The perfect mishap

Flying Safety, July, 2002 by Andreas K. Wesemann

Cold drops of sweat beaded up on my forehead. The other T-6 instructor behind me talked slowly on the radio. The gear handle was placed down, but there were no gear down indications--nothing! Only a red light indicating that the gear door was not closed. A chase aircraft was directed to rejoin, and it verified that the inboard gear door was partially down. Slowly, my worst fears were realized. The newest aircraft that the Air Force was flying--still with the "new car" smell--would have to be intentionally landed gear-up. Despite two hours of troubleshooting and burning down gas, it was inevitable. As the aircraft came in on the final approach, the engine was shut down. An eerie silence ensued as Tail 32 became a glider. The aircraft touched down about 1000 feet down the runway and skidded to a stop about seven feet off center. In a shower of sparks, the propeller mustached itself outward. I slowly stood up, and checked my binoculars once more. I was glad that I was in the Runway Supervisory Unit (RSU) and no t in the mishap aircraft!

It was the perfect mishap--not that it was preventable, or that the instructor pilots were able to counter the malfunction, but that every aspect of Operational Risk Management (ORM) was put into place and functioned flawlessly. Using the 5-M methodology (Man-Machine-Method-Management-Medium) I will show how in the space of about three hours, an aircraft malfunction became the "perfect mishap."

Background

A T-6A aircraft experienced a gear malfunction five minutes into a Continuation Training (CT) sortie with two instructors on board. Using a chase ship, they confirmed that they had a gear door partially extended, and then proceeded to the high pattern to troubleshoot. After almost two and a half hours of flight, efforts by the crew proved to be fruitless in lowering the gear. Upon the consultation and recommendation of many agencies, the mishap crew performed a flawless intentional gear-up landing.

Method: Operational Risk Management

Two main factors were analyzed using ORM over the previous several months in the 3d Flying Training Squadron. First, in a Continuation Training meeting last June, squadron leadership had the instructors brainstorm possible scenarios for the most likely mishap. The two items highlighted as the most likely were an engine malfunction and a gear malfunction. Several instructors noticed that one checklist directed an Emergency Gear Extension in Step 6--an irreversible step--and another checklist stated that attempts to recycle were advisable, and that it would be better to land gear-up than in some partial configuration. We all agreed that this section of the T-6A checklist was not well written, and that with good hydraulic pressure we would not advise blowing down the gear.

Second, good training was given to all instructors for the new tandem cockpit design for our side-by-side experienced instructors. We held many CT meetings where defensive techniques were discussed and how we would handle emergencies from the backseat. Briefings were given by Navy T-34 instructors familiar with the tandem cockpit environment as to how to handle emergencies from the rear cockpit. We also prepared ourselves on what to expect when we shut an engine down, using a recent engine shutdown experience at Randolph AFB.

RESULT: Proactive use of ORM prepared the mishap crew as well as the RSU crew for the mishap.

Machine: The Brand-New Raytheon T-6A Texan II

The mishap aircraft had been picked up from the factory several months prior to the mishap, and had flown without any major malfunction. All of the maintenance was properly performed and documented. The aircraft was on initial takeoff, and thus had a full load of fuel. With a full load of fuel, the mishap aircraft was able to fly for over two and a half hours while the mishap crew, ground personnel, supervisors and others attempted to troubleshoot and solve the problem. When the crew attempted to lower the landing gear on the first overhead pattern, they got an unsafe gear indication--no green lights, a red light in the handle and one gear door light on. The aircraft gear lighting system gave the proper indications for the malfunction, and the engine and all other systems performed as advertised. The chase aircraft had just taken off and was able to stay airborne for over two hours as well.

RESULT: Plenty of time to troubleshoot the malfunction, and the luxury of a similar chase ship.

Man: Dual Aircrew, Both Qualified Instructor Pilots

Both crewmembers were fully-qualified instructors in the T-6A. Both were also handpicked initial cadre, due to their experience as Air Education and Training Command instructors. The Front Cockpit (FCP) instructor had over 1993 total hours and 140 hours in the T-6A. The Rear Cockpit (RCP) instructor had over 2441 total hours and 92 hours in the T-6A. Both had adequate crew rest and nutrition, and both were prepared to fly. The chase ship crew had similar flying time, experience and duty day.

RESULT: Highly experienced crewmembers were current, qualified and proficient in the aircraft.