Breaking the Chain
June 30, 2011
The crew had just returned from a 12-month deployment. They were re-integrating into the routine flight training of the commander’s task list. After a long, accident-free deployment in a challenging environment, flying in their own backyard didn’t seem all that risky.
This all-too-common mindset is prevalent in Army aviation. As Army aviators, we are conditioned to believe we are “Above the Best.” This is a necessary belief for us to complete the most difficult tasks. Unfortunately, when asked to complete the less difficult tasks, we often do not give them the same attention to detail in all aspects of planning and preparation. The problem this night wasn’t that the task was easy, but the perception that it was easy because so many aviators had accomplished it before, including those crewmembers flying this Black Hawk.
The tasks flown this beautiful night under night vision goggles were Task 1155, Negotiate Wire Obstacles, and Task 2024, Perform Terrain Flight Navigation. The crew was transitioning from nap-of-the-earth flight with the intention of doing an over-wire crossing at a known and approved wire obstacle. Regrettably, on this night, the training flight ended abruptly when the UH-60 contacted two static lines associated with high-tension power lines.
First, I want to make something clear. This is not about pointing fingers or blaming individuals. That has already been done. We now must all learn from this mistake " or should I say from these mistakes because there were several opportunities to prevent this accident if a link had only been broken.
In our training, we have all heard of the infamous accident chain and the connecting links that lead to an aircraft accident. If at any point leading up to the accident a link is broken by a sound decision, the accident is prevented.
This training flight was originally a two-ship mission. However, the first aircraft, which had an instructor pilot and air mission commander onboard, was mission briefed but had to cancel due to a maintenance issue found on preflight. The second aircrew decided to continue their training flight, although they had never been briefed directly from the briefing officer. Since this training flight entailed terrain flight with a wire obstacle, a face-to-face briefing discussing the hazards and techniques of negotiating a wire obstacle might have been enough to break this link.
The crew was familiar with this route; however, this particular wire obstacle was actually an underwire crossing. Yet on this night, the crew felt they would mitigate the risk by crossing over the wires. On the surface, this sounds like a good decision; however, GPS waypoints used in conjunction for an underwire crossing are plotted between the stanchions, not directly over them. This would have been the place to cross when flying over a wire obstacle. In addition, as the crew continued on the route and the GPS was counting down their distance, they attempted the wire crossing without seeing the wires. This also might have been enough to break the link.
Aviation accidents come in all shapes and sizes. However, accident reports have concluded that nearly 90 percent aviation accidents have human factors as the primary cause. To quote Pogo, “We have met the enemy and he is us!” When I say “us,” I am not merely assigning that position to the individuals in the front seat of the aircraft. This can apply to commanders, briefers, crew chiefs or the line guy who sees something that doesn’t look right, but never speaks up. Usually when an accident occurs, it doesn’t just happen unless it is a mechanical failure. Accidents happen because no one breaks the link to a sequence of events leading up to them.
Fortunately, for this crew, the Wire Strike Protection System and a lot of luck were in their corner on that night and they walked away without a scratch. We might not be so lucky next time if “you” are not willing to break the chain.