A Simple Mission

By JOHN H. STRICKLANDHeadquarters, U.S. Army Reserve Center Fort McPherson, Ga.May 9, 2011

The mission was simple. An OH-58C had made a precautionary landing on the range and needed a part flown out. It would take about 30 minutes to replace the part and then the aircraft could be signed off and flown back home.

Chief Warrant Officer 3 Jason Merrill (a fictitious name) was tasked to perform the single-pilot support mission. He was told to take along a technical inspector (TI) and a crew chief to perform the work and then return to base in the repaired aircraft.

Merrill did the normal things - preflight, weather check and mission planning. The mission brief was simple; after all, it was a simple mission. He knew the range by heart - every landing zone (LZ), road and checkpoint. Navigating was a cinch; he wouldn't have to rely on a map. Of course, he'd take it along with all the other required publications. He believed in doing things by the book.

The only thing that bugged Merrill was the weather. He didn't like flying single pilot at night. Ever since he had gotten used to night vision goggles (NVG), night unaided had lost its luster. Besides, quite honestly, he hadn't flown unaided in a good while. This was the "Cav," where night flights meant goggle flights. He looked at the weather information closely. The sky was clear, the moon would be up and visibility unrestricted. As he prepared a local flight plan, he thought about the fact that this was the fall - hot in the day and cool at night. Ground fog was coming fast on the range.

"Oh, well," he thought. "I know that range like the back of my hand - every creek, every lake where the fog likes to hide." Besides, he would be returning early, before the fog began to settle in over the low areas.

The flight to the downed aircraft was uneventful. After shutting down, the TI and crew chief went to work. Merrill talked with the aircraft's two aviators, kidding the pilot in command (PC) about causing him to miss getting home early and having supper with his family.

"Should have let you stay out here - good survival training," he joked.

The work took longer than expected, but, about an hour later, it was time to head for the barn. At first, the pilots of the now-repaired OH-58 suggested Merrill follow them back. However, as they discussed the idea, they realized they hadn't been briefed for formation flying and decided it wasn't a good idea.

Merrill told the other crew to take off first. He would wait a few minutes and then follow. After all, they were going in the same direction. As long as they were not in formation, it shouldn't be a problem. Everyone agreed.

On the flight home, both aircraft kept their distance but maintained internal FM radio communications. Merrill kept the lead aircraft's position lights in sight as they exited the range.

Except for the fact they had been delayed almost 90 minutes, everything was going smoothly. It was simple to follow the route back - mostly range roads - but patches of ground fog were beginning to show in low areas.

About five minutes from home, things began to go wrong. The fog got worse, and Merrill lost sight of the lead aircraft. One call assured him they were OK and had the airfield in sight.

Suddenly the fog thickened. Merrill told the TI, who was in the left seat, to let him know if he began to lose sight of the ground. The pilot slowed the aircraft a little but decided to maintain altitude.

Should he turn around' He could still see the ground and the PC of the lead aircraft had just flown through the weather without any problems. Merrill knew they had followed the same route and were no more than a kilometer ahead.

When Merrill was almost to the exit point where he would change frequency from range control to the airfield tower, he looked to his right. The terrain was mostly open fields, which, at night, looked like a black hole.

Suddenly, engulfed in fog, the crew rapidly lost all visual contact with the ground. How deep was this fog' How high was it' Was it a simple scud layer' Single pilot at night on instruments' Should he climb' Descend' Do a 180' That didn't sound smart. Neither did the idea of flying in this soup.

The TI saw a "sucker hole" and said, "Your left, sir."

Merrill immediately turned left, descended through the hole, leveled off and looked for an open field. He knew there was a field somewhere to his left off the range road. Below there were trees and more trees, and it was getting difficult to maintain visual reference. Then, straight ahead, he saw the field he had been searching for. Before landing, Merrill made a quick call to unit ops to inform them he was landing and shutting down. They could come get him - he didn't intend to fly back tonight.

As Merrill and his crew sat by the fire they'd built in the field where they'd landed, the fog continued to roll in. He looked at his TI and crew chief and realized he could have killed these young Soldiers. Merrill realized his poor choices not only could have killed himself but, also, his buddies.

What had seemed like a simple mission had turned into a close call - brief seconds of fear and high-risk decisions.

This is a true story. I know because it happened to me about 25 years ago. I am "Merrill."

Never Underestimate Those Simple Missions

Much can be said of how safety programs and improved aviation technology have reduced risk and significantly lowered our overall accident rates. However, regardless of that progress, we aviators are still the same human beings who flew the first biplane. Though more knowledgeable, we are still capable of making the same errors we've always made.

We have been successful at standardizing our equipment and technology has allowed us to improve equipment across the board. As human beings, however, we have to improve one at a time. That is the reason standardization is critical. It allows us to train each aviator to a particular level and standard.

What went wrong on this night was that the humans involved were not adhering strictly to standards. I had completed the risk assessment sheet with all the right numbers and it had come out "low risk" - nice if everything goes perfect, which it seldom does.

I had not flown unaided in quite a long time, and it's not the same as flying NVG. I knew that, but I wasn't going to turn down a mission because of it. I didn't consider it to be a serious factor. In addition, we fudged on the formation flight. Sure, we were legal, but we weren't very smart. My intentions were to keep the other aircraft in sight - we would "unofficially" flight follow each other. What I did not know was that the other crew was flying NVG, and that's why they had fewer problems than I did. Of course, since we were not "flying formation," there had been no need to brief, so critical information was never shared.

Last, but hardly least, was the weather. The risk level changed when the timeline changed - the weather was changing even as we were discussing our takeoff. And my decision-making process left out still another critical fact as we droned along that night: the other aircraft was a kilometer ahead, and that made a difference.

The only weather you should trust absolutely is what you are seeing out your cockpit window. That night, the weather was saying, "Land!" I hesitated almost 30 seconds too long, and that could have cost my life and the lives of my crew. The ability to learn from your own mistakes is a blessing, not a given. I was allowed to learn from my experience.

It's not our equipment or the environment that causes most of our accidents. Machines and environment are fairly predictable. We can plan on these with acceptable accuracy. Human beings are not quite as predictable; they make decisions that lead to accidents. It's not too difficult to determine what they did wrong, but determining why is more challenging.

Lessons Learned

From this event, I learned what I call my Top 10 "why" lessons.

1. Most "extremely high" risks are self-imposed. Actions we take in flight or on the ground usually are influenced by personal motivation or unplanned responses to a situation. Whether it is desire to complete the mission, ego or simply not thinking consequences through, the result can be catastrophic.

2. The response to accepting "high" risk is influenced more by actual outcome than by possible outcome. If we gamble and succeed, we are more apt to see it as a good decision than a bad one. Too many times we insist on learning our lessons from accidents rather than close calls. Both can teach the same lesson.

3. It's better to have a damaged ego than a damaged aircraft or body. Many times, we go that extra 30 seconds simply because we cannot or will not admit we've exceeded our capability or made a mistake or bad decision. That leads us to make an even greater mistake or worse decision.

4. Every aviator will be faced at least once in his or her life with making a decision in which the outcome can mean the difference between an accident, a close call or a good no-go choice.

5. Aircrew coordination must involve effective communication and teamwork. One thing I remember most is the silence between the TI and me during our flight. I never communicated my concerns to him (or him to me) about continuing to fly that night as visibility grew worse. He was ready to land and get out several minutes before we ultimately did. The crew of the other aircraft never communicated to me that they were flying NVG. Two highly skilled pilots do not automatically equal good aircrew coordination.

6. Making a critical decision based on a self-imposed emergency is seldom done without hesitation. The same professional pilot who will instantly respond to an emergency, such as an engine failure, may hesitate to abort a mission because of fatigue, bad weather, poor forward-looking infrared radar conditions or a simple personal conflict with another crewmember. We don't react as quickly to internal warnings as external ones.

7. Risk management during every phase of mission planning reduces unpredictable "human" actions. We reduce risk by reducing unpredictable actions. Accident-causing errors usually result from individuals' unplanned actions, and unplanned actions are usually due to unidentified risk.

8. We must seek to anticipate and eliminate every risk. Every aviator must be prepared to identify risk and work the process through to completion. Don't accept unnecessary risk, no matter what phase of the mission you're in.

9. There are no simple missions. The more we identify and eliminate risk, the greater our opportunity for success.

10. Every flight should start and end with standardization. Human beings are the most complicated of the man-machine-environment mix. There is no substitute for training to standards and enforcing those standards. Ignoring standards will cause accidents.

Summary

My Top 10 "why" lessons are not all-inclusive. When it comes to safety, nothing is. Accidents do not just happen; they are caused. The goal of every individual in the unit should be to ensure that nothing he or she does will cause an accident. And, because you may not get the chance to learn from your own mistakes, take every opportunity to learn from someone else's.