Blame the Dead Pilots?

Whenever there is a major aviation accident, it usually turns out there is a series of factors that contribute to the cause, any one of which could have changed the outcome.  As safety investigators weigh those factors, they tend to settle on the final, often fatal, mistake.   Except when there’s a clear case of mechanical malfunction, it often comes down to “blaming the dead pilots.”   But it’s also important to understand how the pilots were put in a position to make that mistake, and to consider whether inadequate training, lack of safety equipment, or other pressures were equally at fault.  In other words, were good pilots set up to fail?

That is the impetus behind the quixotic quest of Congressman Walter Jones (R-NC), who has for years been trying to clear the names of two Marine Corps pilots who were blamed for the deadly crash of a V-22 Osprey in 2000, a crash that almost claimed the entire V-22 program among its casualties.  Read Jone’s Letter Here

The April 8, 2000 accident in Marana, Arizona was blamed on “human factors,” which has been widely interpreted in the news media as “pilot error.”   The proximate cause was that the pilots, following another V-22’s lead, descended too quickly, putting the plane into a “vortex ring state” while in helicopter mode.   The loss of lift caused the fiery crash, which killed all 19 Marines on board, including the pilots: Maj. John A. Brow, 39 and Maj. Brooks S. Gruber, 34.

At the time, many critics (cynics?) thought the Marine Corps was anxious to blame the pilots to avoid the perception that the V-22, with sophisticated computer-assisted avionics, was too “unforgiving” to be flown safely in combat conditions.  That perception could well have doomed the troubled program.  But experts I talked to blamed general overconfidence of V-22 crews, and the fact that some pilots routinely ignored the “placarded” limit for the rate of descent of 800 feet-per-minute.   The pilots on the mishap aircraft were going down at least three times as fast.

That clearly was the final mistake that caused the crash, but in appealing to the Navy to revise the record, Congressman Jones has reviewed the official investigations and public records and talked with other aviation experts and come to a different conclusion: namely that the fatal factor was “the aircraft’s lack of a Vortex Ring State (VRS) warning system as well as the pilots’ lack of critical training regarding the extreme dangers of VRS onset in the Osprey.”  In a “Memorandum for the Record” he has requested be placed in all official records relating the accident, Rep. Jones writes, “Lieutenant Colonel Brow and Major Gruber and their families are dishonored by the assertion that the aircrew was in any way responsible for this fatal accident.”

REQUEST DENIED

I understand the intent of Jones’ crusade.   The cause of the accident was far more complex than simply “the pilots screwed up.”   But accident investigations are done in a way that is designed to totally insulate them from any outside factors, including sympathy for the families or political pressure.  And that’s how it should be.

I think the official response that Jones got from Rear Adm. A. J. Johnson, Commander of the Naval Safety Center, was exactly right.  Rear Adm. Johnson wrote, “All safety investigations are conducted solely to determine root causes and identify corrective actions, not to assign blame or document accountability.  Aviation safety investigations are conducted by a team of specialized investigators, including at least one professional aviation safety investigator. They are exceptionally adept at what they do, and they have access to all of the expertise and resources within the Department of the Navy in reaching their conclusions. Their process, which is tried and true after more than 50 years of experience, is closed to outside influences. It would be inappropriate to alter the official safety investigation report by appending your Memorandum for the Record.”

But that doesn’t mean the pilots are being depicted fairly in media accounts as the sole cause of the accident.  Training was a factor, as evidenced by the emphasis post-accident training has put on understanding and avoiding vortex ring state, and subsequent improvements in the flight software that helps the pilots avoid the problem.

For a dispassionate view, I asked my old pal Rick Whittle, a former Dallas Morning News defense correspondent, for his take.  Rick has written extensively on the V-22, and has a book coming out next year [The Dream Machine, the Untold History of the Notorious V-22 Osprey]

Here’s what he e-mailed me:

“Before I investigated the crash for my book, I thought the Marines were using a euphemism when they called the cause “human factors,” but I’ve changed my mind. I interviewed a number of Marines who were on the mission that night – including four pilots who were in other Ospreys and the copilot and crew chiefs of the Osprey that led the way into Marana. What they told me, and other evidence I gathered, makes it clear that a lot of things contributed to that crash, and they didn’t all happen in the cockpit of the Osprey that went down. For that matter, they didn’t all happen that night. “Human factors” may be about as close as you can come to describing those causes in two words.
In any event, “pilot error” makes it sound like John Brow and Brooks Gruber were cowboys taking reckless chances, and that wasn’t the case. They were two of the best pilots in the Marine Corps.
They were coming down too fast when they went into vortex ring state, but they were flying wingman for another Osprey and following it in to Marana. The first Osprey descended too fast, too, partly because its pilots got distracted during the mission and started their descent into the airfield late. They were part of a big exercise that night, and there were a lot of other things going on.
I tell the full story in the book.”

Sounds like a great read.

Tags: Marines, Rep Walter Jones, V-22