Cause of C-130J crash Oct 2015

Maxed-out

Maxed-out

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Maxed-out
I don't know about anyone else, but I read reports like this and I think that it really doesn't take much for even the best trained pilots to screw up royally and cause the ultimate loss of life. It's the old "fate is the hunter" thought that seems to occupy my thinking more and more these days. It's just waiting on you and me to make that one stupid decision, oversight or lapse in judgment so that it can come down on us like a pile of bricks. Since my training wasn't anywhere near the quality of training these guys had received, It has to make me wonder just how close that "hunter" is to me at any given time.

Last Friday (4-15-16), the Air Mobility Command released the results of the accident investigation of the C-130J crash during a takeoff last year from Jalalabad Airfield, Afghanistan. It killed all 11 individuals onboard and three on the ground. The Taliban made claims of having shot down the aircraft but Air Force officials in Afghanistan and at the Pentagon said there were no signs that enemy action caused the crash. The investigation indicated that the pilot forgot to remove a hard-shell night vision goggle (NVG) case that he had placed in front of the yoke to hold the elevator in a raised position (see pictures in accident report) to provide additional clearance during engine running off-loading/on-loading operations (ERO). That action, along with the time of day (midnight), distractions during the ERO and misidentification of the malfunction once airborne, resulted in the crash. Here's a couple of links including the complete accident investigation if your interested:

http://www.amc.af.mil/news/story.asp?id=123472467
http://www.airforcemag.com/AircraftAccidentReports/Documents/2016/100215_C130J_JALALABAD.pdf
 
Yeah, just one of those things that's not covered by checklist and is incumbent upon the pilots to remember. Not in your FOV, it's dark and not a checklist item = bad. Been there, done that.:(
 
When I was stationed at Zweibrucken Air Base 1971 one of our F-4s took and crashed about 1000'agl. Our base football coach was in the back (WSO). We were at practice and knew Coach was flying, and it was him. Both pilots ejected safely and the F-4 glided like a crowbar into a German cemetery and missed a German grade school by a hundred or so yards. The back seater's knee pad had a clamp break off and it fell to the floor, jamming the stick. Air Force F-4s had controls in both front and back, so the pilot's stick was jammed as well. They punched out as we watched and the F-4 crashed.

A couple of us went to the crash site a short time later and it seemed the biggest pieces were the two engines. Some "civilian" started taking pics and the Air Force Security Police took his camera from him, opened it, and exposed the film. Can't recall if he got his camera back. It was common knowledge that spies observed all our bases back then.
 
mscard88 said:
Some "civilian" started taking pics and the Air Force Security Police took his camera from him, opened it, and exposed the film. Can't recall if he got his camera back. It was common knowledge that spies observed all our bases back then.
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They still do. Too bad many of them are American citizens. :(

And those cops would be thrown in jail today - can't offend anyone!
 
denverpilot said:
Flight controls free, and correct... RIP...
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This piece broke off right after T.O. and not before. Jammed the stick and as they are belted in pretty tight couldn't get to it to remove it. It was an RF4C so some very classified cameras onboard. They didn't die although the WSO (backseater) years later got a pilot slot and crashed and died in an A-10. Great guy, crazy, a lot of fun.
 
mscard88 said:
This piece broke off right after T.O. and not before. Jammed the stick and as they are belted in pretty tight couldn't get to it to remove it. It was an RF4C so some very classified cameras onboard. They didn't die although the WSO (backseater) years later got a pilot slot and crashed and died in an A-10. Great guy, crazy, a lot of fun.
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Did you mean to quote me or someone else in your reply?

(My comment was about the C-130J.)
 
Yes, thought you meant the F4 story. Sorry.
 
Tha
Velocity173 said:
No doubt. Unfortunately the checklist didn't include a check of the flight controls prior to departure.
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Thats one of those things that somebody comes up with and it catches on, because it seems like a good idea. Somebody should have spoken up and put a stop to it or added it to the brief/checklist. It was just a matter of time before it was overlooked. I don't know how common it was though, maybe it was just this one guy.
 
Does anybody else find it unusual that the U.S. Air Force AIB doesn't mention the use of a ERO checklist that DOES NOT include a line item "Flight Controls..... Checked" immediately prior to departure as a contributing factor to this accident. The AAIB states that the ERO checklist doesn't include a step to check the flight controls, but they don't list that as a contributing factor. Also, even if that's not a line item on the ERO checklist,I would think that immediately prior takeoff, a C130 checklist would contain that item somewhere in the sequence. Probably missing something.

Excerpts from AAIB Report:

The ERO checklist did not include a step requiring the pilots to check the flight controls prior to departure; therefore, it was incumbent on the MP and the MCP to remember to remove the hard-shell NVG case (Tabs BB-63 to BB-65 and CC-54).
The AIB could not determine whether a flight control check would have alerted the MP or MCP to the hard-shell NVG case forward of the yoke (Tab CC-54).
3. CONCLUSION I find by the preponderance of the evidence that the cause of the mishap was pilot error due to the combination of the MP’s decision to place the hard-shell NVG case forward of the yoke blocking the flight controls, the distractions experienced by the MP and MCP during the course of the ERO, and the misidentification of the malfunction once airborne resulting in the destruction of the aircraft and cargo and the loss of fourteen lives. I also find, by a preponderance of the evidence, environmental conditions, inaccurate expectations, and fixation substantially contributed to the mishap.
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Maxed-out said:
Does anybody else find it unusual that the U.S. Air Force AIB doesn't mention the use of a ERO checklist that DOES NOT include a line item "Flight Controls..... Checked" immediately prior to departure as a contributing factor to this accident. The AAIB states that the ERO checklist doesn't include a step to check the flight controls, but they don't list that as a contributing factor. Also, even if that's not a line item on the ERO checklist,I would think that immediately prior takeoff, a C130 checklist would contain that item somewhere in the sequence. Probably missing something.

Excerpts from AAIB Report:
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I don't find it surprising. These guys are doing an ERO or "hot load and go." It's no different than what we did with helos there. You're throwing pax and cargo in the back while the engines are running. There's nothing in the checklist for "controls free and correct" in that scenario because there's nothing in the checklist for putting your NVG case behind / around a flight control.

Actually had an NVG case get lodged in the collective before. Ours are soft cases so it was a non issue.
 
So from the time you do a "hot load and go" to rolling onto the runway, the C130J checklist doesn't call for a "flight controls checked' prior to takeoff? Just trying to understand this.
 
Maxed-out said:
So from the time you do a "hot load and go" to rolling onto the runway, the C130J checklist doesn't call for a "flight controls checked' prior to takeoff? Just trying to understand this.
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Based on the what the AAIB stated, no, there's nothing on the checklist to do another flight control check. I imagine if the ERO was done by the book, the pilots stayed at their stations with the engines running. Unless someone deviated from the checklist (NVG case), there really shouldn't be a need for another flight control check.

Perhaps in the future it will be added to the checklist. Sometimes accidents / incidents precipitate the need for checklist additions.
 
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Incidentally, my airplane at my airline doesn't have a flight control checklist item - it's part of our flow after we get the engines running (FO does the ailerons and elevator, I do the rudder), but there's no official item on any checklist. The way our flows are built it'd be next to impossible to miss, but nonetheless this accident has me thinking that perhaps we should have it listed on the actual checklist.
 
This is information obtained from another web site, so unsure of the accuracy but according to this individual, C130J's didn't have an "ERO flight control check" (as mentioned above) but most of the pilots did one anyway. C130Hs had the flight control check, but pilots had the tendency to just say "previously checked" when running the checklist. The C130J ERO checklist (from landing to takeoff) had less than 15 items and the C130H procedures required completion of in excess of 40 items to check which included running after landing, ERO, before taxi, and before takeoff. So if this information is correct, changes were made that didn't exactly contribute to safety. It's happened before. Nothing new. Sometimes we don't learn. An L100-30, leased to Southern Air Transport (SAT) July 1986, crashed into a hangar during night take-off from Kelly Air Force Base, Texas – control lock in cockpit not removed. Sad. Sympathies go out to the crew, passengers and families. Full flight control check, stop to stop, before takeoff. How hard is that?
 
Maxed-out said:
Full flight control check, stop to stop, before takeoff. How hard is that?
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"During the 60 minute ERO, the MC had to address issues concerning the cargo and passenger loading, aircraft gross weight, climb out procedures, and Takeoff and Landing Data (TOLD). Performing a nighttime ERO during contingency operations is a complex procedure requiring the full attention of the aircrew to maintain safe parameters."

Harder than you might think.
 
Is it possible they did check 'stop to stop' and didn't notice that it was stopping a couple inches shy of full forward? Just saying, maybe they did check. And/or the guy checking controls wasn't the guy who placed the door stop. I don't know how big an NVG case is or how noticeable it would be.
 
I would think if they did do the flight control check, the case would have fallen down when they went full aft. I would also think if they tried to go full forward the pilot would realize that the yoke isn't anywhere near full forward and stuck at a positive 6-8 degree elevator position.

Just one of those memory item things that you either need to write down or put a sticky on something for a reminder.
 
Velocity173 said:
There's nothing in the checklist for "controls free and correct" in that scenario because there's nothing in the checklist for putting your NVG case behind / around a flight control.
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Don't they have a 'Before Taxi' checklist? On all the large aircraft I've flown, the control check was usually on the before taxi checklist.
 
exncsurfer said:
Is it possible they did check 'stop to stop' and didn't notice that it was stopping a couple inches shy of full forward? Just saying, maybe they did check. And/or the guy checking controls wasn't the guy who placed the door stop. I don't know how big an NVG case is or how noticeable it would be.
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FDR would be able to tell.
 
Fearless Tower said:
Don't they have a 'Before Taxi' checklist? On all the large aircraft I've flown, the control check was usually on the before taxi checklist.
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I guess it would be on their normal "before take off" checklist but it sounds like this ERO is an abbreviated form that doesn't include it. Basically not the first flight of the day stuff so it's a thru flight checklist item.

Probably either needs to be a write in or future amendment to the checklist.
 
This is the image and thought that always come to my mind in cases like this:

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FastEddieB said:
This is the image and thought that always come to my mind in cases like this:

9437357014_17fcef4778_z.jpg
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Haha. I bought that once for a student who got his private. He was a little cocky and wanted to buy a plane. Tried to talk him into a fixed gear C182 but for some reason he wanted a Maule. So off we go to Moultrie and he buys one. About 17 hours later we had a falling out and I still hadn't signed him off. Don't know who worked with him after that but he had a couple incidents with the Maule and ground looped trying to land at a private grass strip he didn't have permission for (I did). He had another guy (shady A&P) fly it out and back to the hangar to fix it. Then next thing I hear he buys a Skybolt and hit trees with that one! So that above is so true.
 
I thought I read where this NVG case was lodged in the controls deliberately to hold the elevator in a certain position for cargo loading? It didn't 'accidently' fall and block the controls. Then late, being dark, NVG on, maybe some fatigue, and it's easy to forget about the case.

One memory aid for events like this is a cockpit 'reminder' of some type. It could be as simple as a checklist card wedged in the throttles, if need be, a combat helmet on the yoke would work. The idea is something that can't be missed to remind you something needs correcting before takeoff.
 
sourdough44 said:
I thought I read where this NVG case was lodged in the controls deliberately to hold the elevator in a certain position for cargo loading? It didn't 'accidently' fall and block the controls. Then late, being dark, NVG on, maybe some fatigue, and it's easy to forget about the case.

One memory aid for events like this is a cockpit 'reminder' of some type. It could be as simple as a checklist card wedged in the throttles, if need be, a combat helmet on the yoke would work. The idea is something that can't be missed to remind you something needs correcting before takeoff.
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You shouldn't need a memory aid though. Just a checklist with control check prior to takeoff.
 
sourdough44 said:
I thought I read where this NVG case was lodged in the controls deliberately to hold the elevator in a certain position for cargo loading? It didn't 'accidently' fall and block the controls. Then late, being dark, NVG on, maybe some fatigue, and it's easy to forget about the case.

One memory aid for events like this is a cockpit 'reminder' of some type. It could be as simple as a checklist card wedged in the throttles, if need be, a combat helmet on the yoke would work. The idea is something that can't be missed to remind you something needs correcting before takeoff.
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I was thinking too that if the pic was concerned enough to lift tail for loading he really might want that free and clear check myself. Odd how simple of a check this seems to us. Even when dropping passengers and doing a quick turn around I always check controls on the ground. Beats an early unplanned uncontrolled departure from the ground.

Sent from my SM-T810 using Tapatalk
 
dottat said:
I was thinking too that if the pic was concerned enough to lift tail for loading he really might want that free and clear check myself. Odd how simple of a check this seems to us. Even when dropping passengers and doing a quick turn around I always check controls on the ground. Beats an early unplanned uncontrolled departure from the ground.
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It's been in every checklist I've ever used.
 
sourdough44 said:
One memory aid for events like this is a cockpit 'reminder' of some type. It could be as simple as a checklist card wedged in the throttles, if need be, a combat helmet on the yoke would work. The idea is something that can't be missed to remind you something needs correcting before takeoff.
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I use this all the time - in the Eagle we have a standby reticle in the HUD, really bright red round gun site that is usually turned off. I turn it on anytime I change something that is important. I use it for everything from turning my tapes off till the fight starts to reminding myself to re-arm my ejection seat if I disarm it and undo some straps while taking a pee...

I have to wonder what their ops tempo leading up to this flight was. When I was in Afghanistan I was averaging 140+ hours a month - the limit is 150. The herc guys were flying about the same. (as a measure, the FAA allows a max of 100 for 121 flying) I can tell you that when I spent 7+ hours a day in an airplane - almost all of it at night - complacency is an issue. As is checklist adherence because you get so used to it and you are so stinkin tired. I'm not saying its right but I'm saying it happens. For those folks who haven't had to do that, you can't understand what it's like. For those of you who have and never blew off a checklist item, never forgot anything along the way and didn't make any mistakes: you are a God. Well done!
 
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