My friend, Chief Warrant Officer Smith, lost his life in the summer of 2009. The accident investigation identified many root causes and systemic defects. What is truly unfortunate about this accident is another member of the organization, CWO Jones, had brought these deficiencies to the attention of our previous supervisor. When the supervisor failed to take corrective action, Jones went to the next supervisor in the chain of command. Again, no action was taken. It wasn't long after this that the tragic accident occurred. Sadly, this is often the case.

Smith had been promoted to the section supervisor after the previous supervisor retired. He had a true love of flying, dedicated himself to the organization and tried to make it better -- largely by listening to the other aviators around him. His loss had a tremendous impact on the organization. With Smith gone, Jones was the only helicopter pilot in the organization and was put in charge of the section.

The loss of the aircraft had shut down the helicopter section. Jones was determined to fix the system defects before the new helicopter arrived to the unit. He went to work immediately. He started with the basics, drafting standing operating procedures based on operations he had previously noted at other locations. He identified training defects and manning shortages and lobbied in the name of aviation safety to have them filled. Using this back-to-basics approach, Jones was able to have programs and policies in place when the new helicopter arrived.

Jones was under extreme pressure to rush the new program; however, he refused to cave in. He demanded everyone to follow the program. He flew missions only when necessary and put training ahead of all else. New pilots and additional aircrew members were hired and placed in the training program. When opportunities came for more efficient operations, Jones made the changes. When unexpected problems were encountered, they were evaluated and appropriate actions were taken. The program continued and was actually ahead of schedule. Pilots received the required training, and aircrew members, in this case tactical flight operators, were developed. No one was flying missions before they were ready.
Fast-forward two years. Another pilot in command, CWO Dixon, had bee
n "raised" through the program. He had been signed-off the previous week and, for his first mission, took the aircraft to a location where it would be a static display. A simple mission, if there is such a thing, in which he could become more comfortable operating the aircraft as PC. The crew was briefed, another process developed by Jones, and a pilot and the TFO flew the mission. Everything was normal during takeoff and the 30-minute flight, but that was about to change.

During the final approach to landing, the aircraft began to yaw uncontrollably. Dixon immediately identified the problem and maintained his airspeed so he could control the aircraft. He directed the TFO to get out the operator's handbook and go through loss of tail rotor emergency procedures. Dixon notified tower of the emergency, and the airfield began preparations for an aircraft crash. Dixon continued to troubleshoot the problem, but it matched nothing in the handbook. His only course of action was a power-off autorotation. The airfield was prepped, the aircraft entered autorotation and Dixon completed a perfect landing without damage to the aircraft or injury to the crew.

I don't want to take anything away from Dixon's superior airmanship. It was superb; but what I want is leaders to take something away from this whole scenario. Everyone has been in a unit where one guy thinks the sky is falling, but the commander briefs how great his unit is doing. What I would like is to challenge leaders at all levels to determine the true status of your organization. I once had a commander sum it up for me when it came to hearing differing opinions: "The truth lies somewhere in the middle." Recognition of a unit's systemic defects is vital to preserving its fighting capabilities.

Sometimes an organization is forced to take a step back to move forward. The goal of all leaders should be to recognize the need to reset the unit prior to a tragic accident like the one that occurred in this organization. Set standards and stick to them. Ensure your organization is combat ready with clear, defined and obtainable standards before sending them into combat.

Editor's note: The names of the individuals involved in this incident have been changed to protect their privacy.