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Crew inexperience, fatigue led to C-17 runway mishap

Dec. 5, 2013 - 03:44PM   |  
Last C-17 Arrival
In May, a C-17 landed 1,000 feet short of the runway at Dover Air Force Base, Del., due in part to crew inexperience and fatigue, an investigation shows. (Airman 1st Class Chacarra Neal/Air Force)
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Crew inexperience and fatigue helped cause a May 9 incident in which a C-17 landed 1,000 feet short of the runway at Dover Air Force Base, Del., an investigation has determined.

The hard landing caused $7 million in damage to the plane, but none of the crew or the 52 passengers on board was injured, according to a redacted copy of the command-directed investigation. The report was provided to Air Force Times by Air Mobility Command.

The crew members came from the 17th and 15th Airlift squadrons under the 437th Airlift Wing at Joint Base Charleston, S.C., the investigation said. On May 9, they were returning from Afghanistan via Turkey and Spain. It was the first full mission with an ocean crossing for the pilot, and the first mission as a fully qualified crew member for one of the two co-pilots.

Things started to go wrong when the pilot became confused flying an instrument approach with a nonstandard glide path angle, the investigation found. The pilot tried to land at a standard 3-degree glidescope, but the glidescope for the runway at Dover is 2.5 degrees.

At an altitude of approximately 300 feet, the pilot made a series of corrections, pulling the nose up to “an unusual attitude” to correct his approach and bringing the engines to idle. Neither the pilot nor co-pilot realized the plane was slowing to an unsafe speed.

The pilot began making positive corrections at 175 feet. He initiated a go-around when he received a stall warning at 75 feet, but it was too late. The plane landed short of the runway, blowing out tires and damaging the landing gear and fuselage.

The entire incident lasted about 22 seconds — from the time the pilot came in at the wrong angle to when the plane hit the ground. An experienced pilot would have realized the plane was coming in at a wrong angle and made the appropriate correction or aborted the landing, but neither the pilot nor the co-pilot had landed at the shallower angle required for Dover, the report found.

The investigation found that the experience level at Charleston has been “steadily decreasing,” and that the 17th Airlift Squadron is undermanned in terms of both pilots and co-pilots.

Missionplanners failed to take into account the crew’s lack of experience, the investigation found.

“As a result, an aircraft commander on his first unsupervised oceanic mission in command was dispatched on a high risk and demanding mission,” the investigation determined.

Fatigue also played a major part in the incident, the investigation found. On May 9, the crew was on a 22-hour duty day. An aerospace physiologist determined that the pilot’s and co-pilot’s reaction times were delayed by 59 percent and 72 percent, respectively.

The fatigue likely caused the pilot to come in at a wrong angle while expecting to touch down 1,000 feet down the runway, the investigation found.

“This led to confusion when visual cues didn’t match the pilot’s expectations,” the investigation said. “The stress of confusion further complicates the effect of fatigue.”

The crew members’ command authorities will determine if any disciplinary action needs to be taken, according to Air Mobility Command officials.

In July, Air Mobility Command launched its “Fatigue Modeling” program after years of development, said Col. Mark Hale, an expert on aviation operational risk management.

“This program is a step forward in understanding and alerting our crews and our command and control system to aircrew fatigue challenges during mission planning and execution,” Hale said in an email.

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