Pilots are creatures of habit with a built-in tendency to rely on what seems to conform with past experience..
2 April 1986
Mazatzal Peak, 12 miles southwest of Payson, Arizona
Northrop T-38A Talon, 67-14836, c/s Willie 51
82nd Flying Training Wing (FTW)/97th Flying Training Squadron (FTS)
Williams AFB (KIWA), Chandler, Arizona
2 Fatal
Aviation is often described as some other jobs are, such as firefighting: Hours of boredom puncutated by moments of sheer terror. In many situations, loosely speaking, the transition from boredom to sheer terror is generally a quick one such as a near-midair collision with another aircraft, or a balked landing requiring a quick go-around, or some other incident where the event quickly or instantaneously occurs and a reaction is either instinctive or there's no time to accomplish one. At other times, the transition from boredom to sheer terror can be a short or moderate or even long period of time such as a fuel leak, or a slowly dying engine, or weather that begins deteriorating more or faster than expected. Continuing the MikeD Accident Synopsis series with accidents/incidents local to the Arizona flying scene, today's accident encompasses the latter factor of deteriorating enroute weather, and pressing a tight situation to the point where one's options begin becoming limited very quickly. Such was the case for the crew of a Northrop T-38A of the 97th FTS from Williams AFB, Arizona on what was to have been a routine low level navigation training mission north and east of the Phoenix area.
On the early Wednesday morning of 2 April, 1986, the weather in the Phoenix area consisted of broken clouds and temps in the 70s. To the north and northeast of the metro Phoenix area, the clouds became more overcast cumulus and dense, with temps falling to the 50s and light to moderate rain and precipitation up to 1/4 inch. Williams AFB, located on the southeast side of Phoenix, was reporting: Temp/dewpoint 70/44, winds from the west at 10 knots, BKN060 in occasional light drizzle. Willie 51 flight was the callsign of a single T-38A from Williams AFBs 97th Flying Training Squadron (FTS) that was originally scheduled for another different mission, but changed to a low-level navigation training mission on one of the local Military Training Routes (MTRs) in the area. Changing to the new mission with a compressed time to plan and brief, the crew of one student in the front seat and an Instructor Pilot (IP) in the back seat began rapidly planning to fly Visual Route (VR) 239, a low level MTR that begins on the north edge of Lake Pleasant on the northwest edge of Phoenix, and wraps around the Phoenix area, continuing southwest into the southwest portion of Arizona near the Mexico border, then turning northwest and emptying into the East Tactical Range of the Barry Goldwater Bombing Range south of the town of Gila Bend and about 35 miles southwest of Phoenix. As the T-38A was fuel limited and the Average Sortie Durations (ASDs) were short anyway, crews usually only flew a portion of the VR route. As with many MTRs, there are designated alternate entry/exit points so aircraft have no requirement to fly the full route from start to finish. For today's mission, Willie 51 flight planned to start VR-239 at Point A next to Lake Pleasant, and exit at Point F at Black Mountain, southeast of Coolidge, Arizona and about 25 miles southeast of Williams AFB. Having flown VR-239 myself many times during my A-10 days, I'm well familiar with the rugged and beautiful terrain that the route traverses from Points A through F in the areas north and east/southeast of Phoenix.
Willie 51s flight briefing concluded, the crew gathered their equipment from life support, the IP signed for the aircraft and both met on the flightline for the van ride to aircraft 67-14836. Stepping out to their aircraft, the flightcrew noticed no change in the reported weather, and flight operations were proceeding normally with no pattern or other restrictions noted. Startup and taxi were all uneventful. The crew of 836 flight planned for a northeast turnout to proceed northbound initially, avoiding air carrier traffic arriving and departing from Phoenix-Sky Harbor International (KPHX), before turning northwest to head to VR-239 Point A on the opposite side of the Phoenix metro area. Willie 51 flight contacted Willie tower for takeoff and was cleared for an unrestricted climbout to 6000, and to change to Phoenix Departure. The flight taxied onto Runway 30C and commenced a standard single-ship takeoff. Willie 51 flight contacted Phoenix TRACON and climbed out of Willie's traffic pattern northbound as planned.
Coming under radar contact from Phoenix TRACON, the controller cleared 836 to climb VFR to its assigned altitude and further cleared them to proceed direct to Point A due to the light amount of air traffic in their area at the time. Cleared to descend in short order, the crew of 836 was advised of slowly deteriorating WX north and east of the Phoenix area and was switched to Albuquerque Center (ZAB) for IFR pickup for the VR route. Although not required for VR MTRs, local 82nd Flying Training Wing (FTW) directives required them even for VR routes for flight following purposes, even though in some portions of the VR-239 route, the aircraft would be too low for radar coverage. Descending to 1500' AGL and accelerating to 480 KIAS for the first leg of the route, 836 passed over Point A and made a left descending 270 degree turn in order to rollout to the northeast and cross Point A on-course at the time of hacking the clock. In the T-38A, these VR routes aren't flown with any kind of NAVAIDS; only with clock, map, ground references, and some Dead Reckoning (DR). Limiting maneuvering at the start point avoids having any timing errors at the start of the route and provides for tighter DR computations for time. Proceeding northeastbound, the crew of 836 squawked 4000 and cruised at the Point A to Point B route altitude of approximately 1500' AGL in preparation for the low-level descent that would commence immediately after passing Point B where the route drops down to 300' AGL.
Point B of VR-239 is located 20 miles northeast of Point A and is defined as the peak of New River Mountain. Reaching this point, the VR route turns eastbound and proceeds that direction for 32 miles until reaching Point C at Mazatzal Peak. At point B, the terrain drops steeply into a mountainous valley along the B to C routing until reaching high terrain at Point C. Cruising underneath the overcast with light rain, 836 crossed Point B in a right turn and rolled into a 120 degree bank, pulling the nose down below the horizon to rapidly descend to 500' AGL in-line with the terrain contouring. Rolling out on course, the crew proceeded eastbound to Point C, racing along at 8 miles a minute and 500' AGL in and around the mountainous valley terrain, adjusting speed in order to cross Point C at the flight planned time. By this time, the rain was beginning increase and the cumulus clouds building lower as the terrain began gently rising towards them. In the area they were flying over now, north of the Horseshoe resevoir dam, terrain elevations were averaging 3000 to 4000 MSL, but began to slowly rise towards the east as the Mazatzal Mountain range began. As the moderate rain continued, the crew noted the deteriorating WX ceiling and rain buildup, but continued towards Point C. At some point within 10 miles of Point C and while maneuvering eastbound in a slight climb, the crew entered inadverent Instrument Meterological Conditions (IMC) in the bottom of the cumulus overcast. Maintaining heading and rolling wings level, 836s crew immediately transitioned to instruments but did not initiate a route abort. Believing that they were only slightly into the WX and that they had adequate terrain clearance, 836s crew began a very shallow descent to regain Visual Meterological Conditions (VMC). Unfortunately, moving along at 8 miles a minute, combined with the inadverent IMC encounter, 836s crew lost Situational Awareness of their geographic position. Rising terrain in the Mazatzal Mountains began reaching up and touching the extreme bottoms of the cumulus cloud deck. Continuing their shallow descent, Willie 51 never regained VMC before impacting the rapidly rising vertical terrain just short of Point C at Mazatzal Peak at 495 KIAS.
Due to low ceilings in the area and rain conditions, combined with this being one of the areas where radar coverage was spotty, 836 remained missing for a day. Search aircraft finally located the missing T-38A where it had impacted, approximately 0.5 NM west and about 800' below the 7903' MSL Mazatzal Peak on a 50 degree cliff side. The aircraft was destroyed and both crewmembers were fatally injured. The wreckage, located in a 200' x 200' square area, had been demolished. There was no attempt to eject, and the remains of both the student and the IP were found on site. To this day, the wreckage of 67-14836 remains on the cliff where it impacted on that early April morning.
Probable Cause:
*Inadverent IMC Penetration- Pilot/IP
*Situational Awareness- Lost- Pilot/IP
*Terrain Separation/Altitude- Not Maintained- Pilot/IP
*Emergency Route Abort- Not Initiated- Pilot/IP
Secondary Factors:
*Weather Condition- IMC/Rain
*Flight Planning/Route Study- Inadequate- Pilot/IP
Tertiary Factors:
*IMC Route Abort Guidance/Directives- Inadequate- Air Training Command (ATC)
MikeD says:
This accident is a reminder to all that a good effective mission begins with good effective flight planning. Changing plans at the last minute, especially in a training environment, can easily set the stage for getting rushed in planning, which can lead to everything else from takeoff to the mission itself getting rushed as the concept of being behind begins to snowball. In the attempt to get "caught up", combinations of any one or many other factors that can affect the flight will usually pop up, and often lead to never getting to where one wants to be "caught-up"-wise, ending up always being behind the proverbial eight-ball for the entire flight. How being behind the eight-ball manifests itself inflight can vary from simply being rushed, all the way to something catastrophic. Beginning with the planning factor, other factors of decision making as well as some outside influences, all combined to take the crew of 836 to their eventual demise. A demise that could've been avoided had some particular items been mitigated beforehand. Specifically, I'll discuss here:
1. MTR route flight planning considerations.
2. MTR route inadverent IMC penetration and Emergency Route Abort considerations and guidance
3. Overconfidence in personal abilities
MTR route flight planning considerations: MTRs, due to their specific routings and turn points, require detailed planning, especially in the western USA where designated mountainous terrain is present. The routes themselves are far more than what's depicted by the thin grey line on most 1:500 Sectional Aeronautical Charts. These charts only depict the centerline of the particular VR/IR route and while good enough to provide SA as to where these routes are located for civilian pilots to be aware of, there's far more detailed planning that goes into flying these routes as the military operator. The routes themselves are spelled out in a Department of Defense Flight Information Publication known as the AP/1B. This publication lays out each route in terms of altitude(s), route centerline, route corridor (X miles left/right of route centerline), responsible unit for scheduling of the route and the lat/longs of each route turnpoint, amongst other information. Detailed planning is required of crews in order to understand the constaints of the particular route's structure, altitude limitations, corridor, terrain....both on the route as well as surrounding, and other factors. These routes aren't generally ones where they can be flown "on the fly", unless someone has flown the local routes and is familiar with them; yet still they'd carry appropriate 1:250 Tactical Pilotage Charts (TPCs) with all the appropriate information for the route noted and plotted.
To give one an idea of how busy these MTR routes are when flying them, I'll describe what I had to do while flying these routes in the A-10A back in the day. I've flown VR-239 myself many times and am well familiar with the terrain and particulars of this MTR. In the A-10, I had no radar for my low-levels, my only separation ability comes from the Mk.1 eyeball. Keep in mind, though, that I have a multitude of cockpit tasks going on while tooling along at 300 AGL/360 KIAS (up to 480-540 KIAS in pointy nose fighters). First, eyeing terrain to make sure I'm doing my job of pilotage correctly (ie- matching terrain features with what's on my map to make sure I'm going the right way), avoiding hitting the ground/power lines/near rocks/far rocks, keeping track of my timing per leg [if I'm going for a specific TOT, or Time Over Target], keeping track of my other aircraft in my formation, insuring my weapons panel is set correctly [such as setup change from air-air to air-ground], going over and over in my mind what the attack plan is [formation, role, weapon, timing, attack axis], and being ready to flex to a different plan if the first one gets screwed up [such as unplanned threats pop-up], and maintaining overall SA over the operation; all while moving at 300 AGL/360 KIAS......that's 6 to 9 miles per minute; and all this in addition to trying to see and avoid. To put it in perspective, at this low altitude and high speed, an insidious 1 to 2 degree nose-low attitude that's not noticed in a turn or otherwise, will result in ground impact in about 5 seconds, depending on terrain. Proper route study beforehand helps minimize heads-down time looking at the map, increasing brain-byte room for me to accomplish other tasks and thus increasing overall SA. Planning for the "what-if's" becomes even more important when dealing with WX on the route, and what to do if it's encountered inadverently.
MTR route inadverent IMC penetration and Emergency Route Abort considerations and guidance: One of the most disquieting situations one can encounter on a VR MTR is an inadverent IMC penetration (IR MTRs are always on an IFR clearance). It's imperative to have an emergency Route Abort Altitude computed that will keep one clear of terrain in the surrounding area. With the IMC encounter being unexpected and because normally an aircraft flying on a VR route is VFR, penetrating IMC unexpectedly can be a shock that sends the workload immediately increasing. Especially on a route where an immediate climb to avoid terrain is necessary. The maneuver itself is an emergency, since the aircraft is now off-route and outside the route structure vertically, and now IMC with no IFR clearance. If no immediate communication with ATC able to be made, then squawking emergency is vital. Crews have to immediately transition from a VFR mindset of navigation, to now an instant IFR mindset, trying to figure out their location and switching from VFR maps to IFR ones. If in an area of airways, there's now the midair collision potential as they're not under radar control with ATC yet. Even the route abort maneuver of a rapid climb away from terrain can itself be Spatial Disorientation inducing. All of this while trying to figure out where one is geographically and not hit anyone else in the air. Its even worse when its a formation of aircraft who all have to route abort, as maintaining deconfliction from each other, as well as aircraft outside the formation, is paramount. All of these reasons are why prior planning and understanding of contingencies and what to do during them, is so highly important and cannot be taken for granted. Add to, being a single-seat aircraft instead of having two-crew, and one can imagine how task saturation can increase exponentially. The last thing one wants to do in an inadverent IMC situation is attempt to descend back to VMC, especially in areas of variable or mountainous terrain, as this accident tragically demonstrated.
At the time of 836's accident, guidance in USAF Air Training Command's (ATC) governing directives regarding inadverent IMC penetration on MTR routes was inadequate. The guidance was later clarified as a result of this accident, stating in part:
"An emergency route abort altitude or exit escape altitude is required for each low-level route. This altitude will be computed to provide 2,000' clearance from the highest obstacle within 25NM either side of course for the entire low-level route."
The directives further described procedures for accomplishing a route abort if IMC is encountered.
Overconfidence in personal abilities: The particular makeup of the crew of 836 is an item that needs to be considered. 836s IP was a low-time 22 year old First Assignment IP, otherwise known as a FAIP. FAIPs are guys who graduate Undergraduate Pilot Training (UPT) and receive a first assignment of remaining at the particular pilot training base and instructing other UPT students for 3 years, rather than receiving an immediate assignment to the Combat Air Forces. The young IP for this mission was crewed with an experienced student, however. The student in the front seat of of 836 was a rated aviation officer, but a student pilot. Rated as a USAF Navigator, the 26 year old student up front had flown for a few years as an F-111 Weapons Systems Officer (WSO), and had applied for and been accepted to UPT to retrain as a USAF Pilot. As such, the student was comfortable and used to operating in the low-level environment, as high-speed low-level tactical flight ops was the raison d'etre of the 111 flight crews. So the former-WSO was very experienced in this area of flying, far more than the FAIP IP. It's possible that there might have been some deference by the IP to the more experienced student; however the student's high level of experience should've caused him to know that regaining VMC from an inadverent IMC encounter was not wise. Although, since F-111 aircraft normally flew IR MTRs where they'd often fly in and out of IMC simply due to the aircraft's terrain following instrumentation, it's possible that there may have been a false sense of security in initiation of a descent in an attempt to get back into VMC. All of this is speculation as it relates to this particular accident, however experience deference is known to be the cause of many instances of what human factors investigators term "passenger syndrome", where one might either defer to or fail to question someone making a known bad decision, due to the fact that they have more experience/rank/status, etc.
MikeDs Final Thoughts: This accident is an example of one where the time between boredom and sheer terror was not instantaneous. The crew was aware of the deteriorating WX as it wasn't deteriorating rapidly nor was it very severe....at first. But as the mission proceeded, the WX began to close its grip on the amount of available clear air to fly in, and thus the options for the crew to keep the mission going. Still, when the IMC encounter occurred, one very big option....the route abort....was available and there, free to use. Whether rushed route planning, or simply a loss SA occurred during the IMC encounter where the crew failed to realize where they were and what was under them; the crew chose the worst of the two remaining choices in their bag of tricks, and paid for that decision with their lives. The sad part is, the crew had ample opportunity to fold their proverbial poker hand, and avoid getting themselves Caught Between the Weather and a Hard Place; but as the title of this Accident Synopsis accurately states, once there, options become very limited...all the way to where it came down to two: Climb or Descend. Each choice had a guarantee that came with it: Guaranteed sky above, or guaranteed terrain very close below. The odds were not with the descent option. They rarely are on these missions.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
2 April 1986
Mazatzal Peak, 12 miles southwest of Payson, Arizona
Northrop T-38A Talon, 67-14836, c/s Willie 51
82nd Flying Training Wing (FTW)/97th Flying Training Squadron (FTS)
Williams AFB (KIWA), Chandler, Arizona
2 Fatal
Aviation is often described as some other jobs are, such as firefighting: Hours of boredom puncutated by moments of sheer terror. In many situations, loosely speaking, the transition from boredom to sheer terror is generally a quick one such as a near-midair collision with another aircraft, or a balked landing requiring a quick go-around, or some other incident where the event quickly or instantaneously occurs and a reaction is either instinctive or there's no time to accomplish one. At other times, the transition from boredom to sheer terror can be a short or moderate or even long period of time such as a fuel leak, or a slowly dying engine, or weather that begins deteriorating more or faster than expected. Continuing the MikeD Accident Synopsis series with accidents/incidents local to the Arizona flying scene, today's accident encompasses the latter factor of deteriorating enroute weather, and pressing a tight situation to the point where one's options begin becoming limited very quickly. Such was the case for the crew of a Northrop T-38A of the 97th FTS from Williams AFB, Arizona on what was to have been a routine low level navigation training mission north and east of the Phoenix area.
On the early Wednesday morning of 2 April, 1986, the weather in the Phoenix area consisted of broken clouds and temps in the 70s. To the north and northeast of the metro Phoenix area, the clouds became more overcast cumulus and dense, with temps falling to the 50s and light to moderate rain and precipitation up to 1/4 inch. Williams AFB, located on the southeast side of Phoenix, was reporting: Temp/dewpoint 70/44, winds from the west at 10 knots, BKN060 in occasional light drizzle. Willie 51 flight was the callsign of a single T-38A from Williams AFBs 97th Flying Training Squadron (FTS) that was originally scheduled for another different mission, but changed to a low-level navigation training mission on one of the local Military Training Routes (MTRs) in the area. Changing to the new mission with a compressed time to plan and brief, the crew of one student in the front seat and an Instructor Pilot (IP) in the back seat began rapidly planning to fly Visual Route (VR) 239, a low level MTR that begins on the north edge of Lake Pleasant on the northwest edge of Phoenix, and wraps around the Phoenix area, continuing southwest into the southwest portion of Arizona near the Mexico border, then turning northwest and emptying into the East Tactical Range of the Barry Goldwater Bombing Range south of the town of Gila Bend and about 35 miles southwest of Phoenix. As the T-38A was fuel limited and the Average Sortie Durations (ASDs) were short anyway, crews usually only flew a portion of the VR route. As with many MTRs, there are designated alternate entry/exit points so aircraft have no requirement to fly the full route from start to finish. For today's mission, Willie 51 flight planned to start VR-239 at Point A next to Lake Pleasant, and exit at Point F at Black Mountain, southeast of Coolidge, Arizona and about 25 miles southeast of Williams AFB. Having flown VR-239 myself many times during my A-10 days, I'm well familiar with the rugged and beautiful terrain that the route traverses from Points A through F in the areas north and east/southeast of Phoenix.
Willie 51s flight briefing concluded, the crew gathered their equipment from life support, the IP signed for the aircraft and both met on the flightline for the van ride to aircraft 67-14836. Stepping out to their aircraft, the flightcrew noticed no change in the reported weather, and flight operations were proceeding normally with no pattern or other restrictions noted. Startup and taxi were all uneventful. The crew of 836 flight planned for a northeast turnout to proceed northbound initially, avoiding air carrier traffic arriving and departing from Phoenix-Sky Harbor International (KPHX), before turning northwest to head to VR-239 Point A on the opposite side of the Phoenix metro area. Willie 51 flight contacted Willie tower for takeoff and was cleared for an unrestricted climbout to 6000, and to change to Phoenix Departure. The flight taxied onto Runway 30C and commenced a standard single-ship takeoff. Willie 51 flight contacted Phoenix TRACON and climbed out of Willie's traffic pattern northbound as planned.
Coming under radar contact from Phoenix TRACON, the controller cleared 836 to climb VFR to its assigned altitude and further cleared them to proceed direct to Point A due to the light amount of air traffic in their area at the time. Cleared to descend in short order, the crew of 836 was advised of slowly deteriorating WX north and east of the Phoenix area and was switched to Albuquerque Center (ZAB) for IFR pickup for the VR route. Although not required for VR MTRs, local 82nd Flying Training Wing (FTW) directives required them even for VR routes for flight following purposes, even though in some portions of the VR-239 route, the aircraft would be too low for radar coverage. Descending to 1500' AGL and accelerating to 480 KIAS for the first leg of the route, 836 passed over Point A and made a left descending 270 degree turn in order to rollout to the northeast and cross Point A on-course at the time of hacking the clock. In the T-38A, these VR routes aren't flown with any kind of NAVAIDS; only with clock, map, ground references, and some Dead Reckoning (DR). Limiting maneuvering at the start point avoids having any timing errors at the start of the route and provides for tighter DR computations for time. Proceeding northeastbound, the crew of 836 squawked 4000 and cruised at the Point A to Point B route altitude of approximately 1500' AGL in preparation for the low-level descent that would commence immediately after passing Point B where the route drops down to 300' AGL.
Point B of VR-239 is located 20 miles northeast of Point A and is defined as the peak of New River Mountain. Reaching this point, the VR route turns eastbound and proceeds that direction for 32 miles until reaching Point C at Mazatzal Peak. At point B, the terrain drops steeply into a mountainous valley along the B to C routing until reaching high terrain at Point C. Cruising underneath the overcast with light rain, 836 crossed Point B in a right turn and rolled into a 120 degree bank, pulling the nose down below the horizon to rapidly descend to 500' AGL in-line with the terrain contouring. Rolling out on course, the crew proceeded eastbound to Point C, racing along at 8 miles a minute and 500' AGL in and around the mountainous valley terrain, adjusting speed in order to cross Point C at the flight planned time. By this time, the rain was beginning increase and the cumulus clouds building lower as the terrain began gently rising towards them. In the area they were flying over now, north of the Horseshoe resevoir dam, terrain elevations were averaging 3000 to 4000 MSL, but began to slowly rise towards the east as the Mazatzal Mountain range began. As the moderate rain continued, the crew noted the deteriorating WX ceiling and rain buildup, but continued towards Point C. At some point within 10 miles of Point C and while maneuvering eastbound in a slight climb, the crew entered inadverent Instrument Meterological Conditions (IMC) in the bottom of the cumulus overcast. Maintaining heading and rolling wings level, 836s crew immediately transitioned to instruments but did not initiate a route abort. Believing that they were only slightly into the WX and that they had adequate terrain clearance, 836s crew began a very shallow descent to regain Visual Meterological Conditions (VMC). Unfortunately, moving along at 8 miles a minute, combined with the inadverent IMC encounter, 836s crew lost Situational Awareness of their geographic position. Rising terrain in the Mazatzal Mountains began reaching up and touching the extreme bottoms of the cumulus cloud deck. Continuing their shallow descent, Willie 51 never regained VMC before impacting the rapidly rising vertical terrain just short of Point C at Mazatzal Peak at 495 KIAS.
Due to low ceilings in the area and rain conditions, combined with this being one of the areas where radar coverage was spotty, 836 remained missing for a day. Search aircraft finally located the missing T-38A where it had impacted, approximately 0.5 NM west and about 800' below the 7903' MSL Mazatzal Peak on a 50 degree cliff side. The aircraft was destroyed and both crewmembers were fatally injured. The wreckage, located in a 200' x 200' square area, had been demolished. There was no attempt to eject, and the remains of both the student and the IP were found on site. To this day, the wreckage of 67-14836 remains on the cliff where it impacted on that early April morning.
Probable Cause:
*Inadverent IMC Penetration- Pilot/IP
*Situational Awareness- Lost- Pilot/IP
*Terrain Separation/Altitude- Not Maintained- Pilot/IP
*Emergency Route Abort- Not Initiated- Pilot/IP
Secondary Factors:
*Weather Condition- IMC/Rain
*Flight Planning/Route Study- Inadequate- Pilot/IP
Tertiary Factors:
*IMC Route Abort Guidance/Directives- Inadequate- Air Training Command (ATC)
MikeD says:
This accident is a reminder to all that a good effective mission begins with good effective flight planning. Changing plans at the last minute, especially in a training environment, can easily set the stage for getting rushed in planning, which can lead to everything else from takeoff to the mission itself getting rushed as the concept of being behind begins to snowball. In the attempt to get "caught up", combinations of any one or many other factors that can affect the flight will usually pop up, and often lead to never getting to where one wants to be "caught-up"-wise, ending up always being behind the proverbial eight-ball for the entire flight. How being behind the eight-ball manifests itself inflight can vary from simply being rushed, all the way to something catastrophic. Beginning with the planning factor, other factors of decision making as well as some outside influences, all combined to take the crew of 836 to their eventual demise. A demise that could've been avoided had some particular items been mitigated beforehand. Specifically, I'll discuss here:
1. MTR route flight planning considerations.
2. MTR route inadverent IMC penetration and Emergency Route Abort considerations and guidance
3. Overconfidence in personal abilities
MTR route flight planning considerations: MTRs, due to their specific routings and turn points, require detailed planning, especially in the western USA where designated mountainous terrain is present. The routes themselves are far more than what's depicted by the thin grey line on most 1:500 Sectional Aeronautical Charts. These charts only depict the centerline of the particular VR/IR route and while good enough to provide SA as to where these routes are located for civilian pilots to be aware of, there's far more detailed planning that goes into flying these routes as the military operator. The routes themselves are spelled out in a Department of Defense Flight Information Publication known as the AP/1B. This publication lays out each route in terms of altitude(s), route centerline, route corridor (X miles left/right of route centerline), responsible unit for scheduling of the route and the lat/longs of each route turnpoint, amongst other information. Detailed planning is required of crews in order to understand the constaints of the particular route's structure, altitude limitations, corridor, terrain....both on the route as well as surrounding, and other factors. These routes aren't generally ones where they can be flown "on the fly", unless someone has flown the local routes and is familiar with them; yet still they'd carry appropriate 1:250 Tactical Pilotage Charts (TPCs) with all the appropriate information for the route noted and plotted.
To give one an idea of how busy these MTR routes are when flying them, I'll describe what I had to do while flying these routes in the A-10A back in the day. I've flown VR-239 myself many times and am well familiar with the terrain and particulars of this MTR. In the A-10, I had no radar for my low-levels, my only separation ability comes from the Mk.1 eyeball. Keep in mind, though, that I have a multitude of cockpit tasks going on while tooling along at 300 AGL/360 KIAS (up to 480-540 KIAS in pointy nose fighters). First, eyeing terrain to make sure I'm doing my job of pilotage correctly (ie- matching terrain features with what's on my map to make sure I'm going the right way), avoiding hitting the ground/power lines/near rocks/far rocks, keeping track of my timing per leg [if I'm going for a specific TOT, or Time Over Target], keeping track of my other aircraft in my formation, insuring my weapons panel is set correctly [such as setup change from air-air to air-ground], going over and over in my mind what the attack plan is [formation, role, weapon, timing, attack axis], and being ready to flex to a different plan if the first one gets screwed up [such as unplanned threats pop-up], and maintaining overall SA over the operation; all while moving at 300 AGL/360 KIAS......that's 6 to 9 miles per minute; and all this in addition to trying to see and avoid. To put it in perspective, at this low altitude and high speed, an insidious 1 to 2 degree nose-low attitude that's not noticed in a turn or otherwise, will result in ground impact in about 5 seconds, depending on terrain. Proper route study beforehand helps minimize heads-down time looking at the map, increasing brain-byte room for me to accomplish other tasks and thus increasing overall SA. Planning for the "what-if's" becomes even more important when dealing with WX on the route, and what to do if it's encountered inadverently.
MTR route inadverent IMC penetration and Emergency Route Abort considerations and guidance: One of the most disquieting situations one can encounter on a VR MTR is an inadverent IMC penetration (IR MTRs are always on an IFR clearance). It's imperative to have an emergency Route Abort Altitude computed that will keep one clear of terrain in the surrounding area. With the IMC encounter being unexpected and because normally an aircraft flying on a VR route is VFR, penetrating IMC unexpectedly can be a shock that sends the workload immediately increasing. Especially on a route where an immediate climb to avoid terrain is necessary. The maneuver itself is an emergency, since the aircraft is now off-route and outside the route structure vertically, and now IMC with no IFR clearance. If no immediate communication with ATC able to be made, then squawking emergency is vital. Crews have to immediately transition from a VFR mindset of navigation, to now an instant IFR mindset, trying to figure out their location and switching from VFR maps to IFR ones. If in an area of airways, there's now the midair collision potential as they're not under radar control with ATC yet. Even the route abort maneuver of a rapid climb away from terrain can itself be Spatial Disorientation inducing. All of this while trying to figure out where one is geographically and not hit anyone else in the air. Its even worse when its a formation of aircraft who all have to route abort, as maintaining deconfliction from each other, as well as aircraft outside the formation, is paramount. All of these reasons are why prior planning and understanding of contingencies and what to do during them, is so highly important and cannot be taken for granted. Add to, being a single-seat aircraft instead of having two-crew, and one can imagine how task saturation can increase exponentially. The last thing one wants to do in an inadverent IMC situation is attempt to descend back to VMC, especially in areas of variable or mountainous terrain, as this accident tragically demonstrated.
At the time of 836's accident, guidance in USAF Air Training Command's (ATC) governing directives regarding inadverent IMC penetration on MTR routes was inadequate. The guidance was later clarified as a result of this accident, stating in part:
"An emergency route abort altitude or exit escape altitude is required for each low-level route. This altitude will be computed to provide 2,000' clearance from the highest obstacle within 25NM either side of course for the entire low-level route."
The directives further described procedures for accomplishing a route abort if IMC is encountered.
Overconfidence in personal abilities: The particular makeup of the crew of 836 is an item that needs to be considered. 836s IP was a low-time 22 year old First Assignment IP, otherwise known as a FAIP. FAIPs are guys who graduate Undergraduate Pilot Training (UPT) and receive a first assignment of remaining at the particular pilot training base and instructing other UPT students for 3 years, rather than receiving an immediate assignment to the Combat Air Forces. The young IP for this mission was crewed with an experienced student, however. The student in the front seat of of 836 was a rated aviation officer, but a student pilot. Rated as a USAF Navigator, the 26 year old student up front had flown for a few years as an F-111 Weapons Systems Officer (WSO), and had applied for and been accepted to UPT to retrain as a USAF Pilot. As such, the student was comfortable and used to operating in the low-level environment, as high-speed low-level tactical flight ops was the raison d'etre of the 111 flight crews. So the former-WSO was very experienced in this area of flying, far more than the FAIP IP. It's possible that there might have been some deference by the IP to the more experienced student; however the student's high level of experience should've caused him to know that regaining VMC from an inadverent IMC encounter was not wise. Although, since F-111 aircraft normally flew IR MTRs where they'd often fly in and out of IMC simply due to the aircraft's terrain following instrumentation, it's possible that there may have been a false sense of security in initiation of a descent in an attempt to get back into VMC. All of this is speculation as it relates to this particular accident, however experience deference is known to be the cause of many instances of what human factors investigators term "passenger syndrome", where one might either defer to or fail to question someone making a known bad decision, due to the fact that they have more experience/rank/status, etc.
MikeDs Final Thoughts: This accident is an example of one where the time between boredom and sheer terror was not instantaneous. The crew was aware of the deteriorating WX as it wasn't deteriorating rapidly nor was it very severe....at first. But as the mission proceeded, the WX began to close its grip on the amount of available clear air to fly in, and thus the options for the crew to keep the mission going. Still, when the IMC encounter occurred, one very big option....the route abort....was available and there, free to use. Whether rushed route planning, or simply a loss SA occurred during the IMC encounter where the crew failed to realize where they were and what was under them; the crew chose the worst of the two remaining choices in their bag of tricks, and paid for that decision with their lives. The sad part is, the crew had ample opportunity to fold their proverbial poker hand, and avoid getting themselves Caught Between the Weather and a Hard Place; but as the title of this Accident Synopsis accurately states, once there, options become very limited...all the way to where it came down to two: Climb or Descend. Each choice had a guarantee that came with it: Guaranteed sky above, or guaranteed terrain very close below. The odds were not with the descent option. They rarely are on these missions.
MikeD
The above is not intended to be an undue criticism of the person or persons involved in the incident described. Instead, the analysis presented is intended to further the cause of flight safety and help to reduce accidents and incidents by educating pilots through the sacrifices of others in our profession.
