a sense in the cockpit that something just wasn't right.

What links in the chain could have been severed earlier? First, an intermittent transponder was the catalyst to this entire melee. I now make it a habit in marshal to check and double-check that I'm squawking all modes and codes. Be acutely aware that if your IFF is being called intermittent or inoperative, you may be susceptible to a sequencing problem on the approach. One solution is additional CATCC training and oversight, to prevent the inadvertent ACLS lock of the wrong aircraft. We also decided that the Air Ops status board should list recovering aircraft in order, rather than by aircraft type. Also, the departure controller, previously undertasked during the recovery, will now assist in correlation and proper order of "Mr. Hand."

What could I have done? First, I could have listened to what was said, not just what I expected to hear. The ACLS lock-on of my Hornet was clearly predicated by a call from the controller that the lock-on was at three miles, not one. I heard the call and reported the needles, but never made the correlation between the two-mile split that CATCC had called. I heard what I wanted to hear, not what was actually communicated. The Tomcat did hear the discrepancy on their final lock-on call but merely made a sarcastic comment and deselected the ACLS. If you're aware that something's wrong, then speak up definitively. You might end up saving your own life, or the life of one of your air-wing buds.

Finally, cross check, cross check, cross check! I didn't do it, and the ultimate responsibility for this near-miss rests with my breakdown. Behind the ship on a dark night, you owe it to yourself to use everything at your disposal: ILS and ACLS correlation, self-contained approach numbers, VSI, DME, and, ultimately, the world's greatest glideslope indicator, the fresnel lens. As a nugget halfway through my first cruise, my scan was unfortunately still developing. On this approach, I'd put all my marbles into one bag, the ACLS; after all, needles don't lie, right? Well, that night they weren't lying, but the story they were telling was not intended for me.

Lt. Blake flies with VFA-34


Any one know who "Mr. Hand" is??? The guy who writes all aircraft info backwards on the CATCC boards?

Sludge:
GOONIE...

I think the "Mr Hand" guy is a fallback reference to the old reverse handwriting guy, but nowadays, since its all electronic boards, he is the guy in CATCC that does the digital "rack and stack" for approach. Not 100 percent sure on this, but thats my prior CDC division officer guess.


--- Quote ---Also, the departure controller, PREVIOUSLY UNDERTASKED during the recovery, will now assist in correlation and proper order of "Mr. Hand."
--- End quote ---
PREVIOUSLY UNDERTASKED = cake eating, coke drinking, butt-scratching bum.
(go to the CATCC scenes, when those pilots are trying to get aboard, the guy in the background, who is doing nothing but stuffing his face and looking at the camera crew)

Funny. Welcome to the US (N)ever (A)gain (V)olunteer (Y)ourself NAVY.

Later
Sludge

SpazSinbad:
New meaning then to the TERMINATOR'S "TALK TO THE HAND" riposte.  ;D Just happened on this CATCC pic which may prove interesting. Looks like a very high tech setup to my old eyes.

"Air traffic controllers aboard USS Harry S. Truman receive training and provide fleet feedback on Navy Unmanned Combat Air System Demonstration software during recent carrier sea trials. (U.S. Navy photo) Jul 19, 2012"

http://www.navair.navy.mil/img/uploads/Truman1_1.JPG

TURNS out this is one big pic so I'll make a small version but keep the link to large (darker photo) above and attach original also now.

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