Capt Jamie LaRivee, 21 AS C-17 Globemaster III pilot, simulates aircraft procedures at Travis AFB, Calif. USAF photo by SrA Sam Salopek
By MSGT MIKE THOMAS, Ops RAMS
Professional aviators often become fearful of how an error is going to affect them individually. What if someone finds out? Will I be downgraded? What will others think of me?
Rather than viewing a mistake as a lack of judgment, maybe we should focus on what we could have done better. This story is from an experienced C-17 crew flying a training sortie. After a potentially catastrophic event, they shared their experience so others could learn from it.
ASAP 5330 (LEGACY ASAP 2945)
My crew was part of an exercise that practiced high-altitude operations; contested, degraded, and operationally limited navigation; and blue air integration to infil/exfil a semi-prepared airfield (dirt runway). The crew was comprised of three highly experienced instructor pilots, each with multiple landings on semi-prepared airfields. We landed uneventfully, completed a turnaround at the end of the runway, and back-taxied to take off in the same direction as landing. The pilot flying (PF) checked the takeoff and landing data (TOLD) and noticed that Vgo, Vrot, and Vr were all equal at 102 knots-indicated air speed (KIAS), noting that in case of a reject, immediate braking would be required to validate the TOLD. There could be no delayed braking because the brakes were already heated from the previous alternate landing zone landing.
After completing our turnaround at the departure end of the runway, the landing zone control officer (LZCO) said the airfield was simulated “under attack” and we needed to take off ASAP. The crew had started the Ops Stop checklist on the taxi back in preparation for a simulated offload. Following the simulated offload, the PF called for the lineup checklist, and the pilot monitoring (PM) immediately moved the flap handle to the slats extend/flaps 1/2 position. The PF directed the PM to move the handle to the slats extend, flaps up position in accordance with the Alternate Takeoff Procedure, which the PM did. The lineup checklist was completed except for setting the flaps to 1/2, per the 1C-17A-1 alternate takeoff procedures for unpaved runways. The crew reconfirmed they were cleared for takeoff with the LZCO.
Per procedure, the co-pilot set 1.15 EPR, released the brakes, and called for flaps. The PM acknowledged and moved the flap/slat handle. The PM called 80 knots, which the PF acknowledged. A few seconds later, the PF asked the PM to confirm the lineup checklist was complete. The PM realized the flaps were not extended, immediately moved the flaps to 1/2, and called “Abort, abort, abort.” The call was just prior to Vgo, and the PF immediately initiated a reject. After the aircraft safely decelerated, the left additional crew member (LACM) mentioned the elevated brake temperatures. The crew taxied back to the departure end again, using inboard engines at idle reverse to minimize braking while mitigating possible foreign object damage (FOD). They discussed an immediate takeoff to cool the brakes before they reached peak temperatures but decided it was wiser (based on the previous landing and reject) to stay on the ground and regroup. The crew waited about 20 minutes, letting the wind cool the brakes so a second reject would be possible without hot brakes. They completed a normal takeoff and returned home uneventfully.
In debrief, the crew said they rejected due to the aircraft being in the improper configuration but could not agree what the configuration was. Some thought they saw the flaps moving up; others thought they were already up. We also could not determine what caused the flaps to move up, thinking perhaps they had not been set in the detent and popped back up into the slats extend/flaps up detent by bumps on the runway. We discussed that at our weights, our rotate speed was 12 knots below slats extend/flaps up stall speed (taking away the 30 percent buffer). We asked to see the Military Flight Operations Quality Assurance (MFOQA) data. Surprisingly, it indicated (a) our configuration prior to Vgo was likely clean, with flaps up and slats retracted; and (b) just after brake release, the flap handle had moved up to the slats retract (clean) detent.
Here are some takeaways from the crew.
1. Limitations of the human brain/reliance on habits. We learned in a high-tension environment, even experienced pilots can revert to old habit patterns. First, when the lineup checklist was called, the PM moved the flaps to 1/2, which is standard procedure but did not match the pre-briefed alternate takeoff procedure.
Second, when the brakes were released and the PF called for flaps, it appears that the flap handle moved to the slats retract (clean) detent. The only other time a C-17 pilot moves the flaps to the 1/2 position while rolling down the runway is during a touch-and-go. This is a likely scenario because the PM stated “tracking” when moving the flaps, the same callout technique suggested by the Air Force Tactics, Techniques, and Procedures (AFTTP) 3-3.C-17 during a touch-and-go.
Finally, after the PM realized the incorrect position and called for the reject, he stated “Abort, abort, abort” rather than “reject,” which is taught in pilot training and is standard for many other aircraft. It is also used for C-17 rejects on formation takeoffs and aborting a combat offload. Our difficulty reconstructing what may have caused the configuration issue can also be attributed to confirmation bias. MFOQA was a powerful tool filling in memory gaps. We knew what we expected to see, so we potentially ignored a warning that could have tipped us off earlier—the “slats” caution, advisory, and warning system (CAWS) alert in addition to the expected “flaps” CAWS alert (provided the aircraft was acting normally). The crew overcame the bias because the lineup checklist was not called complete when expected, and a crewmember verbalized that to get the crew to diagnose the problem in time to reject safely.
2. Understand TOLD. By definition, an airplane is accelerating when a decision is made to reject. The C-17 TOLD builds in a 1.5-second pilot reaction time, but acceleration in that time should be included in discussions of hot brakes during a reject. Though the reject was initiated just below Vgo (102 knots) and the PF saw about 105 knots at first brake application (which correlated with MFOQA data), MFOQA also showed a top speed of 114 knots after the reject was initiated—perhaps partially because of winds gusting to 20 knots on takeoff. Also, the reject procedure calls for brakes as required, so you must know what distance from the end of the runway maximum braking must be applied to stay on the runway. We were at a safe taxi speed with 500-1000 feet of runway remaining, but a slight hesitation in braking could have sent us off the end of the runway.
3. Trust CRM. Several times, “crew saves” have avoided improper procedures, potential damage, and perhaps destruction of a C-17 and its crew. No one is perfect. Having the humility to admit mistakes and call for the appropriate corrective action was critical. Also, the PM could not communicate the reason for the reject to the PF until after the reject was initiated because of the speed at which the issue was recognized. Many emergencies in the C-17 allow a few minutes to process and discuss courses of action. This was a split-second, life-or-death decision. We must trust the person in the seat next to us and be the pilot that other crewmembers can trust.
4. Train for non-standard procedures. We must do dangerous things sometimes, but we do them so often that we mitigate the risk with repetition. We generally have one annual simulated semi-prepared runway operations (SPRO) takeoff. Although it would be profitable to practice this more in the sim, there should be training opportunities in the aircraft because many aspects of SPRO can’t be properly replicated in the simulator.
This ASAP submission resulted in adding the scenario as a briefing item during Phase 1 simulator training. It provided great talking points and prevented others from making the same errors. Mistakes happen. It’s important to acknowledge them, learn from them, and move on. The real problem is ignoring mistakes—or worse, trying to hide them.