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MAY 1998 u Vol 26 u No 8 visit our web site - http://safety.army.mil L L e e s s s s o o n n l l e e a a r r n n e e d d : : N N e e v v e e r r g g i i v v e e u u p p . . Food for thought. It is unacceptable that we are losing soldiers in POV accidents at the rate of one every 3 days. And we are losing more than our fair share of aviation-MOS soldiers. According to the Chief of Staff, Army, the key to reversing this trend is active, caring leadership at every level to increase command emphasis on POV safety. I agree wholeheartedly. See page 8 for General Reimers recent guidance on the subject. BG Burt S. Tackaberry, Commanding General, U.S. Army Safety Center

Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

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Page 1: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

MMAAYY 11999988 u VVooll 2266 u NNoo 88

visit our web site - http://safety.army.mil

LLLLeeeessssssssoooonnnn lllleeeeaaaarrrrnnnneeeedddd:::: NNNNeeeevvvveeeerrrr ggggiiiivvvveeee uuuupppp ....FFoooodd ffoorr tthhoouugghhtt.. It is unacceptable that we are losing soldiers in POV accidents at the rate of one every 3days. And we are losing more than our fair share of aviation-MOS soldiers. According to the Chief of Staff,Army, the key to reversing this trend is active, caring leadership at every level to increase command emphasis

on POV safety. I agree wholeheartedly. See page 8 for General Reimer�s recent guidance on the subject.��BBGG BBuurrtt SS.. TTaacckkaabbeerrrryy,, CCoommmmaannddiinngg GGeenneerraall,, UU..SS.. AArrmmyy SSaaffeettyy CCeenntteerr

Page 2: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

�First and foremost, control the aircraft.��Fly the aircraft all the way to the ground.��Never stop flying the aircraft.�These are all words our instructors have used to

drive home the important point of aircraft controlduring simulated emergencies in the aircraft andsimulator. Chapter 9 of every Army aircraft operatorsmanual stresses the importance of controlling theaircraft when responding to real emergencies: �Themost important single consideration is aircraftcontrol.�

Recently, four crewmembers survived invertedflight in a CH-47 because the pilots never stoppedflying the aircraft�even when it appeared theaircraft was unrecoverable.

The two pilots, the flight engineer, and a mechanichad done everything right. They had spent 2 daysinventorying, inspecting, and test flying the aircraftthey were receiving from depot following phases onethrough four maintenance services. Although not

required, they had performed a full maintenance testflight of the aircraft and found and corrected a fewminor problems. They were more than merelysatisfied that the aircraft was suitable to accept andfly; they agreed that this was one of the smoothestflying CH-47s they had ever flown.

The first leg of their planned 2-day mission backto their unit was without incident. They were aboutan hour into the second leg�and only 18 minutesfrom their destination�when they encountered theiremergency.

The PC, who also was an IP and MP, was on theflight controls when the nose of the aircraft began aslight pitch down. He applied aft cyclic to correct forwhat seemed to be a normal divergence in the CH-47.But as he applied aft cyclic, the nose began a slowleft yaw that he could not control with full rightpedal.

The aircraft then began a slow left roll to aboutthe 90-degree point and then continued with what

Flightfax ww May 19982

Never stop flying the aircraft . . .

After 360-degree roll in flight, the crew managed to land the Chinook with surprisingly little damage. Duringshutdown, however, damaged droop stops allowed the aft rotor blades to pound into the fuselage.

Page 3: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

seemed to be a snap roll through the remaining 270degrees.

But it didn�t happen that fast; it felt like eternityto the crewmembers. As the aircraft inverted, the PI,figuring he had nothing to lose, joined the PC on theflight controls. (I am not advocating that two peopletry to fly an aircraft, but this action confirms thatboth pilots knew they were in a desperate situation.)Instinctively responding by doing what they had beentrained to do, the pilots continued to fly the aircrafteven as they saw the ground through the greenhouseand it appeared there was no hope of recoveringcontrol of the aircraft.

The aircraft miraculously returned to a wheels-down attitude at about 250 feet agl. The pilots wereable to control the aircraft to a near-normaltouchdown, although full right pedal was stillnecessary to control aircraft heading. As the crewperformed an emergency shutdown, the aft rotor

blades made contact with the fuselage since thedamaged droop stops did not operate normally.

They had, in the words of the PC, �killed thebeast��all with only minor injuries to the mechanic,who had been standing at the onset of theemergency. The aircraft was severely damaged, butfour extremely valuable aviation resources whounexpectedly found themselves in a life-or-deathsituation that was not of their making are still withus today because they did not give up.

All four of these crewmembers share their storieson the following pages. What you�ll read comes fromthe first-person accounts they gave only hours afterthe incident. We are publishing their stories herewith their permission and approval, and we�regrateful to them for their generosity. �MAJ Herb Burgess, Aviation Systems & Investigation Division,USASC, DSN 558-9853 (334-255-9853), [email protected]

CW3 Bric Lewis, PC

It was cold, but we couldn�t have asked for betterweather�you could see forever.

We were going along at 1100 to 1500 feet abovethe ground, running between 130 and 135 knotsindicated, and I was letting it float. I didn�t havealtitude hold engaged. I had my feet resting on thepedals and my hands lightly monitoring the controls.The aircraft would float up, and I�d bring it backdown to between 1500 and 1100 feet, depending onthe terrain.

I�d made a correction in altitude because it wasclimbing a little bit; we were somewhere around1100 feet agl when I felt satisfied I was at an altitudethat was okay. We were about 135, 140 knots when Inoticed that the aircraft nosed over. I let it go for asecond. And then it yawed. The tail end was comingaround the right side. I applied right pedal and alittle bit of aft cyclic to stop the descent. But it gotworse. The yaw rate increased dramatically, and I hadfull right pedal. It continued on around and Pat, thePI, grabbed the dash. I didn�t hear anything from theguys in the back.

There were no indications on the dash that therewas anything wrong, no lights�nothing. I thoughtfor a second that there was an AFCS problem.

Flightfax ww May 1998 3

AAfftteerr mmoonntthhss ooff iinnvveessttiiggaattiioonn aanndd eexxtteennssiivvee rreesseeaarrcchh,, tteessttiinngg,, aanndd aannaallyyssiiss,, tthhee ccaauusseeooff tthhiiss aacccciiddeenntt hhaass nneevveerr bbeeeenn ddeetteerrmmiinneedd.. TThhee AArrmmyy SSaaffeettyy CCeenntteerr,, tthhee CCCCAADDIInnvveessttiiggaattiivvee AAnnaallyyssiiss UUnniitt,, AAMMCCOOMM,, aanndd BBooeeiinngg ccoonnttiinnuuee ttoo mmoonniittoorr aanndd eevvaalluuaattee aallllCCHH--4477 fflliigghhtt--ccoonnttrrooll aannoommaalliieess ttoo ddeetteerrmmiinnee tthhee ccaauussee ooff tthhiiss aacccciiddeenntt aanndd ttaakkeeccoorrrreeccttiivvee aaccttiioonnss..

The view from the cockpit

Page 4: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

And then the aircraft got on its side. Pat wasscreaming, �Catch it, Bric, catch it!�

At that point, I had the pedal jammed against thestop, and it was still yawing to the left. By this timewe were on our left side. The seat of my pants toldme that the tail was coming around, so I applied fullright cyclic.

The stick wouldn�t move; it was like it was inconcrete. Just about the time I noticed the stickwouldn�t move, the nose pitched UP, and the aircraftrolled over on its back.

I yelled, �Oh, God!� and Pat got on the controls. Ididn�t know which way we were going. All I knewwas, it�s upside down. I was looking through theceiling, and I could see the ground rushing uptowards us. Pat was beneath me�from where I was, Icould see the top of his head below me, and theaircraft was falling upside down. The nose was low,and I knew that the cockpit was going to hit first. Istill hadn�t heard anything from the crew chiefs. Icould sense Pat on the controls with me. And theyweren�t moving.

I saw my wife.Then the stick hit me in the leg, and I said, �This

thing ain�t gonna kill me!� We were flopping thecyclic around, but it wasn�t doing anything.

We were getting fast, real fast. I had that elevatorfeeling in my stomach. And I thought, �This is theway it is. They lied. They tell your family it�s instant.�But you have that two or three seconds, and youknow what�s going on. It made me mad.

I remember thinking to myself, �It�s upside down.There ain�t nothin� you can do.�

And then it flipped over! I don�t know why; I don�thave any idea why it did.

Pat was on the controls with me. And we wereFAST, fast. I looked at the airspeed indicator, and itsaid zero. I said, �No! It�s FAST!� And he screamed,�250!� I thought he was calling out airspeed, but hemeant altitude. The ground was rushing up.

Something flashed by the window, and I said,�We�re close to the ground.� I honked back on thestick, and Pat was with me. It was yawing terribly tothe left, and we went�I know he was there�fullright pedal and applied just as much aft cyclic.

I felt it lift. And I thought, �Yeah, we ballooned.Airspeed�s coming back.� I looked at the rotor, and itwas coming back down through 115 percent�I don�tknow where it had been. And it was SCREAMING.

And I thought, �I�m gonna MAKE it!� It wasslowing down; everything was coming in good. Wehad back some altitude, and there was nothing in

front of us. Justlevel ground. Ithought, �Yeah,we�re gonna makeit.�

And then thenose kept comingup. �No,� Ithought, �we�regoing to end upstopped, but we�llbe 25 feet off theground!� So wepushed the stickforward, and thenose came down.We were gettingready to comedown. This time itwas SLOW; it wasREAL slow. I don�tknow how slow itwas.

We got ready tocushion, but Icouldn�t lift thethrust. With all mystrength, I couldn�tlift the thrust.

I could feel thatlittle jump you get

Flightfax ww May 19984

During the wild ride, flight pubsstowed on the right side created ablizzard inside the cockpit. Most ofthem ultimately settled on the left

floor and dash.

Page 5: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

when it�s in the hangar and you move the controls�a little inch or so of movement. Pat was pumping it,and I was pumping it, and it wouldn�t move. Theaircraft was yawing BAD to the left, and we still hadfull right pedal. Finally, I just flared a little bit morewith the cyclic, and the back wheels touched. Andthen the front wheels touched. And it STOPPED. Wedidn�t hit brakes; it just stopped.

For the first second or two�and it wasSCREAMING�we sat there. And then WE startedscreaming, �We made it! We killed the beast!� Andwe gave each other the big high-five right there inthe cockpit.

Pat did the emergency shutdown while I tried tocenter the controls. The cyclic came back. We couldmove the thrust. The right pedal was stuck all theway to the front. And Pat was excited. He washollering, and the blades were starting to winddown. And then he asked the crew chiefs to see ifthere was any fire. But we could tell; it wasn�tcoming apart. I mean, it felt normal. Pete, the flightengineer, said, �I don�t see any fire.� That was thefirst we�d heard from him.

And then there were three real fast bangs. Andthe whole airframe shook.

And then there were three more, not as fast. Afterthe first three, we knew what it was.

Pat tried to lean down over the console, and Itried to get down between the pedals, but ourshoulder harnesses were locked and we were fightingwith that. And I was thinking, �Man, this thing is stilltrying to kill us!�

All of a sudden, it came to a stop. It just�everything stopped. We didn�t holler again. We justshut off the battery. Pat was going to go through thechecklist. �Just leave it like it is,� I said. �Just leave it.Just make sure we�re all okay.�

We got out, and we were pumped. We looked atit; it was torn up, but we were on the ground.

CW2 Pat Nield, PI

We were at about 1000 to 1100 feet agl, right atbetween 135 and 140 knots. The aircraft was

tracked really smooth; it flew better than anything I�dever flown out of Corpus. I was looking down at themap when I felt the nose pitch down, and I got alittle bit of a shudder. I looked up and saw that theairspeed had picked up. At that point, Bric, the PC,started pulling back on the cyclic. That�s the last timeI looked at him because we started an abrupt yawthat made me grab onto the dash. My perception isthat the nose pitched UP and continued to yaw reallystrongly. At this point, I knew things were bad; Ididn�t think we were going to be able to recover.

All of a sudden, the aircraft just snapped over; it

felt like it went upside down. I was seeing groundthrough the greenhouse. Maps were flyingeverywhere in front of me. I heard Bric say �Oh,God!� a couple times and things got really frantic. Iremember thinking, �Oh, God, this is bad if HE�ssaying �Oh, God�,� because Bric�s the best pilot Iknow.

When we went upside down, I figured I hadnothing to lose, so I went ahead and got on thecontrols. I was fishing around, but nothing wouldbite. It was just like the rotor system was unloaded. Icouldn�t see anything inside the aircraft, becauseeverything was shaking too much. There was lots ofnoise, lots of vibration.

I was trying to obtain a ground reference point; Ididn�t get one until I could see the ground throughthe windscreen right in front of me. It was justrushing up, and we were turning. At that point, Iremember trying to put in full right pedal, and I felta response. I don�t know if that was the response Ifelt or the billions of others I was doing. Butsomething bit. Something took hold, and we got aninput. I can remember pulling back aft left, and theaircraft started coming up. It was then that I realizedthat Bric was on the controls with me. He was stillthere. When we were upside down, I had no idea.

When the aircraft finally recovered, we wereabout 100, 200 feet agl and screaming out of the sky.We were both pulling back on the cyclic, flaring theaircraft. We started getting to where we were flareda little too much, and we thought the bottom wasgoing to drop out on us. We attempted to pull up onthe thrust and got maybe an inch at the most. Thrustjust wouldn�t go anywhere. So we started pushing itthrough. Bric said later that I was yelling outinstructions; I don�t really remember that. I justremember pushing the stick down.

We made a pretty good approach angle, and Iremember touching down at what I�d estimate at 10to 20 knots. It was really a relatively smoothtouchdown. At that point, I released the controls,turned off the AFCS, and took both engines to stop.After that, I told the chief to check for fire on board.Then I looked at Bric; we got a little emotional andhigh-fived each other.

We thought it was over.And that�s when the rotor blades started

slamming into the fuselage.I knew that was a pretty bad thing because it

could come through the companionway and chop upa crew chief or get Bric and me up in the cockpit.But, luckily, it slowed down and stopped.

I don�t know how this thing righted itself otherthan God reached down and snatched this aircraftand turned it over. But it was like Bric and I had beenjoined at the hip at birth. We had worked togetherreal well.

Flightfax ww May 1998 5

Page 6: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

DAC Peter Biessener, flight engineer

We were in level flight. I had done a ramp check,so I was looking at my watch and listening to

the pilots and looking out the left forward windowand thinking I probably needed one more ramp checkbefore we landed. I looked over at Bill, the mechanic,in the other seat. Suddenly, the aircraft pitcheddown, and it started picking up speed. I thought,�That was kind of a strange descent.�

And then it started yawing. I thought, �Gee, we�reout of trim. This isn�t right.� And then there was thistremendous lateral g force. The aircraft was reallypopping, and I thought, �This is really bad.� I saw Billwasn�t in his seat anymore; he was up by the right-hand post of the companionway, right by the heatercloset.

I saw the ground rotating around in my window,and I thought, �Oh, Jesus. We�re going upside down.�

We rolled to the left. Out the left window, theground was going around. And then Bill was up bythe ceiling. We were upside down, and the aircraftwas shaking really bad. �This is it,� I thought. �We�reupside down, and this aircraft�s coming apart.�

I heard Bric say, �Oh God!� And then it got reallyquiet. I never heard anything else from anybody.

I don�t know why, but I started thinking, �I gottaget Bill.� He was up on the ceiling. I was being pulledall over in my seat, but I was there; my seatbelt washolding me in. And I had to get Bill because he wasflying. I could see the terror in his eyes. The nextthing, he kinda came down on top of me, right infront of the radio closet, and I held on to him.

It started getting really noisy, a lot of wind noise.Everything was really FAST. Like the engines. And therotors�really noisy. Bill was trying to get up, and Iwas just hanging on to him. And then I looked outthe window.

The ground was not above us anymore. It wasn�ton top of the window, it was on the bottom. And Ithought, �God, we�re right side up.�

The ground was coming up really fast. I wasthinking, �I have to get Bill into a seat! He has to getinto a seat because this is going to hit hard.� He wastrying to get up and go across the aircraft, and I waspushing him over there. He was looking at me, and Iwas pushing him. I was yelling, �Bill, get in the seat!�He grabbed the seat, and he fell back on the floor.And then I started calling, �Put your seatbelt on!� Idon�t know why, but I grabbed mine, and it hadbecome disconnected.

I looked out the window, and the ground filled theentire window. Bill was in a seat, but he didn�t have aseatbelt buckled. I rebuckled mine and again lookedout the window.

The ground was right there, and it wasn�t moving.I thought, �This is impossible; there was no impact!�

Everything was really quiet, and I got up. Lookingdown, I saw my mic cord on the floor; that�s when Irealized I had come unplugged. That�s why I hadn�tbeen hearing anything. I picked up my mic cord andplugged it in. From the companionway, I looked upfront at Bric and Pat. They said something like, �Wedid it!� and gave each other a high-five. Then Patsaid, �Okay, guys. Let�s check for fire. We�re okay.We�re on the ground.�

So I turned around, and that�s when I noticed thatthe entire cabin was a mess. All our baggage hadcome out from underneath the cargo straps; it wasthrown everywhere. I saw an oil can underneath myseat. The first-aid kits were on the floor. I couldn�tbelieve it. I turned and went to the ramp and hit theramp down. I stayed on the ramp�I didn�t want toget off�and looked out the left at the engine. Therewas no smoke or fire or anything. Then I turned togo to the other side.

That�s when the pounding started. Everything

6 Flightfax ww May 1998

The view from the cabin

View from inside cabin.

Aft rotor blades tore hole in top of fuselage during emergency shutdown.

View from outside.

Page 7: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

started hammering, and I looked up at the afttransmission. I started moving fast; I wanted off thatramp really bad. I�d seen a Chinook where the afttransmission had fallen out and onto the ramp, and Ididn�t want to be there. Somewhere toward the frontof the ramp, I fell down. At that point, with all theshaking, I realized that the blades were actuallypounding on the fuselage. As I was crawling on thefloor toward the front, I saw that Pat and Bric werelaid over in their seats. Pat was down by the centerconsole, and he started hollering, telling me, �It�sokay! Stay back! Stay back!�

I guess I stopped moving near the cargo hole. Iwas on the floor, and that�s when everything just gotquiet. And everything quit moving.

I got up and took my helmet off. Bill was pullingon the door and looking to the back. Wheneverything stopped, he kinda stood up, holding hisback. His face was cut below his eye. He was hurting.

I looked around. I�m still amazed the wayeverything flew around the cabin. The scary part wasthe oil cans that were underneath my seat. Iremember thinking that I don�t always lock the rampfire extinguisher in; a lot of times I just set it in itsmount. And I thought, �Yeah, this time I locked it in,and it stayed there. It�s a good thing.�

I guess I thought a lot about securing equipmentin the aircraft; I kept thinking about that. I wasamazed. Stuff came out from behind the seats. It wasin the cockpit. I mean this stuff that had beenproperly secured was thrown everywhere. The crossedstraps on the boxes of gear worked well. I have toremember this, that it�s not all just forward loadingor a hard landing or something. This stuff could bethrown sideways out of its straps.

We were just really happy. We thought that if theyever put this aircraft back together, we want it back.Because it stayed together. I mean, no matter what itdid wrong, it still stayed together.

At the hospital, I started thinking that this wasreally a good day. Because we should have been a bigpile, just a smoking hole. Chinooks don�t go upsidedown and come back to life. They just don�t do that.It�s like God reached over and set us right side upagain.

DAC Bill Gorenflo, mechanic

So we�re flying along. Pete does his ramp check. I�mimpressed with ol� Pat; I can see him sitting in the

front seat. He�s got his map, and he puts an X andsays, �I�ve got this tower over here. Bric, did you seethat tower?� I mean, they�re a good team. And Peteand I give thumbs up; these guys are all right. I said,�Man, it was a good trip.�

The aircraft�s flying smooth.

We�re just flying along, fat, dumb, and happy.Another ramp check comes up, and Pete says,�Systems okay. Ramp check good.�

It was cold. We had the heater going, but I wascold, so I went to my suitcase and got my flightjacket out and put it on. I don�t know how muchtime went by before I decided to unbuckle and seehow ol� Bric was doing up there. I had just unbuckledmy belt and started to get up when, all of a sudden,it�s like catching one of those big updrafts. As I wasgetting up, it just threw me, slammed me up on thestructure between the heater and the closet area.Just slammed my face up there. And I�m telling you,holy hell broke loose.

I turn around, and it slaps me up against the radiocompartment. I�m airborne. I�m going, �What�s goingon?� It rips my headset off, and I can�t hear anythingbut transmissions screaming.

I can�t see anything. I mean, my face hit that postand then, like when something pops you in the eyeand you see a little bit of stars, and then all of asudden, I�m spinning back toward the closet. I can�tgrab anything. Pete�s in his seat, strapped there. He�strying to grab me. All I know is we�re just rolling. I�mgoing, �Oh God, no!� And I picture my 6-year-old boyright there. And I go, �God, no!� And Pete�s trying tohold me, and I�m looking at that seatbelt over there.I say, �Oh, God, no!� I know�we�re waiting for theimpact. You know, here comes the impact.

It throws me to the floor, and I�m trying to go forthe seatbelt over there. It�s just happening so fast.And I�m on the floor. When the aft gear touchesdown, I�m still on the floor.

Finally, I look at Pete. He mouths, �We made it.� I can hear the pilots hollering up front, and I look

up there. All of a sudden, the pounding starts.I knew THAT sound; I knew the blades wanted to

come through. It was just POW, POW, POW! I try toreach the knob to the lower cabin door so I can getthe hell outa there. But the handle was turned; it wascatching the top cabin door and I couldn�t get out. Ilooked back, and Pete already had the ramp down.He makes a beeline�I think he set a speed recordfor the low-crawl.

Finally, it gets quiet. I look up. My face is hurting;my back is hurting. And we get out of there.

It�s cold out there; I�m shaking. And I�m hurting.And I�m thinking, �What just happened?� I go backin. Pat�s still inside, standing there. We just hug eachother. I say, �Man, you guys saved our lives. What inthe world...?� He says, �I don�t know. Just thank Godwe�re on the ground.�

All I�ve got to say is that those two guys were ateam up there, and with their ability and theirexperience and their training or whatever and thegrace of God got us out of that or else it would havekilled all of us. I don�t know how they did it.

7Flightfax ww May 1998

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Iam deeply troubled that, on average, one soldierdies every 3 days in a POV accident. Thus far in

FY98, 53 soldiers have perished in POV accidents.This is a 71-percent increase over the previous year,an alarming and unacceptable trend.

The causes of these accidents arenot new or different: speeding,alcohol, fatigue, and carelessness.Use of seatbelts in many of theseaccidents could have saved soldiers�lives.

Your involvement is paramount ingaining control of this situation,influencing how our soldiers operatetheir POVs, and stopping this tragicand needless loss of life. Positive,hands-on leadership at all levels isimperative, particularly at the squadleader or first-line supervisor level.

The Director of Army Safety has developed aModel POV Safety Program. I am directing that thissix-point program be used in every unit. It is theminimum standard. The Model POV Safety Programrequires�n CCoommmmaanndd eemmpphhaassiiss.. Positive leadership at all

levels is imperative. Leader emphasis on POV safetymust be unrelenting. Our junior officers andnoncommissioned officers see their soldiers everyday. They should know where their soldiers go, whatthey do, and then assert positive influence on how,when, and where they operate their POVs.n DDiisscciipplliinnee.. Our junior leaders work with their

soldiers daily and know them well. Soldierssometimes telegraph signals that translate later intoaccidents. Negative behavior such as traffic offenses,alcohol abuse, misconduct, and poor performanceoften are indicators of potential POV accidentvictims. Identify �at risk� soldiers; counsel them; takeproactive measures to modify their risky behavior.n RRiisskk mmaannaaggeemmeenntt.. Use risk management.

Identify hazards associated with POV operations;assess the hazards; make decisions to control them;implement the controls; and supervise execution. TheDirector of Army Safety has prepared a POV riskmanagement toolbox for commanders and leaders.This toolbox provides a comprehensive set of toolsand controls that have proved successful throughoutour Army. The toolbox is available athttp://safety.army.mil. Use it. Make it available toleaders at all levels.

n SSttaannddaarrddss.. Set high and unmistakablestandards. Enforce them. Follow Army regulatorytraffic standards. Be uncompromising on the use ofseatbelts and motorcycle safety equipment. Educate

soldiers on the risks of speed,fatigue, and use of alcohol. Conductmandatory POV safety inspectionsand random roadside checks.Emphasize the use of designateddrivers for social events.n PPrroovviiddee aalltteerrnnaattiivveess.. Provide

alternatives for soldiers to drivingPOVs. Schedule activities on post tokeep soldiers on post and off theroad. Keep gyms, recreation centers,and other places soldiers use off-duty open later. These samemeasures also can provide

alternatives to alcohol use. Look for transportationalternatives as well. Promote use of alternatetransportation methods to POV use. Prominently postpublic transportation schedules. Where possible, useMorale, Welfare, and Recreation (MRW) Services toprovide buses or vans to transport soldiers to theplaces they go when off-duty. Arrange reduced hotelrates in nearby communities to encourage soldiers toremain overnight on weekends and stay off thehighways late at night.n CCoommmmaannddeerr��ss aasssseessssmmeenntt.. Following every fatal

and serious-injury POV accident, commanders willconduct an assessment of the accident with theinvolved soldier�s chain of command. Determine whathappened, why it happened, and how it could havebeen prevented. Implement corrective and preventivemeasures. Publicize lessons learned.

I have tasked the Director of Army Safety to visitmajor installations beginning in late March and briefleaders on the Model POV Safety Program. You willreceive coordinating instructions about this briefingin a subsequent message.

I want every Army leader to clearly understand thedepth of my determination to end these tragic andneedless POV fatalities. I cannot accept the currentPOV fatality trend we are experiencing. Direct,positive, hands-on leadership will make a difference.This is leaders� business at every level of our Army.�General Dennis J. Reimer; Chief of Staff, Army; 24 March 1998

General Reimer sends

CSA directs leader action against POV accidents

Flightfax ww May 19988

Soldiers are our credentials!

Getting there is half the battle

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ALSE-message update

The project manager for aircrew integrated systems (PM ACIS) recently published its annual update of messages dealingwith aviation life-support equipment. Following is a recap of current messages.n AIS 96-03, 072220Z Mar 96, overview of SPH-4/4B helmet.n AIS 96-08, 041239Z Apr 96, aviator and crewmember laser eye protection.n AIS 96-10, 051938Z Mar 96, survival ration (NSN 8970-00-082-5665).n AIS 96-15, 301900Z Jul 96, personnel distress signal kit (NSN 1370-00-490-7362).n AIS 96-18, 051531Z Aug 96, Mustang survival, MAC-10 anti-exposure suit.n AIS 96-19, 142203Z Aug 96, disassembly/reconfiguration authorization for aircraft modular survival system.n AIS 96-20, 232000Z Sep 96, requisitioning life raft and container assembly.n AIS 97-02, 052025Z Feb 97, delayed implementation of paragraph 7-6b, AR 95-3.n AIS 97-03, 052029Z Feb 97, compressed gas cylinder overhaul/inspection.n AIS 97-04, 052031Z Feb 97, use and inspection of safety harnesses (NSNs 1680-00-982-9973 and 1680-00-169-0656).n AIS 97-05, 052034Z Feb 97, battery used in distress light marker.n AIS 97-06, 052054Z Feb 97, multi-climate survival kit for OH-58D aircraft.n AIS 97-07, 052103Z Feb 97, ALSE course.n AIS 97-08, 052104Z Feb 97, manual reverse osmosis water purifier.n AIS 97-09, 031939Z Jun 97, leg straps on restraint harness (NSN 1680-00-982-9973).n AIS 97-10, 032017Z Jun 97, HGU-56/P ear-cup assembly.n AIS 97-11, 221812Z Sep 97, SARVIP modification strap kit.

Visit the PEO-Aviation web site at http://134.78.40.107 for additional news, system updates, and copies of ALSE messages. POC: SSG M. Fisher, AMCOM, DSN 897-4259 (256-313-4259), [email protected]

ShortfaxKeeping you up to date

Flightfax ww May 1998 9

�How could they have had anaccident? They were just . . .�With today�s real-world missions, commanders

anticipate hazards. They integrate riskmanagement into planning to ensure missionaccomplishment and to reduce the chances ofinjury to personnel and damage to equipment.They brief, back brief, rehearse, and supervise atthat critical time and place on the battlefield,especially on those moderate- and high-riskmissions.

But what about the low-risk missions? Everymission conducted today could have an element ofhigh risk hidden in it�especially those that are�just low-risk� missions. For example:n The most experienced crew is �just going to

land� in an observation position for a fewmoments. There�s a loss of situational awareness inthe cockpit, and the PC fails to maintain groundtrack on touchdown. Result: One aircraft destroyedat a cost of $6.6 million. n The most experienced crew is �just finishing

up an APART evaluation� on a marginal FLIR night.There�s a breakdown of crew coordination, and theSP lands the aircraft in the trees. Result: One

aircraft destroyed at a cost of $11 million.n The crew is �just doing an MOC on the

parking pad.� There�s a crew-coordinationbreakdown and a failure to follow standards.Result: two fatalities and an aircraft destroyed at acost of $6.3 million.

The next time a crew says they are �just goingto� go do something, take a few moments withthem to make sure they are not �just going to�have an accident.�CW3 �Stew� Milligan, Aviation Systems & InvestigationDivision, USASC, DSN 558-9857 (334-255-9857),[email protected]

Page 10: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

Class EFF sseerriieessn At 2000 feet and 105 knots, aircraft

went into immediate right roll,accompanied by severe vibrations. Pilot�scyclic became uncontrollable untilcollective pitch was reduced. Aircraft wasimmediately landed and shut down; itcontinued to rock until blades came to astop. Cause not reported.

Class CAA sseerriieessn Aircraft was at 500 feet msl and 100

KIAS in downwind condition when birdstruck and damaged day side of TADS.n Crew heard thump while on base leg

of traffic pattern, and SP in rear seatnoted flock of birds approaching.Postflight inspection revealed damage toleading edge of right wing in vicinity ofinboard pylon.n Bird strike during cruise flight at

night damaged windshield, wiper arm,and No. 2 engine air intake cowling.

Class DDD sseerriieessn No. 2 engine cowling door came

open during maintenance test flighttraining. Engine heat blanket was blownup into main-rotor system, damaging twomain rotor blades.

Class EAA sseerriieessn Aircraft was at 150 feet agl and 10

KIAS when wingman saw smoke comingfrom exhaust of No. 2 engine. There wereno engine-malfunction indications.Aircraft landed in field without incident.Caused by failure of No. 2 B-sump seal.Engine was replaced.n Postflight inspection revealed that

main rotor blade had debonded. Bladewas replaced.n Crew noted uncommanded lateral

flight control inputs during low-levelflight. Mission was terminated, andaircraft landed at nearby airfield withoutfurther incident. Troubleshooting withtest equipment revealed numeroussensors inoperative or out of adjustment.nWhile in cruise flight during night

unaided training flight, crew detectedburning odor in cockpit. As aircraftturned toward nearest airfield, mastercaution and shaft-driven compressorsegment warning lights came on. Crewimmediately landed and performedemergency shutdown. During egress,crew saw thick gray smoke billowingfrom catwalk area in vicinity oftransmission and rotor-head area.Inspection revealed SDC housing hadsplit.

Class CDD sseerriieessnWhen aircraft entered autorotation

as part of track and balance duringmaintenance test flight, No. 2 engine N1decreased below 60 percent and enginefailed. PTIT reached 1100°C. Crewconducted power recovery on No. 1engine and performed abort-startprocedure on No. 2 engine. Aircraftreturned to home base, where crewperformed roll-on landing withoutfurther incident.

Class DDD sseerriieessn During water-bucket mission,

aircraft approached fire from downslopeat 20 knots. When pilot increased powerto initiate climb, water bucket hit top oftree and punctured side of Bambi bucket.

Class EDD sseerriieessn Right bubble window blew out 30

minutes into flight. Crew was unable tofind window and continued mission.Reason for loss of window could not bedetermined.n On approach to unimproved area

during multi-ship external-loadoperations, aircraft encountered

whiteout due to blowing snow. As crewflew out of snow cloud, load (M105howitzer) became entangled in sling legs.

Class CJJ sseerriieessn During approach to land during NVG

flight, pilot of Chalk 3 applied additionalpower to arrest descent when the aircraftdescended below Chalk 2�s flight path.Postflight instrument monitoring systemrevealed transmission overtorque.

Class ADD((RR)) sseerriieessn Main-rotor blade struck tree during

dual-ship NVG gunnery training. Aircraftdescended and contacted groundupright. Main-rotor blade mast and tailboom separated. One .50-cal roundremained in gun chamber and seven 2.75-inch detonation rockets remained onboard. EOD personnel removed ammowithout incident. No injuries werereported.

Class CDD((II)) sseerriieessn When aircraft was picked up to

hover after refueling at civilian airport,vertical fin contacted ground, bendinglower 8-inch portion out about 90degrees. SCAS had been deactivated. Finwas replaced.n During pickup to hover, tail stinger

contacted ground, followed by verticalfin and tail rotor. Aircraft landed afterspinning to right about 200 degrees.Damage reported to tail stinger, verticalfin, drive shaft, and tail-rotor blades.

Class EDD sseerriieessn During climbout, small bird flew up

from the left into main-rotor system.Aircraft landed without incident. Therewas no damage.

Flightfax ww May 199810

Accident briefsInformation based on preliminary reports of aircraft accidents

Page 11: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

DD((II)) sseerriieessn After 1.7 hours of flight during

gunnery training at night, IP and studentnoticed breeze in cockpit. Pilot�s doorwas missing.n At completion of overwater NVG

gunnery, 14 NM from land, Chalk 2reported flames coming from enginecompartment of lead. Lead continuedpowered flight to nearest land andlanded without incident. Maintenancepersonnel found that internal metal o-ring seal had not been installed on powerturbine oil strut T-fitting.n Crew door came off and hit left-skid

during hover at 120 feet agl duringgunnery operations at night. Doorbecame hooked on the skid through ahole in the window created by impact.n During cross-country formation

flight, PI smelled burning odor. As PCtook controls, all auxiliary interior lightsfailed. PC landed aircraft in open fieldwithout incident. Caused by burned wirebehind mag compass.

Class EHH sseerriieessn Master caution and right fuel boost

pump lights came on during takeoff, andaircraft landed. Caused by cloggedejector pump.n While at stationary IGE hover,

aircrew heard two loud bangs andaircraft shuddered and yawed. Crewimmediately landed. Suspect compressorstall.n Improper aft crosstube was installed

on aircraft. Crosstube from UH-1M wasinstalled on UH-1H aircraft. Improperinstallation caused all four saddle mountbrackets to mushroom with excessiverollover of mount bracket.n During hover awaiting takeoff,

aircraft experienced violent compressorstall. Pilot reduced power and landed inplace without further incident.Maintenance replaced VIGV self-aligningbearing.

VV sseerriieessn During cruise flight, rpm warning

light came on and N2 tachometerdropped from 6600 rpm to zero. Tachremained at 324 and all other engine

instruments were normal. Caused bysheared shaft to N2 tachometergenerator.

Class BAA sseerriieessn After landing to confined area, crew

of lead aircraft noted small tree withinrotor-disk radius. On-site inspectionrevealed no damage, and aircraftreturned to home station. Inspection thefollowing day revealed damage thatrequired replacement of all four main-rotor blades.

Class DAA sseerriieessn Aircraft stabilator struck ground

during approach to unimproved landingarea.n Chalk 2 in flight of four on approach

to unimproved LZ entered near whiteoutconditions and did not see 2-foot ditch inLZ. Upon landing, aircraft rolled intoditch, and nose contacted opposite sideof ditch. Damage consisted of two largedents in front underside of nose section.

Class EAA sseerriieessn After landing during air-assault

training, passengers on both sides pulledemergency-exit handles instead of cargo-door handles. Right front cargo windowfell out, breaking the Plexiglas.n During fuel transfer on ERFS in

preparation for flight, crew noted strongsmell of fuel in cockpit and stopped fueltransfer check. CE found puddle of fuel inleft aft portion of cabin. Caused byimproper connection between fuel ventand fuel transfer line.

LL sseerriieessn Postflight after first leg of service

mission revealed ¾-inch-long skindebonding on trailing edge of tail-rotorblade.n Small wooden box entered main-

rotor system about 3 feet inboard ofblade tips during ground taxi. Nounusual flight control response orfeedback was noted.n During assault landing, right wheel

rolled into hole, causing 3-inch crack onlower right fairing.n During multi-ship landing at tactical

PZ, two aircraft at 90-degree angle underblackout conditions made evasivemaneuvers to prevent midair collision.Rotor rpm of one aircraft bled off andmain generators went off line due toabrupt maneuver. Aircraft shuddered andcrew landed aircraft abruptly. Inspectionrevealed all four main-rotor blades weredamaged by striking the ALQ-144. It isnot known whether excessivemaneuvering or abrupt landing causeddamage.

Class DFF sseerriieessn During landing flare just prior to

touchdown, bird struck left wing invicinity of stall strip. Postflight revealeddent in lower leading edge of wing.

NN sseerriieessn Aircraft was taxiing to parking when

left pod (located on wing tip) and dipoleantenna struck 2½-foot fence. Dipoleantenna broke off.

Class EDD sseerriieessnWhen power was applied for takeoff,

torque on No. 1 engine fluctuatedsignificantly. Takeoff was aborted.Caused by broken wire connector ontorque meter.

Class EDDHHCC--77n During cruise flight, crew

experienced full indication of fire on No.4 engine. After executing emergencyprocedure for in-flight fire, crewexpended both fire-extinguisher bottles,secured No. 4 engine, and landedwithout further incident. Caused by shortin fire indicating system.n Hydraulic fluid leak in left-main gear

area came from brake shuttle valve.

Flightfax ww May 1998 11

For more information on selected accident briefs, call DSN 558-2785 (334-255-2785). Note: Information published in this section is based onpreliminary mishap reports submitted by units and is subject to change.

Page 12: Lesson learned: Never give up. - Boeing Chinookchinook-helicopter.com/Flight_Fax/1998/Flight_Fax_May_1998.pdf · Lesson learned: Never give up. Food for thought. It is unacceptable

UUHH--11--9988--AASSAAMM--0033,, 225511993333ZZ MMaarr 9988,,mmaaiinntteennaannccee mmaannddaattoorryyThe UH-1 tail-rotor control tube(P/N 204-010-742-9), which is aflight safety part, has beenundergoing fatigue testing toensure that all vendors� parts meetthe strength requirements of theoriginally qualified design. Partsmanufactured by Master Swaging(cage 05056) do not conform andwill be removed from service.

The purpose of this message isto outline requirements for a one-time mandatory inspection of alltail-rotor control tubes.

AMCOM contact: Mr. RobertBrock, DSN 788-8632 (256-842-8632), [email protected]

CCHH--4477--9988--SSOOFF--0011,, 118811551199ZZ MMaarr 9988,,tteecchhnniiccaall In two reported instances, thewrong bolt was installed betweenthe aft upper boost actuators andthe aft stationary swashplate. Inboth cases, the aircraft had comeout of the refurbishment/standardization program at CCAD.In addition, confusion may exist inidentifying the correct bolt due toincorporation and labeling of theforward and aft controlsinstallation on the same page ofthe parts manual.

The purpose of this message isto require a one-time verificationof hardware installation on the aftupper boost actuators to stationaryswashplate for proper attachment.

AMCOM contacts: Mr. Dave

Scott, DSN 897-2068 (205-313-2068), [email protected];or Mr. Teng Ooi, DSN 897-2094(205-313-2094), [email protected]

UUHH--11--9988--SSOOFF--0044,, 228800113366ZZ MMaarr 9988,,eemmeerrggeennccyy Since November 1997, UH-1helicopters have operated underflight restrictions due to a trend ofspur-gear failures caused byvibrations in the aircraft�s T-53engine.

The purpose of this message isto ground the Army�s fleet of UH-1helicopters until each engine canbe tested to determine if thevibration is present.

AMCOM contact: Mr. HowardChilton, DSN 746-7271 (205-876-7271), [email protected]

Flightfax ww May 199812

IN THIS ISSUENever stop flying the aircraft . .2The view from the cockpit . . . . .3The view from the cabin . . . . . .6CSA sends: POV accidents . . . . .8How could they have had anaccident? . . . . . . . . . . . . . . . . . .9ALSE-message update (SF) . . . .9

WWSS -- WWaarr SSttoorriieess,, CCCC -- CCrreeww CCoommmmoo,, SSFF -- SShhoorrttffaaxx

Flightfax is published by the U.S. ArmySafety Center, Fort Rucker, AL 36362-5363. Information is for accident-prevention purposes only and isspecifically prohibited for use forpunitive purposes or matters of liability,litigation, or competition. Addressquestions about content to DSN 558-2676 (334-255-2676). Addressquestions about distribution to DSN558-2062 (334-255-2062). To submitinformation for publication, use fax DSN558-9478/3743 (Ms. Sally Yohn) or e-mail [email protected] our website at http://safety.army.mil

Burt S. TackaberryBrigadier General, USACommanding General

Aviation safety-actionmessage

POV-fatality update through March

FY98 = 56FY97 = 35

n No seatbelt n Speed n Fatigue

No newcauses, justnew victims.

Aviation messagesRecap of selected aviation safety messages

Safety-of-flightmessages