C-17 Crash Report

C-17 crash report exposes cracks in USAF safety culture

What a completely moronic (and inaccurate) title for the piece. Neither the USAF AIB report says this, nor does the actual article.
 
There seems to be some inacuraccies in the report.


Freyholtz, however, seemed "channelised" on completing the turn, the report says. He reversed his stick pressure, but at the same time applied left rudder, which made the stall even worse. The C-17, already dangerously low, crashed within seconds.

If I am in a tight right turn, and the bank is getting steeper, and I have full left aileron in, shouldn't I use left rudder as well? It seems to me that in a situation like this, it should help. Please, correct me if am I wrong. Maybe I have something thats needs to be corrected in my thought process.
 
There seems to be some inacuraccies in the report.




If I am in a tight right turn, and the bank is getting steeper, and I have full left aileron in, shouldn't I use left rudder as well? It seems to me that in a situation like this, it should help. Please, correct me if am I wrong. Maybe I have something thats needs to be corrected in my thought process.

The pilot was already in a skidding, stalling turn to the right. In this steep, skidding turn the nose was dropping due to poor rudder control (too much right rudder). The pilot tried to counteract this dropping nose with aft stick which just deepened the stall and increased the bank angle. To then try to use aileron to roll the airplane without first recovering from the stall will probably just make matters worse as you'll get into "reverse command" where left stick will actually cause the airplane to roll more to the right. It's the classic "base to final" stall spin scenario. This is why I commented on the poor stick/rudder skills when I first saw the video without even reading the report. You can see the rudder being used to yaw the airplane around and the nose dropping due to poor rudder control as the bank angle steepens.
 
Regardless of the stick and rudder use, the bottom line is it was another example of Lt Col Holland in a B-52. History repeats itself.
 
The pilot was already in a skidding, stalling turn to the right. In this steep, skidding turn the nose was dropping due to poor rudder control (too much right rudder). The pilot tried to counteract this dropping nose with aft stick which just deepened the stall and increased the bank angle. To then try to use aileron to roll the airplane without first recovering from the stall will probably just make matters worse as you'll get into "reverse command" where left stick will actually cause the airplane to roll more to the right. It's the classic "base to final" stall spin scenario. This is why I commented on the poor stick/rudder skills when I first saw the video without even reading the report. You can see the rudder being used to yaw the airplane around and the nose dropping due to poor rudder control as the bank angle steepens.

I get what your saying, and I fully agree with it. But you state everything in terms of "right." He was in a right turn, and applied left rudder. That should have caused the airplane to snap back to the left. That was my issue with the article.
 
I get what your saying, and I fully agree with it. But you state everything in terms of "right." He was in a right turn, and applied left rudder. That should have caused the airplane to snap back to the left. That was my issue with the article.

Multiengine spin aerodynamics make my head hurt, but I would think this might not necessarily be the case. Think about the mass distribution along the wings- the engines acting like big dumb bells; plus the lack of airflow over the rudder in a deep stall which is what this pilot was inducing. Part of why you don't want to get into this scenario in a multiengine airplane much less a transport category airplane, especially close to the ground. TGrayson may jump in with more thoughts.
 
The pilot was already in a skidding, stalling turn to the right. In this steep, skidding turn the nose was dropping due to poor rudder control (too much right rudder). The pilot tried to counteract this dropping nose with aft stick which just deepened the stall and increased the bank angle. To then try to use aileron to roll the airplane without first recovering from the stall will probably just make matters worse as you'll get into "reverse command" where left stick will actually cause the airplane to roll more to the right. It's the classic "base to final" stall spin scenario. This is why I commented on the poor stick/rudder skills when I first saw the video without even reading the report. You can see the rudder being used to yaw the airplane around and the nose dropping due to poor rudder control as the bank angle steepens.

IMHO - the rudder control issue was penultimate - the AF analysis basically said it was pretty much an angle of attack issue.

I'm pretty sure the crew were ACE card holders. I can't speak for mil demos or large airplanes- but in typical airshow profiles of less performing aircraft, a major portion is what is going on is about how it looks to the outside viewer. Rudder is often used to "cheat" turn to get some symmetry or to give 'crisper' control movements into/out of a turn.

Again, from I'm getting from the report - it wasn't necessarily the rudder position, but rather coming off the climb a little slower and doing the reversal with less energy... combined with retracting the slats.
 
Regardless of the stick and rudder use, the bottom line is it was another example of Lt Col Holland in a B-52. History repeats itself.


I respectfully disagree with you. The C-17 was designed to be flown high performance/low level stuff.... The normal C-17 demo is pretty cool to watch - definitely a capable aircraft. The command pilot was a well-liked, experienced guy. I'm just speculating, but I don't believe it was just willful negligence like the B-52... he had a specific profile he was flying and made several minor mistakes that added up.
 
IMHO - the rudder control issue was penultimate - the AF analysis basically said it was pretty much an angle of attack issue.

I'm pretty sure the crew were ACE card holders. I can't speak for mil demos or large airplanes- but in typical airshow profiles of less performing aircraft, a major portion is what is going on is about how it looks to the outside viewer. Rudder is often used to "cheat" turn to get some symmetry or to give 'crisper' control movements into/out of a turn.

Again, from I'm getting from the report - it wasn't necessarily the rudder position, but rather coming off the climb a little slower and doing the reversal with less energy... combined with retracting the slats.

I understand being ACE card holders. The problem was doing the maneuver they did, one that was not the parameters spelled out by the airforce. There is a big difference between skidding around a turn in a light aerobatic airplane at low altitude and doing so in a transport. Also, the problem with "cheating" the turn with rudder is that is called a skid. When the MA was in the steep turn this contributed to the nose dropping- in effect the rudder became like an elevator. The pilot reacted to this poorly by pulling back on the stick which just steepend the bank. One just needs to sit in a chair, tilt it to the side (try not to fall on your head when you do this), then imagine pulling elevator to see what this would do. Pilot then tried to decrease the bank with aileron which would probably have the opposite effect in this situation. I've actually demonstrated this to pilots- put the airplane in a deep stall, push the stick one way laterally and the airplane rolls the opposite way.
 
Regardless of the stick and rudder use, the bottom line is it was another example of Lt Col Holland in a B-52. History repeats itself.

Very different supervisory factors, actually.

With Bud Holland, he had a repeated history of violations that leadership knew about. Some of those violations were glossed over by leadership because of the 'halo effect', and some of the reprimands that leadership handed down simply failed to change Holland's behavior since he believed himself to be of such superior airmanship.

At Elmendorf, the report is saying that, outside of the group of demo crew members (including the trainers/certifiers), there was not leadership awareness that the demo team was pushing the limits (unapproved checklist developed/used, not strictly adhering to altitudes, bank angles, etc, during practices and performances). In other words, there WASN'T anyone actively aware or worried that the MP's actions were risky and trying to keep him from doing it.

Specific causes are best left to discussion in safety channels, but there is a massive difference here. Although my Navy brethren frequently scorn the USAF's pyramid scheme of supervision of flying operations (operations supervisors in the squadron, SOFs in the tower, ORM sheets, etc), this system is a result of these types of accidents and incidents in the past. It was designed and implemented to try and find and fix this type of situation. As someone who has been on all sides of the system, I can tell you categorically that it WORKS. IMHO, what the report says about Elmendorf is that this oversight system failed.

My objection to the article was that it implied that two incidents in 16 years somehow indicated that there was some flaw in USAF safety culture. People who think that obviously have no sense of perspective, either about past track records of any of the military flying services, or similar incident rates in civilian flying. I'm certainly not saying that the Elmendorf accident is any less egregious than it is, but I AM saying that the "system" is really damn good, and can't be damned based on one incident.
 
The command pilot was a well-liked, experienced guy. I'm just speculating, but I don't believe it was just willful negligence like the B-52.

From that perspective, actually they're very (eerily) similar. In both cases, the pilots were highly experienced in their aircraft, and widely considered by their peers to be extremely good airmen. Both had considerable 'halo effect', wherein peers, supervisors, and subordinates would not object to minor rule busts because they assumed "they know what they're doing" because of their skill and experience.

I won't use the term "willful negligence" like you did, but without question both incidents are dealing with pilots who did feel like they knew better than the system, and felt that they were skilled enough to operate outside those limits and regulations. Holland was apparently more arrogant about it -- I say 'apparently' because I didn't know the C-17 pilot, and I haven't heard anything outside of what the AIB says about his past adherence (or non-adherence) to the published limitations of the performance. A lot is known about Holland's psyche, though, thanks to Tony Kern's book.

Either way, there are striking parallels here when you look at it academically. What's interesting is that, my bet is that if you asked the C-17 pilot to compare himself (or for his peers to compare him) to Bud Holland, there would be a 'no way, not even in the same category' reaction. That is the difference between the two.
 
I'm just getting into this and I'm new here. I see things here that tell me you don't have all the facts and I don't know if you can get all of them. Neither can I give them to you.

This was a daily routine in practicing for the air show; They did a lot of combat turns with this aircraft, all week; steep climbs, steep landings, steep turns. None of this appeared to me to be different. Don't know what this pilot did but I do know he didn't accelerate when turning so sharply. People on the ground did not hear the plane's engines rev up at all. I do know you need to accelerate when doing this stuff. Maybe that will help y'all figure it out better.

I enjoy reading how you think this through; I'm learning. I am sure it was pilot error - or malfunction of something; that noise that was heard still nags at me!

I believe it is in everybody's best interest to sift this and all emergencies so we don't repeat and have similar results. Been to 26 aircraft crashes and 5 train wrecks; don't like them a bit.

One person said it is not the thing to do outside of a combat arena. That steep takeoff is normal when practicing for such things. Practice here makes you live longer there. A lot of such practice goes on at home. Combat is a poor place to begin the learning curve. i am a firm believer in practicing for real because the way you practice is how you'll do when it counts. When it counts, it should be automatic mostly, from training incessantly. No time to think it through and learn when plop hits the rotary oscillator. If you don't do it right in practice, you won't do it right when it counts. I had friends I don't have for that very reason.

The patterns for this practice are set by safety margins so that if a bird does go down, it should fall into the woods, like this and the last one did. The footprints are only yards away from one another. But that other one was taken down by birds. This was pilot error, so the Monday morning quarterbacks say. I wasn't in that plane so I don't know what he did or didn't do correctly or whether there was a malfunction. But he knew.

Been in several situations where the sidewalk superintendents say one thing and the facts say another; I'll just keep on learning and practicing.

As I've heard it from others, the B-52 that crashed similarly in Washington was a case of hot-dogging as the "rumors" from fighter pilots I've talked with say the probability is that that bomber pilot had a record of hot-dogging. I don't know; not accusing, just sharing. But it's something that may be significant in the factoring on that one.

Done enough of pushing the envelope all my life. Taking risks was not my job but taking calculated risks was. Still here so I reckon it worked out okay then but I won't try them now since I'm 127 now. :) Just a joke; it's the miles, not the years.

I'm enjoying reading much of your writings. Pretty sober stuff and educational.
 
What's your background, COBRA?

Did you read the AIB report we're all talking about? If you did, some of your comments (about the maneuvering, and the 'so the Monday morning quarterbacks say') are very strange.

The comments in this thread aren't really based on speculation -- the FLDR and CVR pieced together what happened very well, and it's documented that pilot error was the root cause: he did over-pitch, over-bank, incorrectly change configuration, and fail to yield to a stall warning in the seconds prior to the crash.
 
What's your background, COBRA?

Did you read the AIB report we're all talking about? If you did, some of your comments (about the maneuvering, and the 'so the Monday morning quarterbacks say') are very strange.

The comments in this thread aren't really based on speculation -- the FLDR and CVR pieced together what happened very well, and it's documented that pilot error was the root cause: he did over-pitch, over-bank, incorrectly change configuration, and fail to yield to a stall warning in the seconds prior to the crash.

Agree with Hacker.....the facts of the mishap are out. No Monday mornign QB'ing what so ever.
 
Very different supervisory factors, actually.

With Bud Holland, he had a repeated history of violations that leadership knew about. Some of those violations were glossed over by leadership because of the 'halo effect', and some of the reprimands that leadership handed down simply failed to change Holland's behavior since he believed himself to be of such superior airmanship.

At Elmendorf, the report is saying that, outside of the group of demo crew members (including the trainers/certifiers), there was not leadership awareness that the demo team was pushing the limits (unapproved checklist developed/used, not strictly adhering to altitudes, bank angles, etc, during practices and performances). In other words, there WASN'T anyone actively aware or worried that the MP's actions were risky and trying to keep him from doing it.

From my professional opinion as a backseat quarterback, and from watching some video of a KC10 taking off 70 * pitch angle, I must say that some heavy drivers seem to be fixated on flying fighters even though they are in a jumbo jet
 
As 3rd string QB I would say that is tactical. I often watch the C-17s practice at VCV and am amazed at the profiles they fly. They fly the same at night.
 
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