CH-53E Readiness Crisis and Mid Air Collision Catastrophe
A US Marine Corp (USMC) investigation charts a readiness crisis in the Sikorsky CH-53E Super Stallion fleet, that resulted in a dip in proficiency and spike in fatigue at a squadron based in Hawaii, that triggered the dramatic relieving the Squadron CO of command and a fatal mid air collision (MAC) that killed 12 marines just days later.
Two CH-53Es (161255 and 163061) of HMH-463 squadron based at MCAS Kaneohe Bay collided during a night training sortie on 14 January 2016, 2 miles off the coast of Ohau, HI. “Low light conditions made it difficult for the aircrew to recognize the rapid decrease in separation between the aircraft which led to the collision,” said Lt. Col. Curtis Hill, a spokesman for the USMC. However as the Marine Times notes:
….the underlying causes of the crash reveal the squadron suffered from severe readiness problems like flight hours and parts shortfalls that are endemic to Marine Corps aviation — especially the troubled CH-53E fleet.
The squadron did not have enough helicopters that could fly; crews were not getting enough flying hours; morale was low and crews were battling fatigue…
Without enough flyable aircraft, the squadron was about 606 hours behind on its scheduled flight hours for fiscal 2016 by January, the investigation says. Pilots feared the low number of working aircraft was causing their skills to atrophy.
According to the investigation, the four pilots had logged 4, 5, 4, and 13 hours of flight time in the 30 days before the accident, all less than the USMC’s 15.1 hour monthly goal for the CH-53E. The investigation also concluded that two of the pilots were not “adequately proficient” in using night vision devices.
We look further at the circumstances leading to this accident.
The Overall Fleet Airworthiness Situation
The heavily redacted USMC report explains that:
A 2015 study noted that readiness within the Marine Corps’ CH-53E fleet was “appalling” due to inadequate inventory; too many aircraft in maintenance; lack of designated resources; no fleet-wide “reset” following operations Iraqi Freedom and Enduring Freedom; insufficient maintenance training, oversight, equipment, formal and on-the-job training, and technical support.
In 2008, the Marine Corps implemented the Integrated Maintenance Concept program. For several years preceding 2008, the number of fully mission capable CH-53Es hovered around 50%. From 2008 to 2015, the number of fully mission capable CH-53Es steadily declined from approximately 50% to 20%.
The CH-53E fleet has the highest cannibalization rate in the USMC rotary fleet.
From 2012 to 2015, the number of Out of Reporting aircraft (i.e. in long term maintenance] increased by 78% fleet-wide.
In FY2015 only 44 of the USMC’s 146 CH-53Es were classed as mission ready on average.
…a fleet-wide “reset” is currently underway. The reset…involves validation and verification of all CH-53E aircraft, training for maintenance Marines, modification of the supply system to make it more agile, and other changes intended to address the erosion of maintenance skills.
In February 2016 The Virginian Pilot reported:
“I’m not happy at all where we are with the (Super Stallion) right now, but I do believe we have a recovery strategy that will work,” said Lt. Gen. Jon M. Davis, the Marine Corps deputy commandant for aviation, in an interview with The Pilot. “I’m proud of what we’re doing to fix this, but I’m not proud of where we’re at right now. The taxpayers should be unhappy.”
Davis ordered the Super Stallion review a year ago, part of a broader effort to improve combat readiness after more than a decade of fighting. Similar studies have been conducted or are ongoing for other Marine Corps aircraft, including the MV-22 Osprey and AV-8B Harrier.
Many of the Super Stallion’s problems can be traced to the decision not to do a full reset after years of fighting in Afghanistan, Davis said.
“We were trying to get maximum readiness at the time, and the best way to do that was to do it in theater (in Afghanistan),” Davis said. “Frankly, we needed to do what the Army did. That would have given us less aircraft to fly then, but we’d have more aircraft to fly now. … We made a mistake. But now we’re recovering from that.”
The Super Stallion’s problems are a symptom of a systemic issue plaguing the military, said Todd Harrison, director of budget analysis at the Center for Strategic and International Studies in Washington. Delays and cost overruns for new weapons systems – including the CH-53K, which initially was expected to begin replacing the Super Stallion last year but won’t be ready until at least 2019 – are putting a strain on the upkeep of existing assets, Harrison said.
Since 2013 the CH-53E accident rate has been 79 per million flying hours, four times higher than the historic fleet average. Accident rates were also rising across the USMC.
The Squadron Airworthiness / Readiness Crisis
The following chart plots HMH-463’s mission ready aircraft (‘RBA’ – yellow line) and total flight hours (‘FHE’ – green line) together with key events top in black from January 2014 to March 2016. Also shown is the total assigned aircraft (‘ASN’ – black line), long-term maintenance ‘Out of Reporting’ aircraft (‘OOR’ – blue line) and the In-Reporting fleet (‘IR’ – red line) which is the assigned fleet minus the long term maintenance aircraft. The aircraft in short term maintenance or otherwise not mission ready is the difference between red and yellow lines. From 2013 to January 2016, the number of mission ready HMH-463 CH-53Es peaked at 6 but was generally around 2.
Marine Rotational Force-Darwin (MRF-D) is a force made of various Marine Corps troops and assets, including aircraft that deploy to and conducts training and exercises in Darwin, Australia for approximately 6 months each year.
In January 2015, Airframes Bulletin 345 was released, which required the inspection and potential replacement of aircraft ramp bushings. The senior leadership of HMH-463 described this as a significant burden to HMH-463 maintenance which was preoccupied with preparing aircraft for MRF-D 2015.
In July 2015, Airframes Bulletin 346 was released, which required the inspection and potential replacement of fuel lines. This also added a significant burden to HMH-463 maintenance department at a time when the Marines were executing scheduled phase inspections.
On 4 September 2016 the results of a a maintenance inspection by the 1st Marine Air Wing were released. HMH-463 failed the inspection. In reality:
In the summer through fall period of 2015, HMH-463 was effectively a three-site maintenance department: supporting MRF-D with a four aircraft detachment in Darwin, Australia; supporting the fall [Weapons & Tactics Instructor] WTI class in Yuma, Arizona; and attempting to fly at home station in Hawaii. The HMH-463 Marines believed this reality made maintenance coordination a challenge.
Flight operations ceased for over a month while HMH-463 focused on fixing the problems.
Due to the poor readiness the unit’s personnel were ordered to go to 12 hours on 12 hours off shift pattern.
Most members of HMH-463 did not see any end in sight with regard to the long working hours. They claim this led to low morale and cumulative fatigue throughout HMH-463.
Fatigue offers one of the greatest potentials for crew error at night.
On 11 January 2016 the squadron commander was relieved of his post “because of a loss of confidence stemming primarily from inadequate improvement in HMH-463 aircraft readiness rates from the time of the failed inspection in September 2015 through the first days of 2016″.
The interim acting CO told the squadron they were not “shut down” and it was to be “business as usual.” On 14 January 2016 a new CO was appointed.
The former squadron CO claims he told the Brigadier General that took this action that:
…his relief for readiness was a dangerous precedent to set. He said, “If the General wants up aircraft, the Marines will get him up aircraft,” implying that readiness reporting would become inflated and corrupted.
The Brigadier General did not recall that.
Brigadier General Sanborn brought HMH-463 together and said, “I just relieved your CO.” He then told each HMH-463 member to look into the mirror and ask “yourself if you were a positive, negative, or neutral force in the squadron” and whether their action or inaction helped lead to the CO’s relief.
Brigadier General Sanborn did not provide guidance on whether to continue business as usual or to cease flight operations through an operational pause.
At 1700, a briefing was held, attended by most HMH-463 Marines. During the address it was stated there were “going to be some changes.” Some Marines believed this mean that more HMH-463 leaders were to be relived of from duty.
A two ship night flight was planned for the 14 January 2016. The previous day the unit Aviation Safety Officer (ASO) had had a “heated discussion” ad he was concerned over the mitigation of risk for this sortie. A Risk Assessment Worksheet was completed for the sortie but appears to have ignored the risk due to low proficiency, fatigue and other organisation issues. Witnesses suggest that briefings were given by personnel who appeared tired and distracted. Mission planning documents featured multiple errors.
During this sortie, while formation flying at night, the two aircraft collided.
UPDATE 20 November 2016: We report on a fast jet Military Airprox in Sweden
UPDATE 30 November 2016: House and Senate negotiators have finalised a $618.7 billion defense policy bill for 2017 that increases funding for military readiness and higher troop levels at the expense of proposed plus-ups for fighter aircraft procurement.
UPDATE 28 December 2016: Aviation crisis continues: Marine fighter squadron commander fired
Lt. Col. Wade Workman was relieved of his duties Wednesday as head of Marine Fighter Attack Squadron 232, which has seen two of its F/A-18 Hornets crash since Workman took command on Jan. 15, said Capt. Kurt Stahl, a spokesman for the 3rd Marine Aircraft Wing. “The decision to relieve Lt. Col. Workman was unrelated to recent mishaps,” Stahl said in an email. “This decision was based on issues concerning command climate within the squadron.”
Maj. Gen. Mark Wise, commander of the 3rd Marine Aircraft Wing, decided to fire Workman due to a ” loss of trust and confidence” in his ability to serve as squadron commander, Stahl said. “There was an unhealthy command climate that negatively impacted trust within the unit that is critical to effective operations,” Stahl said.
Workman is the fourth commander in the aviation community to be fired in 2016.
On Dec. 5, Wise relieved Lt. Col. Michael E. Hernandez as commander of Marine Aviation Logistics Squadron 11. Wise’s decision to fire Hernandez was based on performance; “No misconduct was involved,” a 3rd Marine Aircraft Wing news release said.
In April, Lt. Col. Armando Gonzalez was fired as commander of Marine Wing Support Squadron 371 in Yuma, Arizona, after a command investigation found he “created an intimidating, hostile, and offensive work environment.”
And in January, Lt. Col. Edward Pavelka was relieved of command of Marine Heavy Helicopter Squadron 463 just three days before two of the squadron’s CH-53E Super Stallion helicopters collided off Hawaii, killing 12 Marines. An investigation found that the squadron did not have enough flyable helicopters, crews were not getting enough flying hours and morale was low prior to the crash.
It is not clear what systemic actions have been taken.
UPDATE 4 February 2017: The BBC say “Death crash US jet pilot ‘did not report issues’” to maintenance.
UPDATE 6 February 2017: Grounded: Nearly two-thirds of US Navy’s strike fighters can’t fly
In 2017, Congress failed for the ninth straight year to produce a budget before the October 1 start of the fiscal year, reverting to continuing resolutions (CRs) that keep money flowing at prior year levels. CRs have numerous caveats, however, and many new projects or plans can’t be funded since they didn’t exist in the prior year.
There is widespread agreement that CR funding creates havoc throughout the Pentagon and the industrial base that supports it – often substantially driving costs higher to recover from lengthy delays. Yet, like the proverbial weather that everyone talks about but no one can change, there seems to be little urgency in Congress to return to a more business-like budget profile.
According to the Navy, 53 percent of all Navy aircraft can’t fly – about 1,700 combat aircraft, patrol and transport planes and helicopters. Not all are due to budget problems – at any given time, about one-fourth to one-third of aircraft are out of service for regular maintenance. But the 53 percent figure represents about twice the historic norm.
The strike fighter situation is even more acute, and more remarkable since the aircraft are vitally important to projecting the fleet’s combat power. Sixty-two percent of F/A-18s are out of service, 27 percent in major depot work and 35 percent simply awaiting maintenance or parts, the Navy said.
With training and flying hour funds cut, the Navy’s air crews are struggling to maintain even minimum flying requirements, the senior Navy source said. Retention is becoming a problem, too. In 2013, seventeen percent of flying officers declined department head tours after being selected. The percentage grew to 29 percent in 2016.
UPDATE 8 February 2017: More than half of all Marine aircraft unflyable in December
Out of 1,065 Marine Corps aircraft, 439 were flyable as of Dec. 31, said Lt. Gen. Jon Davis, deputy commandant for aviation. That represents roughly 41 percent of the service’s fixed- and rotary-wing aircraft.
“My target should be 589 [flyable aircraft]; so I am 150 airplanes shy of what I need to make my flight-hour goal.”
“November and December every year are low productivity months,” said Davis, who noted that 473 Marine aircraft were flyable at the beginning of October.
“I can only reset a CH-53E so fast. I’ve got seven on the East Coast; eight on the West Coast and one in Hawaii — 16 airplanes in reset right now. I can only get so many of those into reset at any given time.”
UPDATE 16 February 2017: Lack of maintainers is fueling the Corps’ aviation crisis
Some of the Marine Corps’ most experienced maintainers were allowed to take early retirement when the service shrank from 202,000 to 184,000 Marines, said Lt. Gen. Jon Davis, deputy commandant for aviation.“We let some people go that probably – if we had better insight into who we had out there and the qualifications of those Marines inside the maintenance departments of our flying units – you’d say: ‘These people can’t go,’” Davis told reporters on Feb. 8.
“We will not grow the size of the Marine maintenance department. But we will grow the requirement to have additional qualifications inside that maintenance department,” Davis said at a Feb. 1 Defense Writers Group breakfast.Davis acknowledged that maintainers are already extremely busy, but he believes they can be more effective… That’s why he wants corporals, sergeants and staff sergeants to spend more time on the flightline mentoring lance corporals on how best to take care of aircraft.
The Navy Times ran a story on 1 October 2016: Naval aviation trying to fix flawed safety culture: 1-star
…all too often these squadron leaders weren’t fixing safety issues over the last three decades, according to the leader of the organization charged with investigating Navy and Marine Corps mishaps, who said some commanding officers stashed the surveys rather than fix the problems. The Navy only got serious about fixing this flawed culture two years ago, he said.
“It was an organization basically frozen in time for about 30 years,” Rear Adm. Chris Murray said Sept. 10, referring to the state of things when he took over the Naval Safety Center in 2014. “Great at investigating things, but not doing a whole lot to prevent mishaps.”
“We’ve been doing surveys in squadrons forever,” Murray told the audience of aviators at the annual Tailhook reunion near Reno, Nevada. “Frankly, it was a great one-on-one with our guys and the squadron’s CO, but it never really got any further than that.”
The safety boss said the culture has been revamped so that these squadron surveys are get more scrutiny from higher ups and that officials are using more mishap data to assess the causes of mishaps.
Aerossurance has previously written the following:
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- Execuflight Hawker 700 N237WR Akron Accident: Casual Compliance
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- How To Develop Your Organisation’s Safety Culture
- Challenger Launch Decision – 30 Years On
- Chernobyl: 30 Years On – Lessons in Safety Culture
- Safety Intelligence & Safety Wisdom
- 10 Year Anniversary: Loss of RAF Nimrod MR2 XV230
- UPDATE 2 June 2017: Avoiding Mid Air Collisions: 5 Seconds to Impact
- UPDATE 30 August 2017: NTSB: Do We See and Avoid or Avoid Seeing?