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Human Factors in a Military Transport Plane Crash (Case Study) On 23 April 2020, at approximately 17:24 hours local time, the mishap aircraft (MA), C-130J-30, tail number (T/N) 11-5736, assigned to the 37th Airlift Squadron, 86th Airlift Wing, Ramstein Airbase (AB), Germany, conducted a routine periodic evaluation flight for Mishap Pilot 1 (MP1).

The Mishap Crew (MC) flew a maximum effort (assault) landing at Ramstein AB and experienced a hard landing with a vertical acceleration load factor (g-load) exceedance value of 3.62 times the force of gravity (g) and a landing sink rate of 384 feet per minute (FPM), exceeding the mishap aircraft’s maximum allowable landing limits of 540 FPM and g-load of 2.0g. Immediately upon touchdown, the MC executed a go-around and coordinated with Air Traffic Control for a visual approach, full-stop landing. The Mishap Aircraft (MA) landed safely at 17:37.

There were no fatalities, injuries, or damage to civilian property. The MA landing gload exceedance resulted in significant damage to the centre wing, both outer wings, left and right main landing gear assemblies, and engines, including mounting structures.

The damages are estimated to be $20, 917,089. The Accident Investigation Board President found, by a preponderance of the evidence, that the cause of this mishap was MP1’s early engine power reduction (power pull), beginning at 70 feet above ground level (AGL) and fully flight idle at 45 feet AGL.

In addition, the board president found, by the preponderance of the evidence, that MP1 and MP2’s failure to identify the excessive sink rate and their failure to arrest the excessive sink rate or go-around in a timely manner were substantially contributing factors that resulted in the MA exceeding the C-130J-30g-load and sink rate landing limits.

MP3 was a current and qualified evaluator pilot in the C-130J (Tabs G-82 and K-6). MP3 had 1,586.6 total hours in the C-130J, 1,824.3 in Remotely Piloted Aircraft (RPA), 2,250.3 total primary hours, 239.3 secondary hours, 607.6 total instructor hours, and 130.2 evaluator hours (Tab T-4 to T-6). Of the 2,250.3 total hours flown, 418.1 flying hours were combat hours and 1827.2 were combat support hours (Tab T-4 to T-5).

You are required to conduct a review of the Human Factors analysis in the investigation report with the objective to propose solutions to prevent a similar accident in the air force. Using this accident as a case study, examine human capabilities and limitations in operating military transport planes in a high-stress situation.

Identify the possible safety and risk management issues in defence and security operations, and examine design principles to reduce human errors both in operations and maintenance of military/combat equipment. You may refer to other reliable news reports or commentaries in your review.

Question 1a

Review the investigation report and identify the human errors presented. Describe how these errors relate to physical and cognitive human capabilities and limitations.

Question 1b

Explain how human limitations contributed to the cause of the plane accident.

Question 1c

Mission planning, pre-flight preparation, take-off and landing phases, situation awareness and decision making, detection and communication of errors are very critical parts of a flight. Given this situation, examine how stress impacts performance and what can be done to manage stress in such circumstances.

Question 1d

Using Crew Resource Management (CRM) principles, evaluate the team performance of the transport plane flight crew comprising the three pilots, loadmaster and other aircrew.

Question 2a

Based on the findings from the report (case study), analyse the safety climate of the 37th Airlift Squadron, 86th Airlift Wing, Ramstein Airbase (AB), Germany, in particular, the attitude towards safety displayed among the airmen. Support your analysis with the evidences reported.

Question 2b

The pilots failed to identify the aircraft sink rate and broke down in visual scan as a result of focusing on maintaining threshold airspeed and failure to identify the Climb Dive Marker (CDM) / aim point shift associated with the rapid sink rate. The lack of discipline to perform adequate risk assessment of critical information, and failure to identify / correct risky or unsafe practices displayed by the aircrew in deviating from established procedures were evident. Illustrate how this discipline issue relates to a unit’s attitude towards safety and risks.

Question 2c

Present how a safety management system, with the implementation of education, intervention and monitoring programmes can possibly avert safety discipline issues.

Question 3a

All the pilots were reported to be good senior pilots.

MP1 was a current and qualified C-130J pilot (Note: there is no qualification differentiation between the C-130J and C-130J-30) (Tab T-17 to T-281). MP1 had 399.1 total flying hours in the actual C-130J, 259.5 primary hours, 113.4 secondary hours, and 26.2 other hours. In the simulator, MP1 had a total of 174.3 hours, 95.3 primary hours, and 79.0 secondary hours.

MP2 was a current and qualified instructor pilot and USAF Weapons School graduate in the C-130J. MP 2 had 1,591.0 total hours in the C-130J, 445.6 primary hours, 282.9 secondary hours, 561.3 instructor hours, and 301.2 other hours.

MP3 was a current and qualified evaluator pilot in the C-130J (Tabs G-82 and K-6). MP3 had 1,586.6 total hours in the C-130J, 1,824.3 in Remotely Piloted Aircraft (RPA), 2,250.3 total primary hours, 239.3 secondary hours, 607.6 total instructor hours, and 130.2 evaluator hours (Tab T-4 to T-6). Of the 2,250.3 total hours flown, 418.1 flying hours were combat hours and 1827.2 were combat support hours (Tab T-4 to T-5).

MP3 flight time for the 90 days prior to the mishap is as follows (Tab T-4 to T-6): Hours Sorties

Given the human errors discussed in this case study, propose design solutions that could have assisted the aircrew in handling the emergency during the mission flight.

Question 3b

Assuming the role of the incident’s unit commander, recommend the actions your unit/squadron need for improvement and to prevent future incidents. Your recommendations should be based on the findings of the investigation report and should include training or re-training options.

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