UNITED STATES AIR FORCE

AIRCRAFT ACCIDENT INVESTIGATION

BOARD REPORT

HH-60G, AIRCRAFT NUMBER 87-26014

66th RESCUE SQUADRON

NELLIS AIR FORCE BASE, NEVADA

LOCATION: N33° 26.3, E064° 04.4

146NM NW OF KANDAHAR AB, AFGHANISTAN

DATE OF ACCIDENT: 20 OCTOBER 2004

BOARD PRESIDENT: COLONEL (BRIGADIER GENERAL SELECT)

MICHAEL N. WILSON

Conducted lAW Air Force Instruction 51-503

SUMMARY OF FACTS

1. AUTHORITY, PURPOSE, AND CIRCUMSTANCES

     a. Authority.

On 26 October 2004, Lieutenant General Michael W. Wooley, Commander, Air Force Special Operations Command (AFSOC), appointed Colonel (Brigadier General Select) Michael N. Wilson to conduct an aircraft accident investigation of the 20 October 2004 crash of an HH-60G aircraft, serial number (SIN) 87-026014 approximately, 146 nautical miles northwest of Kandahar Air Base, Afghanistan. The investigation began at Kandahar AB, Afghanistan, on 15 November 2004 and concluded at Hurlburt Field, Florida, on 17 December 2004. Technical advisors were Lieutenant Colonel David P. Charitat, Legal Advisor; Major Yonel J. Dorelis, Pilot Member; Captain Kurt F. Dittrich, Medical Member; Capt. Ahave E. Brown, Jr., Maintenance Member, and TSgt. Vickie E. Gamble, Board Recorder.

     b. Purpose.

This aircraft accident investigation was convened under Air Force Instruction (AFI) 51-503. The primary purpose is to gather and preserve evidence for claims, litigation, and disciplinary and administrative actions. In addition to setting forth factual information concerning the accident, the Board President (BP) is also required to state his opinion as to the cause of the accident or the existence of factors, if any that substantially contributed to the accident. This investigation is separate and apart from the safety investigation, which is conducted pursuant to AFI 91-204 for the purpose of mishap prevention. The report is available for public dissemination under the Freedom of Information Act (5 United States Code (U.S.C.) Section 552) and AFI 37-131.

     c. Circumstances.

The accident board was convened to investigate the Class A accident involving an HH-60G aircraft, SIN 87-026014, assigned to the 66th Rescue Squadron, Nellis AFB, Nevada, of the 347th Rescue Wing, Moody AFB, Georgia, which crashed on 20 October 2004.

2. ACCIDENT SUMMARY

Pave Hawk Helicopter, HH-60G, 87-26014 impacted terrain during a combat rescue mission in support of Operation Enduring Freedom on 20 October 2004.

Two HH-60G helicopters departed Kandahar on a mission to medevac a local Afghani national who was a member of the Joint Election Monitoring Board (JEMB) overseeing the Afghani elections. (Tab V, 3-1) Reports to JEMB indicated that the injured party had suffered a gunshot wound to his right arm and his companions (with no medical training) were unable to stop the bleeding. (Tab V, 3-1) He was with his two Afghani Police escorts, who were in contact with the JEMB through a Thoria satellite phone. The communications link was very weak, as the two Afghani Police personnel on the ground spoke to the JEMB, then a US military liaison/translator collocated at the JEMB relayed that information to JTF 76, and ultimately the JSRC. The survivor's position was given as being approximately 146 NM NW of Kandahar AB, Afghanistan. Based upon available information, the JSRC determined that the mission involved a life, limb, or eyesight (LLE) situation. (Tab V, 3-1 to 3-2)

Take off, departure, and transit to the survivor's location where uneventful with aerial refueling accomplished enroute. Approach into the LZ was uneventful. As the Mishap Aircraft (MA) descended below 200 feet AGL and began to establish a hover, it encountered severe brownout conditions that obscured all outside references from the cockpit. (Tab V, 6-12 to 13) Brownout at such high altitude is extremely rare and was completely unanticipated. Brownout is rarely encountered above 75-100 feet. At this point, the MP determined the need for a go-around, called "on the go," and initiated a go around. Approximately 1 to 2 seconds after leaving the dust cloud, the MA impacted rising and rolling terrain. The helicopter skipped up the side of the hill on its belly for several feet until the momentum dissipated. The helicopter then rolled down the hill 5-7 times, coming to rest on its right side approximately 180 feet below the point of impact. (Tab V, 7-7 to 7-12)

The Flight Engineer AIC Jesse M. Samek was killed in the mishap. The aircraft was severely damaged in the crash and deemed unsalvageable by qualified maintenance personnel. (Tab V,

16-3). The aircraft was destroyed in place by US EOD personnel, with the loss valued at $14,072,043 (Tab P, 2). The aircraft crashed in contested territory and there was no evidence of damage to private property. There were no civilian casualties and all injured personnel (both US military and the original Afghani election official) were recovered safely.

3. BACKGROUND

Moody Air Force Base is home to the 34ih Rescue Wing. The 347th Rescue Wing is comprised of five groups, four of which are located at Moody AFB and one at Davis-Monthan AFB, Arizona. The 563rd Rescue Group. The 66th Rescue Squadron, the unit of assignment of the Mishap Aircraft (MA), is located and Nellis AFB, Nevada, and is subordinate to the 563rd• The 59th Expeditionary Rescue Squadron is the mishap unit. This is an expeditionary unit located at Kandahar Air Base, Afghanistan. The crewmembers of the MA were deployed to the 59th from the 66th. The Pararescuemen on the MA were deployed to Kandahar from the 48th Rescue Squadron, located at Davis-Monthan.

The mission of the 34ih Rescue Wing is to organize, train, and employ a combat-ready, HC-130 and HH-60 rescue wing consisting of approximately 4,054 military and civilian personnel including Geographically Separated Units in Nevada and Arizona. The wing executes worldwide peacetime and Combat Search and Rescue (CSAR) operations in support of humanitarian and U.S. national security interests, and in support of the global war on terrorism (GWOT). The wing and its subordinate units are all components of Air Force Special Operations Command.

The primary mission of the HH-60G Pave Hawk helicopter is to conduct day or night operations into hostile environments to recover downed aircrew or other isolated personnel during war. Because of its versatility, the HH-60G is also tasked to perform military operations other than war. These tasks include civil search and rescue, emergency aeromedical evacuation, disaster relief, international aid, counter-drug operations and space shuttle support.

The Pave Hawk is a twin engine, medium-lift helicopter operated by Air Force Special Operations Command, Air Education and Training Command, Air National Guard and Air Force Reserve Command.

The Pave Hawk is a highly modified version of the Army Black Hawk helicopter. It features an upgraded communications and navigation suite that includes an integrated navigation/global position/Doppler navigation system, satellite communications, secure voice and Have Quick communications.

All HH-60Gs have an automatic flight control system, night vision goggle lighting, and a forward looking infrared (FLIR) system that greatly enhances night, low-level operations. Additionally, Pave Hawks have a color weather radar and an engine/rotor blade anti-ice system that give the aircraft an all weather-capability.

Pave Hawk mission equipment includes a retractable in-flight refueling probe, internal auxiliary fuel tanks, two crew-served 7.62mm machine guns and or .50 Cal machine guns, and an 8000 pound capacity cargo hook. To improve air transportability and shipboard operations, all HH-60s have folding rotor blades.

Pave Hawk combat enhancements include a radar warning receiver, missile warning system, infrared jammer, and Flare/Chaff countermeasure dispensing system.

HH-60G rescue equipment includes a hoist capable of lifting 600 pounds from a hover height of 200 feet and a personnel locating system that is compatible with the PRC-112 survival radio and provides range and bearing information to the survivor's location.

4. SEQUENCE OF EVENTS

     a. Mission

The mishap crew was assigned to the 66th Rescue Squadron (RQS), and deployed forward with the 59th Expeditionary Rescue Squadron (ERQS), in theater. The 59 ERQS used "hard crews" while deployed. (Tab V, 4-9 to 4-10) "Hard crews" are aircrews whose members fly exclusively together during deployment. The Mishap Crew (MC) was identified as follows: the Mishap Pilot (MP) was Major Kevin R. Haff; the Mishap Copilot (MCP) was First lieutenant (lLt) Benjamin R. Scheutzow; the Mishap Flight Engineer (MFE) was Airman First Class (AIC) Jesse M. Samek; the Mishap Gunner (MG) was Senior Airman (SRA) Vanessa E. Dobos; the Mishap Pararescue Team Leader (MPH) was Staff Sergeant (SSgt) Paul Schultz; and the Mishap Pararescueman (MPJ2) was SSgt Scott J. Bilyeu. The two pararescuemen were not hard crewed with the helicopter crew, but were on a different shift schedule and had flown with this particular crew on several occasions. (Tab V, 8-2 to 8-3) All aircrew members were current in their aircraft duty assignments and crew positions.

The Combined Joint Task Force 76 Rescue Coordination Center (CJTF 76 RCC) was notified of a medevac mission at approximately 1229Z. The mission was to medevac a local Afghani national who was a member of the Joint Election Monitoring Board (JEMB) overseeing the Afghani elections. Reports to JEMB indicated that the injured party had suffered a gunshot wound to his right arm (accidental weapon discharge) and his companions (with no medical training) were unable to stop the bleeding. He was with two Afghani Police escorts, who were in contact with the JEMB through a Thoria satellite phone. The communications link was very weak, as the two Afghani Police personnel on the ground spoke to the JEMB, then a US military liaison/translator collocated at the JEMB relayed that information to JTF 76, and ultimately the JSRC. The survivor's position was given as being approximately 146 NM NW of Kandahar AB, Afghanistan. Based upon available information, the JSRC determined that the mission involved a life, limb, or eyesight (LLE) situation. (Tab V, 3-1 to 3-2)

Initially it was determined that Army medevac aircraft from Shindand AB would be unable to take this mission and the JSRC scrambled the 59 ERQS assets at 1319Z. (Tab V, 3-2) Crews began mission planning and preparing the aircraft for the mission. HC-130s from KarshiKanabad AB, Uzbekistan, were also scrambled with the intention of meeting the helicopters at Shindand for trans load and further transport of the injured party. Shortly after 59 ERQS got a scramble order, the Army determined they were able to accomplish the mission and the 59 ERQS. assets stood down at 1333Z. (Tab V, 3-2, 9-2)

Nevertheless, at 1434Z, the Army once again determined that they were unable to take the mission. 59 ERQS crews were recalled to the TOC to once again begin planning in anticipation of a scramble call. (Tab V, 9-2) The JSRC accepted the mission from the Army and scrambled the 59 ERQS. Two HH-60s, HALO 41 and 42 (MA), with full crews including two pararescuemen each, scrambled at 1503Z. (Tab N, 11)

Meanwhile, since no helicopters had yet taken off for the survivor's location, the HC-130 diverted from its plan to land at Shindand for trans load and proceeded directly to the survivor location. (Tab V, 13-1)

     b. Planning/Briefing

The 59 ERQS alert mission briefing, a briefing given to each alert crew as they come on duty, was appropriately completed prior to the daily alert changeover. The briefing includes Area of Responsibility (AOR), weather, ongoing operations, intelligence, aircrew and aircraft status, and any other pertinent information that the oncoming alert crews would need.

The overall mission was planned by the Flight Lead, Captain Bernie Smith, and Major Haff (MP) using the Portable Flight Planning System (PFPS), available imagery, current weather, and intelligence. Crews received briefings for this particular mission by their respective Aircraft Commanders in the aircraft prior to takeoff. (Tab V, 8-8, 9-2)

Operational Risk was discussed between the 59 RQS Commander, Lt Col Poole, and the Flight Lead. Risk factors pertinent to this particular mission were deemed to be: moon illumination, poor communications, power, brownout, and enemy threat. These items were discussed at length. (Tab V, 4-3 to 4-6) It was determined that moon illumination would still be available at the survivor location and that the survivor group was in indirect contact with JSRC via Sat phone They also determined that out of ground effect (OGE) hover power was available. Brownout was a standard risk throughout Afghanistan. The HH-60 crews had trained extensively for brownout conditions during "Spin Up" training prior to deployment. The enemy threat in the area of the survivor was considered low-to-moderate, based on the fact that no significant anti coalition forces activity had occurred in the area in recent months. After the thorough discussion of the risk factors, it was determined that the mission was doable and the overall risk was determined to be moderate. (Tab V, 4-3 to 4-6) The AlB members have reviewed the classified Operational Risk Assessment Matrix used by the 59th ERQS for determining risk.

     c. Preflight.

Each aircraft was prepared and put on an alert status called "Hover Cocked" by the respective alert crews. The crews performed the required preflight, engine, communications, and hover checks and then signed the aircraft up on alert, meaning that no one was allowed to perform any maintenance or change the configuration of the aircraft in any way without the express permission of that aircraft commander. Essentially the aircraft was "sealed" and prepared for a rapid start up and takeoff.

HALO 41 Flight launched (scrambled) off their alert status having complied with all required aircraft preflight requirements.

     d. Flight.

HALO 41 and 42 (MA) departed Kandahar uneventfully, wearing night vision goggles (NVG). The flight time to the survivor's location was approximately 2 +30 hours and an in-flight refueling (AR) was planned at approximately the halfway point. AR and the remainder of the flight to the survivor's location were uneventful. (Tab V, 10-2) Upon arrival at the site, Halo 41 and 42 (MA) located the survivor (in a truck with its light on, accompanied by 2 Afghan police). (Tab V, 7-4) Halo 41 marked the survivor location with chem lights and the two aircraft separated by altitude blocks. The survivor was located in an east-west oriented valley surrounded on 3 sides by steep sloping terrain. (Tab S, 4) It was a very restricted landing zone and was not the most suitable landing zone for an HH-60. An approach to this LZ would be challenging to the most experienced of pilots. In accordance with standard procedures, Halo 42 was to be the pickup aircraft, while Flight Lead orbited above to provide mutual support. Since Halo 42 would be the pick-up aircraft, it began a series of reconnaissance passes over the sight to find the best approach into the area. MA made 8-10 passes over the sight and several mock approaches to find the best way to attempt the pick-up. This process took 30-40 minutes, far in excess of the normal time spent looking at an LZ. (Tab V, 6-6 to 6-10) All the while the MP was discussing the various options with his crew and Flight Lead, and coordinating with the HC-130 to drop illumination flares as needed. (Tab V, 14-1) This was an outstanding example of Crew Resource Management and illustrates the great pains taken by all parties to ensure this rescue was executed in the safest manner and with the maximum amount of risk mitigation. Because of the restricted area that the survivor was located in, the MP queried higher authority about moving the survivor to a more suitable location. However, due to poor communications from the survivor to outside agencies, they never received a reply. (Tab V, 6-7, 9-4) The MP determined that the best way to get into the LZ was to approach from the north and execute a left turning approach to a hover over a flat area in the valley and lower the PJs via hoist to the survivor location. He queried his crew and flight lead and they all agreed that this approach would allow them the shallowest approach angle and prevent any rapid or unrecoverable rates of descent. They again made several mock approaches to further evaluate the terrain, obstacles, and best escape routes before making the actual approach to the LZ. (Tab V, 6-6 to 6-11)

     e. Impact.

Approach into the LZ was uneventful. As the aircraft descended below 200 feet AGL and began to establish a hover, it encountered severe brownout conditions that obscured all outside references from the cockpit. (Tab V, 6-12) This is extremely rare, and was completely unanticipated. Brownout is rarely encountered above 75-100 feet and there have been no recent examples of brownout conditions being encountered at that high an altitude. The MP transitioned to flying off the hover cues on his Heads-Down Display (HDD) while the MCP monitored the engine and system instruments. (Tab V 6-12 to 6-13) The MG still had visual reference with terrain outside the left side of the aircraft. She observed a left drift and made several "Stop left" calls. She noticed sparks coming off the blade tips and believed that the blades touched the terrain, or the vegetation associated with the terrain, just before the MP corrected to the right. (Tab V, 7-9 to 7-10) The MP corrected to the right but was still in brownout conditions and tried to maintain a stable hover. The MP commented to the crew that they were making "good calls." (Tab V, 6-13) At the same time, the MCP noted that the engine TGTs were in "limiting." (Tab V,6-13) (This condition occurs when the turbine temperature of the engines reaches a specified upper limit and, by design, the engines will not allow additional power to be applied without emergency steps by the crew that were not warranted at that point in time. Once this limit is reached, the engines cannot produce additional power. This feature keeps the engines from over temping. Any attempted increase in power at that point would result in rotor droop and power degradation). At this point, the MP determined the need for a go around, called "on the go," and initiated a go around. Approximately 1 to 2 seconds after leaving the dust cloud the MP and MCP noticed terrain directly to their front and the MP applied aft cyclic. (Tab V, 6-13 to 6-14) At 1812Z, HH-60G tail number 87-26014 impacted rising and rolling terrain at approximately 20-40 knots. The aircraft hit blades first and then with its belly. The helicopter skipped up the side of the hill upright and on its belly for several feet until the momentum dissipated. The helicopter then rolled down the hill 5-7 times, coming to rest on its right side approximately 180 feet below the point of impact. (Tab S, 4 to 5, Tab V, 6-14) Outstanding CRM was again demonstrated by the Mishap Crew, as evidenced by the fact that, while the aircraft was violently rolling down the hill, the MP and MCP maintained the presence of mind to execute checklists for the throttles and fuel selector levers to be shut off, preventing a potentially fatal post crash fire. (Tab V, 6-14)

     f. Life Support Equipment, Egress, and Survival.

The HH-60G PaveHawk helicopter is not equipped with a crew ejection system. There is no evidence of equipment failure relevant to life support, egress, or survival procedures. Of the six MA crew members, three remained inside the aircraft throughout the sequence of the MA impacting the terrain, violently rolling down the hillside and coming to rest below the impact site. The MP and MCP were restrained in their seats with the appropriate restraint systems. Upon coming to rest, they were able to disconnect themselves from their restraints and egress the aircraft through the pilot's side (right) window, which had been shattered. (Tab V, 6-15) The MG was secured to the left inside of the aircraft via her waist mounted gunner's belt (NSS: 1680-01-133-9975). (Tab V, 7-11) At the time of impact, the left door was closed; however, during the roll sequence, the door windows were removed. After the MA came to rest, the MG was able to safely egress through these open windows. (Tab V, 7-14)

At the time of impact, the two Pararescuemen (MPJI and MPJ2) were both secured to the Stokes litter cable which was connected to the Stokes litter in preparation for a hoist to the ground. (Tab V, 8-10) During the last roll of the aircraft (as evidenced by the cable exiting the right door and wrapping only once under the bottom of the aircraft with the cable coming over the left side of the aircraft (Tab Z, 8», MPJI, MPJ2, the Stokes litter and cable were ejected from the right side door of the aircraft, landing approximately 10 feet from the MA, on the uphill side. (Tab V, 814) They had unsecured themselves from the inside of the aircraft just prior to impact in anticipation of preparing to be hoisted down with the Stokes litter. MPJ2 sustained more significant injuries than MPJI. MPJI and MPJ2 both had all of their appropriate life support equipment on at the time of MA impact. (Tab V, 8-12 to 8-13)

The MFE was ejected from the aircraft during the violent roll sequence and found by MPJI approximately 6-8 feet on the downhill side of where the MA came to rest. (Tab V, 8-14) He was found not breathing and without a pulse, clothed in only his flight suit with no body armor, no helmet and no JSAVES (Joint Service Aircrew Vest and Extraction System) vest. (Tab V, 8-16) His helmet was found some distance from the MA and his JSAYES vest was found inside the aircraft with the associated gunner's belt (IJSV-H60BELT) secured to the aircraft. All ofthe MFE's survival equipment was sent to the Life Sciences Equipment Laboratory (LSEL) located at Brooks City-Base in San Antonio, Texas. Through extensive evaluation of the survival equipment, including standard optical microscopy and MacPhails blood reagent testing, the LSEL concluded that the MFE was wearing the JSAYES vest, body armor and helmet at the time of the mishap. They deduced that the leg straps of the JSAYES were not connected around either leg at the time of the mishap and that the aircraft impact forces created tension on the retention strap between the crewmember and the aircraft, causing the JSAYES and helmet (HGU-56/P) to be stripped from the crewmember during this mishap. (Tab J, 11) The MFE had been trained by Life Support technicians as to the proper wear of the JSAYES vest, which included the proper wear of the leg straps (Tab V, 19).

     g. Search and Rescue.

After the crash, the mishap crew exited the aircraft and began to assess the situation. MP11 immediately began to assess the medical conditions of the crew, he determined that the MFE was deceased and that MPJ2 was seriously injured. The remainder of the crew was not seriously injured. (Tab V, 8-13 to 8-15) MPl1 then began life-saving treatment of MPJ2. Simultaneously,

HH-60G, the MP was contacting HALO 41 via PRC 112 radio to inform them of the crash and the crew's status. Eventually the MP began to show signs of shock and the effects of the crash (repetitive questions) and the MCP took over the radio. (Tab V, 7-16) Crash info was passed to JSRC and CJTF 76 RCC and the recovery process began. At approximately this time the HC-130 was forced to return to Kandahar to refuel. After MPJ2 was stabilized, it was determined that his

injuries required immediate evacuation. (Tab V, 8-15 to 8-18)

HALO 41 made several attempts to get into the area, but met with the same conditions that MA had, and by the third attempt was forced to sheer the hoist cable and return Shindand for fuel as well. HALO 41 then requested Army CH-47 support and the JSRC requested Army help. (Tab V, 9-5 to 9-8) CJTF 76 RCC assessed the mission as high risk and determined that the Army assets would not launch before first light. (Tab V, 3-3, 9-6 to 9-8) The 59 RQS commander had also launched his third HH-60, HALO 43, to head to the crash sight and assist. (Tab V, 4-7 to 4

8) A short time later an AC-130 arrived and assumed on-scene commander duties.

Soon after, the HC-130 returned to the area. Having single-handedly attended to the medical needs of 5 personnel, MPJI requested the PJs from the HC-130 jump into the area to assist him. (Tab V, 8-18 to 8-19) The PJs parachuted into the crash site. They backed up MPJI's assessments and also made contact with the vehicle that contained the original patient and treated him as well. They also determined that the site was not suitable for any more pick-up attempts. (Tab V, 7-16,9-8)

They then teamed with the local nationals who were with the original patient and had a vehicle, to move the MP, MPJ2, and the wounded election official to a more suitable LZ. They left MCP, MG, MPJI, and the deceased MFE at the crash site. (Tab V, 7-19) They located an LZ approximately 4 miles to the southeast of the crash site. HALO 43 arrived on scene and eventually was able to land and recover the MP, MPJ2, and the wounded LN. (Tab V, 14-2) At that time, HALO 43, 41, and the HC-130 proceeded to Shindand for transload and fuel.

At Shindand the MP, MPJ2, and LN were loaded on the HC-130 and flown back to Kandahar for medical treatment. (Tab V, 3-3) The PJs from the HC-130 had meanwhile proceeded back to the remaining survivors to prepare them for extraction. (Tab V, 14-2) After gassing a Shindand, HALO 41 and 43 arrived back at the crash site and attempted to pick up the remaining survivors, but were unable to do so due to severe brownout. They remained in the area to provide support until the arrival of the Army helicopters. (Tab V, 13-1 to 13-3, 14-1 to 14-3) At Approximately 0418Z, the Army CH-47s arrived on scene and were able to extract the remaining survivors. The survivors were flown back to Kandahar for treatment and the MA was declared unsalvageable and destroyed on the ground. (Tab V, 3-4, 13-3)

     h. Recovery of Remains

The MFE's remains were moved from the Mishap site at the time of extraction of MCP, MG and MPJI. His remains were flown to Shindand AB, then Kandahar AB. In Kandahar, the U.S. Army's54th Quartermaster Company mortuary affairs took control of his remains. A Death certificate was issued by a US Army Physician at 0606Z on 21 October 2004. His remains were released to the USAF and flown onboard a C-17 to Dover AFB on 22 October 2004. An autopsy was performed by AFIP on 23 October 2004 and on 25 October 2004, he departed Dover AFB

and was flown via commercial air to Rogers, Arkansas, where he was placed to rest on 27 October2004.  

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