Abstract
On the 3rd of April, 2006, a C-5 aircraft crashed at Dover Air Force Base in Delaware. Poor decision-making was the main cause of the expensive, but unfortunate, accident. The essay reviewed the chain of events that led to the mishap and measures that the pilot could have taken to prevent it.
The essay used information from reports of survivors and investigators. The author provided a short summary of landing basics that the pilots ignored, leading to the mishap. The essay addressed the application of KISS, which stands for Keep it Simple Stupid. It also addressed the issue of how an alternative thinking process could have averted the crashing of a multi-million dollar jet.
The Occurrence
The C-5B Galaxy crashed and disintegrated into three pieces at around 6:42 in the morning. The crash occurred in a grassy area adjacent to the Air Force Base. In fact, the crash site was near the edge of the facility’s fence (Federal Information & News Dispatch, 2006a). The Air Force categorizes the land as proprietary to the base. As such, the crash took place within the property of Air Force. The land was acquired by the government a number of years ago for specific purposes.
For example, the land is used by authorities to monitor activities taking place in the surrounding airspace. It was also meant to shield the civilian population from rare and unlikely mishaps like this crash. To this end, it is important to note that if Air Force had not acquired this piece of land, the crash would have taken place on civilian property. The arising damages can only be imagined.
The jet that crashed was used for transport by Air Force. It had taken off from the base at about 6:21 a.m. Its destination was Ramstein Air Base in Germany. The jet was carrying merchandise destined for troops participating in the worldwide war on terror (Federal Information & News Dispatch, 2006b). As such, it can be argued that the crash occurred when the crew was participating in the fight against global terrorism. Given the conditions under which the jet was operating, the crew should have declared an emergency.
To this end, members of the crew should have scrutinized their operations to ensure the jet was still under control. In addition, they should have evaluated the origin of the emergency. They should also have processed their jet checklists and settled for an appropriate location to securely land the jet to avoid risks and loss of lives. Finally, they should have informed everybody in the jet and on the ground about the measures they were taking to control the situation.
A number of parties responded to the accident immediately after the crash. They include the Air Force personnel and neighboring fast response teams. The latter was composed of health experts, firefighters, members of the defense forces, and civil engineers. All of the parties were interested in rescuing survivors and helping in any way they could.
Dover AFB C-B Crash 2006: A Review of Possible Errors Made
A plane crash can be attributed to a number of errors. The errors can either be human or mechanical. A crash can also be brought about by unfavorable weather conditions, such as storms. A crash can also be brought about by a combination of a number of errors. The errors responsible for the crash can only be determined after extensive investigations into the occurrence. That is the reason why commissions are formed to investigate any crash. The findings made in such investigations go a long way in averting future crashes.
An investigation into the AFB CB crash 2006 made findings regarding the errors responsible for the occurrence. According to the findings, human error was liable for the crash of the C-5 jet at Dover Air Force base. The military official inspectors reported that the cockpit crew committed three serious errors.
The errors, which later led to the crash, were committed before the crew declared an emergency soon after takeoff. The crash occurred on the 3rd of April, 2006 (Pilot error blamed for USAF Galaxy crash, 2006). According to the report made by the investigators, there was apparent and persuasive proof that the crew attempted to restart an engine they had already shut down.
At the same time, the crew was not using a fully equipped engine that was available to them. In addition, the crew made use of flap settings, a decision that led to too much haul for the jet. It was also found that C-5 crew settled for the wrong strategy to deal with the conditions they were experiencing.
Investigations also revealed that the crew manning the jet received a false alarm to the effect that they had not shut down the power reverser on one of the engines. As a result, the crew shut down the engine and attempted to fly back to the base. The jet stalled roughly a mile from the landing strip. After stalling, it hit a telephone pole before crashing into open grassland. The impact of the crash made the jet split into three. At the time of the crash, 17 people were on board. Lucky enough, all the seventeen people in the jet survived.
The jet was under the control of two pilots. The two were captains Brian LaFreda and Harland Nelson (Pilot error blamed for USAF Galaxy crash, 2006). A third one, Robert Moorman, was seated at the back of the jet (Rolfsen, 2006). In addition to the three, there were two expert jet engineers. Between them, the three jet pilots had more than ten thousand hours of flying time in a C-5 jet. What this means is that they were experienced professionals.
The same applied to the two jet engineers in the crew. The jet was owned by the 436th Airlift Wing. The wing is the dynamic duty department at Dover. However, the jet was under the command of a different department. It was under the control of the 512th Airlift Wing. The wing is a reserve section at Dover. It was revealed that the crew lacked situational ‘smugness’ and alertness.
To compound their initial mistakes, the crew applied a complete flap strategy. Utilizing flap settings of 62 or 40 percent, rather than 100 percent, would have been very helpful. Such a strategy would have decreased the haul on the jet, which weighed 730000 pounds. The jet was 100000 pounds heavier than its ordinary landing weight. The surveyors reported that a 40 percent flap would have saved the situation. The flap would have increased the airspeed by roughly 20 knots or 166 knots on last approach (Rolfsen, 2006).
As already indicated above, the crew failed to utilize engine number 3 and placed the flaps wrongly. In addition, the crew incorrectly attempted to adopt a visual strategy to access the airstrip.
Using the strategy, they took the C-5 jet below the standard flying path for a tool approach or the standard visual air travel altitude. Finally, the inspectors discovered that Captain LaFreda did not give a full approach notice to the ground crew. Had he briefed them, the situation may have been a lot different. For example, the crew would probably have raised queries that could have prevented the accident.
A number of simulation tests were conducted during the investigations. The tests showed that the crew could have averted the crash with the same flap positioning and approach they had applied. A crash would have been averted if the crew had started engine number 3 about 300 feet above the ground.
Even if the crew had at their disposal only two functioning engines, a crisis may have been averted. For example, the simulation tests showed that a decreased flap setting would have led to a safe landing. The crew could also have achieved a safe landing with just two functioning engines and at complete flaps. They would have achieved this by applying a tool landing strategy on a different airstrip (Rolfsen, 2006).
A Review of AFB-CB Crash 2006 from a KISS Perspective
KISS is an ellipsis for Keep it Simple Stupid (Siegler, 2009). It is a design principle established by the U.S. forces in 1960 (Siegler, 2009). The principle states that the functioning of nearly all systems can be maximized if the designers ‘keep them’ uncomplicated. Intricate and complex designs make it hard for users to utilize equipment.
That is why designers should try as much as possible to avoid intricate models. Consequently, simplicity should be the ultimate goal in design. To this end, engineers should desist from embracing pointless intricacies. The KISS strategy is often associated with software and mechanical engineering. Nevertheless, the strategy can also be applied in most areas of human endeavor.
A story is told of Kelly Johnson giving a group of engineers few tools to work with. The story best exemplifies the principle of Keep it Simple, Stupid. Johnson is well known for engineering jets for the American military as an independent outworker. He is regarded as one of the exceptional engineers due to the realistic nature of the strategies he used to solve the various problems he encountered. His attitude reflects the opinions and belief systems of other great philosophers in the past.
For example, he has been likened to such prominent figures as Leonardo da Vinci and Henry David Thoreau (Siegler, 2009). Experts frequently quote the KISS principle in their works. For example, the principle is especially utilized when technological improvements and upgrades are carried out. In addition, the strategy is used in addressing the various problems brought about by increasing population growth in contemporary world.
Johnson challenges contemporary engineers to fix a problem in a jet aircraft they are designing using a standard mechanic approach. In the story cited above, he challenged his engineers to fix a problem encountered in war using the few tools he gave them. According to Siegler (2009), Johnson uses the term stupid to refer to the link between the way things break down and the complex nature of conventional ideas available to repair them.
In the jet crash case referred to in this paper, the accident could have been averted if the crew had applied the KISS principle. The crew should have taken the time to completely close down the power reverser on one of the engines. The crew should have settled for the right strategy to address the problems raised by the conditions they were exposed to. In addition, the crew should have flown the jet without engaging other units.
That way, the crash could have been averted. They should not have complicated the issue by exchanging their problems with reserve crews (C-5 crash blamed on human error, 2006). If they had kept their responses ‘simple’, may be the jet could not have crashed. The complex nature of their responses may have played a part in the crash.
According to Siegler (2009), the principle emphasizes on the application of the least number of tools to address a given problem. The small number of tools enhances efficiency in a given situation.
For instance, utilizing the flap settings of sixty-two or forty percent, rather than hundred percent, would have decreased the haul on the seven hundred and thirty thousand pound jet. As indicated earlier in this paper, a forty percent flap would have increased the airspeed by roughly twenty knots or one hundred and sixty six knots on last approach (Federal Information & News Dispatch, 2006a).
The KISS principle insists that individuals should adopt the correct approach in addressing a problem. For instance, the crew did not utilize engine number 3, which could have proved to be the right approach to the problem. Instead, not only did they fail to power the engine, but they also placed the flaps wrongly.
The crew also adopted the wrong visual strategy to return to the airstrip. The crew dropped the jet below the standard fly path for a tool approach. In addition, they dropped below the standard visual air travel altitude. The jet crew could have averted all these problems by applying the KISS principle. Furthermore, Captain LaFreda failed to provide the ground crew with a full approach notice. Such a notice would have averted the crisis given that his actions would have been questioned by the crew.
KISS principle focuses on the application of the ‘simplest of tools’ and the ‘easiest of techniques’ (Siegler, 2009). As indicated above, the principle is applicable to the crash case analyzed in this paper.
The simulator tests conducted during the investigation showed that the KISS principle would have worked wonders even under the challenging situations the crew was exposed to. For example, the realization that the same flap positioning and approach adopted by the crew could have led to a safe landing points to the fact that application of KISS principles would have saved the situation.
If the crew had adopted the KISS strategy, they could have switched on engine 3 at three hundred feet above the ground. Likewise, the application of KISS principles would have helped the crew to adopt a decreased flap setting with only two functioning engines. In addition, the crew could have applied a tool landing strategy to a different airstrip.
Over Thinking and the Crash
Over thinking is actually detrimental to people’s performance. It appears that under some circumstances, paying full attention and trying very hard can really hinder performance. The reason is that individuals must access their working reminiscences to effectively carry out a particular task.
Today, scientists believe that there are two forms of long-term reminiscences. The first is implicit reminiscing, which does not require ‘mindful thoughts’ (Siegler, 2009). It is expressed by means instead of words. There is also explicit reminiscing, which is created consciously by the individual. It can also be describe in words. Experts consider these two different areas of functioning to be both habitual and mind-based.
The inspectors report indicated that the crew attempted to start an engine they had shut down. They seemed to forget that there was fully equipped engine that was lying idle. The error, coupled with others that were revealed during investigations, makes it apparent that the crew was desperate. They were doing anything they could think of to avert the accident. Consequently, they ended up thinking in their own way, committing a number of errors in the process.
Investigations also revealed that the crew did not think the signal could have been false. It never occurred to them that one of the systems may have malfunctioned and given them the wrong signal. They acted on this false alarm by shutting down the engine and attempting to go back to the base. The crew should have taken the time to think whether the signal was right or not. They could have landed the jet immediately to avert any accident. Instead, it appears that they panicked and failed to think straight.
The crew decided to use a different strategy to solve the issues that arose prior to the crash. For example, they thought that by applying a higher percentage flap, they would have increased the speed of the jet, averting an accident. It is clear that they deviated from the standard rules and formulated their own approaches to address the problem. It is this misdirected and misinformed ‘creativity’ on the part of the crew that led to the accident. The crew should have adhered to the normal percentage of flaps.
The investigations also revealed that the crew decided to formulate their own ways of utilizing engine number 3. The placing of flaps, which was wrong, was also their own way of responding to the crisis. Their strategies were ineffective in addressing the situation. They should have adopted the right strategy. If the crew acted calmly and responded to the crisis with a clear mind, perhaps the accident could not have occurred.
It appears that, just like the rest of the crew, Captain LaFreda was over- thinking. For example, the investigations revealed that he thought of trying his own ways to avert the accident. He was over-thinking and forgot to communicate with the emergency crew on the ground.
The conclusion is based on the findings made by the investigators to the effect that Captain LaFreda did not give a full approach notice to the crew. He came up with his own strategies, which he thought will avert the crisis. Instead of averting the problem, his ‘creativity’ led to an accident.
In addition to Captain LaFreda, other members of the crew came up with their own strategies to address the problem. The common denominator in the strategies adopted by the crew was that they were panicky responses to a crisis. For instance, the crew decided against revving up engine number 3 three hundred feet above the ground. They came up with their own ineffective strategies to address the situation.
Conclusion
Investigations carried out to determine what caused Dover AFB C-5 crash that took place in 2006 pointed out that human error was to blame. The crew made a number of tactical errors that led to the crash. The pilot adopted the wrong strategy in addressing the problem. Over-thinking was one of the factors that led to the human errors responsible for the crash. Adoption of the KISS strategies could have averted the accident.
References
C-5 crash blamed on human error. (2006). Web.
Federal Information & News Dispatch. (2006a). C-5 accident investigation board complete. Web.
Federal Information & News Dispatch. (2006b). 17 airmen survive Dover C-5 Galaxy crash. Web.
Pilot error blamed for USAF Galaxy crash. (2006). Web.
Rolfsen, B. (2006). Too low, too slow board faults 5 crew members in crash of C-5B Galaxy at Dover. Web.
Siegler, M. G. (2009). Keep it simple stupid. Web.