Learning from the Past
After completing a hilltop resupply mission, the pilot-in-command conducted an accelerative nose-low takeoff while following the descending terrain. As the decent continued, the aircraft lost longitudinal control and impacted the ground. This resulted in seven fatalities, one injured crewmember and a destroyed aircraft. (Photo Credit: Photo courtesy of U.S. Army) VIEW ORIGINAL

Mishap Summary: A UH-60L Black Hawk crew’s mission involved three legs. The first leg was to conduct reconnaissance around key terrain in the local flying area. The second was to support an internal unit reenlistment. Both legs were completed without incident. The third leg of the mission was to resupply an outpost within the local flying area, which included both internal and external loads. The first portion of the resupply leg involved internal loads. Upon delivering the internal loads and while back at the unit airfield, the aircraft experienced four consecutive auto mode failures of the stabilator. The crew made the decision to continue the mission and departed the airfield to conduct the sling load resupply mission. During the sling load mission, the aircraft experienced an additional three consecutive auto mode failures of the stabilator while hooking up a water bladder external load. The aircraft experienced an eighth and final auto mode failure of the stabilator upon approach to the outpost with the water bladder. The standardization pilot (SP) made the decision to leave the stabilator in manual mode after the auto mode failure and the crew finished executing the sling load mission. Upon departure from the outpost, with the stabilator still in manual mode and in the full down position, the SP conducted an accelerative nose low takeoff following descending terrain. As airspeed increased the aircraft experienced a loss of longitudinal control and impacted the ground.

Over the past decade, the U.S. Army Combat Readiness Center (USACRC) has transformed itself regarding how it informs the broader Army of the results of safety investigations and associated approaches to risk mitigation. The purpose of the safety investigation generally remains the same as it did in the 1950s when the USACRC was first established as the Army Accident Review Board: determine what happened during the mishap sequence, determine why the mishap happened and conclude what can be done to prevent similar mishaps.

Advances in technology, mostly in the area of flight data and cockpit voice analysis, have helped investigators streamline the process. A fourth element to the safety investigation process was also added to better inform the greater aviation community of the mishap facts and associated risk mitigation. Following the official safety investigation outbrief to the mishap unit’s senior commander, the director of Army Safety and USACRC commander now distributes a one-page summary to select general officers highlighting the salient lessons from the mishap.

Each printable summary provides a synopsis of the mishap, key facts and actionable recommendations to mitigate similar events from occurring in the future. The reports are then uploaded to the Lessons Learned portal on USACRC’s homepage. The portal, which was developed in 2017, currently contains more than 60 ground and aviation mishap summaries that are available to leaders and units to aid them in their safety programs. Gone are the days when the final safety investigation report sat dormant on a shelf after the investigation was completed and mishap unit was outbriefed.

The unfortunate mishap recounted at the beginning of this article resulted in seven fatalities, one injured crewmember and a destroyed UH-60L Black Hawk helicopter. However, the story doesn’t end there. This mishap summary, along with the many others on the USACRC website, will give aviation leaders a reference document to train and mentor aircrews well into the future. We know all too well that those who fail to learn from the mistakes of their predecessors are destined to repeat them.

Visit the USACRC’s Lesson Learned page at https://safety.army.mil/lessonslearned. A CAC login is required.

Readiness through Safety!