Deadly safety problemsplague military aircraft
Mechanical mistakes, faulty equipment often the cause of crashes
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Copyright 1999 Dayton Daily News
The U.S. Army knew it had a potentially deadly problem when an OH-58 Kiowa Warrior helicopter lost power and crashed into an Alabama pine forest, destroying the aircraft and injuring both pilots. A secret Army report on the Nov. 8, 1993, crash concluded that a fuel filter used on OH-58 helicopters was prone to trap air and "may cause engine malfunction."
Both Army officers died.
"If they knew something was wrong with it, why did they let it go on?" said Ernest Aguilar, an Army veteran of two wars and the father of the pilot. "Something should have been done."
Every day thousands of men and women go into the sky believing in an unspoken promise: The military is doing all it can to keep them safe.
But an 18-month Dayton Daily News examination found that the military breaks that promise virtually every day.
The newspaper found that the military routinely allows helicopters and airplanes in the air that it knows are plagued with potentially deadly safety problems -- conditions, in some cases, allowed to persist for months, years or even decades.
The Daily News reviewed thousands of pages of accident reports and analyzed hundreds of thousands of computer records made public for the first time.
Among the findings:
The military's already flawed aviation safety system recently has become further strained by massive downsizing and budget cuts, the loss of thousands of experienced pilots, global conflicts and an aging fleet of aircraft. Amid these problems, the rate of serious aviation accidents increased this year for all the services except the Navy, which was rebounding from an 82 percent increase in 1998. The Army's rate for serious accidents was the highest since Desert Storm.The military's system for repairing and maintaining aircraft is itself broken. Hundreds of in-flight emergencies and accidents -- some deadly -- can be traced to parts installed improperly, engines overhauled incorrectly and other mistakes by mechanics or the people supervising them. The military has concealed its true aviation safety record from the public. Since 1980, hundreds of serious accidents were omitted from the military's official accident rate, and the percentage of uncounted accidents is growing, from 1.6 percent of all accidents in 1980 to 23 percent in 1997. Decisions critical to the safety of the men and woman who fly on military aircraft frequently are left to private civilian companies with millions of dollars riding on those decisions. In some cases, those companies participate in secret accident investigations even as they face multimillion-dollar lawsuits involving the same accidents. Federal investigators suspect that several CH-47D Chinook helicopter accidents may be linked to gears made with a specially processed metal at two factories, one in Springfield. In August, 14 years after the first accident, problems with gear parts made with the same metal led to a worldwide grounding of Chinooks, the largest such grounding ever.
The military operates more than 15,000 fighter jets, helicopters and other aircraft with virtually no independent oversight. If the safety of civilians depended on the same system, airlines could choose their own employees to investigate accidents, decide when to ground their own aircraft or when to replace unsafe parts, and make these decisions in secret, with little fear of being sued.
"I'm beginning to understand how the military deals with this stuff," said James Browne, whose son was killed when he flew a helicopter that Navy investigators later determined was not safe to fly. "They don't want to spend the money to fix something until they're between a rock and a hard spot.
"They're willing to sacrifice as acceptable risk the lives of military personnel."
The military's top safety officials said aviation has never been safer. They acknowledged the recent increase in the accident rate, but said their statistics during the past 30 years show a drastic drop in the rate of serious aviation accidents.
"I care about these sailors and Marines," said Rear Admiral Frank M. "Skip" Dirren, Jr., commander of the safety center in Norfolk, Va., that oversees Navy and Marine Corps aviation safety. "If we find something wrong, we fix it."
Brig. Gen. Gene Martin LaCoste, commander of the U. S. Army Safety Center at Fort Rucker, Ala., said many accidents are caused by human error, not by long-standing problems ignored by the military.
"We see guys making more mistakes because of less experience in the cockpit," he said.
Major Gen. Francis C. Gideon, Jr., commander of the Air Force Safety Center at Kirtland Air Force Base, N.M., and the former director of operations for the Air Force Material Command at Wright-Patterson Air Force Base, said serious aviation accidents have become so rare that they are "almost statistically irrelevant."
PROBLEMS CONTINUE DESPITE WARNINGS Despite assurances that the military is doing everything it can to prevent accidents, planes and helicopters keep falling from the sky for the same reasons.
The engine-control assembly (ECA) in the Navy's F-18 Hornet had failed 114 times when a pilot in Florida reported a problem on July 1, 1996. "Multiple ECA failures fleetwide posing unacceptable risk to aircraft crew," an investigator warned after that incident. Exactly one month later, another F-18 reported the same problem. Three months later, another was reported.
Hydraulic failures in the Navy and Marine Corps' CH-46 Sea Knight helicopters caused more than 71 emergencies and accidents since 1988, three resulting in a loss of helicopters -- one of them part of President Clinton's fleet. Earlier this year, 11 years after the first incident was documented, two people were injured when a helicopter filled with reporters and photographers caught fire off the coast of California. It was the second time in four days that hydraulic problems had forced a Sea Knight to make an emergency landing in California.
An electrical relay used in the vapor system for the Navy's twin-engine E-2C Hawkeye airplane failed at least 54 times -- 26 of the incidents causing fires or an electrical spark. In 1996, an investigator warned: "This situation needs to be rectified. . . . We were fortunate that this incident happened on preflight." Two months later, an E-2C reported smoke in the cockpit after the vapor system failed. Two similar cases were reported in 1997 and at least one in 1998.
Sometimes recommendations go unheeded even after problems turn deadly.
Chief Warrant Officer David E. Glamuzina, 46, and Specialist Thomas Nessmith, 22, were flying in an AH-1F Cobra helicopter above a pineapple field in Hawaii on March 5, 1996, when Glamuzina radioed the nearby Wheeler Army Airfield tower that he was having a maintenance problem.
Eighteen seconds later, tower officials received another transmission from the helicopter, one they couldn't hear well enough to understand. Witnesses heard the Cobra's engine begin to wind down as it descended through trees, snapping a tree with an 18-inch trunk as it crashed and slid 60 feet into a deep ditch that ran through the pineapple field.
"It was the absolute worst place to go down," said Army Lt. Col. Stan Nessmith, who flew to the site from his job at Maxwell Air Force Base in Alabama upon hearing that his only brother was in a helicopter crash.
Glamuzina and Nessmith were killed.
"For as long as I can remember, Thomas Nessmith wanted to be a soldier," Lt. Col. Nessmith wrote in a memorial he had published in a Florida newspaper. "I never knew anyone who knew him who didn't like him. He had a way of walking into a room and within minutes he would have everyone laughing."
Several weeks after the crash, Army technicians concluded that a gear failure "produced ferrous metal debris" or metal chips in the engine oil system -- a problem usually preceded by a "chip detector" warning light.
That light illuminated when a magnet in the engine oil system collected enough debris to signal a potential problem.
The magnets were left in the engine's oil system, but the warning light on this helicopter -- and on 800 others -- had been disconnected after pilots complained of unnecessary emergency landings. That system had been replaced by a new warning system manufactured by a company owned by Eaton Corporation of Cleveland.
The new system, located in a different part of the aircraft, vaporizes metal debris with an electrical current. Unlike the old chip detector system, the Oil Debris Detection System, or ODDS, was designed to warn pilots only when the electrical current cannot vaporize the debris.
After the Hawaii crash, Army technicians recommended that the service reconnect the old chip detectors because they provided "an effective warning of impending failure."
But the lights were not reconnected.
"We received the recommendation and decided there was no value added" by reconnecting the old warning lights, Army spokesman Mark J. Jeude said during a September briefing to Dayton Daily News reporters at the Pentagon.
The lights are wrong most of the time, Jeude said, and nuisance lights are "not something we want to accept."
"That's unbelievable that somebody made that decision," Lt. Col. Nessmith said. "It seems to me it's not worth the chance of somebody's life."
On March 1, 1997, nine months after Army technicians recommended that the service reconnect the warning lights, four soldiers from the Indiana National Guard were flying 200 feet above an Indiana pine forest when the engine failed on their UH-1V Huey helicopter. The pilot, Chief Warrant Officer Thomas L. Miller, started a desperate diagonal descent toward a clearing in the trees.
"We didn't make it to the landing area," said Staff Sgt. Keith Pyle, the crew chief, who was strapped in just behind the pilots.
"I was thinking this was a bad situation and life as I know it was over. It was not a pretty picture."
Just 40 yards from the clearing, with the helicopter pointed downward in a 45-degree angle toward the intended landing site, the aircraft crashed skid-first into a small grove of trees.
Miller, a father of two, was killed in the crash. Pyle, whose full-time civilian job was driving trucks, broke his back and needs metal braces to walk. The other two crew members, Lt. Todd Bouslog and Staff Sgt. Don Brinker, also were seriously injured.
The Army sent the engine to the same shop, supervised by the same people who oversaw the examination of the Hawaii wreckage. Again, the technicians recommended reconnecting the old chip-detector warning lights.
If the Army wasn't going to reconnect the old warning lights, the technicians recommended, it should remove the old system altogether. The old system, they said, may be hiding potential problems by collecting debris in the engine oil system before the debris is able to make it to the ODDS warning system.
Again, the Army decided not to follow the recommendation of its experts.
"The old chip detector has not been reconnected or removed," said Army spokeswoman Martha Rudd. "There was no need to."
In a prepared statement, the Army acknowledged that the old chip detector "might still occasionally collect some metal debris that settles to the bottom when the engine is shut down." But the ODDS system, the Army said, should alert pilots of any problems caused by this debris.
This year the Air Force, through the Air Force Material Command at Wright-Patterson, began buying 65 ODDS kits for its helicopters. An additional 135 kits are earmarked for the Greek Army, and negotiations are under way with the governments of Taiwan, Turkey, Jordan and Thailand.
After hearing of the newspaper's findings, Pyle, Bouslog and Miller's widow, Josephine, filed a lawsuit against the companies involved in the manufacturing of the ODDS system. The suit, filed in the federal district court in Indianapolis, alleges that the oil debris detection system on the helicopter was defective.
Peter Parsons, a spokesman for the Eaton Corp., referred questions about the ODDS system to the Army.
'NO FIX IN SIGHT' Even when it acts on a potentially deadly problem, the military frequently chooses small, measured responses, postponing more difficult solutions until the same problem leads to more accidents.
After the OH-58 Kiowa Warrior helicopter crashed in Alabama in 1993, the Army issued a technical bulletin requiring mechanics to use new procedures to bleed air from the fuel system.
Months later, after Lt. Michael A. Aguilar and Capt. Kenneth Sexton were killed in another OH-58 crash, Army technicians recommended further steps to keep air from the fuel system, including the possible introduction of a vent.
Some aircraft, however, fly for years or decades as the military struggles with persistent mechanical problems.
For years, the military struggled to prevent engine problems that plagued the AH-1W Super Cobra attack helicopter.
There were two types of malfunctions: rollbacks, causing the engine to roll back to idle; and flameouts, the sudden loss of engine power -- different problems that can be linked to a single cause.
In October 1995, a AH-1W Super Cobra helicopter from Camp Pendleton, Calif., suffered the eighth engine malfunction by the same squadron in a little more than a year. Mechanics first suspected water in a wiring harness, but when they took the helicopter up, the same engine flamed out again.
The Super Cobra has two engines, so losing one is not necessarily critical. In 1995 and 1996, however, the Navy investigated reports of dual engine failures.
In one of those cases, on April 18, 1996, an AH-1W from the Marine Corps Air Station in Iwakuni, Japan, suffered a dual engine failure.
Maintenance personnel in Japan checked a fuel switch. They swapped engines. They replaced the engines. But they couldn't fix the problem. So the engines were sent to General Electric "for investigation."
A year later, on March 25, 1997, an AH-1W from the USS Nassau reported its number 2 No. 2 engine had failed, prompting his commanding officer to write: "This is the second rollback in four months on this engine in this aircraft. . . . This hazard is being addressed. . .with no fix in sight."
By March 1997, the military had documented more than 70 rollbacks and flameouts involving the Super Cobra.
Less than two months later, Alice Ruff was sitting at her desk at Ruff House Ministries about 15 miles southeast of downtown Dallas when she spotted a Super Cobra helicopter that appeared to be in trouble.
"I saw it come over the tree," she said.
Twenty minutes after takeoff, the helicopter crashed in a field near a high school, killing both pilots. The helicopter, however, missed the fiveacre ministry property, which includes dormitories housing homeless families.
"We're a Christian organization," Ruff said. "We don't call it luck. We call it blessed. But I felt bad for the people in it."
Maj. Michael J. Browne, the father of two girls and a combat veteran of Desert Storm and Somalia, and Lt. Robert B. Straw, also a husband and father, were killed.
"It doesn't take but a word or a thought for someone to cry," Browne's father said. "His wife is alone taking care of the girls."
A Navy investigation found that the helicopter "was not safe for flight and should have been grounded" before it left Bell Helicopter Textron Inc. near Fort Worth, Texas. The investigation found that there were outstanding "urgent" technical directives for work on the aircraft -- at least two of them aimed at preventing engine failures.
Rear Adm. Dirren, who reviewed Naval Safety Center records of the accident at the request of the Dayton Daily News, said: "We blew it."
By the time of the Dallas crash, the Navy had assembled a special "tiger team" to investigate the cause of the engine problems.
"The tiger team was window dressing," said Dallas attorney John Howie, a former Navy pilot who now represents the Browne family in a lawsuit against Bell and General Electric Co. Inc., which manufactured the engine. "Somebody was going to die. It was predicted before this crash.
"If the helicopters cannot be flown safely, you park them."
Dirren said that the Navy never found the exact cause of the Dallas crash.
On May 5, 1998, a year after the Dallas crash, an AH-1W assigned to the USS Wasp reported an engine flameout. A report on the incident says: "Since this incident, there has been another aircraft flameout occurring."
In November 1998, more than four years after the Navy begin documenting engine failures in the AH-1Ws, drains were installed to prevent fuel from building up in the engines, Dirren said, adding that the new drain was a result of the tiger team investigation.
"We know we have an issue (with rollbacks and flameouts)," the admiral said. "We think we got a fix."
COST A FACTOR WHEN LOOKING FOR SOLUTIONSSometimes problems go unresolved because the military decides the solutions are too expensive.
"You look back at the risks," said Marine Corps Col. Roger Dougherty, who until earlier this year was aviation safety chief at the Naval Safety Center in Norfolk, Va. "What's the severity of the risks and what's the potential of it happening again?
"And then we have to make hard choices based on dollars and cents. If it's a high risk that's going to happen often, it gets fixed. That's the bottom line."
In the system used to ensure civilian aviation safety, independent federal regulators can mandate safety changes. In the military system, the services decide for themselves.
"I think the independence is a critical part of the investigation," said Gene L. Sundeen, chief of regional operations and general aviation for the federal National Transportation Safety Board.
"It's difficult to ask an agency to investigate itself and criticize itself. When an agency is asked to investigate itself, it often has an urge to hide problems."
Free to choose, the military has made some poor choices, writing problems off as not warranting expensive solutions only to find the same problems turn catastrophic.
By early this year, the Air Force had documented 11 in-flight failuresof afterburners on Pratt & Whitney F-100-220 engines, used on F-15 and F-16 fighters. The afterburner, or augmentor, fits into the exhaust section of the jet and provides extra power by shrinking the size of the exhaust while injecting and igniting additional fuel.
Pieces of sheet metal called stiffeners, each welded on in 70 places, are attached to the afterburner on the F-100-220 engine to keep it from buckling under the tremendous heat and pressure produced by the engine.
The Air Force found that vibration and aging caused the welds to split until eventually the afterburner cracked.
"The nozzle and augmentor actually came off," said Robert May, Jr., who as propulsion product manager is in charge of engines for the Air Force.
An afterburner used for engines on another type of F-16 is chemically milled, or attached without welds, May said, and the Air Force could have easily solved its afterburner problem by putting chemically milled afterburners on its F-100-220 engines, used on both the F-15s and F-16s.
But there was a catch.
"To retrofit this new augmentor...is 40 to 50 million dollars," May said, and that's just for the F-16s.
Forty to 50 million dollars is roughly the cost of a couple of F-16s.
The decision was put off. After all, none of the 11 in-flight failures had caused a major accident. The F-15s, which have two engines, continued to fly on one engine, and the F-16s, which have only one engine, were able to land before the problems turned catastrophic.
"We didn't rush to put these parts on because none of the events caused Class A (accidents)," May said.
That changed this year.
On Feb. 3, an F-16 piloted by a student from Luke Air Force Base, Ariz., crashed near Gila Bend, Ariz. No one was seriously injured, but the $20 million aircraft was destroyed.
The next month, on March 26, another F-16 from Luke Air Force Base crashed on private property near an Arizona freeway. The pilot ejected and no one was injured. The aircraft was destroyed.
Both F-16s had afterburners that were attached with welds. In each case, the afterburner broke free and the engine fell apart, igniting a fire as flying debris ruptured the fuel lines.
"Our risk analysis shows we were in error before," said Major Gen. Gideon, the Air Force Safety Center commander.
Maj. Derek Kaufman, a Luke AFB spokesman, said the Air Force now plans to replace the old afterburners, but it could take several years. Until then, he said, mechanics will do more comprehensive inspections.
"Inspections allow us to mitigate the risk, but we know the real fix is replacement parts," Kaufman said. "We can't manage risk through inspections forever."
Al Michaels, a national resource specialist for the Federal Aviation Administration, said that in similar situations involving civilian aircraft the FAA would issue a safety warning after one or two reports of parts falling off planes.
"We wouldn't have waited for three," he said.
Cost also was the reason the Navy denied a recommendation to install a safety feature following the Dec. 17, 1992, crash that killed Lt. Cmdr. James E. Boyle when his Navy F-16 crashed in Idaho. An officer assigned to investigate the crash blamed pilot error, but he also found that the Navy wasn't using a computer software package that warns F-16 pilots when the plane is at a dangerous angle. The Air Force, the investigator found, already was using the software on its F-16s to warn pilots when they are flying close to terrain.
The Navy decided that installing the safety feature would not be "cost effective" because its F-16s would only be used for two more years.
RISKS NECESSARY TO COMPLETE MISSION Sometimes the military's needs -- its missions -- are deemed more important than the risks posed by safety hazards.
"All U.S. Air Force missions and our daily routines involve risk," says a copy of "Risk Management" guidelines for Air Force officers. "Accept necessary risk required to successfully complete the mission or task."
"Avoiding risk altogether requires canceling or delaying the job, mission or operation, but is an option that is rarely exercised due to mission importance."
Maj. Eric Johnson learned this first hand.
Johnson, the aviation representative at the Pentagon for the Army Safety Center, had his body permanently scarred from an aviation accident.
Johnson's face and legs were burned on Feb. 23, 1993, when a UH-60A Blackhawk helicopter crashed in Germany, causing a 230-gallon external fuel tank to explode.
Johnson was on fire when he ran from the burning helicopter. Another officer's clothes were still smoldering when he stumbled from the wreckage. Four others, including Maj. Gen. Jarrett Robertson, the deputy commander of V Corps in Germany, were killed.
"Had there not been a fire, three of those four individuals would have survived," said Johnson, who filed suit against the helicopter manufacturer, United Technologies Corp. "I'm not speaking for the Army, only from a personal aspect."
The reason they didn't survive, Johnson said, is that the huge external fuel tanks, added to the helicopter so it can fly longer without landing, were never designed to survive a major crash. In addition, he said, the helicopter was never designed to fly regularly with the tanks.
An Army report on the accident says one passenger was killed by impact forces, and seven other passengers were either killed or injured by "thermal injuries."
Three years before the Germany crash, investigators working for a Congressional committee warned Congress that putting certain types of external tanks on Blackhawks could create "potential dangers."
"What we found out was that because of the weight of these things, the nose (of the helicopter) came near to touching the ground," said Lawrence Dandridge, one of four General Accounting Office investigators temporarily assigned to the committee staff. "We also found out they were not crashworthy fuel tanks, so we told them not to use them."
After the Germany crash, Johnson said he tried to convince the Army Safety Center to consider using crashworthy tanks, just as the congressional investigators had done three years earlier.
"I raised it as an issue," he said. "I think the safety center has always been interested in crashworthy tanks, but it just wasn't a top priority."
Instead of replacing the tanks, the Army decided to better educate pilots of potential problems in controlling the helicopter when the tanks are mounted.
"I guess they thought the training would help fix it," Johnson said.
Four years after the Germany crash, on July 8, 1997, a Blackhawk helicopter crashed into a stand of tall trees in North Carolina, rupturing both 230-gallon fuel tanks and killing all eight people aboard as the helicopter exploded into a fireball.
The Army issued a press release blaming the accident on pilot error. But accident investigators noted that the crew would have survived had it not been for the external fuel tanks rupturing and causing the fire.
In a separate written response to the Dayton Daily News, Army officials at the Pentagon said the external fuel tanks were designed to be jettisoned from the helicopter and not intended to be "directly involved in every helicopter crash."
"It is not likely that a tank designed with any different specifications would have made a difference in the crash," the written response says.
Following the Fort Bragg crash, the Army took further steps, requiring that missions involving Blackhawks using the external fuel tanks must be first approved by a high-ranking officer, usually someone with the rank of least a lieutenant colonel or above.
Nine years after the investigators warned Congress, the Army still allows Blackhawks to fly with the old tanks. Johnson said tests are under way on a safer tank.
"They continue to use them," Johnson said. "The leadership in the military is not forceful enough to simply say, 'It wasn't designed for that. Let's quit using it.' "
Sidebars to Part 1:ANATOMY OF A CRASH - ONE PILOT'S STORYPart 2: Oct. 25, 1999: Investigators suspect metal linked to deadly crashes |