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We Made it, but let’s not do that again!

  • Published
  • By Maj. Jen Yates
  • HQ AMC/SEF
Sicily Drop Zone, Pope AFB, circa 2000. It was a young crew by 2000 standards. It included a brand new aircraft commander; first time off-station as an AC, an experienced co-pilot, a middle-of-the-road flight engineer, a navigator flying for the first time off-station without an instructor, and two new loadmasters with an experienced instructor. The DO signed off on this young crew's trip to Pope based on their performance in upgrade training as well as perceived maturity. There was also the caveat that they would always be number two in the formation and never on their own.

As every good C-130 crew knows, the lead aircraft always breaks, especially when lead is flying a good old E-model. The crew quickly found themselves hauling jumpers around the routes and dropping pass after pass of paratroopers on Sicily. They were feeling very confident and definitely cocky. Now they were single ship, successfully flying the mission, patting themselves on the back for being so good. Confidence is good, but over-confidence is not.

The second part of the mission was to accomplish engine running onloads from Sicily Landing Zone. The conservative method was to land, taxi back to pick up the paratroopers, ERO, taxi back and take off in the opposite direction from landing. The crew quickly determined that this method wasted time and was not very "flashy," and began brainstorming whether they could take off the same direction as landing. The FE computed the TOLD, and yes indeed, the crew could take off. The pilot briefed the departure and the crew looked at all the tall trees at the departure end. The nav briefed the obstacles and got the watch ready for the time check. "Hack," "Timing," "Go," "Rotate." Silence. Really big trees. Climbing ... slooooooowly. Really big trees, lots of leaves. More silence. Time slowing. Did I mention there were REALLY BIG TREES?! Trees that the aircraft was approaching QUICKLY?! Time then slid into that slow motion "Matrix" phenomena. The crew members were all holding their breath in that subconscious attempt to lighten the aircraft; willing the aircraft to be lighter so it would somehow miraculously climb over the trees.

The aircraft did make it over the trees, but just barely. The crew was still eerily silent. The FE was wondering if that smell was emanating from the co-pilot because of his high protein diet or a present in his flight suit. He was also wondering whether there were going to be leaves in the landing gear (there weren't). The navigator still swears they were close enough to the trees to see a bug on a leaf waving through the co-pilot's kick window. Silence continued on for a few more seconds (which still seemed like eternity) then simultaneously the crew let out a collective sigh of relief -- WOOHOOOO -- followed by verbiage that can't be stated in this publication.

That story is just one of many that I've heard throughout my years in flight safety. The crew of that aircraft had a happy ending and I'd like to think they learned something from the experience. I wish I could say this happened 12 years ago and isn't relative today, but unfortunately it is still very relevant.

AFI 91-204 lists several human factors that can be used during mishap investigations to assist investigators in determining causal factors. Below you will find merely three -- factors that have been present in recent Class A's and B's, HATRs, ASAPs, and the scenario I presented above.

The first factor is assertiveness. Assertiveness is the commonality that will tie into all the other factors I point out in this article. Assertiveness is a factor in mishaps when individuals fail to state critical information or solutions with appropriate persistence. Pressures come from external sources (deployed commanders, supervisors, CAOC, TACC) and internal sources (crewmembers).

External players all have missions to execute. Planning has occurred and risk has been assessed, mitigated, and accepted, but the operational environment is dynamic. In many cases, the external players are not in the moment experiencing what the crew sees in real time and they are not in the mind of the crewmember. These players are not aware of all the strengths and limitations of the crew.

Internal pressure depends on the number, experience, and personality of the crew members. Some days are tougher than others to stand up and call timeout. However, one poignant tidbit a former instructor told me was to speak up if something does not look right because, while it may be the pilot that does something stupid, I, as the navigator, will die a tenth of a second after him/her. Everyone on the crew has the responsibility to be assertive and point out when something has been entered incorrectly into a computer, a radio call has been missed, altitude/airspeed are off, or any other thing that may ultimately end in a mishap. Ask the questions, know the directives/instructions/rules, and speak up when something doesn't seem right.

The second common factor is limited total experience. This occurs when a supervisor selects an individual who has performed a maneuver, or participated in a specific scenario infrequently or rarely. Unfortunately because of budget constraints and operational demands, supervisors have had to weigh the risks and make tough decisions, but ultimately crews have to accomplish the mission and know when their limits are reached. This ties back to factor one, assertiveness. You should know your strengths and limits and be willing to stand up and say something or take necessary action when your limits have been passed.

The last factor I want to discuss is overconfidence, which often goes hand in hand with limited total experience. Overconfidence occurs when the individual overvalues or overestimates personal capability, the capability of others, or the capability of aircraft/vehicles or equipment, which leads to an unsafe situation. Supervisors may observe high performing individuals at home in a vanilla (predictable) environment and perceive that extra pressure or risk can be handled by the crew or the individual while off-station. It again falls on the crewmember to recognize their own strengths and limits and be assertive when pushed beyond the limits.

That's just three of many human factors that have occurred not only in the BIG TREES incident, but have presented themselves in recent mishaps and events. Crews frequently share stories like the one above. One way to communicate such instances is via an ASAP report -- doing so could prevent another crew from repeating your mistakes! Please continue to share your stories, but most importantly learn from past mishaps, stand up for yourselves, and make safety a priority.

2013 Critical Days of Summer Campaign

This year's campaign will run from 1600 hrs 24 May - 0700 hrs 3 Sept. The theme this year is "Safe n' Sound, All Year Round." The AMC Commanders kick-off video will be available on the Mobility Airman YouTube page NLT 15 May at this link:
www.youtube.com/MobilityAirman

For additional summer safety contact your local installation safety office.