Monday, October 5, 2009

Blame the Dead Pilots?

Blame the Dead Pilots?
By Jamie McIntyre Monday, October 5th, 2009 12:37 pm
Posted in On Media, Readings and Reviews
Whenever there is a major aviation accident, it usually turns out there is a series of factors that contribute to the cause, any one of which could have changed the outcome.  As safety investigators weigh those factors, they tend to settle on the final, often fatal, mistake.   Except when there’s a clear case of mechanical malfunction, it often comes down to “blaming the dead pilots.”   But it’s also important to understand how the pilots were put in a position to make that mistake, and to consider whether inadequate training, lack of safety equipment, or other pressures were equally at fault.  In other words, were good pilots set up to fail?
That is the impetus behind the quixotic quest of Congressman Walter Jones (R-NC), who has for years been trying to clear the names of two Marine Corps pilots who were blamed for the deadly crash of a V-22 Osprey in 2000, a crash that almost claimed the entire V-22 program among its casualties.  Read Jone’s Letter Here
The April 8, 2000 accident in Marana, Arizona was blamed on “human factors,” which has been widely interpreted in the news media as “pilot error.”   The proximate cause was that the pilots, following another V-22’s lead, descended too quickly, putting the plane into a “vortex ring state” while in helicopter mode.   The loss of lift caused the fiery crash, which killed all 19 Marines on board, including the pilots: Maj. John A. Brow, 39 and Maj. Brooks S. Gruber, 34.
At the time, many critics (cynics?) thought the Marine Corps was anxious to blame the pilots to avoid the perception that the V-22, with sophisticated computer-assisted avionics, was too “unforgiving” to be flown safely in combat conditions.  That perception could well have doomed the troubled program.  But experts I talked to blamed general overconfidence of V-22 crews, and the fact that some pilots routinely ignored the “placarded” limit for the rate of descent of 800 feet-per-minute.   The pilots on the mishap aircraft were going down at least three times as fast.
That clearly was the final mistake that caused the crash, but in appealing to the Navy to revise the record, Congressman Jones has reviewed the official investigations and public records and talked with other aviation experts and come to a different conclusion: namely that the fatal factor was “the aircraft’s lack of a Vortex Ring State (VRS) warning system as well as the pilots’ lack of critical training regarding the extreme dangers of VRS onset in the Osprey.”  In a “Memorandum for the Record” he has requested be placed in all official records relating the accident, Rep. Jones writes, “Lieutenant Colonel Brow and Major Gruber and their families are dishonored by the assertion that the aircrew was in any way responsible for this fatal accident.”
REQUEST DENIED
I understand the intent of Jones’ crusade.   The cause of the accident was far more complex than simply “the pilots screwed up.”   But accident investigations are done in a way that is designed to totally insulate them from any outside factors, including sympathy for the families or political pressure.  And that’s how it should be.
I think the official response that Jones got from Rear Adm. A. J. Johnson, Commander of the Naval Safety Center, was exactly right.  Rear Adm. Johnson wrote, “All safety investigations are conducted solely to determine root causes and identify corrective actions, not to assign blame or document accountability.  Aviation safety investigations are conducted by a team of specialized investigators, including at least one professional aviation safety investigator. They are exceptionally adept at what they do, and they have access to all of the expertise and resources within the Department of the Navy in reaching their conclusions. Their process, which is tried and true after more than 50 years of experience, is closed to outside influences. It would be inappropriate to alter the official safety investigation report by appending your Memorandum for the Record.”
But that doesn’t mean the pilots are being depicted fairly in media accounts as the sole cause of the accident.  Training was a factor, as evidenced by the emphasis post-accident training has put on understanding and avoiding vortex ring state, and subsequent improvements in the flight software that helps the pilots avoid the problem.
For a dispassionate view, I asked my old pal Rick Whittle, a former Dallas Morning News defense correspondent, for his take.  Rick has written extensively on the V-22, and has a book coming out next year [The Dream Machine, the Untold History of the Notorious V-22 Osprey]
Here’s what he e-mailed me:
“Before I investigated the crash for my book, I thought the Marines were using a euphemism when they called the cause “human factors,” but I’ve changed my mind. I interviewed a number of Marines who were on the mission that night – including four pilots who were in other Ospreys and the copilot and crew chiefs of the Osprey that led the way into Marana. What they told me, and other evidence I gathered, makes it clear that a lot of things contributed to that crash, and they didn’t all happen in the cockpit of the Osprey that went down. For that matter, they didn’t all happen that night. “Human factors” may be about as close as you can come to describing those causes in two words.
In any event, “pilot error” makes it sound like John Brow and Brooks Gruber were cowboys taking reckless chances, and that wasn’t the case. They were two of the best pilots in the Marine Corps.
They were coming down too fast when they went into vortex ring state, but they were flying wingman for another Osprey and following it in to Marana. The first Osprey descended too fast, too, partly because its pilots got distracted during the mission and started their descent into the airfield late. They were part of a big exercise that night, and there were a lot of other things going on.
I tell the full story in the book.”
Sounds like a great read.
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AJM · 193 weeks ago
ONLY IN CASES IN WHICH THERE IS ABSOLUTELY NO DOUBT WHATSOEVER SHOULD DECEASED AIRCREW BE FOUND NEGLIGENT”

AP3207 – RAF Manual of Flight Safety, Chapter 8, Appendix G, page 9.
/web/20130618002051/http://www.chinook-justice.org/

Here in the UK there has been a similar controversy regarding RAF Chinook pilots posthumously blamed for a fatal crash in 1994.

'The evidence against two special forces pilots who were blamed for crashing an RAF Chinook helicopter into the Mull of Kintyre, killing all 29 on board, was too thin to reach such a damning verdict, campaigners for the servicemen claim today'.
/web/20130618002051/http://www.timesonline.co.uk/tol/news/uk/article6407986.ece
+1
Tregonsee 49p · 193 weeks ago
These are very old numbers, ca 1975, and for military aviation. At that time, if even one crew member survived to testify, even a non-pilot such as a flight engineer or loadmaster, the likelihood of finding crew error as the primary cause was half of what it was if all aboard were killed. With the greater use of black boxes on military aircraft, the ratio is lower today, but there is still an discrepancy.
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brusty · 193 weeks ago
I think we have to be careful with the term "human error". In a sfaerty investigation this is not interchangeable with "pilot error". Human error can be improper training or education for the pilots that is out of their hands and precedes the accident.

Vortex ring state is an annomally of rotor-wing flight that does not occur in fixed-wing flight. The human error of the accident could be placing two experienced fixed-wing aviators in the same ****pit with limited rotor experince. In that case it is not the pilot error, but a breakdown in training on much higher levels.

Human error should never excuse others or the military aviation community from making needed changes.
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TheSwabbie · 192 weeks ago
Human error could mean that bugs from the Flight Engineers lunch flew in the eyes of both the pilot and copilot causing temporary blindness and distraction enough to loose control of the aircraft.. that COULD be construed as human error (as stupid and silly as it sounds). I've flown (on P3s) with some great Naval Avaitors who on a number of occasions did some magnificent flying in some difficult circumstances and situations.. Fire in engines when you are 500+ miles north of Iceland - Over the cold North Atlantic.. in the Arctic Circle. No room for error there - and we got home... DRY.
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Alan Diehl, Ph.D. · 191 weeks ago
Congressman Jones' efforts are commendable. As explained in my book "Silent Knights: Blowing the Whistle on Military Accidents and Their Cover-Ups," a senior Pentagon official tried unsuccessfully to get me assigned to that investigation "to keep the Marines honest." I was a former NTSB and USAF aviation psychologist who had long campaigned to get officials to systematically examine the underlying causes of "human error." Needless to say the Marines refused that request, just like they'll do with the Congressman's efforts.
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luke · 187 weeks ago
It is allways blamed on human error when a computer is involved,look at all th F/A-18 crashes never has one been blamed on the plane.even when it first came out and when using night vission in flight not all of the insterments could be read like say the altimator and yes it could not be read and we had 2 planes go into the ground at night both pilots were wearing night vison at the time but they were blamed and not the plane or equipment.
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