C-5 Crash Report

AdamZ

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This was just sent to me by Col. John Lowery. For those Military Aviators out there what do you think will happen to the crew?

Human error blamed in cargo plane crash
17-member crew of C-5 survived after hard landing in Del. field in April



By Randall Chase
The Associated Press

June 13, 2006, 7:45 PM EDT

DOVER, Del. -- Human error is to blame for the crash of a giant C-5 cargo
plane at Dover Air Force Base, military officials said today.

Investigators said the cockpit crew made three critical errors after
declaring an emergency shortly after takeoff on April 3.

Investigators found "clear and convincing evidence" that the crew tried to
throttle-up an engine they had shut down while not utilizing a fully
operational engine, used flap settings that resulted in too much drag, and
selected the wrong type of approach for the conditions they faced.

After receiving a false indication that the thrust reverser on one of the
engines was unlocked, the crew of the C-5B Galaxy shut down the engine and
tried to return to base. The aircraft stalled about a mile from the runway,
clipped a telephone pole and plowed into an open field, breaking into three
sections.

All 17 people aboard the aircraft, which was laden with jet fuel and
carrying supplies for U.S. troops in the Middle East, survived.

The two pilots at the controls of the plane were Capt. Brian LaFreda and Lt.
Col. Harland Nelson. A third pilot, Lt. Col. Robert Moorman, was sitting in
a jump seat behind them. The veteran cockpit crew also included two flight
engineers. The three pilots collectively had more than 10,000 hours flying
time in the C-5, as did the two flight engineers in the cockpit.

The plane belonged to the 436th Airlift Wing, the active duty unit at Dover,
but was being flown by a crew from the 512th Airlift Wing, a reserve unit.

"This crew developed a lack of situational awareness and complacency, " said
Col. Ray Torres, head of the accident investigation board.

Torres said the fate of the cockpit crew, none of whom has flown since the
crash, is outside the scope of the investigation board. The board's report
will be referred to their commanders, he said.

"We are premature on making any statement on the crew, whether the crew will
ever fly again or not," said Col. David Wuest, vice commander of the 512th
Airlift Wing.

Wuest said Air Force Chief of Staff Gen. T. Michael Mosely had signed off on
the accident report, but that it remains to be determined who will make the
decisions regarding the fate of the crew members.

"It will be in the chain of command," Wuest said.

Dover Air Force Base spokeswoman Lt. Col. Cheryl Law said all of the crew
members had been offered the opportunity to speak to the media, and that all
declined.

Delaware's congressional delegation, Democratic Sens. Joseph Biden and
Thomas Carper and Republican Rep. Mike Castle, released a statement
expressing confidence in the safety of the C-5 fleet. They noted, as did
Torres, that there was no evidence that new cockpit avionics equipment with
which the aging fleet is being outfitted played any role in the crash.

"We found no linkage between the update to the cockpit and the causes of
this accident," Torres said.

The crash occurred after a cockpit signal indicated, falsely, that a thrust
reverser on the No. 2 engine was unlocked. Following procedure, the crew
shut down the engine and turned back for the base, idling the other three
engines to "reconfigure" the aircraft and prepare for descent.

When re-throttling the engines, however, LaFreda mistakenly throttled up No.
2, which was shut down, instead of No. 3, which remained fully operational,
yet idling. The other two pilots and the two flight engineers failed to
notice the mistake.

Compounding the error, the crew used a full flap approach. Using flap
settings of 62.5 percent or 40 percent, instead of 100 percent, would have
lessened drag on the 730,000-pound aircraft, which was about 100,000 pounds
heavier than the normal landing weight. Investigators said a 40 percent flap
setting would have boosted airspeed by about 20 knots on final approach to
166 knots.

According to the cockpit voice recorder, Nelson told LaFreda about 45
seconds before the crash that the aircraft was a "little slow," and that a
"lot of power" was needed. After confirming that the airspeed was too slow,
LaFreda called for "flaps 40," but followed up immediately with "Aw,
disregard, don't do that yet."

Meanwhile, the two flight engineers were talking to themselves about why a
40 percent flap setting was not being flown.

"Guys, I'm concerned," LaFreda said as an alarm signaled an altitude of 300
feet.

At about one mile out, with the plane traveling at about 127 knots and an
altitude of about 150 feet, the crew finally reduced flaps to 40 percent,
which resulted in the aircraft stalling.

In addition to not using the No. 3 engine and setting the flaps incorrectly,
the crew also mistakenly tried a visual approach to the runway, bringing the
C-5 well below the normal glide path for an instrument approach or the
normal visual flight rules pattern altitude.

Finally, investigators found "substantial evidence" that LaFreda did not
provide a complete approach briefing to the crew, which may have resulted in
crew members raising questions that might have averted the crash.

Torres said numerous simulator tests indicated that, with the same flap
settings and approach used by the crew, the crash could have been avoided
had the No. 3 engine been throttled up as late as 300 feet above the ground.
Similarly, even with only two engines working, a reduced flap setting would
have resulted in a safe landing. A safe landing also could have been
achieved, with only two engines and at full flaps, had the crew used an
instrument landing approach to a different runaway or even a "non-precision"
instrument approach to the runway they selected, investigators determined.

"Clearly there was complacency, and clearly a lack of situational
awareness," Torres said. "Our crews are highly trained. This is not normal
behavior for our crew members."
Copyright © 2006, The Associated Press
 
My suspicion is that there will be Flight Evaluation Boards for all three pilots. How those will go is beyond my ability to guess, but I'd say that as aircraft commander, Capt. LaFreda is in the most vulnerable position. Possibilities if they are judged deficient include anything from loss of certification/qualification as crewmembers in the aircraft and retraining/recertification, to losing their wings permanently.
 
Ron Levy said:
My suspicion is that there will be Flight Evaluation Boards for all three pilots. How those will go is beyond my ability to guess, but I'd say that as aircraft commander, Capt. LaFreda is in the most vulnerable position. Possibilities if they are judged deficient include anything from loss of certification/qualification as crewmembers in the aircraft and retraining/recertification, to losing their wings permanently.
Oh Cr_p.
 
I wonder if anyone will ask how the crew became so suddenly incompetent....
 
Steve said:
I wonder if anyone will ask how the crew became so suddenly incompetent....

There does seem to me that there are some CRM issues here that need to be investigate. If people knew that wrong confgurations were being used yet remained silent there must be a reason.
 
Steve said:
I wonder if anyone will ask how the crew became so suddenly incompetent....

"and complacency"

This seems to be a big factor not incompetentcy.
 
Two Lieutenant-Colonel pilots aboard but the aircraft commander was a Captain? How often do airlines put senior pilots in the right seat unless they're giving line checks to people upgrading to Captain?
 
Witmo said:
Two Lieutenant-Colonel pilots aboard but the aircraft commander was a Captain? How often do airlines put senior pilots in the right seat unless they're giving line checks to people upgrading to Captain?

Very common in military to have a lower ranking AC. The higher ranks may only be getting their time in to maintain flight pay. We used to get our deputy MAJCOM commander (a one star general) flying with us once a quarter while our AC remained our regular pilot, a major.
 
smigaldi said:
Very common in military to have a lower ranking AC. The higher ranks may only be getting their time in to maintain flight pay. We used to get our deputy MAJCOM commander (a one star general) flying with us once a quarter while our AC remained our regular pilot, a major.

I know it's common--I just don't think it is right. Getting time in to maintain fly pay is pretty weak. I've seen several instances where senior officers, who should have known better, allowed (or attempted to allow)their junior officer AC or flight lead to take the blame for bad judgement. Case in point: Squadron Commander flying as wingman in a 2-ship formation of F-15Cs shoots down American Blackhawk. His defense was "I was only the wingman." No squadron commander I ever had would fly as wingman to a junior officer during a wartime sortie (during training/peacetime perhaps, and only then to evaluate the junior officer).
 
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