1-212th Aviation Regiment
Topics of Discussion
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•
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•
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Accident Trends
Accident Prevention
PL Procedures
SOP
Close Call Program
SAFETY
1-212th Aviation Regiment
Battalion Accidents
• FY05
– Class A – 2
– Class B – 0
– Class C – 3 (2 material failure)
– Class D – 6 (1 material failure)
• FY06
– Class A – 0
– Class B – 1
– Class C – 1
– Class D – 3 (1 material failure)
SAFETY
1-212th Aviation Regiment
Battalion Accidents
• FY07
– Class A – 1
– Class B – 0
– Class C – 3 (2 ground, off-duty)
– Class D – 3 (1 bus/pick up on flight line)
– Class E – 1 (reach pendant broke)
• FY 08
– Class D – 1 (Bird Strike)
SAFETY
1-212th Aviation Regiment
Battalion Accidents
• FY 09
– Class B – 1 ( Blade Strike @ Monroeville)
– Class D – 2 (Search light , Bird Strike)
– Class E – 7 (Search + landing lights, Birds, ENG Failure )
• FY 10
– Class D – 1 (LTE, Overtorque)
– Class E – 2 (#1 ENG Fire Light, ENG Failure)
SAFETY
1-212th Aviation Regiment
FY05 Trend Analysis
10 Class A – E w/ damage
Human Error Aviation Accidents
UH-60
10 of 10
Tactics
6 of 10
Aircraft Tail
8 of 10
Recent MOI Grad 8 of 10
FSXXI
8 of 10
IP on Controls
5 of 10
Guest IP
4 of 10
NVG
3 of 10
SAFETY
UH-60 Roll On
E 1-212 AVN
For Accident Prevention Purposes Only
Summary of Event
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•
•
•
Date:
31 March 2004
Time:
1525 Hrs
Location:
Stinson Stagefield
Synopsis:
While performing a roll on
landing during Flight School XXI, the main
rotor blades contacted the tail rotor drive
shaft.
• Remarks: Class B ($467,000 ECOD)
UH-60 Tail Rotor Strike
E 1-212 AVN
For Accident Prevention Purposes Only
Details of Event
•
•
•
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Date: 02 December 2004
Time: 2055 Hrs (NVG)
Location: RT 186 (EV879557)
Synopsis: While turning during a 15ft AGL hover,
the crew of a UH-60 felt a vibration coming from
the tail of the aircraft. The crew flew the aircraft
approximately 60 meters away then turned to
see they had struck a tree. Inspection revealed
damage to all tail rotor blades and the stabilator.
• Class C Accident, $75,171.00 damage
035 deg
LOWE AHP
Distance
Estimation
Site
(North Hover Area)
30
45
45 degrees, 3 disk
30 degrees, 3 disk
(not to scale)
(not to scale)
E
N
+
S
W
Distance
measured from
cockpit to tail
Lowe AHP Distance Estimation Site
Site enables IPs to
train and demonstrate
safe distance
estimation cues for
the UH-60 to aid in
clearing the tail. Also
aids on recognizing
proper formation
distance of 3 disk for
multiship purposes
UH-60 Stabilator Damage
E 1-212 AVN
For Accident Prevention Purposes Only
Summary of Event
• Date: 04 April 2005
• Time: 2047 hrs
• Location: RT 367 (16R EV 985373)
• Classification: Class D ($8,392.00)
• Remarks: Health Usage Monitoring System
(HUMS) installed
Summary of Event
• Synopsis: While conducting a terrain
flight deceleration in conjunction with an
evasive maneuver, during Initial Entry
Rotory Wing (IERW) NVG training, the
stabilator of the UH-60 contacted the
ground. The flight crew was unaware of
the ground contact and continued the
mission. During post flight inspection the
crew did not inspect the stabilator.
Inspection by maintenance personnel the
following morning revealed damage to the
trailing edge of the stabilator.
TM 1-1520-237-10 para 9.12.b
“With pitch attitude beyond 25°
there is the possibility of ground
contact with the stabilator trailing edge.”
BACKGROUND
•
UNIT: E Company, 1-212th Aviation Regiment
•
EQUIPMENT: UH-60A
•
DATE/TIME: 29 MAR 05 / 0817(L)
•
LOCATION: TAC X
•
RESULTS: Aircraft Destroyed
•
COST: $6,600,000
•
MISSION: Individual Aircrew Training, UH-60
Basic Combat Skills Training
Board Synopsis
Human Error—Training Failure. That is, the
Instructor Pilot (IP) through lack of experience
and training, perceived an emergency situation
(left yaw as loss of tail rotor thrust) and
responded with an inappropriate procedure for
the perceived emergency. This caused the
aircraft to impact the ground, destroying the
aircraft and injuring the occupants.
330
TAC X
UH-60 Tower Strike
F 1-212 AVN
For Accident Prevention Purposes Only
Summary of Event
•
•
•
•
Date: 28 February 2005
Time: 2257 hrs
Location: 16R FV 13584971
Synopsis: While in low level flight at 100 kts, on
an IPC NVG mission, the UH-60 struck an unlit
radio tower. The crew felt a sharp jolt followed
by severe vertical vibrations. During the
emergency (forced) landing the aircraft struck
wires and came to rest on its left side.
• Remarks: Class A (>$2M).
N
Radio Tower
Power Line
A/C
Broken Poles
BACKGROUND

UNIT: UH-60 -- F Co, 1-212th Aviation Regiment
OH-58 – LSSI, Tactics Division, Shell Field

EQUIPMENT: UH-60A, OH-58C

DATE/TIME: 11 May 06 / 2253(L)

LOCATION: 16R FV76387079 (Elba AL.)

RESULTS: Two Aircraft Moderately Damaged

COST: $376,903.13 + $65,352.00 = $442,255.58

MISSION: Individual Aircrew Training, UH-60 Instructor
Pilot Course and OH-58 Basic Combat Skills
RT 216
1-212th Aviation Regiment
SAFETY
1-212th Aviation Regiment
SAFETY
FACTOR ANALYSIS
ENVIRONMENTAL:
Not Contributing
MATERIEL:
Not Contributing
HUMAN:
Present & Contributing
FINDING - 1

PRESENT AND CONTRIBUTING:
(Human Error – Individual Failure)
Both aircrews failed to detect another aircraft that was closing on
their position while in the terminal area of the landing site
 Both Aircrews failed to ensure that adequate scanning
techniques were used in vicinity of the landing site
 That is, they failed to Maintain Airspace Surveillance while
performing terrain flight
FINDING - 2

PRESENT AND CONTRIBUTING:
(Suspect Human Error – Individual failure)
During NVG terrain flight to RT 216, the UH-60A and OH-58C
aircrews did not hear the other aircraft transmitting on the
assigned RT frequency.
FINDING - 3
PRESENT AND SUSPECT CONTRIBUTING:

(Human Error – Individual failure)
Both Aircrews failed to ensure proper radio procedures were
followed.
•
•
Mandatory "1K call" required by the 1-212th SOP was not
accomplished at the correct location in order to advise other
traffic in the vicinity of the RT.
Accomplishment of this call may have alerted the other aircraft
vicinity of the RT of his presence
UH-60 Roll On
E 1-212 AVN
For Accident Prevention Purposes Only
Roll On, Class A, 10 MAR 07
While conducting a roll-on landing at Skelly Stagefield in
a UH-60A during Initial Entry Rotary Wing training, the
instructor pilot (IP) failed to take appropriate action to
correct an unsafe condition. That is, when the pilot trainee
(PT) improperly manipulated the flight controls, the IP
allowed the flight condition to deteriorate beyond
acceptable limits contrary to guidance in TC 1-237. As a
result, in the ensuing crash, the aircraft was destroyed, the
instructor pilot (IP) received fatal injuries, and three PT’s
received minor injuries.
SW
NW
N
S
SE
NE
2.
1.
Aircraft touches down nose
high, heading left of
centerline
3.
Right main landing gear touches down
hard with minimal collective and aft
right cyclic inputs. Main rotor blade
contacts and severs tail rotor drive
shaft
4.
Right main landing gear drags
right until strut snaps off
Rotors contact ground and
aircraft yaws to the right 540
degrees, breaking off the tail
section in the 2nd 180 degrees
W
SW
NW
N
S
SE
NE
E
Tail Rotor Gearbox
AFT Troop Seat
Tailboom
FY 09 Accident Pictures
FY 09 Accident Pictures
1-212th Aviation Regiment
SOP
Down and Safe –
An aircraft with an emergency that has landed without any damage to the aircraft,
civilian property, or any injuries. Must be released by competent maintenance
personnel to the PC depending on circumstances prior to recovery. The following
are examples of down and safe.
•
engine chip light
•
master caution light with no other indications
•
low fuel indications
•
weather
•
boost off conditions
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ECU will not go out of LOCKOUT
•
Hydraulics off
•
Tail wheel pin broken**
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Engine failure (when no visible damage occurs)
Completion of an AAAR or AAAR worksheet is required to be filed at the
appropriate Basefield Operations. The release authority for the crew is the
PIC.
SAFETY
1-212th Aviation Regiment
SOP
Down with Suspected Damage/Injury – When an aircraft has landed with the
possibility of damage or personnel injury:
(a) The following incidents are examples of “down with suspected damage” and can be
released by the Battalion Commander.
•
spike knock (once confirmed by maintenance)
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bird strikes
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hot start
•
overspeed
•
over temp
•
over torque
(b) The following incidents are categorized as “down with suspected injury” and can only
be released or transported by FLATIRON.
•
sick flight personnel
•
smoke and or fumes in the aircraft
•
Any injury that occurs during flight duties after takeoff
Completion of an AAAR or AAAR worksheet is required to be filed at the
appropriate Basefield Operations.
SAFETY
1-212th Aviation Regiment
PL Notification
Flat Iron
ATC
CCC
OPS
BN Initial
Responder
SAFETY
1-212th Aviation Regiment
SOP
Secured area – An area, which provides sufficient protection to preclude
vandalism or unauthorized tampering with the aircraft. The following are
considered secure areas:
(a) Military airfields, which are operational or have a monitor/guard during
non-operational hours.
(b) Any area, which has military personnel or civilian police on duty as
monitors/guards.
(c) Stagefields will be considered secure areas as long as a stagefield crew
(ATC operator) is on duty or during hours of operation as depicted on Fort
Rucker Form 196, Stagefield and Support Requirements.
Secure Airfield – An airfield that has a tower that is staffed by military personnel
and is operational. Example – If an aircraft is left at an airfield, other than a
basefield, that has a tower staffed by military personnel and is operational,
the responsibility of security is transferred to the tower personnel, who are
required to remain on site until a guard arrives, thereby maintaining
uninterrupted aircraft security.
SAFETY
1-212th Aviation Regiment
SOP
•
Logbook Entries following a PL: Prior to recovery of aircrews, the
aircraft must be marked with chemsticks and a write-up entered on
the DA Form 2408-13-1. The entry will state, “chemstick markers
placed on tail rotor and windshield”, along with a write-up explaining
the deficiency. The aircraft key will be returned to the basefield
operations upon return.
•
Crash Control: PLs for other than low fuel and weather require
notification of Cairns Crash Control. No one may interrupt the crash
system sequence once a PL has been declared. The aircrew, cover
ship, AMC, or ATC will not reject flatiron. PL aircraft will not be moved
unless released by maintenance personnel or the Battalion
Commander or designated representative as applicable.
•
PC/IP Responsibilities: The PC will remain with the PL aircraft at
unsecured locations until relieved by maintenance or a guard.
SAFETY
1-212th Aviation Regiment
SOP
AAAR/ACR Requirements:
1. After making a PL, aircrews will report to their Basefield Operations
and complete the DA Form 2397-AB (AAAR) IAW the example posted
in operations. The AAAR will be completed by the IP/PC anytime after
the starter is energized and an unscheduled termination occurs,
regardless of whether or not a PL is declared. It is incumbent of the
PC that the AAAR or AAAR worksheet is completed at appropriate
Basefield Operations, as soon as practicable after the incident.
2. An aircraft landed due to a weather PL will complete the AAAR with
“aircraft recovered” or “aircraft secured at”, and give location.
3. A complete form to include Page 2 is required anytime damage or
injuries exist.
4. Completion of an Aircraft Condition Report (ACR) is required anytime
scheduled maintenance is not completed properly, aircraft condition
is not flyable, and the starter switch(s) have not been pressed.
SAFETY
1-212th Aviation Regiment
SOP
Downed Aircraft Site:
The crew of the first aircraft discovering an accident/incident will orbit
the area not lower than 500’ AGL, squawk emergency, and contact
HUB/ATC, giving approximate location and request that radar position
be marked and reported to Crash Control. The aircraft will continue to
orbit as long as practical, or until FLATIRON, THE BATTALION
SAFETY OFFICER / DESIGNATED REPRESENTATIVE, or a
MAINTENANCE recovery aircraft arrives. Extreme care will be
exercised if landing is necessary to render emergency assistance to
the downed aircrew. Aircraft landing at the crash site will ensure
adequate safe landing area remains for FLATIRON. Pilots will monitor
frequencies 30.10 FM and 139.450 and 243.0 UHF. Solo aircraft may be
relieved by any aircraft with two rated aviators onboard or any aircraft
with an Instructor Pilot onboard.
SAFETY
1-212th Aviation Regiment
• USAAVNC Form 1891
– Dated FEB 2009
•
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•
•
BN OPS 255-4033 (Lowe) / 255-4157 (Shell)
BN SAFETY 255-4372
BN SAFETY Cell (334) 470-7635
HUB Radio 255-8431/8435
SAFETY
1-212th Aviation Regiment
SOP
Crew Endurance:
Maximum duty hours per day
Maximum factored flight hours per duty day
Maximum factored flight hours per 7-day period
Maximum factored flight hours per 30-day period
12
8
40
110
NOTE 1: Factors applying to aircraft time flown:
Day/SFTS
Contact/Combat Skills/Terrain Flight
Spanish/MTP
Night /Instrument/Hood/NVG
3:1 Flight
1.0
1.5
1.5
2.0
2.0
NOTE 2: The Battalion Commander is the extension authority and is the only
person that can authorize deviations of any crew endurance factors.
SAFETY
1-212th Aviation Regiment
SOP
• The individual aviator will ensure he does not exceed
crew endurance limits.
• The individual aviator is the final authority when fatigue
is a factor for flight.
• The duty day begins when the aviator departs his place
of residence enroute to duty and ends when he is
released from duty.
• Crewmembers will receive at least 10 hours of off duty
time between duty days. Crewmembers will receive at
least 10 hours off between shift changes from AM/PM to
Nights or from a Night schedule to an AM/PM schedule.
SAFETY
1-212th Aviation Regiment
SOP
• Student Pilots: Students will not factor their
individual flight times. Flight time, including
OR/CP time, will not exceed 6.0 hours daily.
IERW NVG PI time will not exceed 2.5 hours per
training day. IPC and AQC will not exceed 4.0
hours of NVG time per training day.
SAFETY
1-212th Aviation Regiment
FOD
•
Any tools or maintenance equipment found in or around the
helicopter will be reported to ACLC immediately. Do not
move the FOD until ACLC has completed their inspection.
•
All personnel are required to police the aircraft and the
immediate area around the parking pads for objects that
could create a FOD hazard.
•
Report significant FOD hazards to the Battalion FOD
Control Officer or Safety Officer as soon as possible to help
prevent recurrence of similar problems.
•
Don’t leave FOD (cans, papers etc.) behind.
SAFETY
1-212th Aviation Regiment
FOD EXAMPLES
SAFETY
Close Call Program
• The program was developed to fill the gap
between accident reporting and the
avoided accident to identify hazards prior
to an accident occurring
• Prior to the program, the first time a
hazard was recognized was when an
accident occurred
Reporting & Tracking
• Hazards are reported via a sheet located in all
briefing and debriefing rooms
• The unit ASO is responsible for collection and
database entry
• The applicable ASO reports to the commander
any new hazards or spikes of a particular
hazard
Close Call
Written
On Close Call
Sheet
Annotated in
database
Database
Searched
Weekly
Risk is
Determined
Awareness
Conducted
What this gives the Commander
The “Close Call” Database
• An MS Access
based database
• Can data mine
info based on the
completed fields:
– Location
– Time
– Task
Commander’s Tools
• Queries of
specific
hazards
– Provides
objective
data to
leaders
Commander’s Tools
• Falcon View
Overlay:
– Allows data
to be
displayed
visually
– Crew
briefings /
Awareness
TNG
Falconview
10
Advantages vs. Disadvantages
• Advantages
– Ease of use
– Performance metric
– Identifies previously
unknown risk
– Provides Historical
Continuity
– Instills sharing not shying
• Disadvantages
– Requires active
participation by unit
members
– Additional work for ASO or
designated assistant.
1-212th Aviation Regiment
Questions?
SAFETY