The Importance of Saying Something

The Importance of Saying Something

By LT Andrew “Gonzo” Gregory, USN

On July 31, 2019, while embarked on USS Theodore Roosevelt (CVN 71), I was the co-pilot of an MH-60S tasked with conducting a routine logistics mission. The first ship we were supposed to land on was late for an underway replenishment, and was therefore reluctant to slow down and turn into the wind–standard procedure prior to landing helicopters. When they provided us with their heading and wind readings, we realized that there would be a true tailwind on our approach. However, since they would be moving so quickly, we would at least still have a relative headwind. The ship also possessed a significant pitch and roll, providing us with a non-standard but technically legal approach overall.

At the time, I was an inexperienced helicopter second pilot (H2P) so my helicopter aircraft commander (HAC) elected to take the landing. Largely due to the sporty conditions, we experienced a relatively hard landing, touching down with the right wheel first as the ship was rolling upward on the starboard side. A moment later, the crew chief, HAC and I began to feel a lateral oscillation develop in the helicopter. Within seconds it had grown so severe that we were being physically thrown from side to side. Alarmed, we requested an emergency takeoff.

Immediately after becoming airborne, the violent oscillations stopped. Sufficiently rattled by the experience, we orbited while we determined whether the aircraft was safe. The crew agreed that it felt like we had just experienced ground resonance. We consulted our NATOPS which specifically delineated that ground resonance can be caused by a blade flying out of track, a malfunctioning damper, or a peculiar set of landing conditions. It further expanded upon “landing conditions” to include hard one-wheel landings, large descents coupled with drifts, and landing downslope with aft cyclic as potential contributors to ground resonance. We knew that the flight deck of this ship naturally had a three-degree downslope, and thus concluded that we had in fact experienced many of the peculiar landing conditions that lead to ground resonance. However, since NATOPS also specifically said the MH-60S “does not have a history of ground resonance,” we decided that we might be mistaken in our diagnosis of the problem. After a few minutes of discussion, we agreed that we would be safe to re-attempt a landing if the ship slowed down and turned into the wind, thereby reducing the chance that we could re-experience such a difficult landing and avoid any peculiar landing conditions.

The ship complied and we landed without issue. Our mission included multiple other shipboard landings which then continued for the rest of the day without any other issues. We hot-seated the aircraft and it continued to fly for another six hours with multiple other crews before shutting down at the end of the day. It was only then that it was discovered that one of the damper hoses had disconnected in-flight and the aircraft had lost all of the hydraulic pressure in the rotor head. Upon learning this, we were convinced that we had in fact experienced ground resonance, and were confused as to why our publication suggested this never occurred. Concerned, I wrote an email to a Sikorsky engineer describing what had transpired to which he replied that all H-60s experience instances of ground resonance and damper hose failures are a recurring catalyst. Shocked, I wrote an article about our experience and submitted it to our Commanding Officer (CO) prior to making HAC. In the article, I made note of the fact that our NATOPS was misleading about the likeliness of ground resonance and pointed out that what we had done to overcome the issue was actually the opposite of what our emergency procedures said to do in the event of unusual vibrations. However, while my writing was well received by my CO, I was unsure that my findings were worth sharing with the community at large since no harm had been done to any people and the maintenance required to fix the damper was relatively simple.

In the end, I did not submit it for publication. I did not believe that anyone would be interested in the experience of a first tour JO. I knew that articles recounting aircraft emergencies were published all the time. Yet, I let my belief that the community did not need another near-mishap story, prevent me from proliferating information that could have helped others stay safe. I did not sound the alarm about the fact that our publications delivered us a falsehood, saying that this dangerous aircraft state was an unlikely occurrence for the MH-60R/S. I did not submit a NATOPS Change, believing it might be received with apathy. Perhaps this assumption was correct. To my knowledge, no article in a publication such as Rotor Review has ever resulted in a change to aircraft emergency procedures or maintenance practices. However, I do know that the pervasiveness of this issue was not brought to the attention of anyone outside of my squadron, and the MH-60 R/S Communities at large remained unaware of this problem, a fact that would be fatal.

On August 31, 2021, two years after my experience, Loosefoot 616 experienced a hydraulic damper failure on short final to the USS Abraham Lincoln (CVN 72) and immediately upon landing was beset by a violent lateral oscillation due to ground resonance. Less than 20 seconds later, the aircraft ripped itself to pieces and flipped over the side of the aircraft carrier. Five of six crew members died.

Immediately after the crash, and after initial findings suggested that ground resonance could have been the cause, squadrons across both communities held meetings to address the emergency. The discussions that resulted from these meetings revealed that many pilots had experienced ground resonance in the H-60 at one time or another over the course of their careers. What’s more, many of them had been identified as linked to similar mechanical failures that had occurred both in my experience and in the 616 crash. Even in the relatively short time-period since the loss of 616, multiple MH-60R/ Ss experienced ground resonance before widespread corrective actions were taken to address the issue. Now that the problem was being talked about openly, many of us were alarmed both that this emergency occurred so frequently and that it was so shockingly underreported.

Since the findings were released, I’ve heard several senior officers say that they had no idea ground resonance was even possible before the crash occurred. This should be a concerning revelation to all of us in the naval helicopter community. The lack of reporting and lack of proliferation of community knowledge about a recurring emergency speaks to both the inadequacy of our current reporting systems and the insufficient attention we give to matters of safety. It appears as though many aviators and their squadrons over the years just didn’t say anything about the matter since it had yet to result in a catastrophic accident.

Naval Aviation is often lauded for its culture of sharing hardearned lessons amongst its members. Nevertheless, the naval helicopter community has fallen short. I, along with many others, failed to bring this issue to light when doing so may have prevented a devastating loss of life. In the Navy, aircrews have traditionally been required to submit brief reports called ASAPs after every flight. I’ve never heard of a squadron that enforced this requirement with consistency, especially because the associated website often didn’t work (especially while underway). Historically, squadrons were incentivized to record ASAPs because safety award metrics included documentation that the number of ASAPs submitted corresponded to the number of sorties flown. This incentive notably lacked any importance placed upon quality of safety reporting, when encouraging quality reporting is the only thing that should matter. Aircrews were faulted in the past for failing to document safety issues but after years of receiving lackluster reporting from the Fleet, the Naval Safety Command should have driven a total re-work of the way that ASAPs and all postflight safety concerns were recorded to encourage more helpful data collection.

The old ASAP Program was recently eliminated and replaced with the Airman Safety App. However, this massive change was not accompanied by any information campaign informing aviators that this had occurred. Any change in safety reporting should be a very high-profile and transparent process considering that it involves the health and wellbeing of aviators who risk their lives every time they strap into an aircraft. The fact that it wasn’t a more high profile change speaks directly to the lack of importance we place on safety. What’s more, while the new app doesn’t rely on a buggy website for access, it still presents a cumbersome process for submission of events. The average pilot or aircrew is unlikely to take the 10 minutes to submit a report about something that only could have been very dangerous. Especially after a long flight, it would be adding yet another step to a multi-step process that already exists.

One way to solve this could be linking safety reporting with already established routines. After every flight, someone in the crew logs a NAVFLIR and someone logs a SHARP. Either of these processes could be linked with safety reporting software of some kind. The amount of money and time that would go into the creation of something in this way is undoubtedly cheaper than the money lost through mishaps and subsequent safety investigations. Attaching safety concerns to a flight log submission means that most of the background data is already recorded so an individual could only have to add a sentence or two, or select a few more options from drop-down menus rather than recreate the whole event. There should be a "safety of flight" section in any flight log. We talk about them in our debriefs already, why not include them in flight logs for posterity and big-data analysis? Individual pilot and aircrew safety data can be collected more efficiently and allow our leadership to track widespread issues more effectively.

Experts in behavioral economics have shown that individuals are far more likely to do something in their interest if they are already opted-in to the action as opposed to having to opt-in on their own. What this means is that if pilots/aircrew had to choose not to include something about safety in their flight log, we would see a much higher level of safety reporting than if we make logging safety reports an optional supplemental activity. In order to submit a flight log, individuals should have to report whether anything related to SOF had occurred in the event. Just a simple tab included in a SHARP would undoubtedly lead to more reports of near misses or minor incidents.

The rate of Class A Mishaps remains unacceptable (three occurred in USN/USMC aviation in June 2022 alone), so we should all be coming up with as many ways as we possibly can to enhance safety processes. There is a common saying in Naval Aviation that our NATOPS is written in blood. It doesn’t have to be. Let’s create a better safety culture, one in which we do a significantly better job identifying hazardous trends early and communicating them. Improved safety documentation and reporting needs to become a higher priority for leaders in aviation from the junior H2P up to the Commodore. There is nothing more important than safety, and we shouldn’t have to lose any more friends before we choose to act. if you think something is a hazard, then trust your gut and say something by reporting it.