a pilot’s first hac flight€¦ · 1094-0405x online) is published twice a year by commander,...

ApproachThe Navy and Marine Corps Aviation Safety Magazine

A Pilot’s

First HACFlight

An Unexpected CRM Drill

2019, Vol. 62 No. 4

Approach

CONTENTSThe Navy & Marine Corps Aviation Safety Magazine

2019 Volume 62, No. 4RADM Mark Leavitt, Commander, Naval Safety CenterCAPT Roger L. Curry Jr., Deputy CommanderCMDCM Baron L. Randle, Command Master ChiefNaval Safety Center (757) 444-3520 (DSN 564) Publications Fax (757) 444-6791Report a Mishap (757) 444-2929 (DSN 564)

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Mishaps cost time and resources. They take our Sailors, Marines and civilian employees away from their units and workplaces and put them in hospitals, wheelchairs and coffins. Mishaps ruin equipment and weapons. They diminish our readiness. This magazine’s goal is to help make sure that personnel can devote their time and energy to the mission. We believe there is only one way to do any task: the way that follows the rules and takes precautions against hazards. Approach (ISSN 1094-0405) and (ISSN 1094-0405X online) is published twice a year by Commander, Naval Safety Center, 375 A Street Norfolk, VA 23511-4399, and is an authorized publication for members of the Department of Defense. Contents are not necessarily the official views of, or endorsed by, the U.S. Government, the Department of Defense or the U.S. Navy. Photos and artwork are representative and do not necessarily show the people or equipment discussed. We reserve the right to edit all manuscripts. Reference to commercial products does not imply Navy endorsement. Unless otherwise stated, material in this magazine may be reprinted without permission; please credit the magazine and author. Approach is available for sale by the Superintendent of Documents, P.O. Box 979050, St Louis, MO 63197-9000, or online at: bookstore.gpo.gov. Telephone credit card orders can be made 8 a.m. to 4 p.m. Eastern time at (866) 512-1800.Periodicals postage paid at Norfolk, Va., and additional mailing office. Postmaster: Send address changes to Approach, Code 022, Naval Safety Center, 375 A Street, Norfolk, VA 23511-4399. Send article submissions, distribution requests, comments or questions to the address above or email to: [email protected].

On the cover:Aviation Ordnanceman 2nd Class Raemont Rozier uses hand signals to communicate before an F/A-18F Super Hornet of Strike Fighter Squadron (VFA) 154 launches from the flight deck of the aircraft carrier USS Theodore Roosevelt (CVN 71). Photo by Mass Communication Specialist 3rd Class Josiah J. Kunkle.

Pages4. When Corporate Knowledge is Not So Corporate -- LT Mason Berry

6. An Unexpected CRM Drill -- LT Allie Cameron

8. My Right or Your Right? -- LT Brian Dalliare

10. Eight-Part Answer to a Four-Part Problem -- LT Jeff Graham

12. ‘She’s Going Hot’ -- LT Justin Engel

14. Spin Doctors: Prop Jockeys Solving Problembs -- LT Mahmood Alaverdi

16. Take it Around -- LT Loren Bluhm

18. My First HAC Flight -- LT Ethan Horn

20. Pump the Brake -- LTJG Julius Jones

22. Bravo Zulu

Adam Hyams, Deputy Director CDR Roger Leech, Aircraft Operations

[email protected] Ext. 7226

[email protected] Ext. 7117

All [email protected] Ext. 7811

Nika Glover-Ward, Editor [email protected] Ext. 7257

Approach Staff

Aviation Safety Programs Editorial Board

CONNECT WITH US

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VOL. 62 , NO. 4 | APPROACH MAGAZINE2

COMMANDER’S PERSPECTIVE

In “A Design for Maintaining Maritime Superi-ority 2.0,” former CNO Adm. John Richardson highlights the importance of data-driven decision making in maintaining the Navy’s competitive ad-

vantage. From a safety perspective, data enables com-manders to identify hazards more quickly and reduce risk more effectively, ultimately preserving warfighting capability and combat lethality. As Sailors and Marines, our job is warfighting. Mishaps degrade our ability to fight effectively, costing lives and resources. It is crucial that we fight back with data to not only learn from past mishaps but also to predict and prevent future ones.

Since the Naval Safety Center’s establishment in 1951, as the Naval Aviation Safety Activity, the rate of aviation mishaps has declined dramatically. This reduc-tion can be attributed to many programs and policy im-provements, including the Naval Aviation Maintenance Program, NATOPS, crew rest, Aircrew Coordination Training, Crew Resource Management and Operational Risk Management. Despite these improvements, Naval Aviation still suffers the loss of aircrew and aircraft in preventable mishaps. One area that has raised specific concern is the significant rise in Class C mishaps since 2013. Although we have identified some of the contrib-uting factors, there are still other unidentified factors potentially influencing mishap rates. To understand the scope of the issue, the Naval Safety Center and our Navy and Marine Corps partners are studying man-ning, experience, training, proficiency, sustainment and equipment shortfalls to determine their effect on

Editor Approach andMech MagazinesNaval Safety Center

EDITORIALAs you read through this issue of Approach, you’ll see

that some of the events depicted took place two years or more ago, but the content and lessons are still relevant. We have quite a catalog of submissions to choose from, and we’re working hard to include all that we can. Thanks for being patient with us as we get to them all. Sailors and Marines have done a great job of providing us with good content. There are times that some submissions need to go ahead of others, especially if it’s time sensitive in terms

of becoming irrelevant if it doesn’t publish the year it’s submitted. Contact our office directly at 757-444-3520 or email us at [email protected] about your submissions.

I hope you enjoy this issue, and don’t forget to see if you can find the Raven on the cover.

RADM Mark Leavitt, Commander, Naval Safety Center

Data Matters... mishap rates. To get ahead of the mishap curve, we are combining the traditional historical event-driven trend analysis with a forward-looking probabilistic approach to identify leading indicators, which can signify in-creased mishap risk. The only way to conduct the kind of analysis required to solve these systemic issues is to have the data. This has been a challenge, and we need your help!

When you see a safety issue, report it. Report-ing mishaps is obvious, but we also need to report near-misses and close calls. Many times, the difference between a near-miss and a mishap is “seconds or inch-es.” Get your safety chain of command involved, and prompt them to conduct a proper investigation. If you are conducting the investigation, put the effort into discovering the “why” and not just recalling “what” happened. If you are writing a HAZREP or near-miss, include as much detail as possible. Accurate and com-plete data allows the types of analyses that enhance our ability to prevent mishaps, save lives and preserve fleet combat readiness. As we move from a culture of compliance to a culture of excellence, remember that I am your advocate and I’m counting on you to “get left of the bang.” As we face great power competition, we must maintain our competitive advantage and keep the United States Navy the greatest Navy in the world.

Help us help the Fleet!

3VOL. 62 , NO. 4 | APPROACH MAGAZINE

Approach

It was going to be great! Our ship, USS Carl Vinson (CVN 70), was scheduled to conduct flight operations around the Northern Marianas Islands for nearly two

weeks before our first port call on Guam. I had done my junior officer tour in Guam at HSC-25 and had great mem-ories of flying around the Marianas Islands. The course rules were easy and the scenery was beautiful. The weather was warm and tropical. My current squadron, HSC-4, was planning on getting as much overland training done as possible while we were around Guam, so I was excited for the opportunity to see the island again and showcase my knowledge of the area. As the ship steamed west toward the island, I offered to brief the ready room on the local course rules.

I was confident that I remembered all the major land-marks and could safely navigate the relatively simple airspace around the island. After sending a few emails to HSC-25 to confirm that nothing substantial had changed, I put together a short briefing and scheduled a time with operations to get the pilots and aircrew together.

Everything was as I remembered it. The eight visual flight rules (VFR) reporting points

around the island had not changed. There were still only two major airfields, and the majority of the airspace to the south was still uncontrolled. However, there was one substan-tial change: the theater high altitude air defense (THAAD) system on the northern end of the island. This part of the island was once a viable training area for helicopters, but it now was an off-limits area with strict boundaries.

A review of the latest HSC-25 course rules had provided the coordinates for the boundaries and our Joint Military Planning System (JMPS) Officer had programmed our Per-sonal Computer Memory Card International Association (PCMCIA) cards with the airspace to ensure we did not accidentally fly through it.

Since the THAAD was on the north end of the island, most crews would stay well away from it, as the south end was where most of the overland training would be con-ducted. However, on this particular night, our flight crews decided to use a training area that was on the north side of the island.

It was a dark night with no moon, and our dual-ship

BY LT MASON BERRY

When Corporate Knowledge is Not So Corporate

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An MH-60S Seahawk helicopter attached to Helicopter Sea Combat Squadron 25 (HSC-25) lands on the flight deck of the amphibious assault ship USS Wasp (LHD 1) . Photo by Mass Communication Specialist 3rd Class Michael Molina.

training required several iterations of the same procedure with some junior pilots. To mitigate the risks, we opted to use the larger and better lighted landing sites at this north-ern training area rather than the more challenging sites down south. This area was also closer to Andersen Air Force Base where we would be getting fuel. The closer proximity and shorter transit meant that we could get a bit more train-ing done before refueling and heading back to the ship.

In our brief, the Squadron Duty Officer (SDO) reviewed the applicable notices to airmen (NOTAMs) which included a temporary flight restriction (TFR) over the north end of the island that began at 2,600 feet mean sea level (MSL) and went up to 14,000 feet MSL. We discussed remaining below the TFR and outside the THAAD bound-aries while also maintaining our situational awareness to ensure we did not accidentally violate the THAAD airspace while conducting our training. I offered to lead the flight into Guam since I was familiar with the area.

We took off on time and began our transit to the island at 500 feet above ground level (AGL). As we approached Guam from the northeast, I set the flight up on a course that would keep us about a mile outside THAAD airspace

and below the TFR as we transited around the north end of the island to the west side.

“Did we just get a flight violation?” The flight lead was talking on our squadron tactical frequency. My co-pilot and I looked at each other and didn’t understand what was going on.

“ATC is calling us on Guard,” was the next thing I heard on the tactical frequency. Sure enough, Guard monitoring had been de-selected by the previous crew and we had not heard the calls from ATC. However, I checked our position on the tactical display and confirmed our altitude. We were at 500 feet AGL, below the TFR shelf from the NOTAM we had been briefed about, and we were well outside the THAAD boundaries on our display.

“I show us well below the TFR and well outside the THAAD boundary,” I replied.

“They gave us a number to call when we land, we’ll worry about it when we refuel,” said our flight lead.

Landing to get fuel two hours later at Andersen AFB, I exited the aircraft and walked into the HSC-25 squadron spaces and called the number. ATC confirmed our call sign and said that we had violated a TFR as we approached the island. I told her that we had been well below the TFR altitude of 2,600 feet MSL and outside the THAAD bound-ary. She said there was an additional TFR that extended three miles around the THAAD boundary that began at the surface and went up to 10,000 feet MSL.

She gave me a NOTAM reference number. I apologized and gave her a phone number for contacting the squadron on the ship. The HSC-25 SDO and I looked up the NOTAM. She was right, of course. There was an additional TFR right where she said. Thinking back to our flight path, I was certain we had violated it. A few weeks later, the Federal Aviation Administration contacted the squadron to report a “pilot deviation” and sent us the radar tapes showing our flight flying directly through the TFR.

I had let my confidence about flying around Guam prevent me from doing basic flight planning. I had relied on the SDO to brief all applicable NOTAMs and had not followed up myself. This oversight resulted in two aircraft violating a TFR. In the high op-tempo of deployment flight operations, it is easy to rely on corporate knowledge and the work of others for pre-flight planning. However, as professional pilots, it is our responsibility to take the time to accomplish all appropriate pre-flight planning ourselves. Had I taken the time to read the NOTAMs myself, this could have been easily avoided.

At the end of the day, I was the aircraft commander and was responsible for the safe and orderly conduct of my aircraft. I was also the lead aircraft as we transited that night. We were lucky that there was not something more significant happening inside the TFR. We could have easily found ourselves in an unsafe situation. In the future, I will be sure to not rely solely on my own corporate knowledge, or anyone else’s, as well as follow up on any SDO briefed items to ensure their accuracy and thoroughness.

When Corporate Knowledge is Not So Corporate


Approach

On a particularly busy day for my crew flying a KC-130T at Air Test and Evaluation Squadron (VX) 30, we were tasked with picking up and dropping off

cargo for the AIR-5.3 Threat/Targets Systems Department between Naval Base Ventura County (Point Mugu), Naval Auxiliary Landing Field San Clemente Island and Naval Air Weapons Station China Lake, Calif. On the last flight leg, after all of the heavy and delicate equipment was delivered, our crew resource management (CRM) training was tested to the extreme.

While returning from China Lake to Point Mugu at 8,000 feet, our aircraft experienced a complete loss of util-ity hydraulic system fluid. One of the loadmasters imme-diately notified the cockpit crew over ICS that hydraulic fluid was pouring out at a rapid rate in the aft section of the cargo compartment. He also said that it was misting out in atomized form, making it far more hazardous due to inhala-tion. Following his notification, the cockpit crew confirmed that the utility fluid pressure was rapidly dropping on the engine instrument display system.

I immediately instructed the copilot to secure the utility system pump switches in accordance with NATOPS emergency procedures, which if done expeditiously would trap any remaining fluid in a wrap-around section of the hydraulic lines, preventing cavitation and catastrophic pump failure. I then instructed the loadmasters in the cargo compartment to put on oxygen masks to avoid inhaling the atomized fluid, and instructed the flight engineer to refer to the NATOPS flight manual to accomplish the remaining emergency procedure steps. We also asked the loadmaster to check the system reservoir in the cargo bay, where he observed that the entire utility system fluid had emptied.

Once the remaining checklist steps were executed and the aircraft was stabilized, the flight engineer proceeded aft to inspect the situation. He discovered that the utility rudder diverter solenoid valve had burst off its mounting location in the rear of the cargo compartment, causing the utility hydraulic fluid to deplete rapidly.

I knew things were about to get even busier. Without the utility hydraulic system, we would have to manually drop the landing gear and hand crank the flaps down to reconfig-ure the aircraft for landing. Upon landing, I would not have the normal brake system, anti-skid, or nose wheel steer-ing available. On top of all that, the sun was quickly going down, and we were about to perform a time-consuming emergency procedure at night with a task-saturated aircrew after a long day. Not exactly an ideal situation and not one that could be rushed if we were to make a safe landing.

I directed my copilot to declare an emergency and request to circle above Point Mugu at 5,000 feet to provide the necessary time to manually crank flaps and extend the

landing gear, run all emergency and normal checklists, and brief the loss of affected systems and subsequent land-ing and wave-off contingencies. We also coordinated on VX-30 base frequency to notify maintenance control and the squadron duty officer of the situation. The loadmasters shared the job of making more than 300 hand crank turns, while on oxygen, to lower the flaps to 50 percent. This entire time, communication was hindered by oxygen masks and atomized hydraulics, which created the effect of smoke in the fuselage. They then completed the manual landing gear extension procedure.

Once all procedures were safely accomplished, we com-pleted all the normal descent, approach and landing check-lists. I briefed the landing roll out, noting that the normal brake system, anti-skid, and nose wheel steering would be unavailable. I also briefed that in the event of a wave-off, the flaps and gear could not be retracted and that I would verbalize if I needed additional power. The crew also spoke with the VX-30 C-130 pilot NATOPS instructor over base frequency to confirm that all procedures and considerations had been discussed.

After descending to pattern altitude and flying an extended final, I made an uneventful and safe full stop landing on runway 21 with over 11,000 feet of useable runway length. I made judicious use of reverse thrust to accommodate the lack of normal braking and nose wheel steering and to mitigate the risk of a blown tire due to lack of anti-skid. I then taxied off the active runway using dif-ferential thrust and shut down on the taxiway. We declined assistance from ground emergency crews, and maintenance provided us with a tow back to the VX-30 line. The three loadmasters indicated that they had headaches and were instructed to seek medical attention.

This scenario presented multiple CRM challenges in an unusual and uncommon failure mode. The lengthy coordi-nation that was required was made more difficult by having crewmembers on bulky oxygen masks that require push-to-talk comms. In spite of all of this, we were lucky that other factors were not against us that day, like inclement weather, low ceilings or visibility, strong winds or a severe bird condition during twilight hours at Point Mugu. We were also lucky to be at a familiar airfield with many internal and external resources. Above all else, we did not rely on luck—we relied on the communication and coordination skills necessary to handle an unexpected malfunction. The loadmasters had the knowledge and familiarization with in-depth emergency procedures thanks to the training they received to prepare them for any array of malfunctions, to include this rarely-encountered scenario. The entire crew had great CRM on our side, and the commanding officer recognized our crew with a BZ for its outstanding work!

An Unexpected CRM DrillBY LT ALLIE CAMERON



A KC-130T prepares to transport in support of Operation Damayan. Photo by Mass Communication Specialist 3rd Class Ricardo R. Guzman.

Approach

Our mission was a simple airways navigation flight from our home base of Naval Air Facility (NAF) Atsugi, Japan to the unfamiliar airfield of Marine

Corps Air Station (MCAS) Iwakuni, Japan, as two sections of F/A-18E Super Hornets.

The weather that day was progressing worse than fore-casted and we were forced to execute individual instrument approaches into MCAS. As we commenced our approach into Iwakuni, our initial concern was whether or not we would be able to effectively circle to land due to the low visibility. The minimums for the circling approach are a 520-foot ceiling and 1.5 statute miles of visibility. The field weather was reported as a scattered cloud layer at 1,500 feet and a broken layer at 2,200 feet with the visibility right at 1.5 statue miles and heavy rain. We were confident the instrument approach would get us below the layers, but the visibility was a bit disconcerting.

As I commenced the approach surveillance radar (ASR) approach, I was advised by the ground-controlled approach (GCA) controller that this would be an ASR to runway 02, circle to land to the east for a left downwind to runway 20. He requested a call advising him when I would be discon-tinuing the approach and executing circle to land proce-dures to the right for a left downwind.

Besides the heavy rain and turbulence, the approach was fairly uneventful. Around four nautical miles (nm) from the field, at 1,000 feet, the approach lighting system became visible. I continued following the controller’s course correc-tions due to the poor visibility until the airport environment became clearer.

Around two nm, and just at approach minimums (550 feet), I advised the GCA controller that I was discontinu-ing the approach and making a right turn to circle to land. Approaching the threshold of runway 02 to my left, tower broadcasted over the GCA frequency that I needed to make a right turn to the left downwind for runway 20. Based on the voice inflection and urgency noticed in tower’s trans-mission, I was immediately confused on which direction I was instructed to circle to land for runway 20.

With my only focus in the cockpit on keeping sight of

the runway environment, the use of left and right in tower’s instructions quickly became incredibly confusing. I began questioning whether or not I may have missed a radio call instructing me to circle to land to the west of the field rather than east -- the direction I was currently headed. I immediately requested that the tower verify the circling procedures, to which they simply repeated their previous transmission: a right turn for a left downwind.

Once again, the voice inflection suggested that my cur-rent location was wrong. Lacking assertiveness, I made the impulsive decision to respond to the tower that I was now turning left for a right downwind to runway 20. I hoped that the tower would now see either an incorrect turn to the downwind and immediately interject on my correction, or would remain quiet, indicating I was making a valid correction.

With no response from the tower, I was convinced that I had been instructed to circle west of the field and was now following their directions. It was not until I had already crossed completely over the runway, at the midfield point, that tower advised I was now circling in the wrong direc-tion. They quickly instructed me to reverse direction, again, to try and circle to land to the east of the field. However, at this point, safety of flight became the ultimate priority, and I decided to land my aircraft. With a completely outside scan for obstructions of flight, as well as keeping the runway environment in sight, I advised the tower that I was initiating a right base for runway 20 and needed clearance to land. The tower immediately responded with clearance to land.

The right base pattern that I flew to touchdown brought my aircraft over Iwakuni at a very low altitude, inevitably causing concern for the local population below. By simply being assertive on my current location, as well as my inten-tions, I could have easily avoided an incorrect circling pro-cedure in very undesirable conditions to an unfamiliar field. Although I felt rushed and crunched for time while exe-cuting the circling approach, by taking a few extra seconds to listen and comprehend what instructions the tower had given me, I could have analyzed and performed the correct procedures without hesitation.

BY LT BRIAN DALLAIRE

MY RIGHT OR YOUR RIGHT?



An F-18E Super Hornet assigned to the Royal Maces of Strike Fighter Squad-ron (VFA) 2 launches off the flight deck of the Nimitz-class aircraft carrier USS George Washington (CVN 73). Photo by Aviation Electronics Technician Airman Josiah Connelly.

Approach

Fleet Logistics Support Squadron (VR) 64 is leading the charge to improved performance and quieter opera-tion of Navy and Marine Corps C-130s. Shortly after a

July 2017 Marine KC-130T mishap in Mississippi, Naval Air Systems Command (NAVAIR) recognized a fault with the current C-130T propellers and instituted a red stripe for the Navy and Marine Corps KC-130T community.

Following the red stripe, NAVAIR instituted new proce-dures for ensuring replacement propellers were airworthy. A thorough investigation and evaluation of the solution using the current propeller system made it clear that the platform needed another way forward. NAVAIR decided that a more reliable system was vital to the platform’s success into the future.

The NP2000 propeller system, an eight-blade variant from Hamilton Sundstrand, was implemented successfully on the E-2C/D Hawkeye and C-2A Greyhound in the Navy’s inventory in the mid 2000s. To meet the needs of the aging Navy and Marine Corps KC-130T fleet, NP2000 was selected

to be installed on all aircraft.The NP2000 propeller system will help NAVAIR and the

KC-130T improve operational performance while reducing maintenance time and cost. With its eight composite blades and enhanced electronic control system, the NP2000 offers several benefits:

• Reduction in vibration and interior noise (approximately 15dB sound reduction in the cockpit.)• Thrust increase (approximately 20 percent increase in low-speed acceleration).• Simplified operator interaction with the system.Reduction in vibration and noise significantly decreases

aircrew fatigue. Cockpit noise in the KC-130T with the legacy propeller system is around 110dBs. The new system brings the levels down to approximately 95dBs, five times quieter than current operations. High noise environments have been shown to degrade reaction times due to noise fatigue. This significant reduction in noise may lead to increased safety by decreasing the effects of noise fatigue.

BY LT JEFF GRAHAM


An MC-130H Combat Talon II, prepares for flight during Exercise Trident 18-4. Photo by Staff Sgt. Corban Lundborg.

Eight-Part Answer to a Four-Part Question

Performance numbers are still being fleshed out on the NP2000. Current operations are subject to significant restrictions as NAVAIR continues to research the increase in performance. An increase in low-speed acceleration should provide increased performance margin where it counts most: low-speed flight in critical phases of flight.

Unlike the C-130’s legacy system, the NP2000 allows operating squadrons to remove and replace individual blades without removing the entire propeller system. This enhancement provides critical value to operators by signifi-cantly reducing maintenance time and cost while increasing maintenance flexibility and the aircraft’s availability.

Since the majority of the KC-130T fleet is part of the Fleet Logistics Support Wing (CFLSW), VR-64 was approved to receive the first Navy KC-130T with the NP2000 propeller system installed.

With the arrival of the first NP-2000 Hercules last Octo-ber, VR-64 has been diligently preparing maintainers, quality assurance personnel, flight engineers, and pilots to be ready to maintain and operate the new system aboard its KC-130Ts.

Squadron maintenance personnel attended two days of

classroom instruction and three days of hands-on training in building up hub assemblies and installing new propeller blades in addition to poring over system schematics and theory of operation.

In addition, a maintenance crew of 10 from CFLSW and VR-64 spent two weeks during the modifications, gaining knowledge of the propeller system installation and preparing the aircraft for its return to Joint Base McGuire-Dix-Lakehurst.

After the arrival of the aircraft at their home station, VR-64 will provide additional training to other CFLSW squadron aircrew and maintainers, and the squadron will prepare the next two aircraft for modification.

The long road to the final product has allowed VR-64 to apply deliberate operational risk management principles in introducing the new system to its own personnel, and later the fleet.

With a solid plan in place, and the support of NAVAIR, the squadron is ready to safely, effectively and professionally incorporate NP2000 into the logistics community, allowing the Condors of VR-64 to continue to play its critical role in our country’s national security strategy.


Eight-Part Answer to a Four-Part Question

Approach

“She’s Going Hot ! ”

The call was simple and routine in nature, however, it was in the middle of a cycle in which

the need to get off deck quickly could not be over emphasized. The sun had just set but there was still some “pinky time” prior to complete darkness.

We quickly talked through the operational risk management (ORM) process and the helicopter aircraft com-mander (HAC) made the call to shut down to reseat the fasteners because the air plan would keep our fixed-wing assets flying well into the night. Upon shutting down, the carrier changed course, giving us a bit of a crosswind on engine start and rotor engagement, but still well within our engagement envelope. Once the maintenance was done to reseat our popped fasteners, we promptly began running through the alert launch checklist to expedite getting off the deck.

During engine start, everything was routine until we engaged the No. 2 Starter. Our gas generator speed (Ng) indication was sluggish but did not warrant aborting the start. As our turbine gas temperature (TGT) fell below 80 degrees Celsius, we moved the power control lever (PCL) to idle and the engine started, again, routine in nature.

I remember a distinct sound of a sort of “knocking” (compressor pop-ping) that was quickly interrupted by my HAC saying “Oh buddy. She’s going Hot!” I looked down at my display to see that the TGT indication was quickly rising through 851 degrees Celsius (our start TGT limit). I promptly reached up and brought the PCL off and completed the rest of my critical memory items to abort the start. We sat there for a moment and discussed the emergency

procedure (EP) and how we would attempt the subsequent start. On the next startup, we motored the engine for one minute and waited until TGT was below 50 degrees Celsius prior to intro-ducing fuel. The next startup on the No. 2 engine was routine and we promptly got off the deck to an uneventful plane guard flight.

I want to take a moment to highlight the importance of ORM and utilization of standard terminology in the aircraft. So many times, I remember briefing for a plane guard flight and talking about the normal things such as our crew day and currency in the aircraft. However, we rarely talk about what is different about today’s particular flight.

Even on a flight that we’ve seemingly done a hundred times, there are things that will always be out of the ordinary. It is paramount to discuss and remain vigilant to better combat it when the rotors start turning. Just as important as ORM is using standard verbiage in the cockpit. On the call of “She’s going Hot,” I had to process what was being said before immediately snapping to my hot start emergency procedure (EP).

Although the time to process what was said was immediate in this case, it may not be that way down the road when the stakes are higher. Clear and concise terminology is outlined in every Naval Air Training and Operating Procedures Standardization (NATOPS), providing a foundation that allows us to fly together interchangeably. In general, our community is not great at using standard terminology. In this instance, had the HAC used the stan-dard emergency procedure terminology of “Abort Start,” my response would have been immediate!

BY LTJG JUSTIN ENGEL

“Sir, walk around is complete, but we have two popped fasteners on the tail.”



An MH-60S Seahawk helicopter assigned to Helicopter Sea Combat Squadron (HSC) 14 hovers while awaiting cargo pallets during a replenishment-at-sea as the Ticonderoga-class guided-missile cruiser USS Mobile Bay (CG 53) cuts through the Pacific Ocean. Photo by Mass Communication Specialist 3rd Class Connor D. Loessin.

Approach

As Naval aviators, we make many decisions during the course of a flight from mission planning to debrief. Due to the life or death nature of aviation, these

decisions may often have dire consequences. In order to make the best decisions and manage the risk inherent in Naval Aviation, it is imperative that aircrew consider how decisions are made in the cockpit and think critically to optimize the decision-making process. With time and expe-rience, pilots become comfortable with their aircraft, mis-sions become “standard,” and the same decisions are made again and again. When unfamiliar problems arise, however, aircrew must use their aerial skill, technical knowledge, and a sound decision-making process to arrive at a safe and effective resolution.

My crew had one such flight on August 23, 2016, when we were scheduled to fly a functional check flight (FCF), profile B, to check the proper functioning of a new starboard engine which had recently been installed. This profile requires that the replaced engine be shut down and restarted airborne. It is one of the only times that the E-2C NATOPS flight manual allows an otherwise properly functioning engine to be shutdown in-flight. Single-engine operation is not a normal regime of flight but FCFs are common enough that my crew and I were confident in our abilities to conduct the flight safely. However, two unexpected events would test our airborne decision-making skills.

The first instance occurred shortly after takeoff when the pilot noticed a minor malfunction affecting the port engine, the one on which no prior maintenance had been conducted. The NATOPS procedure for this malfunction recommended that we “continue normal operations.” Of course, our mis-sion today required abnormal operations: an engine shut-down. As a crew, we discussed our situation. Attempting an engine shutdown with a known malfunction on the operating engine was an unnecessary risk and one we were unwilling to accept. We elected to land and let maintenance check our port engine for any critical faults prior to continuing the FCF.

On deck, the mechs successfully cleared the malfunction. With plenty of time and fuel, we decided to make another attempt at the FCF. Shortly, we were airborne once again and this time, with no abnormal indications on either engine, the starboard engine was shutdown and the propeller feathered normally.

Before executing the airstart, the NATOPS airstart pro-cedure was verbalized and the responsibility for each crew-member was briefed. When the pilot placed the condition lever to the airstart position, there were initial indications that the airstart was progressing normally; however, the propeller blades never moved from the feather position and rotation was not achieved. After 15 seconds with no propeller movement, the pilot moved the condition lever back to the feather position as prescribed by NATOPS. None of the crew

Spin Doctors: Prop Jockeys Solving ProblemsBY LT MAHMOOD ALAVERDI


had encountered this issue previously. Since we had a con-trollable aircraft and we were not otherwise under duress, we decided to go through the procedures again ensuring that all circuit breakers were set and all switches and levers were in the correct position. Again, the propeller failed to unfeather.

Following our procedures in NATOPS, we executed the airstart—prop failed to unfeather checklist. This checklist attempts to induce a successful unfeathering by reseating electrical connections and using an override command to the propeller’s hydraulic pump. Again, the propeller failed to unfeather.

At this point, our situation was outside the scope of any NATOPS procedures. We elected to contact maintenance and speak directly to the mechanics in the hopes they could provide additional means of troubleshooting. They suspected a possible malfunction of the electronic propeller control (EPC), the computer that electronically controls the propeller blade angle (as well as the airstart function). They suggested pulling and resetting three EPC circuit breakers in a spe-cific order in an attempt to reboot the EPC. We obliged in their request and then attempted yet another airstart of the starboard engine. This time, the propeller moved from its full feather position and rotation was observed. It was an unusu-ally slow airstart but the engine started and operated within limits. We landed uneventfully shortly after that.

This flight tested our decision-making skills and left us, as aircrew, with several important lessons. First, decision making is an analytical process, not a dogmatic process. There is a limit to the amount of troubleshooting that NATOPS provides in its procedures. As described in the preface to NATOPS, procedures provide specific solutions to common or time-critical problems; they cannot “address

every situation completely or be a substitute for sound judg-ment.” Our failure to restart the engine in flight proved to be outside of any procedure found in NATOPS. In the absence of any categorical guidance, further troubleshooting required that we make decisions based on knowledge of the aircraft systems and critical reasoning skills while considering the context of our mission and environment.

Additionally, optimizing the decision-making process requires we use operational risk management (ORM) during all phases of flight. The deliberate ORM practiced in the preflight brief helped provide the appropriate framework for the decisions made airborne. In flight, time-critical ORM was integrated into our analytical process. Our decision to land instead of continuing after the first engine malfunction was made with this maxim in mind: accept no unnecessary risk. The ORM process is inherent in sound aeronautical decision making.

Finally, resources must be leveraged to the maximum extent possible for effective decision making. When the crew had all but exhausted our own systems knowledge, we turned to a maintenance subject matter expert to provide novel insight. Their suggestions helped us not only restart our engine but further isolate the malfunction for trouble-shooting on deck.

Our profession is an unforgiving one. We cannot afford to make decisions haphazardly or rely solely on rigid checklists. We must look critically at our own decision-making process and consider how rigorously we apply that process while airborne. It’s easy to become complacent going through the motions of a typical flight; but when the unexpected hap-pens, the aircraft and crew always depend on the execution of safe and effective decision-making skills.


Two E-2C Hawkeyes fly in formation during a training exercise. Photo by Mass Communication Specialist 2nd Class Thomas Peterson.

Approach

On July 1, 2014, a beautiful VMC day, our flight out of Naval Air Station (NAS) Lemoore quickly turned into a flight to remember. Within ten minutes of takeoff, the

flight was interrupted by the failure of the left generator in my F/A-18E Super Hornet aircraft indicated by a L GEN caution. Utilizing good crew resource management (CRM), I commu-nicated with the squadron duty officer (SDO) on the base radio frequency and completed all procedures using my NATOPS pocket checklist. I decided to return to base and land the aircraft. After coordinating with approach control and tower, I made my way back to NAS Lemoore and into the day landing pattern. After entering the pattern, I completed my landing checklist and received clearance to land.

No malfunctions were apparent in the cockpit; gear was down and locked with flaps set to full. As soon as I touched down I noticed a light in the gear handle, a flashing left main gear light, and the audible gear tone. The jet had no problems with handling as I continued down the center of the runway. My first thought was that I had some sort of sensor failure because I had no loss of directional control with the aircraft. I began to brake; as soon as the aircraft began to slow it swerved aggressively to the left, and I departed the runway at speeds near 80 knots. I reached for the ejection handle, pulled, and the simulator immediately froze. “It’s on freeze, you are cleared to get out,” my simulator instructor said. Not properly reacting to indications and completing the necessary NATOPS boldface procedure was an easy lesson to learn that day with no real consequences. A disappointed sim instructor was the worst thing I faced and I lived to finish the Fleet Replacement Squad-ron.

On March 16, 2017, a terribly dark night flight out of NAS Fallon, quickly brought back the memory of my disappointed sim instructor. The mission was a division, night self-escort strike during the Strike Fighter Advanced Readiness Program (SFARP) detachment that my squadron was conducting as part of our biennial training requirement. Start-up, taxi, and takeoff were uneventful and no mechanical issues were noted. The mission went mostly as planned and ended in mission success. The division lead fenced out the flight, and my section lead and I detached to return to base as a section. We followed the vectors given to us from approach control, soon had the field in sight, and we then proceeded to the initial for pattern entry. After entering the pattern, I completed my landing checklist and received clearance to land. No malfunctions were appar-ent in the cockpit; my gear was down and locked and flaps set to full. As soon as I touched down I noticed a light in the gear

handle, a flashing left main gear light, and the audible gear tone.

My first thought was that I had some sort of sensor failure because I had no loss of directional control with the aircraft. At that moment, my disappointed sim instructor’s voice echoed in my head and reminded me to execute the NATOPS boldface procedures and go around. As I selected max afterburner and began to accelerate, I felt a slight pull to the left as my aircraft began to fly again. As soon as I was airborne, all indications disappeared and my cockpit was again quiet with no tones. I coordinated with the tower for an altitude sanctuary, leveled off, and began to coordinate with the SDO on the base radio. I did not change my aircraft configuration since I did not know what failure I had (if any).

After executing good CRM with the SDO, I completed all procedures using my NATOPS pocket checklist. I then began to coordinate a fly-in arrestment. Tower cleared me for a short-field arrestment on the off-duty runway because they did not want me to foul the main runway in use. As I began to set up for the fly-in arrestment, I soon realized I could not see where the arresting gear wire was located. I could not see the arresting gear location lights either, and I had no time to get a landing signal officer (LSO) on station for a “paddles” talk-down into the runway arresting gear. The runway did have an Improved Fresnel Lens Optical Landing System (IFLOLS) providing glideslope reference, so I elected to fly a center ball (or as close to glideslope as I could) to touchdown. I was almost certain the “meat ball” would probably drive me short of a fly-in arrest-ment, however, I was confident that I would have the ability to maintain directional control until arrestment based on aircraft performance during my first landing attempt.

As soon as I touched down, I put the throttles at idle. Again, the light in the gear handle, the flashing left main gear light, and the audible gear tone appeared. Once again, my jet tracked straight and I had no directional control issues. I rolled about 300 feet into the arresting gear and I immediately knew I had a good trap. The aircraft began to decelerate, and I felt a hard pull to the left. I countered the pull by applying right rudder to use the nose wheel steering and it only helped slightly. I came to a stop in the center of the runway and I had about a 30 degree left heading difference when compared to the runway. The crash crew made their way to my jet and chocked the wheels.

I waited a few minutes for maintenance personnel to tow my aircraft back to the line. When they arrived they immediately signaled to me they would not be able to tow the aircraft with-out more equipment, so I shut the aircraft down and gave them

TAKE IT AROUND!BY LT LOREN BLUHM


custody of the jet. I climbed out of the jet, down the ladder and saw the left main landing gear cocked with a thirty-degree inward cant angle. The tire itself looked to be made of fabric, as it no longer possessed rubber. How the tire did not explode or come apart I do not know. The planing link had failed, as it was just dangling from one end. Adrenaline shot into my veins at that moment. There is no doubt in my mind that my jet would have departed the runway had I not executed the proper emer-gency procedure.

The first lesson I learned that night is the same lesson I

learned as an FRS student three years prior -- always react and treat indications from the aircraft as if they are a worst-case scenario. I could have trapped with no planing link failure that night, but the potential for negative consequences from not exe-cuting the proper procedure were extremely high. I continually try to remind myself that traps are free, even if it is just precau-tionary. And even though they may not be “completely” free, they are much less costly than the loss of a jet or worse, loss of life. The second lesson I learned is that we are the best-trained pilots in the world.


An E/A-18G Growler from Electronic Attack Squadron (VAQ) 141 and an F/A-18E Super Hornet from Carrier Air Wing (CVW) 5 launch from the flight deck aboard the USS Ronald Reagan (CVN 76) during flight operations. Photo by Mass Com-munication Specialist 2nd Class Janweb B. Lagazo.

Approach

Though my day started like any other on the ship, I knew this one would be different. This day would be my first flight as a helicopter aircraft commander

(HAC). The flight was scheduled for 4.5 hours of day plane guard (PG). Despite being a relatively simple flight, I was a little nervous and eager to start passing on my acquired knowledge to the next generation of Navy helicopter pilots and aircrewmen.

The flight brief went off without a hitch. We discussed our mission and any operational risk management factors that would affect our ability to complete the flight that day. After the bulk of the brief was over, the crew started discussing what training we could complete during our flight.

Our hot seat was quick and professional. Shortly after takeoff, we completed our check-ins, and began investigating surface contacts. Knowing that we were going to hot seat this aircraft into night PG, I decided to test the automatic approach functionality. Per our T/M/S NATOPS, the auto-matic approach function is required for night PG; otherwise, the aircraft is not search and rescue (SAR) capable at night. I briefed the crew on my intentions and we began working the automatic approach checklist. Seven miles from the carrier, my copilot began a 360-degree turn to refine the wind di-rection indicator and ensure our approach would be into the wind. I was heads down reading the checklist when I heard over the ICS, “We have a fire light.”

My initial thought was, “You’re messing with me, right?” After realizing that we, in fact, did have a fire light, the months of HAC training took over. Critical memory items (CMIs) were completed by each crew station and our crew chief opened the engine fire in-flight checklist. I instructed my copilot to immediately turn toward the carrier as my crew chief began reviewing the checklist. After a few tense seconds and following the checklist, we determined that we did not have an engine fire. However, we still had a fire light. I checked the fire detector switch position to make sure it didn’t inadvertently move to the test position without our knowledge. It was in the correct position. I told my copilot to make 30-60 degree heading changes to determine if the sunlight was the cause. If this was the source of the problem, I expected to see the fire light at least flicker. It didn’t. Un-able to come up with any other trouble-shooting techniques, I asked tower for a squadron representative to inform them of our issue, and communicate our intent to land for trou-ble-shooters. Three miles astern, and clear of the fixed-wing

aircraft on approach, I contacted tower and requested spot seven.

I elected to take the landing since I was in the left seat and spot seven requires a left slide for landing. Once my copilot announced landing checklist complete, we began reviewing our plan to execute the landing safely. I briefed my intent to make a normal, left slide-in approach since we were confi-dent we did not have an actual fire. As expected, our landing was uneventful.

In reality, we were not experiencing an actual emergency. However, I couldn’t help but let out a sigh of relief as the wheels touched down. A mere 45 minutes after takeoff on my first HAC flight and we were back, safe on deck. Maintainers immediately swarmed the aircraft and, within a few minutes, they confirmed what we already suspected; we had a fault somewhere in our fire detection system. After a thorough

BY LT ETHAN HORN

My First HAC Flight


conversation with my crew, I relayed to tower that we would remain spinning on spot seven until they could get the alert 30 aircraft off deck. Later, I followed up with maintenance control and learned that the culprit was a faulty relay that had gone bad just over 30 minutes into our flight.

As we sat on the deck, waiting to finish the shutdown checklist, I couldn’t help but shake my head and laugh silently to myself. I don’t know anyone who would admit to honestly enjoying the process of becoming a helicopter air-craft commander. It’s a period defined by more senior pilots using scenarios to test your knowledge, decision making and crew resource management skills. Some pilots can make the transition from helicopter second pilot to helicopter aircraft commander more easily than others. Some pilots need a little more polish before they can shine. One thing was for sure, at that moment: I was thankful for all the time other helicopter

aircraft commanders had spent preparing me. The mindset that “it will never happen to me” is dangerous. A helicopter aircraft commander must always be ready for the aircraft to “not respond” as predicted.

That is why we are there, to use every resource in our grasp to complete the mission and bring the crew and air-craft home safely. Even at the moment where I thought there is no way this is happening, the months of training took over and at no point did I ever feel overwhelmed by the situation. It was like all the scenarios I had talked through time and time again. It required me to apply a process to arrive at the right course of action and ensure the safety of my aircraft and crew.

The aircraft is unbiased; it does not pick favorites. Wheth-er you have over 2,000 hours in-model or are just starting the Fleet Replacement Squadron, you must always be ready.


Cmdr. Sean Knight, commanding officer of the Helicopter Sea Combat Squadron (HSC) 4, flies an MH-60S Sea Hawk helicopter near the Nimitz-class aircraft carrier USS Carl Vinson (CVN 70). Photo by Mass Communication Specialist 3rd Class Dylan M. Kinee)

Approach

As a newly designated helicopter second pilot (H2P), I was on top of the world. I had crammed so much information in my head over the past couple of

months that I felt I could answer any question thrown at me. Although the qualification is just a stepping stone on the way to helicopter aircraft commander (HAC), I was now allowed to do ground turns on the helicopter without a HAC. How-ever, I quickly learned that no amount of knowledge can fix a bad habit. After seeing four folded rotor blades swing to the four o’clock position while on spot seven of an aircraft carrier, I realized how lucky I was to be alive and how much I still had to learn.

It was another day on USS Carl Vinson (CVN 70) during our deployment. While there was no shortage of plane guard and logistics flights, I finally had a day off. This can be a blessing or a curse as a junior officer though, especially on the carrier. After retiring for the night, I received a call from the squadron duty officer (SDO) around 12:30 a.m. My pres-ence was required to spin an aircraft on spot seven to assist troubleshooting faulty torque and Np indications.

I rolled out of bed and walked down to the ready room in a sleepy haze, ready for action. I proceeded to maintenance control to find out if the aircraft was ready to be pre-flight-ed. After waiting for half an hour, I walked up to the flight deck and pre-flighted the aircraft with the exception of the folded tail pylon. Finishing up, I hopped in the cockpit to unlock the tail wheel for the tow truck only to find a battery low charge indication. This prevented the tail wheel from coming out of the lock position for the tow. By the time we discovered the issue and charged the battery, the tow truck had given up on us.

It was 3 a.m. by the time the aircraft was on spot seven. I climbed the tail to preflight it before the blade crutches were taken off the folded main rotor blades. Then I strapped in and was ready to start my first maintenance spin. I pulled my PCL out and started the prestart checklist. I made it through 10 steps before things got much more interesting. Reaching the step calling for “rotor brake – on” I did what I had become accustomed to doing and checked the pressure on the rotor brake gauge.

I noticed it was under the usual 450 psi - 200 psi to be exact. Out of habit, I released the rotor brake and quickly reapplied it to increase the pressure to at least 450 psi and

continued going through the checklist. I was about to turn on the auxiliary power unit (APU) when I noticed maintainers yelling to get my attention and pointing to the right side of the helicopter. I looked over and saw all four folded rotor blades at the four o’clock position on the cusp of crossing the deck edge.

I looked up to verify the rotor brake pressure again and saw it indicated zero psi. Quickly, maintainers came into the cockpit to look as well. They asked what happened, and I told them I didn’t know. With my adrenaline pumping I had not put together the fact that upon releasing and reapplying the rotor brake, there was a brief moment when there was nothing keeping the rotor blades in their proper folded position. After a thorough inspection, the main-

Don’t Pump the Brake

BY LTJG JULIUS JONES


tainers were able to push the blades back into their folded position. They climbed on top of the aircraft to conduct a head check and see if there was any indication of a failure in the rotor brake or the gust lock. Fortunately, they found no indications of a faulty system, or damage to the aircraft.

Climbing out of the aircraft, I packed up my gear and walked over to talk with the flight deck chief. He asked me what happened and I admitted to releasing the rotor brake and reapplying it while the blades were folded. He was shocked and told me that I was lucky to be alive. After talking with him, I realized that the aircraft could have easily rolled over and gone into the water if the blades had rotated any further. Maintainers around the aircraft could have also been injured. I had forgotten such a fundamental

function of the rotor brake system as well as a warning in NATOPS that specifically talks about this situation.

Looking back, it is easy to see my mistake. I knew better. I have studied the rotor brake system and read the warning about this situation. However, at the end of the day, a bad habit took over. MH-60 pilots are accustomed to checking rotor brake pressure and instinctively pumping the brake if the pressure is below 450 psi. Two months into a deploy-ment, it is easy to get complacent and forget the little things. Pilots train to follow checklists, however, as humans, we are typically told to also follow our instincts. This is a shining example as to why we train to follow checklists. I encour-age everyone to stay fresh on NATOPS knowledge and also reflect on what bad habits or instincts you may have.


Sailors chock and chain an MH-60S Sea Hawk helicopter assigned to the Helicopter Sea Combat Squadron (HSC) 23 on the flight deck of Nimitz-class aircraft carrier USS Carl Vinson (CVN 70). Photo by Mass Communication Specialist Seaman Josiah J. Kunkle.

Approach

Bravo Zulu

Sailors and Marines Preventing Mishaps

Cpl. Damian GaribayCpl. Damian Garibay was maintenance trouble-shooter from the Flight Line Division for a launch of MV-22B Ospreys. One of the squadron’s aircraft returned shortly after takeoff due to a malfunction and the crews had to roll to a backup aircraft to complete their combat mission. While moving cargo, tools and flight equipment onto the backup aircraft, one of the crewmembers from the flight noticed a popped latch on an exterior aircraft panel. A Marine brought over a ladder and began to extend it so the panel could be secured. That Marine lost situational awareness and extended the service ladder dangerously close to the spinning blade. Cpl. Garibay immediately saw the unsafe action and swiftly took control of the ladder, moving it safely away from the rotor arc to finish extending it. He secured the panel and moved the maintenance Marines clear so the aircraft could taxi outbound. Cpl. Garibay’s actions resulted in mis-sion success, avoiding a mishap from the shrapnel generated if the rotor blades had impacted the ladder, potentially saving several Marines from injury.


Marines hook-up a UH-1N Huey helicopter onto a CH-53 Super Stallion helicopter during an external lift. Photo by Cpl. James P. Aguilar.


“ Even on a flight that we’ve seemingly done a hundred times, there are things that will always be out of the ordinary. It is paramount to discuss and remain vigilant to better combat it when the rotors start turning. ” – LT Justine Engel

Commander, Naval Safety Center“Preserving Combat Readiness and Saving Lives”