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Lex's Accident Report

HokiePilot

Well-Known Member
pilot
Contributor
Well, I don't know how long this has been out but I just found it. "Lex" Lefron's accident report is out.

Talk about swiss cheese. I can't say I would have done differently.

http://www.ntsb.gov/aviationquery/brief2.aspx?ev_id=20120307X13644&ntsbno=DCA12PA049&akey=1

For the record, I noticed that they spelled TOPGUN ("one word, all caps") as both Topgun and as Top Gun in the report. Someone could have done a better job checking that.

I read his blog daily and met him twice. Both times at the Fallon O'Club. Every time there is a discussion in Naval Aviation, I wish I could see what he would write about it.

It is interesting comparing this accident against some of his recent posts.

Lex 5 days before said:
I’m on the early page it seems, with the 0515 brief burned into my forehead. And the late go as well, so long as your definition of “late” is expansive enough to admit a 1215 brief, 1400 take-off, and 1500 land. With the debrief to follow. Well within the limits of crew day, mind. But a 0415 wake-up, day after day, is rough country for old men.

Especially when, as it was today, the whole thing seems to be for naught.

Used to be that Navy had an on-site meteorology staff at every major deployment site to do their weather guessing for them. People that had spent five, ten – even fifteen or twenty years – learning what secrets old Gaea had hidden up her sleeves to trap the unwary or ill-informed. For it’s a dead solid truth that you’d rather be on the ground, wishing you were in the air, than on the air wishing you were on the ground. The corollary to which is that every airplane which takes off will land eventually, in one fashion or another. Sometimes they taxi back to the line. Sometimes they are swept up.

The Sandy Eggo-based weather guessers were full of bad omens and fearful visions. A ninety-degree crosswind at 25 gusting to 35 knots, we were foretold. A situation utterly beyond our capabilities, for the drag chute loves to fair itself into the wind regardless of whether that wind is down the runway, and you only have so much rudder to keep her tracking true once the rubber meets the prepared surface.

And yet, when it came time to walk to our machines, the flags hung limply, with no hint of later vengeance. So too, after we started and taxied to the hold short. Sometimes weather phenomena do not materialize as they have been forecast. And sometimes they do, but only after you have committed to going flying. Mr. Murphy still gets his vote. As does Mr. Finagle.

There are old pilots and bold pilots, but the overlap is minimal. Yet were we aware that our customers would take off if ever a plausible reason presented itself, and it would not be well thought of if the oldest among us proved chary while the youngest checked the X in the block. So at the hold short my lead called the local metro agent, who has been here since Darius stood in ranks, and asked him what he thought: You should be good to go, quotha. The weather not coming in until after 0900.

And so go we did.

Of the mission itself, not much to report. We joined up, held until committed, pushed out bravely and died unmourned. We were rewarded by the fates for our intrepidity by good conditions upon return to base. Gave thanks for our deliverance, and headed over to debrief our observations.

Heading into the debrief, a strapping young lieutenant I did not know passed me at the door, saying, “Seriously? I read your blog every day.” And that was at a distance mind, too far to read my name patch. Some other man, I replied gamely, knowing it was a lost cause. And wanting to add, “and where are your comments, at all?”

Weather guessers are often accurate, but only occasionally precise. Crosswinds did indeed manifest themselves, albeit after their predicted window. We lost the middle sortie.

The afternoon go also had predicted weather. Down the runway, or very nearly, but at 35 knots gusting to 40. In the bandit brief afterwards, the question was asked of our Navy friends what winds they would suffer. Twenty-five sustained knots, the answer came. On account of the ejection risks.

We did a little hangar flying then. When I was leaving the squadron I had the honor to command, a Marine Harrier pilot had the misfortune to lose his only engine on a gusty day in the Owens Valley east of the Sierras. He successfully ejected and was dragged to his death by the surface winds. I was for a time warned that I would lead his Judge Advocat General Manual investigation. I was happy to have the burden lifted, for JAGMAN investigations – somewhat perversely written by line officers, rather than JAGs themselves – are publicly releasable, unlike mishap investigations. What evern I determined in the course of that investigation could have brought no solace to the man’s family. And there was other work for me to do.

Another pilot remarked that a former TOPGUN instructor and his wingman had suffered a similar fate a few years back after a midair collision over Kuwait. It made for a somewhat subdued conversation afterward, but this is how we remind ourselves that for all the larks that are in it, there are tigers in the grass as well.
It seems a strange irony that the egress system which would save your life in an emergency could snatch it away from you based on something so intangible as surface winds. But just imagine being dragged behind a pickup truck at 25-35 miles per hour while grappling with your harness release and you’ll get some sense of our trepidation. The odds of losing an engine on a gusty day are no better or worse than on any other day. The odds of survival, given the conditions, are much reduced. And there would be other days to fly.

We all of us volunteered for this business, but all of us want a chance, should some bad thing arise, especially in a peacetime training environment: You’ll probably never have to eject. But if you have a bad day and are forced to, you’d a whole lot rather have an even chance to explain why you did so later.

Not long after we’d made our decision the snow was falling sideways and the wind howled through every nook and cranny, piercing though our flight suits and forcing us to shoulder through the gusts. I made my way to the O’Club for a pint of Guinness (for strength) followed by a shot of Jameson’s (for courage). Grateful for the day I’d had.

Looking forward to the next.

Lex 1 day prior said:
I supposed it had to happen eventually, everybody has one in time. And I had mine yesterday. It was a good hop, really. Raging around down low, hiding in the mountains, waiting for a chance to pounce on the unwary. Although this is graduation week at the (prestigious) Navy Fighter Weapons School, and there are very few unwary students left. Still, good clean fun, and your host can say “Copy kill” with the best of them.

Cruised on back to the field for the recovery with few cares, being very nearly the first to land. The students being further away from the field at the knock-it-off, and the instructors taking advantage of whatever fuel they had left to whirl and flail at one another in the best traditions of the service. A tolerably precise landing, there’s the seven thousand feet to go board, and at 150 knots indicated I pulled the drag chute lever aft, bunting the nose slightly out of the aero-braking attitude to ensure a tangle-free deployment.

Which is precisely when nothing happened.

Ordinarily you feel a pretty good tug on the shoulder harness as the drag chute deploys. Not like an arrested landing aboard ship, mind. But the sensation is unmistakeable, as is the effect, particularly at higher speeds. Which I was still traveling at, the chute having either failed to deploy or parted behind me, there was no way to know. Look, there goes the six board. Still about 150 knots indicated. I’ve mentioned to you before how much runway the jet takes up during the take-off roll with the afterburner howling behind you. It takes up a surprising amount of pavement at idle, too. Especially with no drag chute. Time to go.

The procedure calls for full grunt, and drag chute lever forward to cut the chute if it’s a streamer. It takes a little while for the engine to make full thrust from idle, time spent nervously watching the departure end come up. At least I was still going pretty fast, so there wasn’t that far to go to get to fly-away speed. And I was light.

Tower cleared me to land on the left runway, which is a few thousand feet longer. Much to the dismay of a student whose need to land was at least as great as my own, the right runway being fouled by a drag chute, and hizzoner being low fuel state as he subsequently admitted under protest when he was asked to go-around and make room for me. But based on the timing he was now second in line for special handling. There’s a good man, wait your turn and ‘fess up first in the future. I hope you’ve learned something from this.

I was already pretty low on fuel myself, so I didn’t need to burn down gross weight. Flew about as slow as I could without risking a tail strike or hard landing, she does not like to fly slow. Still about 185 knots in the round-out. With no drag chute the book calls for aerobraking until 130 knots, and judicious use of the wheel brakes from that point on, balanced across the length of the runway remaining. You’re a long time holding the aero-braking attitude with no chute. You go by a lot of runway. Depending upon headwinds or tailwinds and runway length, one might even shut the engine down to reduce residual thrust.

I didn’t in the event, but the brakes – and anti-skid – got a pretty good workout. When I taxied back to the line the maintenance guys told me to go away for 10 minutes. Just in case the brakes might, you know: Catch fire. Which they didn’t, so no harm done.

It’s funny how quickly you can go from “comfort zone” to “wrestling snakes” in this business. But even snake wrestling beats life in the cube, for me at least. In measured doses.
 

nittany03

Recovering NFO. Herder of Programmers.
pilot
None
Super Moderator
Contributor
I read the report; was meaning to post it but never did. I'm not sure if the ASO crowd has seen this yet, being as it is an NTSB thing, but this should be mando reading. I have enough experience flying out of KNFL that it scares the shit out of me. So many times we read a mishap report where we can point to the mistake they made, so glaringly obvious in hindsight, and comfort ourselves by saying "well, I'd never do that." "I'd never let that happen." Maybe, right, maybe wrong, but that's what we tell ourselves. Yet diversion at bingo fuel is drilled into people, and that's part of what bit him. I'd be interested to know what if anything happened to ATC, and I'm surprised that the controller on duty was not familiar with the RNO divert option. In my time flying there, we always briefed that. Like mentioned above, it's the classic "swiss cheese" case.

I guess the only solace to take from it is to keep fighting, fly the airplane all the way to the end, and realize that one day, sooner or later, due to something or other, in or out of the cockpit, it's finally going to be your day. I do wonder in hindsight what led him to the decision not to punch. Fear of surface winds, as mentioned in the report, or just not wanting to be the guy who ran out of gas?
 
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wlawr005

Well-Known Member
pilot
Contributor
EVERY Naval aircraft needs GPS and/or ILS NOW (preferably GPS)!!!

It's absurd that the premier fighter weapons school in the world has to rely on shitty "fuzzy" PAR displays in an environment that routinely goes from 5000/5 to 100-1/2 in minutes.
 

nittany03

Recovering NFO. Herder of Programmers.
pilot
None
Super Moderator
Contributor
And the controllers probably don't get much practice until they need it. I can't speak to what happens when no one is TAD there, but during my fleet tour, no one PARed into NFL if the break was open, practice approaches be damned.

Oh, and though Lex's blog is no longer hosted, the Wayback Machine is still functional. Those who never read his writing should do themselves a favor.

https://web.archive.org/web/20110208170051/http://www.neptunuslex.com/
 

Renegade One

Well-Known Member
None
EVERY Naval aircraft needs GPS and/or ILS NOW (preferably GPS)!!!
Um…this was not a Naval aircraft, as I understand it. But I get your point. Not sure if there's a way to "mandate that capability" for contracted air services…but maybe.
 

Fallonflyr

Well-Known Member
pilot
I don't think KNFL has an ILS approach. They do have a RNAV. I believe the ATAC F-21's have Garmin 530's but don't know if they are WAAS or IFR certified.
 

sevenhelmet

Low calorie attack from the Heartland
pilot
There is no ILS at KNFL. The RNAV does have LNAV/VNAV, but most of the jets flying out of Fallon aren't certified or equipped for GPS approaches.

For me, this brought back memories of flying during a November Airwing Fallon a few years ago, and how dicey the weather was. I agree that it should be required reading for ASOs and for anyone flying or conducting ATC at Fallon. Some of the highest-density (and highest stress) ATC comm I have ever heard was during the RTB following the final KIO call.
 
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pourts

former Marine F/A-18 pilot & FAC, current MBA stud
pilot
I am pretty sure the Hornets in front and behind Lex had the runway designated with the A/G radar. If the PAR controller's corrections seemed out to lunch they probably trusted their life to their own radar, not the kid on the scope. I am pretty sure that capability doesn't exist in the Kfir.
 

Swanee

Cereal Killer
pilot
None
Contributor
I am pretty sure the Hornets in front and behind Lex had the runway designated with the A/G radar. If the PAR controller's corrections seemed out to lunch they probably trusted their life to their own radar, not the kid on the scope. I am pretty sure that capability doesn't exist in the Kfir.


Ah, the old Hornet 1. I've also heard of guys dropping marks on the end of the runway on takeoff to accomplish the same thing when their APG-65 isn't having a good day.
 

Python

Well-Known Member
pilot
Contributor
Ah, the old Hornet 1. I've also heard of guys dropping marks on the end of the runway on takeoff to accomplish the same thing when their APG-65 isn't having a good day.

The APG-65 doesn't have too many good days. I dropped marks on the runway in the rag but haven't done it since. Only would now if I think I need to.

This story really makes me pissed about the hornet field ILS deal. I still to this day do not understand it, and it has always bothered me. This accident just adds fuel to that fire.
 

pourts

former Marine F/A-18 pilot & FAC, current MBA stud
pilot
APG-73 is a better radar.

There's a pretty good HAZREP in a file somewhere that tells the story of a squadron of Marine F/A-18Ds that get into a tricky situation on a TRANSLANT into Lajes. Having some kind of precision approach other than the PAR would have really helped out in that situation, at least the way the story was told to me.

Anyone on here actually ever given a PAR? Is there a huge difference when one A/C approach speed is 120kts and the next guy's approach speed is 185? That could get tricky, especially when everyone is using the callsign "TOPGUN ##" regardless of aircraft model.
 

picklesuit

Dirty Hinge
pilot
Contributor
I've taken a couple PAR's to mins, KGAA and KNDZ stand out. KGAA because it was in a valley at night and the 2P kept getting right of course (big ass water tower there) but the one that got my armhair up the most was a 7 minute hop from KPNS to KNDZ this spring.
Had the fog/low vis rain going on and the wave of T-6's had gone in to NSE via the ILS 14.
I was repoing solo after coming home from KROW...as I got to hold short at PNS, the ILS went down...I took a minute to review the mins/procedure for PAR 32 at NDZ and opted for that.
I'd never been there (landed 05 in the day once) at night, and had never worked with their controllers before.
The strobes, landing and taxi lights were all giving me a good case of the leans, so it was pretty dark on the way down, and then flipped all of it on when I broke out at 205' AGL...
The standing water was probably the worst part, hydro planing and going dark because the rooster tail obscured the lights...
The controllers were Johnny on the spot, I think they had the supervisor in...
One of the times I missed having two other people in the cockpit to back me up though...
Pickle
 

jarhead

UAL CA; retired hinge
pilot
There's a pretty good HAZREP in a file somewhere that tells the story of a squadron of Marine F/A-18Ds that get into a tricky situation on a TRANSLANT into Lajes. Having some kind of precision approach other than the PAR would have really helped out in that situation, at least the way the story was told to me.
Deviating from plan or SOP is rarely an AF trait but the decisions the AF tanker crew made that day saved some lives and aircraft. One would think that that day would have made higher decide on putting ILSs in Hornets.

It used to be standard to drop a mark just prior to running the engines up for take off, just in case the weather went to crap while you were out flying.

Over my career, I've flown many actual PARs in the T-45 and F/A-18 and many actual ILSs in the T-45 ... there's something to be said for flying an approach that won't tell you "you're left of course and holding, turn left 230". I'll take an ILS any day.

S/F
 
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