Human Factors in a Military Helicopter Crash

Question 1 – Human Capabilities and Limitations

Human Factors in a Military Helicopter Crash

On 15 March 2018, at approximately 1840 Zulu time, a United States Air Force (USAF) HH60G Pave Hawk helicopter crashed in an uninhabited desert area. Four mishap aircraft (MA) flight crew members and three members of the Guardian Angel team were fatally injured in the mishap. The MA was destroyed upon impact, there were no other injuries or fatalities, and there was no damage to private property.

The mishap formation (MF) consisted of two HH-60G helicopters, with the MA operating as the lead aircraft and the mishap wingman as the trail aircraft. The assigned mission was to preposition the MF to a helicopter landing zone (HLZ) closer to the vicinity of ground operations. The flight plan for the pre-position mission was a near direct path from the base of departure to the intended HLZ with an air refuelling control point between the origin and destination points. A more extensive route of flight was loaded to the navigation system for potential follow on mission taskings, but it was not supposed to be utilized on this mission. The loaded navigation route continued north to points beyond the intended HLZ. Night illumination for the flight was low.

The MF departed the base at approximately 1800 Zulu time. The flight up to air refuelling was uneventful, but refuelling operations concluded later than planned. While conducting normal crew duties, the MF erroneously overflew the intended HLZ and descended to low altitude. As the mishap co-pilot turned left to avoid a tower, a blade on the MA’s main rotor assembly struck the second of four 3/8 inch galvanized steel cables horizontally spanning two 341-foot towers. The cable tangled around the main rotor assembly resulting in catastrophic damage, rendering the aircraft un-flyable. The MA impacted the ground at approximately 1840 Zulu time. An extensive rescue operation was immediately conducted.

The USAF investigation using the Human Factors Analysis and Classification System found the pilot misinterpreting aircraft navigation displays, causing the mishap formation (MF) to descend into an unplanned location and strike a 3/8-inch diameter galvanized steel cable strung horizontally between two 341-foot-high towers. In addition, the investigation also found three factors substantially contributed to the mishap: (1) mission planning created a route of flight that enabled navigation beyond the intended helicopter landing zone (HLZ); (2) a breakdown in crew resource management (CRM) within the mishap crew (MC) and between the mishap formation (MF) failed to sufficiently detect and effectively communicate the navigation error; and (3) low illumination conditions present during the mission rendered night vision goggles (NVGs) insufficient to detect the cables.

Question 2 – Safety and Risk Management

You are required to conduct a review of the Human Factors analysis in the investigation report with the objective to propose solutions to prevent a similar accident in the armed forces. Using this accident as a case study, examine human capabilities and limitations in operating military / combat machines and operating in a high stress situation, identify the possible safety and risk management issues in defence and security operations, and examine design principles to reduce human errors both in the operations and maintenance of military / combat equipment. You may refer to other reliable news reports or commentaries in your review.

Question 1 – Human Capabilities and Limitations 

(a) Review the investigation report and identify the human errors presented. Describe how these errors relate to physical and cognitive human capabilities and limitations. 

(b) Explain how human limitations contributed to the cause of the accident. 

(c) Mission planning, interpreting aircraft navigation displays, information, detection and communication of errors among the aircrew are very critical parts of a helicopter flight. Given this circumstance, examine how stress impacts performance and what can be done to manage stress in such situations. 

(d) Using Crew Resource Management principles, evaluate the team performance of the helicopter flight crew comprising the pilot, co-pilot, and other aircrew. 

Question 2 – Safety and Risk Management 

(a) Based on the findings from the report (case study), describe the safety climate of the 332nd Air Expeditionary Wing, in particular, the attitude towards safety displayed among the airmen. Support your analysis with the evidences reported. 

(b) The lack of discipline to detect and effectively communicate the navigation error displayed by the aircrew in deviating from established procedures was evident. Illustrate how this discipline issue relate to a unit’s attitude towards safety and risks. 

(c) Present how a safety management system, with the implementation of education, intervention and monitoring programs can possibly avert such safety discipline issues.

Question 3 – Human Factors Design

(a) The pilot was reported to be a good pilot - he was a qualified Instructor Pilot and experienced with HH-60G. He was current in all Combat Mission Ready (CMR) flight areas, in accordance with AFI 11-2HH-60. The co-pilot was a qualified and experienced HH-60G Co-Pilot. He was current in all CMR flight areas, in accordance with AFI 11- 2HH-60 and completed the most recent mission qualification check ride in the HH-60G on 19 December 2017. Similarly, all other fight crew were qualified and experienced in their respective profession in the US Airforce. Given the human errors discussed in this case study, propose design solutions that could assist the aircrew in handling the emergency during the mission flight.

(b) Assuming the role of the incident unit’s commander, recommend the steps to take for your unit / squadron to get better and prevent future incidents. Your recommendations should be based on the findings of the investigation report and should include training or re-training options.