Blaming Pilots, Instead of the Machine

Aerial view of the site of November 2010's F-22 crash.

By NICK SCHWELLENBACH

Are military accident investigation reports objective or are the conclusions of some reports being bent to blame pilots rather than flaws with expensive, highly controversial weapons systems?

The recently released Air Force report detailing the conclusions of an investigation into the fatal crash of an F-22 in November 2010 is coming under such criticism. As the Los Angeles Times’ W.J. Hennigan reported yesterday:

Last week's report generated much debate over whether the Air Force turned Haney, an experienced and award-winning aviator, into a scapegoat to escape more criticism of the F-22.

Haney "most likely experienced a sense similar to suffocation," the report said. "This was likely [Haney's] first experience under such physiological duress."

To save himself and the plane, Haney should have leaned over and with a gloved hand pulled a silver-dollar-size green ring that was under his seat by his left thigh to engage the emergency system, the report said.

It takes 40 pounds of pull to engage the emergency system. That's a tall order for a man who has gone nearly a minute without a breath of air, speeding faster than sound, while wearing bulky weather gear, said Michael Barr, a former Air Force fighter pilot and former accident investigation officer.

"It would've taken superhuman efforts on the pilot's behalf to save that aircraft," he said. "The initial cause of this accident was a malfunction with the aircraft -- not the pilot."

Barr said the Air Force blamed Haney because the brass doesn't want more criticism of the F-22 program, which will cost an estimated $77 billion and whose need was called into question even before its first test flight.

"They've taken all the heat they want to," Barr said. "They paid a lot of money for an aircraft that doesn't work."

Questions have also been raised about accident reports involving the V-22 Osprey, which is used both by the Marine Corps and the Air Force. Brig. Gen. Donald Harvel, who investigated the April 2010 crash of an Air Force V-22, told the Air Force Times that “There was absolutely a lot of pressure to change my report.”

And Harvel was overruled. As Wired’s David Axe recounted in an article this fall:

Air National Guard Brig. Gen. Donald Harvel, the lead accident investigator, concluded that engine failure was the likely cause. But his boss, Lt. Gen. Kurt Cichowski, vice chief of Air Force Special Operations Command, overruled Harvel. “The convening authority disagreed that engine power loss was supported by the greater weight of credible evidence,” the Air Force concluded.

What explanation did Cichowski offer as an alternative? None, really. The investigative board “was unable to determine, by clear and convincing evidence, the cause of this mishap,” the Air Force stated. But the flying branch did mention pilot error as a “substantially contributing factor.”

Harvel, who retired a month after the release of the full, final accident report (.pdf), cried foul: “My heart and brain said it was not pilot error. I stuck with what I thought was the truth.” The pressure on Harvel echoes at least two occasions when Marine officers told Osprey mechanics to falsify records in order to downplay the tiltrotor’s mechanical problems.

This isn’t the first time V-22 pilots have been blamed when investigators thought that problems with the tilt-rotor aircraft itself were the root cause of the accident. As POGO’s Dana Liebelson wrote in a story highlighting Rep. Walter Jones’ (R-NC) valiant efforts to clear the names of two Marine Corps pilots who died in a 2000 crash of the V-22:

…technical problems with the aircraft and its flight envelope were especially not well understood back in 2000 when the Arizona crash occurred, according to William Lawrence, who was in charge of testing the V-22s from 1985 to 1988. In a letter he wrote to Jones, Lawrence said he was “convinced [the crash] was the result of poor design and possible inadequate training.” He added that the flight crew, composed of Lieutenant Colonel John A. Brow and Major Brooks S. Gruber, “could not have understood the actions necessary to prevent the crash.”

Lawrence’s concerns were backed up by the three Marine investigators who were responsible for establishing findings from the crash. According to their investigation, the “asymmetric vortex ring state” (VRS)—a hazardous condition encountered in helicopters, which can derail a controlled landing—was the cause of the crash. The report said that there was no warning of VRS in the pilots’ manual, and Bell/Boeing didn’t fully test for this “dangerous design flaw.” 

“The accident aircraft was under control until the moment the right prop-rotor lost lift, after which the roll was unrecoverable,” said the investigators’ report.

What should be done? Congress should consider holding hearings. It also should ask the National Transportation Safety Board (NTSB), which investigates accidents in commercial aviation and other transportation sectors, to review these questionable conclusions. NTSB’s investigations have an excellent reputation for independence, something that may be lacking in military accident investigations.

Nick Schwellenbach is POGO’s Director of Investigations.

Follow @schwellenbach

Photo by Air Force Master Sgt. Jeremiah Erickson / U.S. Air Force.

Comments

[Dfens]

The report the DoD makes public after an aircraft crashes is the Accident Investigation Board (AIB) report. The one that stays classified is the Safety Investigation Board (SIB) report. The AIB has become a white wash that always blames the pilot. The SIB report digs deeper and often results in changes being made to the aircraft. Usually the manufacturers are more cooperative with the SIB because they know they cannot be sued for anything coming out of that report. Plus the program office is more cooperative with the SIB because they don't have to worry about their program being cancelled due to bad press coming out of the SIB report. As usual, our classified data system exists not to protect our data from foreign enemies, but from taxpaying US citizens. The first amendment is a joke to the military industrial complex.

On the other hand, as can be seen in the C-5 example, at least the problem was fixed, most likely due to the SIB report. That's better that what happened with the Kapton wiring insulation used in commercial and military aviation for years, even after it was found to promote arc tracking, because it was cheaper to pretend it wasn't a problem than to pay the lawsuits. Perhaps the topic of tort reform should be part of this discussion?

[Dfens]

There is also a paper available regarding a study that was done regarding changes made to the C-5 AMP engine displays after the Dover crash. A copy of the paper can be purchased here. It does not mention the crash, but shows pictures of the engine display used when the crash occurred and the updated version. There have clearly been features added that make it more obvious to the pilot which engine is not operating such as a red box around the instruments of the engine that is shut down. The crash was (publically) due to the fact that the pilot grabbed the wrong 3 throttle levers at one point in his landing descent resulting in the airplane crashing short of the runway. Obviously the pilot made an error, but at what point is the airplane also identified as being at fault, and that pilot lived, though I understand he will never walk again.

[Dfens]

It occurs to me that there are some things about a military flight safety investigation that aren't like an investigation of a private airplane accident. For instance, did you know that there are actually 2 reports filed for a military airplane crash saftey investigation? One report is for the public and the other is classified. Knowing the classified report exists makes it possible to request that report via the Freedom of Information act. Typically now the public report always blames the pilot, and the short comings of the airplane are in the classified version of the report. I believe the classified version of the report was inadvertently released publically for the C-5 crash at Dover in 2006. I never saw it, but apparently it could be found on the internet somewhere. The video of that crash can easily be found on YouTube was supposed to stay classified, I believe.

[Dfens]

There is a huge bureaucratic lobby for the the airplane, but the pilot has no advocate. There is a similar problem in civil aviation where the manufacturer is well represented by the manufacturers, but no one speaks for the pilot. Then we wonder why 80% of all airplane accidents are "pilot error" and the statistic doesn't get any better. There is a whole discipline of developing good human interfaces called Human Factors. They are mainly represented by the Human Factors and Ergonomics Society. I think it is well past time that we had people with this specialty advocating for good pilot interfaces in the FAA, on NTSB investigation boards, and on USAF accident investigation boards. A good user interface would not have allowed this stupid "ring pull" air system backup control on the F-22. In fact, I know personally that the F-22 had a highly dysfunctional Human Factors effort. Even the US Air Force is aware of this. I have a friend who took an Air Force class on Human Factors where the F-22 was specifically used as an example of what not to do in the development of pilot controls.