2.2.1 Black Hawk Helicopter Crash—Executive Summary
To set the scene for discussion, the following was extracted from the Executive Summary of the Black Hawk Board of Enquiry (Australian Army, 1996. Reprinted by permission of the Australian Department of Defence (Copyright) Australian Department of Defence. All rights reserved.):
Preliminary Facts
1. On Tuesday 12 June 1996, 1 Squadron Special Air Service Regiment (1 Sqn SASR) and A Squadron 5th Aviation Regiment (A Sqn 5 Avn Regt) were participating in a live firing Counter Terrorist/Special Recovery Operation (CT/SRO) exercise at Fire Support Base (FSB) Barbara in the High Range Area. This activity was part of Exercise DAY ROTOR 96 and was being conducted on the second day of the Exercise program. Training on 12 Jun 96 commenced at 1000 hours when orders were delivered to participants for the day’s activities which were to be:
a. a day airmobile live fire assault on to FSB Barbara, incorporating live fire from fire support helicopters;
b. a day ground live fire assault on the same objective; and
c. a night airmobile assault, incorporating mortars, but otherwise the same as the day airmobile assault.
2. Six (6) Black Hawk helicopters from A Sqn 5 Avn Regt with an aircrew complement of 24 were committed to the exercise. A total of 43 1 SAS Sqn soldiers were involved in the airmobile assaults. These were to be effected by fast roping from four assault aircraft at points adjacent to gun emplacements at FSB Barbara, with fire support being provided from two aircraft on the flanks. The ground crew of 16 personnel consisted of Safety Officers and Administrative staff, predominantly from 1 SAS Sqn.
3. The day serials of the exercise were conducted without incident, although the objective was found to be more confined than pilots had expected from the orders and briefings they had received. In addition, some uncertainty existed in the mind of CAPT Burke, the flying pilot of Black 2, about the respective locations of Black 1, Black 2 and Black 5 in relation to the gun emplacements. This uncertainty may have been caused by an inaccurate whiteboard diagram of FSB Barbara which had been used in the orders and briefings at Garbutt prior to commencement of the exercise. Having expressed his concern to CAPT Hales, Flight Lead in Black 1, CAPT Burke discovered that Flight Lead did not share his concern, and a compromise solution was reached between the two pilots to go to the same positions for the night mission that had been used during the day.
4. Although the night mission was supposed to replicate the day airmobile assault, some changes to the day mission’s profile, to mask the approach and noise of the helicopters and to give fire support aircraft more time over the target, were requested by SAS personnel. A proposal by Flight Lead to use a different formation in a river valley further to the West of the day track was refused by OC A Sqn, MAJ Jameson. However, a decision was made to release the flanking fire support aircraft earlier than by day and, before launching the night mission, Flight Lead briefed aircrews that he would fly lower from the Initial Point (IP) than during the day.
The Accident
5. At 1830 hours, the formation departed FSB Barbara and headed south before making a wide Left turn to intercept the IP and commence the run-in to the FSB. The track adopted was to the Left (West) of that used during the day by some 300 metres. All of the preparatory and formation calls were transmitted and at the 30 second call, which was given approximately 1 to 1.25 minutes from the objective, the formation changed to line abreast with Flight Lead in Black 1 on the Left and Blacks 2 and 3 formating to the Right of him at a separation of two rotor diameters (33.5 metres) between rotor discs. Black 4 positioned at the centre rear, astern of Black 2 and the Fire Support aircraft, Blacks 5 and 6, accelerated ahead of the assault formation towards their firing positions.
6. The formation approached FSB Barbara to the Left of the day track and at a lower altitude. Flight Lead was not informed by the pilots of any of the other aircraft that he was off track. Because the approach was different, visual cues were difficult to acquire under Night Vision Goggle (NVG) conditions. Additionally, identification of the gun emplacements on the FSB was hampered by the lack of aboveground features and the shadow cast over the objective by high ground to its West which was still backed by sunset skyglow. The gun emplacements became visible to NVG observation only in the final few hundred metres of the formation's track.
7. By the 30 Second call, the formation was about 400 metres off track and just prior to the call, Flight Lead made the first of three adjustments to the Right to bring the formation onto the target. The second of these Right turns was made just after the 30 second call and caused the convergence between Black 1 and Black 2. This was detected by the aircrew in both aircraft and separation restored. Black 1's third manoeuvre to the right brought it into collision with Black 2.
8. Because of unfamiliar and confusing visual cues, it is likely that CAPT Hales misidentified his gun emplacement and turned Right towards the roping point of Black 2. His aircraft converged on Black 2 which was maintaining the previous heading of the formation. The entire formation had decelerated from 100 knots and possibly during this deceleration and the previous two Right turns, Black 2 had moved slightly ahead of Black 1. In any case, Black 1 approached Black 2 from behind and slightly lower, where its crew would have had difficulty seeing Black 2. SGT Mark, Black 2’s Lefthand Loadmaster saw the approach of Black 1 moments before impact. He called “Come right, come right, come right”, then “Come up, come up” as Black 1 began to pass beneath Black 2 from behind. Black 2’s Pilot had little time to react and, being unaware of Black 3’s position, believed that he could not turn Right. He had applied aft cyclic to climb just as Black 1's Pilot attempted to take avoiding action, banked Left and struck the aft sections of Black 2 with its Main Rotor.
9. Black 1's main rotor blades were destroyed mid-air. Their strikes on Black 2 severed its tail boom, ruptured one of its fuel tanks and fractured the support structures of the aft section of the passenger compartment. Fuel sprayed from Black 2 and ignited causing a huge, instantaneous fuel/air explosion. Fire was also ignited in the severed Tail Boom of Black 2 and fuel spewed into the passenger compartment. Black 1 continued to roll to the Left and crashed to the ground enveloped in flame. It impacted the ground inverted and was consumed by fire. Black 2 went into a flat spin, revolving clockwise a number of times, before impacting in an upright position facing generally in the direction of its flight path. Fire from the burning rear section spread forward through the fuel-saturated main body, eventually engulfing and destroying it.
10. Very effective rescue efforts were made immediately the aircraft crashed to the ground. Casualty treatment, classification and evacuation were organised very well. Nevertheless, three aircrew and eight passengers in Black 1, and seven passengers in Black 2, died as a result of this mid-air collision.
Causes
11. Although the collision sequence described above reveals that the terminal cause of the accident was the convergence of Black 1 into Black 2, the Board has found that there was a Chain of Events that successively and cumulatively created the conditions and environment in which the accident became an inevitable outcome. All of the factors and events in the chain untimely combined in one fatal culminating point. The following is a synopsis of the Board's Findings and the notable links in the chain which constitute causes contributory to the final actions which brought the two aircraft into mid-air collision:
a. aircraft unserviceability in 1994/95 which reduced the opportunity for pilots to gain experience and proficiency in flying CT/SRO missions;
b. high pilot separation rates which further eroded the experience base within 5 Avn Regt;
c. inadequate and untimely joint exercise planning between SASR and 5 Avn Regt;
d. inadequate supervision and checking of delegated exercise planning tasks by responsible superior commanders;
e. incomplete and uncoordinated reconnaissance of the exercise site, including inadequate air photography of FSB Barbara;
f. inaccurate diagrammatic representation of FSB Barbara which was used for briefing both SASR ground assault teams and 5 Avn Regt aircrews;
g. changing flight profile and direction for the night mission from that which had been practiced in the day airmobile assault;
h. employing a complex flight formation which permitted no individual aircraft manoeuvre flexibility, and with no abort procedure practiced, under NVG conditions on a tight objective with no vertical identifying features;
i. appointing an inexperienced Flight Lead to lead the formation on a combined arms, live firing, NVG, three aircraft abreast airmobile assault mission;
j. failure of the Air Element Commander (AEC) to exercise command and control of the formation in the air because of his involvement as the flying pilot of one of the assault helicopters; and
k. failure of the AEC or any other pilot to inform Flight Lead that he was off track and that difficulty in identifying individual roping and firing points was being experienced.
Recommendations
12. At Part 5 of this Report, the Board makes a significant number of recommendations with the purpose of advising those remedies which it considers necessary to ensure compliance with regulations, safety in training and implementation of, and adherence to, "best practice" procedures. Above all, these recommendations are designed to ensure that Army can continue to satisfy all its capability and readiness requirements, including those involving high risk, while also ensuring that the circumstances which caused this accident can never be repeated.
13. In summary, the Board's recommendations attend to the following matters:
a. Risk Analysis;
b. Australian Defence Force (ADF) and Army Directives and Plans for CT/SRO;
c. command and control relationships between SASR /5 Avn Regt for CT/SRO;
d. information gathering responsibilities for CT/SRO exercises;
e. attendance at exercise orders and briefings;
f. conduct of missions requiring use of NVG equipment;
g. aircrew training for CT/SRO and maintenance of proficiency;
h. technical control of flying operations;
i. equipment acquisition and maintenance;
j. personnel and logistics remedies;
k. tasking priorities for 5 Avn Regt;
l. responsibilities of Army Accident Investigation Team (AIT); and
m. disciplinary action against persons affected.’