Report: Pilots in deadly Black Hawk crash disobeyed orders

[Ian_J]

Meant to post this the week this report came out but time and events got the better of me. This was a pretty high-profile accident for the National Guard and brought reoccurring themes out of the pages of powerpoints, oral exams, and manuals and into tragic reality.

It's hard to imagine you could get two experienced pilots so spatially disoriented in such a capable helicopter, but the spatial d was just one of the last links in the accident chain here. From the report one of the things that really stood out to me was:

"No one spoke up and questioned the wisdom to conduct the mission," the report said.

In this case the command structure was decentralized. The crew was briefed in advance for multiple missions rather than getting briefed and approved for each mission (the wisdom vs. necessity of doing that is debatable), so the people available to say "no" was most likely limited to the pilots and crew chiefs.

You'll also notice both pilots on board were very senior, and very experienced. The unit involved picked these two on purpose because they wanted a very senior crew due to the complexity of the mission (that's confirmed) and the PIC for the flight was known for being aggressive (that's unconfirmed, but from a pretty reliable source). How many times has any unit defaulted to two of the most senior pilots (often both instructor pilots) for high profile missions? It happens all the time but I always argue the most senior crew is not automatically a risk mitigation factor.

Of little mention in the article is what role the second UH-60 played and who was the air mission commander. When this incident initially occurred we all heard that the second ship turned around due to weather and I would love to know the dynamic between the two aircraft. It would be hard to think of a situation in which unless one was already IIMC that they wouldn't turn around at the suggestion of another ship in the formation.

Many units are going to focus on spatial d as a focus item as a result of this incident - which is fine - if anything this shows it CAN happen to anyone. But the real lessons here go a lot deeper. I think the 121 world has a pretty good culture of voting with the parking brake when things don't look right - the only thing really on the line is revenue. In the military there are certainly cases where you have to accept unmitigated risk to accomplish the mission, but those cases are rare. We've come a long way over the years with crew coordination (CRM, ACT-E, etc) and one of the most powerful things we've done for safety is give everyone in the crew a voice. However, that voice doesn't do anyone any good if it's not used.

NEW ORLEANS — The pilots of a Black Hawk military helicopter that crashed last March, killing all 11 service members aboard, had disobeyed direct orders by flying into worsening weather, according to an investigation report.

The military said in June the crash was caused when the pilots became disoriented at night off the Florida coast. The training took place as dense fog rolled in from the Gulf of Mexico.

The full report, obtained by The Associated Press late Thursday through a public records request, said the pilots were not authorized to fly in such bad weather and others failed to challenge the overconfidence of the lead pilot.

The report was a joint investigation by the Louisiana National Guard and U.S. Special Operations Command. Details of the report were previously reported by the Irish Times in June.

The training involved two Black Hawk helicopters from the Louisiana National Guard taking teams of Marine special operations servicemen over water so they could rappel into the sea.

Both crews "disobeyed a direct order ... by choosing to fly in lower then (sic) briefed weather minimums."

The report went on to fault the lead pilot, Chief Warrant Officer George Wayne Griffin Jr., 37, of Hammond, Louisiana, for pushing ahead with the mission even though weather was worsening March 10.

According to the report, the training was supposed to take place only if cloud cover was no lower than 1,000 feet and visibility was 3 miles. Conditions were worse, with cloud cover as low at 200 feet.

Fog began to set in about 40 minutes before the helicopters took off at 8:16 p.m., according to testimony. The same service member told investigators that Griffin dismissed concerns from members on boats where the training was to take place.

Records show that the National Guard felt that Griffin was a top-notch veteran pilot fully capable of doing the training.

"No one spoke up and questioned the wisdom to conduct the mission," the report said.

Griffin Jr. and Strother both were decorated veteran pilots. Griffin had twice served in Iraq; Strother had served in Iraq, Afghanistan and Kosovo.

The Louisiana National Guard did not return messages seeking comment. The U.S. Special Operations Command declined to comment.

http://www.armytimes.com/story/mili...y-black-hawk-crash-disobeyed-orders/74464070/

This article is older but has better details:

http://www.nola.com/military/index.ssf/2015/06/black_hawk_crash_caused_by_pil.html

 

[MikeD]

The big takeaway from this one is pressing the WX when there was no critical operational need to do so. For nothing more than a stateside training mission, not a rescue mission or something else that could be justified risk-wise. Even the personnel on the boats they were to be working with, were calling back and reporting that they thought the WX wasn't workable. I'd been wanting to talk to some of my agency people in the Hammond Air Branch, as a good few of them are also part timers in that NG Blackhawk unit, see what kind of inside scoop they have on this.

 

[Bandit_Driver]

@MikeFavinger you are right about the parking brake in the 121 world. The parking brake is the only time you get use "position freeze" when not in the sim.

I agree with MikeD, why press the bad weather when the risk isn't justified.

 

[Nark]

We're doing an Air Assault tomorrow. After the AMB tonight the BC stood up and reiterated: this is stateside training, if you have to pump the brakes, and we miss a time hack, so be it.

Amongst other things, I can't help but respect the man.

 

[hook_dupin]

Sea fog in that part of the country has caused more than a few early Gone West trips. A damn shame...

 

[Soku39]

The big takeaway from this one is pressing the WX when there was no critical operational need to do so. For nothing more than a stateside training mission, not a rescue mission or something else that could be justified risk-wise. Even the personnel on the boats they were to be working with, were calling back and reporting that they thought the WX wasn't workable. I'd been wanting to talk to some of my agency people in the Hammond Air Branch, as a good few of them are also part timers in that NG Blackhawk unit, see what kind of inside scoop they have on this.

I wish I could say that I've never been a part of a crew that pushed it too far wx wise on a low level stateside to get the training done... I wish, but I can't say that, this a good rehack for all of us.

 

[alaskadrifter]

We'd all like to think this wouldn't happen to us, but this is a good reminder that these accidents seem to be happening to experienced folks.

 

[ppragman]

We'd all like to think this wouldn't happen to us, but this is a good reminder that these accidents seem to be happening to experienced folks.

Yepppppp.

Sooo many CFIT accidents in similar conditions. Heli's have it easy, "land and live" is a good thing... Fixed wing same thing, it's pretty hard to get killed by a cloud, mountains will kill you. Clouds not so much.

 

[MikeD]

I wish I could say that I've never been a part of a crew that pushed it too far wx wise on a low level stateside to get the training done... I wish, but I can't say that, this a good rehack for all of us.

We'd all like to think this wouldn't happen to us, but this is a good reminder that these accidents seem to be happening to experienced folks.

Truth. What sucks is that this wasn't a case of WX being close.......1000/3 required, and it was maybe right at 1000/3, or perhaps even slightly lower in ceiling/vis to where it could've even been remotely considered "close enough". The ceiling was 200' average, with the viz probably far lower than 3 with the fog. So it couldn't even be called "close enough".

For whatever reason, the AC wanted to press ahead. Which to me is especially surprising and perplexing in a cultural sense, being that he was an Army Aviator......which is a branch of the military whose crews generally do not push WX ever (unless critical operational need), and are usually very on the conservative side of that. I've seen even the most confident Army aviators, put the brakes on when it comes to messing with WX, especially in training or non-critical operations. So that part is quite surprising to me. Granted, -60 and -47 crews are far more comfortable with dealing with WX than -58 or -64 crews, mainly in terms of aircraft capability; but no Army crews just go punching into the soup for the heck of it, especially WX that may be beyond the capability of the aircraft, comfort of the crew, or in this case, breaking set WX mins.

We may never know why this particular mission was one the AC was willing to lean so far forward on. Interservice pride to show a can-do spirit to the supported pax? Overconfidence in personal ability? Belief that the WX wasn't as bad as the boat crews were making it out to be (even though it could be seen at the departure point)? We'll really never know.

As I've used in my MikeD Accident Synopsis reports I've written on the site here:

"Overconfidence is what gets us into trouble. Pride is what keeps us there."

 

[dustoff17]

This report surprised me as well. I, too, am curious about the second aircraft; when did they RTB and what the dynamics were between the crews. The fallout from this has already revealed itself to some degree. In the future, I see a shift in the use of assets for outside training from Guard/Reserve units to Active only. It's a shame as there are many highly experienced crew members out there.

The loss doesn't make sense to me. NO training mission is worth the unforeseen loss of life.

 

[Roger Roger]

This report surprised me as well. I, too, am curious about the second aircraft; when did they RTB and what the dynamics were between the crews. The fallout from this has already revealed itself to some degree. In the future, I see a shift in the use of assets for outside training from Guard/Reserve units to Active only. It's a shame as there are many highly experienced crew members out there.

The loss doesn't make sense to me. NO training mission is worth the unforeseen loss of life.

We have experienced this a lot on the floatplane side....one guy keeps going and the other turns around. It's a headache. The rule now is no matter how confident YOU are with the weather if the other plane turns around, so do you.

 

[ppragman]

We have experienced this a lot on the floatplane side....one guy keeps going and the other turns around. It's a headache. The rule now is no matter how confident YOU are with the weather if the other plane turns around, so do you.

Is this a steadysm?

 

[Roger Roger]

Is this a steadysm?

No this is common sense when you have pax and the guy with their bags turns around going to elfin.

 

[ppragman]

No this is common sense when you have pax and the guy with their bags turns around going to elfin.

Maybe you guys should set some objective criteria for when you continue on? That's what we did at my old gig when we had the same problem.

 

[dustoff17]

We have experienced this a lot on the floatplane side....one guy keeps going and the other turns around. It's a headache. The rule now is no matter how confident YOU are with the weather if the other plane turns around, so do you.

This is the way it's SUPPOSED to be in the Army as well in these situations. I think that's why I'm curious to learn the dynamics between the two crews.

 

[TC_ABM]

The results from this -60 crash will be interesting, too. My neighbor who is an AVN MX CO commander and I feel there has been a shift lately in what's acceptable vs not acceptable in the Army as whole. We've both seen some startling things in 4ID that are a significant shift from acceptable risks as a whole for the Army in the last five years or so.

 

[FEtoDX]

I was stationed there in a much better equipped helicopter and with crews that were highly training in zero/zero operations and we still didn't operate training missions below 500' and 2sm at night. That fog is no joke and has caused a lot of problems both for aviation and traffic cruising down hwy 98.

 

[///AMG]

Just a really big guess…….but perhaps over a decade of sustained combat ops in really austere places, bad weather, and from a RW perspective, significant kinetic threats, has built some complacency, or at least confidence in bad scenarios that would otherwise make guys & gals think twice in peacetime, based on their combat experience. I know my comfort level shifted a little after the stuff we routinely did over the mountains and in bad weather over Afghanistan to get the mission done. Just a thought.

 

[Lawman]

Just a really big guess…….but perhaps over a decade of sustained combat ops in really austere places, bad weather, and from a RW perspective, significant kinetic threats, has built some complacency, or at least confidence in bad scenarios that would otherwise make guys & gals think twice in peacetime, based on their combat experience. I know my comfort level shifted a little after the stuff we routinely did over the mountains and in bad weather over Afghanistan to get the mission done. Just a thought.

This combined with customer requirements.

I've seen plenty of missions that went nowhere for regular dudes but suddenly were green lit for whatever no-go condition because we were working for special people.

Went so far with go fever one day I had to tell a senior ranking officer and the aircraft commander, "find another bird or find another gunner." It took that to re-cage him.

 

[dustoff17]

This combined with customer requirements.

I've seen plenty of missions that went nowhere for regular dudes but suddenly were green lit for whatever no-go condition because we were working for special people.

Went so far with go fever one day I had to tell a senior ranking officer and the aircraft commander, "find another bird or find another gunner." It took that to re-cage him.

Kudos!
Sometimes this is ALL it takes to give the mission risk a second look. I wonder if ANY of the crew members involved here said anything or if they just went along with it.