Report: Missteps led to fatal Navy helicopter crash

By Mike Hixenbaugh The Virginian-Pilot ©

By the time the Norfolk-based Navy helicopter began falling, it was too        late.

The MH-53E Sea Dragon was spinning counterclockwise, drifting out of        control as its engines strained against the weight of a downed aircraft        it had lifted moments earlier out of a canyon in the mountains of Oman.

Panicked crew members shouted orders to drop the oversized load and        abandon the heavy-lift mission. Before they could, the chopper’s tail        smashed into a ridge, and the helicopter careened into a canyon, landing        upside down and bursting into flames.

Three of five crew members escaped the fiery crash on July 19, 2012. The        others, Senior Chief Petty Officer Sean Sullivan and Petty Officer 2nd        Class Joseph Fitzmorris – “Sully” and “Fitz” – were mourned days later        at a memorial service in Bahrain.

Their deaths, and the loss of a $50 million helicopter, could have been        avoided if the crew had followed standard Navy flight guidelines before        and during the botched salvage operation, according to a command        investigation.

The extensive investigative report, obtained this week by The        Virginian-Pilot through the Freedom of Information Act, blames the        entire crew for skipping preflight safety checks and for failing to        develop a concrete plan for how and when to abort the mission.

“There were several opportunities to break the chain of events that led        to this tragedy,” the report stated. “This mishap was completely        preventable.”

Moreover, the report said, the crash revealed a series of systemic and        cultural problems in Helicopter Mine Countermeasures Squadron 15 and        within the broader Navy Sea Dragon program, which is headquartered at        Norfolk Naval Station.

“The tragic events of that day shed light on a lot of things that a lot        of people, myself included, should have seen a long time ago,” Capt.        Todd Flannery, the commander of Helicopter Sea Combat Wing Atlantic,        said in an interview Friday. “This event, unfortunately, was years in        the making.”

Days before the crash, the Royal Air Force of Oman requested the Navy’s        help moving a twin-engine helicopter that had crashed a week earlier in        a rocky ravine about 58 miles southwest of Muscat, the capital.

Cmdr. Sara Santoski, then the skipper of HM-15, hand-selected a crew of        her most experienced aviators to airlift the downed helicopter to a        nearby airfield. Santoski, who was later relieved of command, directed        the crew to “take no unnecessary risk,” according to the investigation.

The names of the surviving crew members were redacted from the report,        but it did identify the co-pilot as the squadron’s executive officer.

The seasoned helicopter crew arrived at Al-Mussanah Air Base in Oman a        day before the flight operation to view the wreckage, record        environmental conditions and plan the mission.

Based on the weight of the downed helicopter – estimated at 13,200        pounds – and the strength of the Sea Dragon’s engines, the lead pilot        noted there would be only a small margin between “power available” and        “power required” to perform the lift.

The pilot later told an investigator that he did not know Santoski had        issued guidance requiring a 5 percent power margin to proceed with the        lift.

During the planning, the air crew briefly discussed dropping two crew        members from the mission to lighten the Sea Dragon’s weight by a few        hundred pounds. The unconventional suggestion made one crew member        wonder whether the lift was too dangerous, but he didn’t reveal his        misgivings until weeks later.

On the day of the mission, the pilot and co-pilot opted against        performing an operational power check of the helicopter, instead relying        on the calculations they gathered a day earlier. They also decided        against setting specific power numbers to determine whether the load was        excessive. The pilot later said he believed he “would just know what        excessive was” when he felt it.

The planning decisions were among several violations of Navy air        training and operating regulations, according to the investigation. The        missteps continued after the helicopter lifted off the ground.

A video of the operation posted to YouTube shows the massive Navy        chopper hovering a few dozen feet above the canyon floor as a ground        crew attaches a hook to the downed Omani aircraft. Moments later, the        Sea Dragon rose above the canyon, the smaller helicopter dangling below.

Based on the torque and power readings following the initial lift, the        co-pilot later told an investigator that it was obvious the Omani        helicopter was heavier than they thought. The power margin hovered        between 0.6 percent and 2 percent as the pilot steered the helicopter        away from the site.

Observers said it traveled about 50 yards before the tail of the Sea        Dragon began to drift, a clear sign of a power deficit. The crew member        responsible for watching through the left window told the pilots to        “pull power,” fearing they were hovering too close to a cliff. They        narrowly cleared it, but seconds later, the chopper began to spin        counterclockwise as the tail rotor lost power.

“Lost tail!” one of the crew members shouted.

The co-pilot shouted “pickle!” – the signal to dump the load. A second        later, two other crew members repeated the signal. But the crew hadn’t        discussed the plan for an emergency jettison, and before anyone could        act, the tail rotor hit the ridge, and the helicopter rolled into the        canyon.

Sullivan, who was standing below the main rotor, was crushed by the gear        box, according to the report, and likely killed on impact when the        helicopter landed upside down.

Another crew member blacked out momentarily after impact, he told an        investigator. He found himself resting on top of Fitzmorris, who was        unconscious. The crew member scrambled out, he said later, fearing they        both would die in the fire if he tried to pull him out.

Both pilots escaped through a cockpit window. The three survivors ran        from the scene as the fuselage erupted in flames, followed by a series        of explosions.

A day passed before the wreckage cooled enough to perform a proper        search and confirm the two fatalities.

The investigating officer recommended that neither pilot be allowed to        fly again. That’s a decision left to a field naval aviator evaluation        board, whose decisions are not made public.

“Proper administrative action was taken,” said Cmdr. Mike Kafka, a        spokesman for Naval Air Force Atlantic.

Flannery, then the deputy commander of Helicopter Sea Combat Wing        Atlantic, was tapped to temporarily lead the squadron after the crash.        It was soon apparent, he said, that the deadly accident was a symptom of        larger problems in the Navy’s Sea Dragon community.

Sea Dragons, assigned only to two Norfolk-based squadrons, are primarily        used to clear mines from shipping lanes, but they are also the Navy’s        preferred option for heavy-lift operations.

The service had planned to begin phasing them out in the mid-2000s, but        without a viable replacement, it kept the Sea Dragons flying.

The mixed signals on the future of the program, combined with a lack of        financial investment from the Navy, allowed the Sea Dragon community to        “fly under the radar” and develop some bad habits, Flannery said. Many        of the sloppy missteps revealed in the crash investigation had become        commonplace, he said.

“This didn’t happen overnight,” Flannery said. “This was an atrophy over        a long period of time.”

Since the crash, Flannery said, the Navy has invested millions of        dollars to upgrade and better maintain its remaining 29 Sea Dragon        airframes, including adding more than 100 maintenance personnel to the        two Norfolk-based squadrons. The Navy also enhanced Sea Dragon pilot        training to include mountain flying exercises and installed new        leadership at both squadrons.

“It was absolutely tragic that it came to a head the way it did, that we        had a mishap and two people lost their lives,” Flannery said. “I can’t        say anything good came out of that. But the changes that came out of        this mishap were profound and have put the community back on the right        path.”

Mike Hixenbaugh, 757-446-2949,

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