[Ed. note: Prior pieces in this series found at AMST 1, AMST 2, AMST 3, AMST 4, AMST 5, and AMST 6.]
I began this series with a brief look at Bud Holland’s actions vìs a vìs the Fairchild AFB crash. The reconstruction of how that all happened, right down to Holland’s illicit parking habits, came from a post-crash investigation, likely more than one. In the military, there are typically two different investigations that happen post-crash: the Safety Investigation attempts to determine accident cause from an aviation safety perspective, free from any possibility of legal consequence, while the Judge Advocate General (JAG) Manual investigation attempts to determine the accident’s cause specifically for possible, follow-on legal determinations – including fault of the pilots. Frequently, these investigations can converge: for example, what if the accident was caused by a faulty component made by a particular sub-contractor? That causal finding is relevant for both safety and legal reasons, and could also exonerate a pilot, for example.
I can talk about this now with the perspective of 20+ intervening years, which has included some relevant experiences: (1) I was a member of an AMB in one of the deadliest aviation training accidents in Marine Corps history (more on that in a later one of these); and (2) while becoming a judge advocate, I served on the prosecution team for this other deadliest Marine Corps aviation accident in Aviano, IT (I’ll get to that one, too). When you’re in flight training, however, suffice it to say that they don’t exactly spend a lot of time talking about surviving mishaps, or what a mishap board is like. Most of crew coordination and safety training is listening to, or looking at, stupid things that people did and got killed doing and then being told, like with the fork in the toaster: “Don’t do that.” While true and one way of mentoring, it’s not exactly comprehensive and doesn’t cover – what happens if you have a mishap and live? This is one of those stories.
More “Top Gun” Bullshit?
I had forgotten, but that ever-helpful repository of aviation knowledge, “Top Gun” does give you a couple of sniffly scenes of poor Pete “Mav” Mitchell in his summer whites all teary-eyed while he gets formally exonerated of “any wrongdoing” in front of the AMB and is returned to flying status. Then, of course, it turns out he can’t, ahem, bring himself to fire his gun after the death of his oily volleyball partner, Goose.
Talk to me, Goose.
“Just Relax, Turn Your Head, and Cough…”
An Aviation Mishap Board is convened by members of the Safety and Standards Office within the squadron and someone else gets separately assigned to conduct the JAGMAN investigation. If there are parts and pieces left after a crash,1 they’ll get collected and then sent various places for testing to try to determine just what the heck happened. I would be remiss if I did not point out that statistically speaking, about 70% of aviation mishaps involve “human factors” errors – i.e. pilot and/or co-pilot and crew fuck-aboutery. This is another way of saying that if you “check out” a perfectly good, flying $15 million aircraft and then it impacts the ground… well, the betting odds are that it was the same category that causes the other 70% of perfectly flyable aircraft planes not making it back.2 This can make things difficult under the best of circumstances; it can make life strange indeed when the aircraft mishap board members, and the JAGMAN investigator, and the pilots being investigated, are all sleeping on cots in the same Quonset Hut within a few feet of each other! (Imagine if the guy investigating your stolen rental car claim was living with you during the investigation. It doesn’t matter how nice the insurance investigator is, it’s just bad for everyone.)
Before I go further, however, there’s a relevant bit of helicopter doctrine you should know about…
Welcome to the Deadman’s Curve
Helicopter pilots live and die by their aircraft’s Height-Velocity diagram, “H-V diagram, for short. The H-V diagram is also very commonly known as the “Deadman’s Curve.” Below is the H-V Diagram for the helicopter I learned on, the Bell 206 Jet Ranger. Other aircraft models and types will be slightly different, but they’ll be similar shaped. The Jet Ranger is known for having a “high inertia” rotor head compared to its mass, which means that if you lose power, the rotor head loses “rotations” (measured in %) much more slowly than heavier, commercial (or “fleet” aircraft). That’s why it makes such a good training helicopter; helicopters only drop out of the sky more quickly as you move through the pipeline out into the “real world” of flying.
The shaded area is where you DON’T want to be. That’s called being on the wrong side of the Deadman’s Curve. This is why whenever you watch helicopters take-off in almost any movies, you’ll see the helicopter come off of the ground, and then the nose drops and the helicopter stays close to the ground as it gains speed… that is NOT simply because we are show-offs and want to fly low and fast – that’s just a bonus! It is because that is the best flight profile to fly around the Deadman’s Curve so that if you lose an engine you’ve got enough whop-whops to auto-rotate to the ground (in theory, anyway – you also need a zone to get into and a relatively unobstructed way in.) Look at that curve and trace a line with your finger starting at 0 feet of altitude and 0 kts of airspeed and don’t let your finger touch the shaded area, you can see that you have to accelerate to 45-50 kts while still below 20 feet below to fly up and away from that big shaded area on the left and above.
If you look at the fattest part of the shaded area, you’re talking about hovering “out of ground effect” – very high hovering where you do not have the benefit of your own air cushion, called “ground effect” when you’re hovering or air taxiing close to the ground. In the -206, we would shoot practice autorotations with the throttle at flight idle all the way to the ground from 500 feet above the ground (AGL), the pattern altitude. As you can see from the H-V diagram, that’s well above the 400′ feet from which you can do an autorotation with zero forward airspeed. The landing pattern is 80 kts or so, so we were plenty to the right and above the Deadman’s Curve. The fields were grass and we would do slide on and full stop landings to the grass – and never bring the power back up.
By comparison, the top of the H-V diagram for the Whiskey was 1080 feet…
…and on the day we augured in, August 11, 1994, we were in a 150’ hover-hold, as wrong a side of the Deadman’s Curve as there is.
Light Switches and Checklists
Given everyone’s proximity, it wasn’t hard to set up interviews. Bill and I wrote our statements separately – when we were finally able to scrape up some pens and paper and a place to write – and then we each read the other’s account of the accident after we wrote it as we walked over to turn them in to the aircraft mishap board, who I seem to recall had a single office with a handful of chairs in one of the few permanent structures at Camp Wilson at the time.3 I can empathize with them now, after multiple careers of interviewing people in extraordinarily uncomfortable circumstances (as a prosecutor, defense attorney, etc.). At the time, not so much.
There are also some important cultural points at play that aren’t readily apparent: in a squadron, there tend to be small “camps” – you could almost call them archetypes, really, because of the nature of a squadron – but they revolve around the competing relationships between Operations/Training, Maintenance, and Safety. The Operations folks are tasked with driving the squadron’s operations, namely, putting out a daily flight schedule. That requires aircraft, so Maintenance and Ops tend to have a slightly antagonistic relationship because sometimes Maintenance can be a kind of governor on Ops.4
Safety sits aside from Operations and looks over Ops’ shoulder to make sure that the squadron’s operations are being conducted safely, with due regard to the operational risks, blah blah blah. Okay, so you can see where I come down on this, but let me just say that personalities migrate to each of these places, and while they’re all necessary to a strong, functioning squadron, they don’t all get along. The Tactics guys want to do ops – shoot, and train – while the Safety guys wonder if everyone’s gotten sufficient crew rest, and the Maintenance guys are all greasy and hot and wondering why everyone keeps breaking all of the f***ing aircraft?! And while there is some movement among these different places during a given tour or career, you tend to see “Safety guys” pursuing those additional courses related to that particular vertical, while the Ops guys are trying to get courses related to the “Warfighting” vertical, and the Maintenance guys are spending time in that vertical.
I say all of that by way of background for the context of our interviews with the AMB within a day or two of the crash. Evidently, our navigation lights were in the “flashing bright” position, rather than “steady bright” – which they should have been per Squadron SOP. It’s also one of the last items on the takeoff checklist, the very last thing you do before you takeoff. The takeoff checklist sits on a placard right on the face of your panel.
AMB: Do you know why were your lights in flashing bright? Me: I was up front, so I can’t say for certain. AMB: Did you complete the takeoff checklist before you left the airfield? Me: Yes. AMB: ‘Yes,’ as in you have an independent memory of doing it? Or ‘yes’ you’re certain because you always do it? Me: The former. I have an independent memory of Captain Dunn and I doing the takeoff checklist before we left to go to the arming area. AMB: Well, can you explain why we found the lights in that position when we returned to the crash site? Me: Captain Dunn had to climb out and jump down from the right side, so perhaps he hit the switch with his boot, or elbow, while getting out. Or maybe when we safed the aircraft up afterwards he hit it. I don’t know – obviously I was up front and I never went to the back cockpit after impact.
Etc.
It can get testy without anyone really meaning it to or even trying.
In the days after the crash, a few interesting pieces of info emerged. When Bill read my statement, his initial reaction was surprise: “You came onto the controls and pulled? I never felt you – at all.”
“You wanna know something weird? I never felt you either. I waited until the last possible second and then pulled for all I was worth.”
We started to refer to it as the “Hand of God” on the controls just between us.
The AMB found it equally unbelievable, as well, but for different reasons. They seemed to struggle because I was admitting that I violated all protocol on who is flying the aircraft by (a) coming onto the controls as (b) the guy not flying, and (c) being the co-pilot and (d) a relatively junior guy in the squadron. I tried to explain to them – none of whom had been in a crash, I should note – that as the ground rushed up it simply wasn’t possible to sit there and allow one’s self to be smashed to pieces if for some reason Bill mistimed his pull. I would give him every benefit of the doubt, but at some point…
When Bill and I talked after our interviews, he mentioned that they had brought it up to him and his impression was that they thought I was “confabulating” – that I was making it up and that I hadn’t actually touched the controls at all. Bill telling them that he never felt me on the controls seemed to help them justify the belief because if I’d come on the controls, Bill certainly would have felt that….right?
The other atypical – ahem, unbelievable part of our story – was our claim that we had a dual engine failure. The Cobra is a twin-engine aircraft, and one-engine alone should be sufficient for us to have flown away safely. Given what I’ve mentioned above about 70% of the time it’s pilot error, I would say confidently that in the early days of the AMB the distinct impression we got was that the AMB believed we had a single-engine failure, panicked, and smashed ourselves right into the ground with a perfectly flyable aircraft.
And then a series of events changed everything…
Deus Ex Machina to the Rescue!
Leading up to the deployment to 29 Palms for CAX 9/10-94, in addition to getting my PQM qual and some “X”s towards Attack Helo Commander, I had started the syllabus for becoming a Post-Maintenance Functional Check pilot, known colloquially as an “FCP” or a “tester” – someone who tests the aircraft after they’ve had squadron and MALS-level maintenance done on them and then certified the aircraft safe for flight for other pilots. I had finished most of the flying and written portions of the syllabus and now at CAX was doing some OJT with ground turns and “riding along” with other testers during their full-card or other tests each day.
Bill was out doing a full-card and taxiing back in as I was in one of our squadron’s rental vans with the CO on our way over to the airfield for some reason. I may have had a night flight, but I remember on the drive to the airfield the road had a bridge that gave us a pretty good look at Bill air taxiing back in, right at dusk, when his aircraft suddenly shot a fireball out one of the exhausts and then the engine quit. We were in a perfect position to both see and hear it happen.
POW! Then, Whoosh from the flame out the back, then beeewwwww, as the engine dropped to idle. We watched Bill’s aircraft settle a bit, but he had it all under control and air-taxied it back into the line. Whatever else we could have said, nothing made our case better than the CO watching one of his perfectly good aircraft throw an engine right before his eyes. Or, put another way, our story had just gotten a lot less fanciful – and maybe the 70% pilot error had suddenly moved more towards the 30% “Other stuff, including mechanical.”
The CO grounded all of our aircraft and let the ground unit commander know that it wasn’t safe to fly his Cobras. Within a couple of days Saint gathered us all together to explain that absent some definitive Fleet-wide grounding, like had occurred with the blades, that the Ground Commander didn’t give a flying fuck and wanted Cobras flying support ASAFP. And he didn’t say it, but we all understood it, if he made this a “wings on the desk” kind of issue, he would be fired and someone else would come in who would tell us to get back to flying and quit whining.
So we got back to flying…
…But we had discussions about where to take up hover holds, how to minimize time in the shaded area of the Deadman’s Curve while still flying the missions, and suddenly all of the Cobra pilots had a personal interest in our mishap.
Then the engineering investigation (EI) report came out saying that it had found something: a brazed bellows, vice a welded bellows, in one of our P3 bleed air valves had some cracking and it appeared to be an issue with some of these bellows that were made by a particular sub-contractor or only on certain series of T700 engines, blah blah blah, the bottom line was – there was a mechanical flaw in one of the engines on our aircraft – the one that had crashed. While it wasn’t a complete vindication, it was at least a quasi-vindication that we had some kind of mechanical failure and it may have involved faulty outputs from this brazed bellows.
The mishap investigation continued apace, but just a few days later the CO signed off on my test papers.
Wordsworth once referred to “…that best portion of a good man’s life, His little, nameless, unremembered, acts Of kindness and of love”5 and the older I get, the more kindly disposed I am to the CO for signing off on that qual. I was a relatively new PQM, maybe 8 months in the squadron, not yet a Captain, facing an aircraft mishap investigation, and by that single act the CO signalled to everyone in the squadron, particularly to the Marines I had to face every day, that the AMB was essentially irrelevant to him. He absolutely could have done the cautious and expedient thing and would have been within his rights. He could have said he needed more time, not signed off on my paperwork, etc., etc., and that decision would have been beyond review of and justifiable to anyone.
Within 10 days of our crash, Bill and I were on the schedule for night autorotations on NVGs. The CO signed off on that flight schedule and never said a word to us. The squadron also had a Sidearm anti-radiation missile to test during that deployment and because I had gotten 2nd place in the test on the Sidewinder – the air-to-air version of that missile – I got to fire it with the CO riding up front.
But that’s a different story.
- Not always the case as some happen over the ocean (and I have thoughts on that one, too – the fatal crash of my friend, Clark “Swab” Cox.) ↩︎
- This is just as true of rental cars as it is of multi-million dollar aircraft; you don’t bring one back and see how long before they stop renting you cars. ↩︎
- I don’t know if it’s been built up in the intervening decades, but when I was there in 1994, you had to go to bathroom “squad bay style.” IYKYK. ↩︎
- I’ve written before about how helicopter Maintenance involves the dismal science of logistics, so additional context and explanation is available there. ↩︎
- “Lines Composed a Few Miles above Tintern Abbey, On Revisiting the Banks of the Wye during a Tour. July 13, 1798,” is more commonly known as “Tintern Abbey,” by William Wordsworth. The full text of one of the Romantic Era’s most famous poems is available here. ↩︎
Pull my finger. I’ll make a fireball.
Where is everyone?
I can’t imagine the stress of the investigation. That must have been terrible.
“Where is everyone?’
I can’t speak for everyone but I’m in North Central Ohio, Laid back sipping on Gin and Juice ( i.e. Old Fashioneds) But I’d wager that Mike S is firstin’ the fuck outta sommat, and that Sloper got called back up and he’s destabilizing some west African “Republic”.
I am in Kansas City, as per usual, working, as per usual, snacking on beef sticks and gulping water, as per usual.
North of Duloot, MN.
Only 4 eggs tonight. 23 birds. Ain’t no free ride, chicken bitches. Put out or get out.
I’m once again safely ensconced in my palatial hotel suite, at a Top Secret location in the (216).
Quaffing Milwaukees Best Light and awaiting my Applebee’s DoorDash.
Once it passes security.
Wife made Indian food. So. That.
I am trying not to jinx it. I have someone who wants to buy the house as is, they are doing an inspection Thursday. Barring any issues (I doubt it) I may be homeless by December 12th.
Hyperbole High Command identified as Ashland, OH, World Headquarters of Nice People.
“Where is everyone?”
I was proving NA right again.
I was asleep but you guys made so much noise it woke me up.
Yo. Was wondering that myself. I just got back from closing the plasma center. Monthly work meeting tomorrow. Should be..whatever it is. I may start prickin’ folk again tomorrow at the new place, my trainer said, but I still haven’t been able to read docs and sign ’em on their system. So, we shall see.
Two of the gals also in training are remarkably cute. They’re black, as are ~75% of the donors. They are far too young for me, but I never mind. I also enjoy listening in to some folk being cozy-cute with ’em. It’s the first time in a while since I’ve been around a lot of black English slang and sayings mixed in. It’s rather nice. Jazzy/Bluesy.
Will certainly read everything soon.
Hey Ozzy, I was thinking of you and this series when I read this.
2ND MARINE AIRCRAFT WING RELEASES COMMAND INVESTIGATION INTO F-35B LIGHTNING II MISHAP IN SOUTH CAROLINA ON SEPT. 17, 2023
He most definitely had a bad day. He made a calculated rational, but wrong decision. Not mentioned here is they did cashier him, which seems like a waste, but maybe you have more insight.
“There were no punitive actions recommended.”
Cashiering the guy seems punitive.
Don’t recall. Did you say you were ship qualed too? We always had the NATOPS pages in CIC and the bridge for the wind envelope we wanted to be in for safe helo take off and landing. That was a completely new thing for me to learn about too (obviously).
We’d do training for safety – flight deck fire crew, etc – simulated “chip light” scenarios, etc (metal shavings in the fuel or lube hoses) for quick emergency recoveries at top speed, etc.
With the DDG, we even did army chinook training in Hawaii – man, that was a tight fit on our small flight deck (thankfully I wasn’t driving then).
Regarding the MV-22 crash a little while back – they did determine it was a faulty gearbox – but also an issue across the fleet. https://www.airandspaceforces.com/gearbox-failure-caused-air-force-v-22-osprey-crash-investigation-finds/
The JASDF hard landing last week was pilot failure though.
Thanks! Now that’s service. Ask ‘what was root cause’ last week, and get a full article as a response. It wasn’t clear above though – were both of your engines impacted by the manufacturing (?) flaw? Or more succinctly, why a double engine failure?
I love this series, Ozymandias! Thank you for sharing your insights into a foreign world for us.
That Deadman’s Curve diagram almost looks like it could be Q Continuum-approved, but then it sags terribly.
Dude, you need to get out of the house more.
😀
You’re not wrong. 😉
I’m going to go out on a limb and say that the front page is throwing people off the non-links posts. The links posts are right there, but you have to scroll down to get to the 11a and 7p posts and people may not know that. They may still be commenting on the 3p links post.
I did that anyway.
I did it my way.
Found it! Thanks to Mojeaux and Bearded Hobbit.
If you have ublock origin installed on your browser, you can block the ‘header’ element and you’ll get something *approximating* the old behavior, at least having the latest post on the top.
Here is the rule that someone else figured out & it works for me (I use AdGuard) – it removes the array of links links at the top and takes you straight to “All Posts”:
I had to learn to scroll down to find later posts.
Mo! Can I have that link to your EBT rant? I know Munch would love it and may entice her to read more. She thanked me and admitted “I get it now” about why I write at night. She’s gotten into writing political/social topics/debates with her work-folk. She’s on my/our page, tho harsher than me. She’s a shark.
Seconded…and I ain’t installing stuff to fix it. I’ll live with remembering to scroll down
And no comment count either to indicate how active it is.
lol
This series is awesome.
Thanks, Ozzy!
Luckily they don’t hand that chart out to the self loading cargo. “Get in the fucking chopper, move!”
Your resume is both terrifying and deeply impressive. We are very different people. (It’s lovely how humans ‘work’ that way.)
(It’d be interesting to see Glibs’ resumes and see if/how professions weighed on the Bell Curve. I reckon it’s quite diverse and inclusive. Perhaps with equity. Fuck them.)
Being both in a crash and also prosecuting one is curious. Perhaps naively, I kinda assume JAG is like other courts, and is actively trying to ‘get’ a conviction. I also thought, before I edited that sentence, that perhaps JAG is a different sort of law (it is), and disinterestedly seeking Truth may be more important, especially considering squadrons and fleets of aircraft/ships and personnel. Humans are also competitive and want to win. With your CO ‘siding’ with you, and your blessed feelings, I’m further confused/ignorant and – as nearly always – happily confused.
tl;dr: How different are JAG/military courts, I s’pose especially with ‘wanting to get’ a conviction?
“Aviano”
You mentioning that place brings back memories. My dad was the Judge on the base in the late 1960’s. I was a young child then, but I remember the place well. There used to be a jet aircraft fuselage (a Sabrejet?) on a pedestal near the entrance. We lived in a pensione in town and got used to the Sunday bells ringing all day. I was too young to appreciate how spectacular the view of Monte Cavallo and the Prealpi was, thrusting out of the plain as though it had been wrenched out of the earth by some giant.
Thanks for the series and look forward to more.
🎶 “I hear the choppers crashing. They’re crashing into the ground…” 🎶
Morning, Glibs.
Gotta go into the office, water the plants, see if they’ve died on me yet.
☕
How goes?
Things are pretty good around here.
How about you?
I didn’t over sleep, but I don’t think I got enough sleep.
Good morning, U, Sean, and Ted’S.!
How goes?
Very well, thanks! I FINALLY got payroll finalized yesterday – had to stay a few minutes late to do so – and the power outage at the office ended well before close of business.
How are you?
I made it to the office, though I’m not sure I got enough sleep.
Can’t find a video editing software that doesn’t want either too much money, too much information, or doesn’t do what I need.
It’s payday, so that’s nice.
Happy hump day, y’all peoples!
🌄👻🎩
https://m.youtube.com/watch?v=GGEjz12YLiM
🎶🎶
https://www.msn.com/en-us/news/crime/student-stabs-2-teachers-aides-at-castor-gardens-middle-school-in-philadelphia-police-say/ar-AA1unxSw
“There’s some developmental issues with the student,” Monique Braxton, a spokesperson for the School District of Philadelphia, said. “I think it’s important we give him some grace. We’re not sure what triggered him today.”
Uh….how about no?
Is it the fault of Trump, or global warming?
Hey, sometimes you just gotta stab some people…
But seriously, therein lies the problem…” We’re not sure what triggered him today”…Who gives a shit?
“To be sure, he’d been told there’d be no math.”
“I lied.” – John Matrix
suh’ fam
whats goody
Tall cans are no goody.
“The View host Sunny Hostin is forced to read a legal letter by Matt Gaetz’ legal team. Look at her face!!”
https://x.com/AutismCapital/status/1859038825219277016
Bwahaha!
Lex Fridman (think more intelligent but less interesting Joe Rogan for those not familiar) long form interview of Javier Milei:
https://www.youtube.com/watch?v=8NLzc9kobDk
I haven’t watched yet but should be interesting.
I laughed when Milei mentioned Rothbard and a picture of Milton Friedman was shown. About 10 minutes in.
Thanks, Stinky, I’ll watch more later.
Good Mornin’ y’all.
Somehow I can’t seem to affect the necessary accent.
Locally Big Red isn’t available so I can use that an excuse.
A little cooler today, maybe the first flakes of the season but only in the air. Still, a little late.
Good morning, 4(20)!
The soft drink or the gum?
Neither but OTOH I’m not looking either. Does anyone chew gum anymore?
I’m pretty much out of that loop these days.
In too-local news, there may be hope for at least some locations of my favorite restaurant chain, the regional Big Boy outfit, which has had many of it’s Dayton- and Cincinnati-area locations closed or facing eviction. My grandfather used to take us to one in Hamilton when I was a kid, and I’d be sad to see the chain go away.
…which suggests a potentially controversial food question: tartar sauce on a burger – yea or nay?
No.
Never.
Neigh.
A burger without tartar sauce is like a nice piece of swordfish without A-1 and by that I mean way better. Can’t say I’ve ever heard of that.
I think it would be a big dill.
That depends. Do you like it?
Morning all
Some people like pineapple on pizza, but that doesn’t make it OK.
Our local Shoney’s went teats up over 20 years ago but I still vividly remember going a few times per year back in the ‘70s with the sportsball team and coaches after particularly good games. Same Del Taco, sadly long gone.
We might be finally getting some rain here in Delaware County PA! Perhaps an inch or so predicted tomorrow! It’s been almost two months since we saw water from on high!
Which reminds me of a story back in the 1930’s of the end of a much more severe drought in the Australian outback (lasted for years), when the weather finally broke and the rain poured down the frightened little kids ran into the house screaming “the waterhole is falling down! The waterhole is falling down!”