The end of another touch-and-go practice landing became anything but routine after a brief, loud noise filled the cockpit of the T-38C flown by Capts. John F. Graziano and Mark S. Palyok.
“What’s that?” one of the pilots asked.
A compressor stall and loss of engine thrust left Graziano with seconds to react as he took control of the Talon, the Air Force’s mainstay supersonic training jet. A probe into the Nov. 13, 2018 crash that killed Graziano, 28, of Elkridge, Md., found that he mishandled throttle and flight control inputs as the jet lost power on takeoff.
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A recent report from a commission studying aviation accidents like that one at Laughlin AFB in Del Rio and another T-38C deadly mishap there in 2017 says that many of them never should have happened.
That they did raises hints that the Pentagon hasn’t done enough to prevent crashes and save lives.
In just five years, 198 military personnel and 157 aircraft were lost in 6,079 “mishaps” — the military’s term for accidents — costing $9.4 billion. Most were avoidable, the National Commission on Military Safety said.
The panel studied the scope and depth of the problem from 2013-18. Congress created it in 2019 to examine the rates and causes of mishaps, and recommend ways to improve aviation safety. While the commission was conducting its study, military aviation mishaps claimed another 26 lives, 29 aircraft, and $2.25 billion.
Everywhere commissioners went, their report stated, “certain answers were consistently repeated, regardless of service, rank, or airframe.” Pilots didn’t fly enough so proficiency waned, crews made do with inadequate training and were slammed with administrative duties while struggling to get funding.
They endured risky maintenance practices and a crushing operations tempo, a term that refers to the pace of troops training, deploying and returning home to repeat the cycle.
Observers said reversing those trends boils down to four fixes: Slowing that pace, getting pilots into the air more often, giving maintenance crews more time to do their jobs and opening the funding spigots for cash-starved aviation units.
“We came away from our visits impressed with the patriotism, dedication, and level of effort we observed throughout the ranks of America’s military,” said retired Gen. Dick Cody, the commission’s chairman. “But we also came away deeply concerned and troubled by the decline in experience, crushing optempo and lack of resources.”
Yet another issue is the fact that many military aircraft have reached the end of their intended lifespans but are still flying. In some cases maintenance crews scrounge for parts at the Boneyard on Davis-Monthan AFB, Ariz., a resting place for old planes.
Military aviation mishaps
The National Commission on Military Aviation Safety conducted a study of mishaps across the armed services from fiscal years 2013-18. It examined more than 6,000 accident reports and talked with aviators and maintainers at 200-plus units at 80 different sites.
Among its findings:
In five years, 198 personnel were killed and 157 aircraft were destroyed in 6.079 accidents, called mishaps in the military. The cost topped $9 billion.
Pilots did not fly often enough, yet a relentless, high operations tempo overall is causing chronic fatigue and unsafe conditions..
Maintainers had too many administrative duties and needed better training.
Lack of consistent, reliable funding was the single biggest readiness issue impacting safety.
Insufficient data collection and analysis is increasing risks.
There are few new causes in accidents. The same mistakes are being repeated. Most are preventable.
SOURCE: National Commission on Military Aviation Safety
Some aircraft now flying go back 65 years. The T-38 has been in the Air Force since John F. Kennedy was president. The C-130 and KC-135 tanker became operational under President Dwight D. Eisenhower.
In their report, commissioners warned the pace of operations is leading to unsafe practices and “driving experienced aviators and maintainers out of the force.” Flight hours are down and waivers for pilots not making them over the course of a year are on the rise, they said. That in turn bypasses “critical currency and proficiency requirements, … increasing risk, and creating major distractions and delays in developing the best possible aviators.”
The commission found that aviation and maintenance experience, keys to doing a job safely and well, are also in decline. New pilots and maintainers report to operational units without basic skills.
As flight hours are replaced with simulator hours, the sims often are outdated. Others are out of service or even unavailable.
Aircrews, moreover, have reported unexplained physiological episodes. UPEs, as they’re called, can result from hypocapnia, a state of reduced carbon dioxide in the blood, or hypercapnia, excessive carbon dioxide in the blood usually caused by inadequate respiration. UPEs linked to flaws in life-support systems in the Air Force’s basic fyling trainer, the T-6A Texan II, forced the 559th Flying Training Squadron at Joint Base San Antonio-Randolph to halt operations for a day in 2018.
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The commission said maintainers are “distracted by career-enhancing assignments unrelated to their highly specialized aviation skills.”
“Both aircrews and mechanics are further deluged with voluminous additional duties depriving them of vital training opportunities. The net result is a shortage of mid-grade maintainers and aviators across the services, and an overall decline in experience levels,” it said.
Then, there’s money. A junior Marine at one base told the commission his unit reused expendable $5 filters on aircraft. When asked why, he said the organization had missions to do even if it didn’t have the money to buy new filters. The report said that “egregious example” of funding woes occurred because money was shifted to other priorities.
“Inconsistent funding, and the tolerance it fosters for maintenance shortcuts, were the likely causes of the next mishap at this unit,” the report predicted.
One of the Army’s most experienced attack helicopter pilots found little in the report that was new. Retired Chief Warrant Officer 5 Lance McElhiney, who spent nearly 44 years as an aviator and flew in four wars, said getting enough flight time has been a problem since the end of the Vietnam War.
Many accidents, he added, are preventable when the right personnel with the right training are in place at critical moments.
“There’s a lot of accidents that happen,” said McElhiney, who joined the Army at 21, flew in Vietnam and retired at 67 after flying the AH-64D Apache Longbow in Afghanistan. “Like I always used to say, we’re more dangerous to ourselves than the enemy ever dreamed of being to us.”
The seriousness of the problem was made clear starting in the summer of 2017. The services saw a number of high-profile mishaps over the next 12 months that called into question the overall state of military aviation safety.
A Marine Corps KC-130 came apart in the sky over Mississippi, killing 15 Marines and one Navy corpsman, the report said. An Army UH-60 crashed into the sea during a night exercise off the coast of Oahu, killing all five aboard. A Navy C-2A Greyhound ditched into the Philippine Sea with three fatalities.
There were other deaths, as well as UPEs that grounded the T-6.
The commission ranked accidents as Class A, which involves a death, to less severe Class B and C mishaps. Overall Pentagon accident rates increased during the five years in the study, largely due to Class C mishaps. Though many were minor, the commission said they “could be a harbinger of more serious safety issues.”
A key commission recommendation is to create a Joint Safety Council that reports to the deputy secretary of defense. The council would establish military aviation safety standards, collect and analyze safety data, and develop safety priorities. It would be led by safety officials from across the services and have the authority to monitor and coordinate aviation safety programs.
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The proposal carries the promise of helping the services learn from each other, said McElhiney, who has 13,000 hours in AH-1G Cobra and Apache attack helicopters and flew with Cody decades ago. Still, he wonders about potential limitations. There has long been a lack of standardization across the services and each service has unique missions.
Still, he believes the council is a good idea in part because his old friend advocates it.
“Dick Cody treated us all very fairly and if he’s doing this, he’s doing it for a good cause. The man has got good intentions, he always has,” said McElhiney, 74, of Harker Heights. “I mean, Dick Cody is probably one of the most stand-up, honest guys I’ve ever met in my life. He’s very loyal and he’s very dedicated to aviation and the betterment of aviation as a whole.”