This one was really tough to brief to my squadron. I will say, the attitude regarding these chips is a lot more conservative now, but most of us were never so cavalier as the mishap pilot seemed to be regarding the emergency. That being said, anyone with significant time in the V-22 knows we have a million things that will say something’s wrong, but in reality it ends up just being a sensor gone bad. So you can really make the argument either way. One thing the AIB report doesn’t mention is the CHIP DETECTOR FAIL at the end was actually the detector itself becoming overloaded with chips since the material degradation was so bad. THAT is a failure mode/progression of degradation I don’t think any of us in the V-22 community knew before this. It’s a damn shame these great airmen had to lose their lives for it, but I can attest the calculus is changing for the better. For those active on Reddit, many of the mishap pilot’s posts are still available under the username UR_WRONG_ABOUT_V22. He was a true believer in his aircraft and loved it to the very end despite its naysayers.
Well I have to say chips is something that should never be taken lightly. Sure it can be a faulty sensor but if it isn't you are risking the lives of multiple people and millions of dollars worth of aircraft. There is no way to justify that level of risk taking on a training flight.
@@Stubbies2003i agree. How can you just brush it off to your opinion based on no evidence of a bad sensor?? Ignoring it 5 times is criminal in my mind. There are a lot of people on board and its a lot of money and resources to just say “ive seen that sensor go bad 3 times” i mean that is so unfortunate. I feel so had for the crew that this pilot and the command let this happen. This is not a war time sortie either i dont get it at all. Ive only ever heard bad things about the cv22
those pieces of junk are always sending false alarms and they get reprimanded always declaring emergency's. Every time they fly that junk it has something go wrong.
I also found it interesting how neither pilot had any rotary time. As a Navy helo pilot/instructor, I think we take chips and land as soon as practical/possible/immediately a little more seriously. Helos and tilts have a lot more moving parts than planes and a lot more things can go wrong. If a plane grinds up an engine they still have another one, or can glide, or can eject most of the time. If a helo/tilt transmission seizes due to grinding or chips you are dead. There is no second chance or recovery. We usually say with a land as soon as possible you're looking for a clearing that you can safely land in. Don't force a bad landing, but don't pass up somewhere you could land either. Take a parking lot, or a beach, or a grass field. Land immediately you're pretty much doing a controlled crash. If there's something below you great, aim for that. Otherwise, you're still putting it down anyways even if there are trees or water below you. You stand a much better chance of surviving a controlled landing into some trees than you do falling like a rock from 1000ft after your transmission seizes.
Dont know about the Navy but i believe the USMC treats it as a fixed wing track as the stick/cockpit setup aligns with FW a/c. Conversion of CH46 pilots to V22 caused several pilot error incidents due to the setup
I find it interesting that the mission commander wasn't automatically relegated to not being in command of the aircraft, flying and so on may workj, but due to the conflict of interest that can and did occur, my view is that the other pilot should absolutely have been the commander of the aircraft, since the mission commander can easily get into a bad CRM situation when the aircraft's needs collide with the mission's. On a technical level it's interesting that there was a sensor picking up vibrations from the gearbox minutes before the first chip, but that was just logged for maintenance crew and not combined with the chip warnings to assess the severity of the problem. It's on the whole a bit odd that such a critical system doesn't seem to have more than a crude chip detection without taking into account the interval of the detections, and at what grade the problem is accelerating. With the gearbox and the otherwise problematic clutch being such critical syatems that lives are quite literally hanging from, it's amazing that there are so little computing power and automation built in to try to handle the extremely fast effects when that stuff breaks.
Late 80s, at the former MCAS Kaneohe Bay. The CO’s last flight before retirement, flying “Pedro” (CH-46 rescue helo). Chip warning comes on!!!….he put that helo down quick, like yesterday. He’s enjoying his retirement today
It's something I would assume would be instantly terrifying in flight. If I'm in my car with 4 wheels on the ground and my oil light comes on, I'm still pulling over and investigating before driving too much more. It's awful this happened, but hopefully it can at least be an accident that promotes safety to others following the accident.
Not even in combat, I daresay, would I ignore repeated chip warnings coming at tighter intervals until the burn fails and the sensor gives up due to overload. As seen in this case, a rotorcraft's gearbox is akin to a climber's rope, or the structural integrity of the wings in a plane without ejection seats, it's not something that can be played around with because it is the absolute final straw. That's what I find sad in this event, they didn't seem to quite realize the potential severity of the problem.
Thank you, Mover, for giving us your insight on this horrible accident, I appreciate how you explain what is said in this AIB Report giving me a better understanding of what were the causes of what happened, my prayers go out to all the families who have lost loved ones. Again, Mover thank you.
Between Hoover & Moover, nobody else does a better debrief with these mishaps. Great job Lemoine. We appreciate the time you take to make these vids. 🙏🏼
That gearbox has been the bane of V-22 program since inception way back in the late 1980s and into the 1990s. Its development was very long due to the complexity of the systems. The chip detectors were developed to mitigate this very issue, but as I remember, the time between the initial metal particulate detection and mitigation (landing) was not long enough so the chip burnoff equipment was developed & incorporated into the aircraft gearbox to increase that time. Also, and here I am speculating, I believe that when the nacelles were being rotated that the change in the mishap nacelle's AoA caused that debris to be dislodged or to move from the flow pattern state that it was in, to one that caused it to move to a location within the gearbox that would cause an immediate catastrophic failure. I certainly see why the Board mentioned that the lack of communication on the importance of the warnings/cautions related to the gearbox was a factor.
@@johncashwell1024 But it’s not unique to the V-22. The Chinook has essentially the same chip detection and burn off system. And a much worse history of crashing.
@@soapbar88 V-22 landing in airplane mode is going to destroy all of its blades, so would only be attempted in an emergency where the nacelles can not be rotated.
I was thinking similar to your line of thinking that the tilting of the rotors may have been the straw that broke the camels back. My thoughts were on the stress that the procession of the rotors would cause while tilting though, but I’m just speculating.
Hey mover I have a clarification for you @32:25. You indicated that the crew rotated their nacelles to prepare for a vertical landing. It should be noted, especially for those who are unfamiliar with how the V-22 operates, that regardless of whether they were going to perform a VTOL or a rolling landing the V-22 has to rotate their nacelles in order to land. If you look at images of the V-22 flying, you will notice that the props extend below the aircraft when flying like a fixed wing aircraft. So it is unable to land like an aircraft because the prop size prevent it. I believe that they would have experienced asymmetrical thrust that led to the aircraft rolling over regardless of whether they were trying to land like a helicopter or fixed wing plane because of the fundamental design of this type of aircraft.
So if the gearbox failure had occurred while the aircraft was in full fixed wing mode I assume they would have to bail out? There would be no way to land? I wonder if the gearbox is under more stress when transitioning the nacelles to vertical mode? If so, I wonder if transitioning to absolute minimum vertical mode and going for a short field airplane landing might have saved them? The V-22 has always struck me as an engineer’s nightmare.
@@robertbutsch1802 It’s hard to say if the gear cracked while in flight or prior to the flight. The crew and maintenance had no way of knowing until the chip sectors started popping off. All we do know for certain is that the gearbox essentially disintegrated/ destroyed itself while in flight AND at a low altitude. It also important to note that bailing out in modern aircraft IS NOT the same as crew bailing out of WW2 bomber. The crew DOES NOT actively wear any bailout equipment. In order to bail the plane would have to land or crash. The v-22 is an engineering nightmare and a shocking amount of people died while testing it. That’s not to say other systems have had bad testing/growing pains (lookup early Blackhawk crashes) but these aircraft are difficult to fly, difficult to maintain, and very complicated
@@narfbite5239 There’s bound to be an emergency procedure for gearbox failure in airplane mode flight. You can’t do an normal everyday airplane engine out landing. You can’t autorotate. Seems like bailing out is about the only option.
I flew in the Army for 24 years and then taught as a civilian for another 10 years. I would say that the Rotary Wing community in general treats chip lights as something that is very important and something that especially when they reoccur like they did in that accident needs to be addressed promptly. Obviously, I don't know how the V-22 schoolhouse trains or addresses these issues. Like C.W. I was somewhat surprised to hear that the pilots arrived to the V-22 through the fixed-wing/transport pipeline and not the rotary wing path. I was also surprised to hear that a Land As Soon As Possible condition wasn't honored properly...that was pretty shocking and sad to me. As much heat as this aircraft receives, the crew and aircraft would still be here today if they had done what the checklist told them to. It's tragic and sad.
Third chip light = land at Kanoya air base just 10 miles away. It should have been a knee-jerk response based on training. After Kanoya, you are leaving southern Kyushu and heading out over the ocean with much fewer options.
I was a CH-53E crew chief in the Marines.We had chip burn capabilities...first one comes and goes...if I got a second one...nope..get me on the ground.
They were opportunities before that Final Destination to land. How many warnings can you ignore? The plane did its part. Lasted long enough to get that far.
in 1995 I was finishing up my ISS assignment as the senior AF RAND Fellow and was picked to be the Det/CC of the AF V-22 Det at Pax River which was in the middle of the test development test program along with the Navy. I ended up getting redirected to lead the X-40 program but during the time would have been there when the first V-22 accident which could have easily been me onboard. I never did get to fly it but was told by those who did it could be quite the handful and very unforgiving, kinda like getting slow in a T-38 turning final ...
One would think that the moment you start getting multiple chip warnings you would recognize that your gearboxes are eating themselves, the burning of the chips isn't the issue, its what the chips are coming from thats the issue.
thing is they were fighting multiple false faults from the mission computer having issues. it wouldn't surprise me if the pilot just ignored it as another false fault initially and just continued on until it was too late. considering how many issues they were having they should have aborted the training mission long before the gearbox failure.
I was based at Edwards AFB and was offered a chance to be on the flight test team of the V-22. During my interview the Major said, "From the second that thing rolls off the assembly line in Amarillo, it is trying to kill you. Respect that and you will do just fine." I declined the position and PCS'ed.
These kinds of accidents are tough, but some of the best learning reports to read about. That whole crew was actively discussing and strategizing about what eventually became the cause of their deaths. How many times have you flown and had a 'Hm, that was a weird vibration, did you feel that?" or "Should we divert for this?". I try with every one of those situations to think about the worst possible scenario, and think "Man, how much would it suck for me to end up dead for a problem that I knew existed, but didn't take the appropriate action for!". The way I teach it to students is to 'read your own accident report'. As in, if you crashed and died on your flight, how would the accident report look when other pilots read it? Would it be a report that contained obvious clues and factors that you ignored or brushed off? If so, the average pilot would look at that report and say, "well that guy fucked up!". Don't be that guy! Make it so your 'accident report' would be about the "1 in a million failure that took him down, even though he made all the right decisions", and there's a 999,999-1 possibility you'll come home at the end of the day.
The families of the lost aviators deserve the sincerest of condolences from all of us, first, foremost, and most importantly.....RIP. I'd also like to say that the AIB reviews you do and the style you use in doing them, is the most intriguing part of your channel. It's not my favorite part certainly, but very informative given your background, so thank you for doing them.
As a non-pilot computer systems guy, one thing that stood out to me was their discussion of previous experiences with the initial alerts as being nuisance alerts. This really hit for me because I've seen prior false positives lead to people dismissing alerts in the past and it's sometimes made situations worse.
They are not false positives if there are chips in the detector. What good does an alert system do if it only alerts after the gearbox has already come apart?
@@blegi1245 you're focusing on the wrong part. There was conversation during the event about one of the crew having seen a similar alert once and that it was just a nuisance. Whether true or not, the perception is what matters - and a perception that it's a false positive does lead to people ignoring alerts
As a computer guy myself, that sort of response caused the network engineer to allow a ransomware attack to inundate our entire company... We're a hospital.
As an Ex UK military engineer, we had chip detectors in the RR Merlin engines but they could only be viewed during major engine inspections which included draining the oil system. Any metalic chips lead to an engine change. I question the use of chip burning off up to 3 or 4 times. Back to the swiss cheese,i would always favour on the Y22 immediate grounding on the first chip detection allowing for a detailed examination of the Propellor/ Engine oil system. The history on the Y22 suggests an aircraft operating at the extremes of flight with a surprising number of aircraft losses.
Up North we have 4, Continue Flight (stuff like degraded GPS), Land as soon as Practible (stuff like MFD failures), Land as soon as possible (stuff such as engine chips or hydraulic failures), and Land immediately (stuff like total loss of flight hydraulics or uncontrollable fire). For Land immediatelies, it's basically to get you on the ground right away, so that means putting it into trees or the water, whatever you can do to make sure the aircraft doesn't break apart with height.
The AH-64 has a LAND IMMEDIATELY in the checklist for primary hydraulic failure, but most aircraft in the Army (especially older ones) were only as soon as practicable and as soon as possible.
@@bgroovin1343 well, in fairness, if you've lost hydraulics you've got about 3 strokes of the collective out of the emergency back-up....so immediately is probably warranted there.
The MDSO was a good buddy of mine… I know you know this well Mover, but these AIBs are a lot harder to read when you know someone involved. Thank you for being respectful to the crew and the situation they were in. It’s easy to judge with hindsight, when you’re not actually in the aircraft dealing with it in real time. Policies have been modified and this crew’s sacrifice will make flying safer from now on. Love you Jakey, and I miss you.
I can understand the initial computer reset caused so many incorrect warnings that can be ignored, so when they got a real one, they were thinking it's another nuisance but the book says not to ignore it, so they didn't ignore it but they didn't believe it either. I can understand bypass the landing pad because the maintenance crew might need a C-130 or something to land parts or ???. I can't understand self cancelling the immediate landing and doing it with the most power intensive method. You're going to maximize stress on the very gearbox that's about to die. Just throttle back and coast on in, telling everyone on the runway to get out of the way. You can apologize later if you find out it was all a bad computer chip.
Most modern aircraft computer systems are built quad redundant. This is great, until the crew gets used to the plane pushing through fails, and assume it will again.
Mover Thank You for this sad report . May they all RIP. Sending my deep heart felt Sympathy and Love to all family members friends coworkers and all the people who new them .
YT enqueued your video after I watched Ward Carroll's debrief on the same topic... and I am so ok with you saying that after all this is a really tough one... I am no real pilot, only the pilot of my own life... yet as a Navy guy to me it is a thin line between mission accomplishment and that safety thing that you should maybe listen to, but ignoring it might make the difference that you've been striving for and that one is a deeply rooted one... even under training circumstances or maybe even more... no one wants to fail others... so just as the theory goes, I am confident, the crew did definitely not want to fail anyone with what turned out to be hell of an edge case... - still I like your way to adress the case... and for you it is even closer and so much more intimate to rehearse what happened, to discern what went wrong and to make the loop back to what we might all have or not have done... lots of respect for that
Does anyone know how often those warning lights illuminate in normal V-22 ops? If it's a known false alarm, I'll cut them some more slack for not taking it seriously. Still, as an FE I can't imagine leaving the flight deck to look at a radio when there are potential issues with the gearboxes; aviate navigate communicate last.
I’m sorry, but if it was me, I’m landing As Soon As Possible if any of those warning lights come on. A runway was not necessary to land, so why ignore warning lights until you find a suitable strip? Thanks Pete!
According to the voice recording, only the MC had ever seen the chip burn caution, and I don’t think any of them had seen the full Chip warning. I would assume it’s not a common failure.
I appreciate how you stick to the facts in your reviews! For context, because of the size of the rotors, the V-22 can’t takeoff or land in airplane mode. Nacelles have to be at 60° or greater for takeoff and 75° or greater for landing. 32:43
Given the flight characteristics of the CV-22 and the high percentage of fatalities with a gearbox failure, I would take absolutely every chip detection as a very serious concern, and certainly when it comes to an immediate landing situation being progressed to. All the process was in place, they had a chance. The fact that it functioned as long as it did is one good thing. Looking at it, you have to consider if the additional strain on the gearbox for a more vertical landing (very short field roll or helipad) sooner would have been preferable to the longer field, low-angle landing, but much later. Certainly the lack of urgency from the pilot at the third detection is a contributing factor and likely doomed them. Perhaps a reevaluation of the possible/immediate conditions and times to likely failure of components should be done.
That's one of the main things I find hard to believe. Even with all the crashes and problems they've had with the Osprey, these guys kept dismissing warnings until it was too late and didn't seem to think much of it.
Obviously, as a non-military and non-pilot, it's easy for me to say "I'd think that would be a cause for worry" but it did strike me as odd. I would think in a helicopter it would be scary enough, but the V-22 seems like something that pretty much can't stand to lose that engine, especially not at slow speed. With those massive engines on the wings, it's gotta be difficult to control in the worst of events.
@@Michael-ol2jn Definitely hard to believe as a person just on the sidelines, which was making me wonder the same thing about how frequently the detections go off. I haven't read through the entire report to see if the report mentions the frequency of these alerts, but it's something we have to deal with in cybersecurity. Trying to find that fine line between over-alerting ourselves and also annoying the users with emails and warnings.
Thanks for your excellent discussion of this tragic crash... When you mentioned the multiple roll, my gut clenched! It seems that the air force approach to training on the CV-22 is part of the "failure mode" here, as I understand, and many have commented, any failure in the drive mechanism in this aircraft leads to catastrophic asymmetry in lift, and any of the indicators of any drive failure can not be *assumed* to be "nuisance failures".... Damned awful that the failures in risk management just stacked up in this case. Our sympathies to the families, friends, and colleagues of the lost crew....
That aircraft was trying to tell them right from the beginning that there were problems. Minor or not, ignoring even small problems can lead to catastrophic problems. I understand there’s risk in everything, but being afraid to ABORT is getting people hurt and worse…..
Having taught accident avoidance and risk mitigation to helicopter pilots, almost every accident has a string of events (the accident chain) that lead up to the accident. If the crew had broken that chain, the accident would never have occurred. This accident had several opportunities for the crew to avoid it and for whatever reason they failed to. We can only hope that others learn from it and the same things aren't repeated in the future. That's the only good that can come out of this.
Hey Mover, you ever looked into or considered doing an AIB review on Shell 77? KC-135 that went down in Kyrgyzstan in 2013... unfortunately all 3 crewmembers were lost. Being a former AF sheet metal guy at that bird's home base it literally hit close to home! Know you don't typically do heavies but just a thought! Love all the content you, Gonky and WOMBAT put out for us.
Perhaps part of the mindset of being the mission commander is acknowledging target fixation on the mission and therefore also making a decision to let the rest of your crew make other decisions, like about when to abort due to a mechanical issue. To finish first you must first finish.
So I cannot be as nice to the pilots on this one. I maintained this aircraft for the last six years of my USAF career and I know the gamble that they took. In gambling terms this was an all in bet. There is no recovery if either PRGB fails as it will create either an unrecoverable roll or yaw input (depending on aircraft or helicopter mode) that the pilot cannot make up for. As soon as a PRGB lets go like this the other prop is the only one making lift and those prop diameters are HUGE. Just no way to recover from that level of imbalance. The pilot doing some things like passing over mission command I don't consider to be that big of mission go-itis. However assuming that a potentially fatal problem like this is a nuisance and not real and concentrating more on being the mission commands IS mission go-itis. That plus failing to know the airfields for emergency landings as well as not thinking of alternate ways of getting it done as pointed out doomed this flight and everyone in it. I was avionics and so if I knew about this as potentially fatal not even directly working on those components the pilots sure as hell knew it. The engineer seemed to be the only one showing any real concern for this problem. Not hearing a peep from the co-pilot so this is where CRM failed as the pilot had mission go-itis and everyone but the engineer just let him roll with it. The fact that it is such a rare thing to see and they had it multiple times should have been the clue they needed to get that bird on the ground. Even if it had been a failed sensor the severity of it if it is real means you get that bird on the ground and let others pick up the slack. That is precisely why you factor in backups.
The last part was my thought exactly. I get the desire to complete the mission, but why have a #3 aircraft along with you in the flight if you're not going to use it when the situation warrants. I feel like there's probably a cultural component here as nobody wants to be the guy that scrubbed a mission and grounded his crew on an island because of a sensor fault. The problem is, at least that guy is breathing.
Man as an engineer this hurts. It's like severe weather warnings. If they've been safely ignored in the past due to (mostly reasonable) inaccuracy, it can cost lives. RIP to the crew, thank you for your service.
I'm as guilty of leaning forward and hacking the mish as most of us, but there's a time and a place for that. Training missions aren't it. Agreed that CRM was lacking; as an FE I've seen it work and it kept me out of dangerous situations, even in combat zones.
As a load on the C-17, this happens to us too sometimes, whether it’s getting the mission done or get-home-itis. I like to think our safety culture is good but there’s nothing more true than when Mover says “but for the grace of God go I”.
Mover, when you were reading about the pilots' qualifications and experience, you skipped past the FE. All I could make out was he had 4 years flying, which should be enough for one of us to know the systems, learn the ins and outs, and be comfortable speaking up when things don't feel right. Could you post what the report said about the FE? Thanks.
I have the 935 page report with tabs downloaded from the official Marine FOIA website, I could probably look at the report and tell you. But first, what is FE?
Interesting that the gearbox should have been considered a catastrophic single point failure scenario, with the associated urgency that could lead to aircraft loss. A failure that becomes catastrophic in six seconds leaves very little time for, and this failure case absolutely no margin for error. Ultimately, the CV-22 requires both gearboxes to maintain positive aircraft control. Unlike an engine failure of a twin engine aircraft, both gearboxes must remain operational throughout the flight. Crew procedures should be required to reflect the criticality of such a failure scenario. I would agree with you that some amount of helicopter experience should be a prerequisite for tilt rotor flight operations.
Even in a twin engine aircraft, single engine failure is extremely dangerous unless handled perfectly. the sudden asymmetric thrust can put you into a spin, especially if it's a prop engine and the dead one isn't feathered. Once an aircraft like that is in a spin, it's very difficult to get back due to so much weight being outside the CG.
Thanks for the great breakdown of the report. The crew was probably not familiar with the V-22's growing pains. Never had a lot of trust in that platform. After the second burn indication I would have went straight to Job 38:11 " You may come this far, but no further".
As a generator mechanic instructor back in 1972 73 the Army was transitioning from scheduled oil changes to sending oil samples from each generator to a lab to be tested. Once a sample shows any significant signs of metal we would be notified to change the oil. If on the next sample after the oil change shows metal, then it was teardown time on the engine. The V-22 series looks like a failure ready to happen on every takeoff.
A few years ago the Air Force changed their training. Rotary wing used to go first to IPT on the T-6 at Columbus, etc. That is how it was when these pilots went through. Now, the pilot candidate decides before IPT, and they get sent directly to rotary wing. This change was made around 2020 or 2021. Kanoya is a JASDF air base, and it was only 10 miles behind them when the third light came on. They should have gone directly to Kanoya. Unlike Kagoshima Airport (the next closest), they would have no commercial traffic to worry about. Also, being a military base, maintenance would probably be easier than a busy commercial airport.
I live in Japan and saw the local news coverage of this accident. My recollection is that the news never really said that the Osprey was trying to make an emergency landing, but rather that it just suddenly disappeared off the radar. Does the US military withhold even such information that a military aircraft had called for an emergency landing when such an accident occurs, until after an official report comes out? The local Japanese news was making a big fuss about how it just got lost but, as it turns out, the S&R teams found the wreckage pretty quickly. Just really tragic.
I was a CH-46 crew member. Twice we go an aft transmission chip light. Fisrt time we immediately landed at a construction site. The second time we were around the Philippine. Islands. We headed straight to a helipad that was closer than the boat. No hesitation by pilots. Each time it was just fuz on the sensor. Cleaned then took off again I currently fly a T-28 alpha if I get a chip light I do not care I head to ground. I would rather land and find no issue then keep going and kill myself and or others.
The engineer was the real safeguard position and while you critiqued the copllot for not speaking up, it was the engineer who should have fully understood the seriousness of the situation and gotten in the face of the pilot to tell him to forget the mission and fly the plane. He also should not have stepped out of his position to deal with other malfunctioning equipment. There were lots of failures here, and nearly all of them were human factors. The plane designers thought of this failure mode and gave the Service a redundant system to monitor for the failure mode and avoid this exact scenario. This was a 100% avoidable accident that shouldn't have happened and the entire Service should retool to train in risk management priority over all other tasks. There's no shortage of examples, but the best analyzed was the space shuttle o-rings failure. America has still not learned this lesson, decades after it discovered what it was doing wrong.
Thank you to each crew member for their service and sacrifice to this great country. May we learn from this so it never happens again and may they rest peacefully.
With regard to this mishap, I agree with the Army pilot. Anything that would be an indication of an imminent gearbox failure needs more attention. The aircraft actually gave the crew lots of time and several warnings that were not given proper consideration by the crew before finally failing. On a different note, I would love to know your take on the 2008 F-18 incident when it flew into a residential neighborhood by Miramar.
I'd like to see a breakdown of one of the many MQ-9 AIBs from the last year. The one where the top 3 starts passing bad instructions was pretty rough. The really bad one was the overzealous test director that killed someone.
I'm not a pilot but I know enough about engines/transmissions in cars that chips in the oil mean something is going to go bye bye catastrophically if you don't sort it.
I'm an Army-trained helicopter guy flying Hueys and Blackhawks, who later transitioned to fixed wing. All helicopter guys know that certain failures will kill you. If you get an indication that one of those types of systems is not well, you don't muck about. You get the aircraft on the ground if at all possible. These guys treatedd that issue as if it wouldn't be a big deal if that gearbox failed. To me, it's a bit like a wing falling off. Why gamble on that? Chip lights were a constant annoyance because 90% of the time, they were false warnings. I've had them. The attitude in the cockpit was, "dang, another chip light. It's probably fuzz. But, let's get her on the ground. " You don't futz around talking about continuing a TRAINING mission when you are facing real-life death. That gearbox failure would lead to certain death if you were in helicopter mode. Why they chose that landing type, I don't understand. If you know you might have a failure like that, then you don't try to hover. A rolling-landing would be much more prudent -- I would think. I'm not a V-22 guy, obviously. But it seems like if that gearbox failed, you're basically single-engine and it's generally not too much of an event. If you lose thrust on one side and cannot transfer thrust from the other side in hover mode, that's unrecoverable. I think this accident shows that. I think all V-22 guys should have helicopter training. Rotary wing track used to go to Rucker . They were there when I was there. They got extra pay because the Army BOQ sucked, but they got solid helicopter training.
Thank you so much for such a LEVEL HEADED analysis of this tragedy. I watched a video a couple days from another UA-camr who I won't mention who has quite a following and the difference is stark. I appreciate you taking the time and effort to put us into the possible mindsets of the pilot and crew, instead of just passing judgement on the pilot with perfect hindsight. Well done, and one of the many reasons you continue to be my preferred channel on military aviation.
Rest in peace crew of 10-0054. The trouble with accident analysis is you come up with some pilot action that was bad, and tell everybody "This was bad. Don't do this" without understanding *why* they did what they did, which is the real issue.
As a prior Flight Engineer in the Air Force they have tried to blame the crew in multiple incidents. The one at Hurby on the Eglin range was not the crews fault but a bad chart said they were good to go.
So, very sad. In first responder roles all the way back in the 1940s when the first incident command system was in place in the forestry fire service, later on in building incident and unified command systems the safety officer became a important part of these systems. The rule of the safety officer is that while the IC is looking at the overall mission, getting the job done the safety officer looks at only the physical safety of the personnel and equipment making sure the FR's are using the right gear for the right job at the right time and that safety protocols ate being followed. Physical stress and FRs rehabbing and proper backups if something goes wrong really fast. PAR time of 20 minutes etc and making sure your RIT team is standing by and not being utilized for something else. Now, I know listening to you Mover Crew resource management is the glue that keeps the puzzle from disintegrating. The crew chief is a very important puzzle peice, that I do beleive since he/she is the plane/rotor wizard that the pilots need input the most from for conditions of the aircraft. While crew management, I would say, should utilize the crew chief in its decision-making at the highest level. Maybe they need to have that SAFETY factor as does first responders do in IC or unified command operations. It sounds as if the crew chief was pressing the fact of the seriousness of the chip master caution alerts. As like in FR scenes, the safety officer has the authority to stop all operations if he she deems that the operation is in danger of failure due to possible injury loss of life to personnel. That safety officer then can order the IC to make safety changes before operations continue. While the pilot and co-pilot were using crew resource management effectively, the crew chief was like the odd third wheel, and his/her inputs were not rising to the level of importance as it should have. Maybe in complex aircraft where there are crew chiefs is also designate them as the overall safety officer of the flight. Tunnel vision of the pilot pushing to get the mission accomplished in training didn't once weigh the fact outside his own mind that this was a training mission and that the load he was carrying i.e intelligence and more important medical personnel for the complete air operations if they are taken out, then there's no further support to the mission so it fails to complete. As you said in war, there's a different thought process, which I understand. But in training, you need to have that third man/woman who's thinking not of mission completion, but safety would had given this flight the best chance of surviving. Also, with safety officers, they are trained to be just that, for the overall safety of all life safety involved in operations. There are plenty of warnings that occurred that day for a safety officer to stop the exercise and make it safe, then continue the training operation. A safety officer is also protected from higher officers such as the IC by using life safety over operations template. Giving the crew chief that additional role as safety officer and that mandate of life-safety over mission protections , overruling the pilot in command by taking the mission out of the life-safety aspect in operations would had saved everyone and the aircraft involved in that specific order. The decision to continue with the training mission overuled the commonsense overall mission of life safety that day.
I did not realize that Air Force Osprey pilots didn’t receive both rotary and fixed wing training. Navy/Marine pilots in the Osprey pipeline would go from Primary in the T-6, to Intermediate rotary in the TH-57, to Advanced multi-engine fixed wing in the T-44, then to the RAG, then to the fleet. The Navy/Marine Osprey pipeline essentially blends the Hawkeye pipeline and Helo pipeline into one. Everything I’ve heard about the Osprey is that it requires fixed wing skills and a rotary mindset. I can see how someone with only fixed wing experience would show less concern with the C&W they were receiving than a helo bubba might because in fixed wing if one engine is wonky, you know you still have single engine options. With helos, and with the Osprey, if one engine goes the entire thing goes. I wonder, faced with the same failure mode, if Navy/Marine pilots might approach it with a different mindset having had helo training.
The CV-22 is really neat in concept...It's both a helicopter AND an airplane. But that transformer capability comes at a high cost in that it's an especially dangerous aircraft in an emergency like the one this crew experienced. Condolences to the families...
Thanks for the walkthrough. Kudos to the aircrew to have the mission as top priority but unfortunately its not supported by this aircrafts' reliability. Maybe the hot-spare ship should have been used and the MA stay on the ground after that the 3rd restart. The maintenance team could then perform fault-finding (eg a common power supply failure might also have been impacting the gearbox). Maybe aircrew response to failures can be altered if "training" vs "in anger" (eg that leg mounted ipad to assist the aircrew ?). Sad to see the V22 still in this state after such a long development program.
Something went really wrong with training and/or mission planning. When the third chip burn happened, Kanoya Air Base was just 10 miles behind them. This would have been the perfect place to land, since it is not a busy commercial airport, and as a military air base the maintenance could have been accomplished easily. In fact, the US Air Force occasionally uses Kanoya. Training should have strongly emphasized considering 360 degrees for available airport.
I think it's very interesting the heavy to Tilt rotor path, I feel like a rotary wing Pilot would be far less cavalier about gear box issues. Seems rotary wing would be a more appropriate lead in to a tilt rotor for a lot of reasons.
Any thoughts on if the rotation of the engine nacelle caused the final gear/drive shaft failure? So would the aircraft had crashed after the first chip alert anytime the nacelle was rotated?
These are tough to watch. The swiss cheese model is a real thing. I appreciate Mover for not sensationalizing these reports for clicks. Just the facts presented in a way that a civilian non-pilot like myself can somewhat grasp.
Hi, Mover. Was the reason the MA didn't simply land in a field or the helipad was that a VTOL landing would be considered high risk with a suspect engine? That's what it sounds like you're saying around 29:00 and later
Actually, they were coming in for a landing at the time. The question is, why did they ignore the several alerts? there were repeated warnings given by the aircraft.
The V22 can’t exactly land like a normal plane, as the blade length is longer than the height of the nacelles off the ground. Depending on conditions they can do rolling takeoffs of landings with the nacelles at at partially horizontal angle, but usually they just land vertically.
The engine wasn't suspect the PRGB was. The engine can be working 100% and it doesn't help at all if the PRGB lets go as the PRGB is what transfers power from the engine to the props.
a video was recently released of a Russian Su-34 escaping from a Patriot attack, a real recording from the cockpit, it would be interesting to see the reaction, the video is on the Command T channel with an English translation
For those of us who flew the Osprey, we recognize this loss was a tragedy that should have been avoided. Nothing more needs to be said publicly. For those flying Osprey's today, this report will be used as a lessons learned, as all AIB's are. For those commenting in this thread, you are entitled to an opinion, as is protected by those who have, do, and will serve. That freedom to express isn't just reserved for those with experience in the aircraft, it belongs to all and unfortunately an overwhelming majority of opinions on the Osprey are made those who have no actual experience in the aircraft. This is why I never comment on topics involving the Osprey, because it is futile to those closed minds. I would like however to share one "retired" insiders perspective and perhaps inspire some to research prior to commenting. I came out of the 130 world and started flying Osprey's in 2006 for AFSOC. The aircraft, from inception, was arguably one of the most politicized MDS to ever take to the skies. Everything in the V-22 was scrutinized to a level, honestly, I have never seen. The overwhelming majority of negativity was based on outside opinions, were narrative driven, and/or people that literally just wanted to "hate". I flew combat missions, in multiple theaters, austere conditions until my retirement in 2013. I went on to spend another three years with the same unit, same mission. I say all this for no other reason than to provide context from a "known" perspective. The V-22 is a modern marvel. The concept of tiltrotor goes back to the 1950's. Operation Eagle Claw was the genesis of what would become the Osprey. With the advent of the microprocessor leading to fly by wire capabilities, the Osprey was born. There is something that is very important to realize when talking about the aircraft. It was the first of its kind, not just as an MDS, but more important, the ability to operate in an aerodynamic envelope never before achieved. When it was a "airplane", it flew just like an airplane and the same as a helo. However; between 1 & 89 degrees nacelle, it was a tiltrotor and those operational capabilities literally had to be written in real time. Heck, the first few years, we didn't have FAA rules so we used whatever was most advantageous for us for "flight mins". People often try to compare the Osprey negatively to other MDS's. The reality is you can't. The aircraft can fly hundreds of miles (thousands with AR), operate off ships, perform multiple SOCOM mission req's, land on up to 9 degree slopes all flying
I have to say that coming from a COMPLETELY outside perspective I'm surprised about the "cavalierness" about the chips. Yeah, sometimes something inside might chip but by the time you hit 3 I'd be thinking... "This engine is EATING ITSELF apart!" And when that happens balances, tolerances, and metal casing integrity will only get worse. At 3 chips I'd be calling it and landing that thing at an airport ASAP. At 4 or 5 I'd be in "land or else" mode. Once I saw the issue with sensor I'd be thinking either its a sensor issue or the sensor is overloaded. IE... get ready to ditch. But I wasn't there. Lot in your lap in those situations. Total bummer.
From the engineering side of things, I would argue that having "nuisance alarms" is a design defect unto itself. If needed, duplicate sensors need to be installed so that a disagreement can be internally diagnosed and queued for service on the ground without pilot distraction. This also allows for actual notifications to be far more likely.
The fact that they treated a sensor telling them that they have measurable metal chips in their gear oil as a nuisance is the root problem here. Even if it is a faulty sensor, you are talking about a critical system that will kill you if it fails 100% of the time.
Maybe it's just me, but if you get a "Land As Soon As Possible" that should automatically trigger an Emergency Declaration if it's not in the checklist already.
This mishap could have turned an exercise into a realistic combat training moment. A bird "goes down" for an emergency. How does the rest of the mission handle that? Makes me think of Op Eagle Claw and its failure that ironically restarted the VTOL program.
I recently retired from the USAF, spending most of my career at SOCOM deploying, leading & developing 19Z combat rescue officers & 1T2X1 pararescue specialists. I also begrudgingly wrote the CV-22 into several training & mission profiles including a mass cas. syllabi, personnel recovery training with the Joint Personnel Recovery Agency, and numerous JSOC C&C PJ infil profiles. Everything SERE scared out of me, the CV-22 put back in. 62 dead men across the services. I hate that bird with the fist of an angry god.
Two thoughts. 1. Obviously they didn’t take the land asap as seriously as they should have bypassing multiple options and making turns in the hold. Even if you think it might be a nuisance your a land asap and you need to treat it that way. If they had they would all still be alive. 2. I’m not a MV-22 guy but I’m not buying the program level issue. It takes very little imagination to figure out what is going to happen if the gearbox on one side comes apart in helo mode. It’s going to be instantly fatal and unrecoverable. Thats just obvious and I find it hard to believe the community wasn’t aware of that. That perhaps indicates another lesson that needs to be learned. Knowing what your aircraft can do that will kill you. What sorts of failures can be fatal and what can you do to counter them. Chips in helicopter gearboxes are not a new phenomenon. So training/thinking about that problem and its potential outcomes should have been front and center.
There's no need for the PIC to also be the mission commander. They had 8 guys on board, the mission commander could easily have taken a back seat and had a pilot and copilot to fly the aircraft.
Any flight / control critical conponent such as this gearbox , that can fail this quickly makes this aircraft unfit for flight. It should never be permitted to start its engines or leave the ground as either of these could turn it into a death machine !
If you do some research it will really humble how stupid we are from a training standpoint. We lose 80ish personnel a year to training accidents. In fact we’ve lost more personnel from 2006-2018 from training deaths than KIA. Yes, train as you fight but keep the big picture in mind as well.
The gear box failure was already in progress but I do think that that transition accelerated the process. The problem is, the only way to land that thing without rotating the nacelles is to destroy the props. With the PIC making an assumption that his warnings were a sensor fault, there is no way he would have considered that.
I think when your gearbox is starting to Injustice self , that's when you know time to get this thing down on the deck be it in the water or on the ground
You need to be honest about what the dead did in this case there's no way to discuss it without disparaging them because they screwed up big time and alot of people killed.
I find this perplexing. I strive to know as much as I can about the equipment I am operating - I'd imagine this would be even more pronounced with personnel operating aircraft, because of the potential risks involved. With how easy is to access information nowadays, I would think that every person riding in a V-22 would know about the multiple fatal accidents caused by gearbox failure - of all the warnings you can get, this would seem to be the one you really should not be dismissive about given the past record.
If ICAO (worldwide) uses Mayday Mayday Mayday to confirm an emergency, why doesn't the US Military (in this case- looking to land at civilian airports) use Mayday, and instead only say Emergency? Seems counterproductive in a life threatening situation.
Does the Osprey glide? Or fly single engine in airplane mode? It looks to me, not having read the report or knowing anything about Ospreys, like the final hole in the cheese was knowing that there was a _potential_ issue around one of the gearboxes, & voluntarily putting the aircraft into a mode where if the gearbox actually fails, everybody dies, out of a mode where it's just a change of underwear if a gearbox fails...
3 місяці тому
Not all that well in aircraft mode. In transition or hover mode, it absolutely cannot. Both GBs are required for operation. The theoretical redundancy of 1 engine operation is made moot by the fragility and complexity of turboprop GB which makes both GBs single points of failure. The CV-22 also lacks ejection seats and an explosive bolt blade off system.
That suggests that if they had elected to stay in 'airplane mode' & take the runway normally, they might have ended up on the runway, or landed short in the sea at best glide, but that the latter would have been potentially survivable
Every time we review a Fire Service LODD report, I look to the causal factors to see if we have found a new way to kill Firefighters; we haven't. Clearly the Mission Commander's Span of Control was exceeded by the mission requirements and his develping emergency. The CRM failure of strong leaders and peer pressure drawing crews into a position that they can't extricate themselves from has to be trained up to the "Unlawful Order" level. ANYONE should have a pass to call out a decision that puts the crew in jeopardy. Even an "explaine why we're doing this" can bring the issues back into a reasonable risk/reward analysis.
This one was really tough to brief to my squadron. I will say, the attitude regarding these chips is a lot more conservative now, but most of us were never so cavalier as the mishap pilot seemed to be regarding the emergency. That being said, anyone with significant time in the V-22 knows we have a million things that will say something’s wrong, but in reality it ends up just being a sensor gone bad. So you can really make the argument either way.
One thing the AIB report doesn’t mention is the CHIP DETECTOR FAIL at the end was actually the detector itself becoming overloaded with chips since the material degradation was so bad. THAT is a failure mode/progression of degradation I don’t think any of us in the V-22 community knew before this. It’s a damn shame these great airmen had to lose their lives for it, but I can attest the calculus is changing for the better.
For those active on Reddit, many of the mishap pilot’s posts are still available under the username UR_WRONG_ABOUT_V22. He was a true believer in his aircraft and loved it to the very end despite its naysayers.
Well I have to say chips is something that should never be taken lightly. Sure it can be a faulty sensor but if it isn't you are risking the lives of multiple people and millions of dollars worth of aircraft. There is no way to justify that level of risk taking on a training flight.
@@Stubbies2003i agree. How can you just brush it off to your opinion based on no evidence of a bad sensor?? Ignoring it 5 times is criminal in my mind. There are a lot of people on board and its a lot of money and resources to just say “ive seen that sensor go bad 3 times” i mean that is so unfortunate. I feel so had for the crew that this pilot and the command let this happen. This is not a war time sortie either i dont get it at all. Ive only ever heard bad things about the cv22
Thanks for the insightful comment, Sir. I pray for all who serve but especially our airmen.
those pieces of junk are always sending false alarms and they get reprimanded always declaring emergency's. Every time they fly that junk it has something go wrong.
@@dragonflydreamer7658 except when its not a false alarm and multiple people lose their lives. Id rather get reprimanded
I also found it interesting how neither pilot had any rotary time. As a Navy helo pilot/instructor, I think we take chips and land as soon as practical/possible/immediately a little more seriously. Helos and tilts have a lot more moving parts than planes and a lot more things can go wrong. If a plane grinds up an engine they still have another one, or can glide, or can eject most of the time. If a helo/tilt transmission seizes due to grinding or chips you are dead. There is no second chance or recovery.
We usually say with a land as soon as possible you're looking for a clearing that you can safely land in. Don't force a bad landing, but don't pass up somewhere you could land either. Take a parking lot, or a beach, or a grass field. Land immediately you're pretty much doing a controlled crash. If there's something below you great, aim for that. Otherwise, you're still putting it down anyways even if there are trees or water below you. You stand a much better chance of surviving a controlled landing into some trees than you do falling like a rock from 1000ft after your transmission seizes.
Dont know about the Navy but i believe the USMC treats it as a fixed wing track as the stick/cockpit setup aligns with FW a/c. Conversion of CH46 pilots to V22 caused several pilot error incidents due to the setup
I find it interesting that the mission commander wasn't automatically relegated to not being in command of the aircraft, flying and so on may workj, but due to the conflict of interest that can and did occur, my view is that the other pilot should absolutely have been the commander of the aircraft, since the mission commander can easily get into a bad CRM situation when the aircraft's needs collide with the mission's.
On a technical level it's interesting that there was a sensor picking up vibrations from the gearbox minutes before the first chip, but that was just logged for maintenance crew and not combined with the chip warnings to assess the severity of the problem. It's on the whole a bit odd that such a critical system doesn't seem to have more than a crude chip detection without taking into account the interval of the detections, and at what grade the problem is accelerating. With the gearbox and the otherwise problematic clutch being such critical syatems that lives are quite literally hanging from, it's amazing that there are so little computing power and automation built in to try to handle the extremely fast effects when that stuff breaks.
Also, the Osprey is even more dangerous than helicopters because it does not autorotate well, due to the slow rotational speed of the blades.
Chip detection is right up there with the Jesus nut in terms of importance.
I was a Huey mechanic in the Army. We used to demonstrate the glide path of a helicopter by picking up an object, and dropping it. Straight down.
Late 80s, at the former MCAS Kaneohe Bay. The CO’s last flight before retirement, flying “Pedro” (CH-46 rescue helo). Chip warning comes on!!!….he put that helo down quick, like yesterday. He’s enjoying his retirement today
It's something I would assume would be instantly terrifying in flight. If I'm in my car with 4 wheels on the ground and my oil light comes on, I'm still pulling over and investigating before driving too much more.
It's awful this happened, but hopefully it can at least be an accident that promotes safety to others following the accident.
I’m so frustrated, in combat I understand, but training?
I’m so sorry for the families
Not even in combat, I daresay, would I ignore repeated chip warnings coming at tighter intervals until the burn fails and the sensor gives up due to overload.
As seen in this case, a rotorcraft's gearbox is akin to a climber's rope, or the structural integrity of the wings in a plane without ejection seats, it's not something that can be played around with because it is the absolute final straw.
That's what I find sad in this event, they didn't seem to quite realize the potential severity of the problem.
Thank you, Mover, for giving us your insight on this horrible accident, I appreciate how you explain what is said in this AIB Report giving me a better understanding of what were the causes of what happened, my prayers go out to all the families who have lost loved ones. Again, Mover thank you.
Between Hoover & Moover, nobody else does a better debrief with these mishaps. Great job Lemoine. We appreciate the time you take to make these vids. 🙏🏼
That gearbox has been the bane of V-22 program since inception way back in the late 1980s and into the 1990s. Its development was very long due to the complexity of the systems. The chip detectors were developed to mitigate this very issue, but as I remember, the time between the initial metal particulate detection and mitigation (landing) was not long enough so the chip burnoff equipment was developed & incorporated into the aircraft gearbox to increase that time. Also, and here I am speculating, I believe that when the nacelles were being rotated that the change in the mishap nacelle's AoA caused that debris to be dislodged or to move from the flow pattern state that it was in, to one that caused it to move to a location within the gearbox that would cause an immediate catastrophic failure. I certainly see why the Board mentioned that the lack of communication on the importance of the warnings/cautions related to the gearbox was a factor.
@@johncashwell1024 But it’s not unique to the V-22. The Chinook has essentially the same chip detection and burn off system. And a much worse history of crashing.
@@andrewtaylor940 Well mission go-itis isn't aircraft dependent and has cost us a lot of lives over decades.
Is it standard to land in helicopter mode during an emergency? I was thinking that aircraft mode makes a lot more sense from a safety perspective
@@soapbar88 V-22 landing in airplane mode is going to destroy all of its blades, so would only be attempted in an emergency where the nacelles can not be rotated.
I was thinking similar to your line of thinking that the tilting of the rotors may have been the straw that broke the camels back. My thoughts were on the stress that the procession of the rotors would cause while tilting though, but I’m just speculating.
Hey mover I have a clarification for you @32:25. You indicated that the crew rotated their nacelles to prepare for a vertical landing. It should be noted, especially for those who are unfamiliar with how the V-22 operates, that regardless of whether they were going to perform a VTOL or a rolling landing the V-22 has to rotate their nacelles in order to land. If you look at images of the V-22 flying, you will notice that the props extend below the aircraft when flying like a fixed wing aircraft. So it is unable to land like an aircraft because the prop size prevent it.
I believe that they would have experienced asymmetrical thrust that led to the aircraft rolling over regardless of whether they were trying to land like a helicopter or fixed wing plane because of the fundamental design of this type of aircraft.
So if the gearbox failure had occurred while the aircraft was in full fixed wing mode I assume they would have to bail out? There would be no way to land? I wonder if the gearbox is under more stress when transitioning the nacelles to vertical mode? If so, I wonder if transitioning to absolute minimum vertical mode and going for a short field airplane landing might have saved them?
The V-22 has always struck me as an engineer’s nightmare.
@@robertbutsch1802 It’s hard to say if the gear cracked while in flight or prior to the flight. The crew and maintenance had no way of knowing until the chip sectors started popping off. All we do know for certain is that the gearbox essentially disintegrated/ destroyed itself while in flight AND at a low altitude. It also important to note that bailing out in modern aircraft IS NOT the same as crew bailing out of WW2 bomber. The crew DOES NOT actively wear any bailout equipment. In order to bail the plane would have to land or crash.
The v-22 is an engineering nightmare and a shocking amount of people died while testing it. That’s not to say other systems have had bad testing/growing pains (lookup early Blackhawk crashes) but these aircraft are difficult to fly, difficult to maintain, and very complicated
@@narfbite5239 There’s bound to be an emergency procedure for gearbox failure in airplane mode flight. You can’t do an normal everyday airplane engine out landing. You can’t autorotate. Seems like bailing out is about the only option.
America 's dysfunctional procurement system enabled the flying coffin.
Get ready for more. The V-280 (tiltrotor) was chosen by the army as the eventual Blackhawk replacement.
I flew in the Army for 24 years and then taught as a civilian for another 10 years. I would say that the Rotary Wing community in general treats chip lights as something that is very important and something that especially when they reoccur like they did in that accident needs to be addressed promptly. Obviously, I don't know how the V-22 schoolhouse trains or addresses these issues. Like C.W. I was somewhat surprised to hear that the pilots arrived to the V-22 through the fixed-wing/transport pipeline and not the rotary wing path. I was also surprised to hear that a Land As Soon As Possible condition wasn't honored properly...that was pretty shocking and sad to me. As much heat as this aircraft receives, the crew and aircraft would still be here today if they had done what the checklist told them to. It's tragic and sad.
Third chip light = land at Kanoya air base just 10 miles away. It should have been a knee-jerk response based on training. After Kanoya, you are leaving southern Kyushu and heading out over the ocean with much fewer options.
I was a CH-53E crew chief in the Marines.We had chip burn capabilities...first one comes and goes...if I got a second one...nope..get me on the ground.
Curious what was the reaction for a BIM light?
They were opportunities before that Final Destination to land. How many warnings can you ignore? The plane did its part. Lasted long enough to get that far.
And Kanoya is a military air base. What could be better? After that, no more military air bases until Okinawa.
in 1995 I was finishing up my ISS assignment as the senior AF RAND Fellow and was picked to be the Det/CC of the AF V-22 Det at Pax River which was in the middle of the test development test program along with the Navy. I ended up getting redirected to lead the X-40 program but during the time would have been there when the first V-22 accident which could have easily been me onboard. I never did get to fly it but was told by those who did it could be quite the handful and very unforgiving, kinda like getting slow in a T-38 turning final ...
One would think that the moment you start getting multiple chip warnings you would recognize that your gearboxes are eating themselves, the burning of the chips isn't the issue, its what the chips are coming from thats the issue.
thing is they were fighting multiple false faults from the mission computer having issues. it wouldn't surprise me if the pilot just ignored it as another false fault initially and just continued on until it was too late. considering how many issues they were having they should have aborted the training mission long before the gearbox failure.
I was based at Edwards AFB and was offered a chance to be on the flight test team of the V-22. During my interview the Major said, "From the second that thing rolls off the assembly line in Amarillo, it is trying to kill you. Respect that and you will do just fine." I declined the position and PCS'ed.
These kinds of accidents are tough, but some of the best learning reports to read about. That whole crew was actively discussing and strategizing about what eventually became the cause of their deaths. How many times have you flown and had a 'Hm, that was a weird vibration, did you feel that?" or "Should we divert for this?". I try with every one of those situations to think about the worst possible scenario, and think "Man, how much would it suck for me to end up dead for a problem that I knew existed, but didn't take the appropriate action for!".
The way I teach it to students is to 'read your own accident report'. As in, if you crashed and died on your flight, how would the accident report look when other pilots read it? Would it be a report that contained obvious clues and factors that you ignored or brushed off? If so, the average pilot would look at that report and say, "well that guy fucked up!". Don't be that guy! Make it so your 'accident report' would be about the "1 in a million failure that took him down, even though he made all the right decisions", and there's a 999,999-1 possibility you'll come home at the end of the day.
As a crew chief (FE to the Air Force types), my favorite teaching point to pilots is “Sir, how will that read in the SIR? (Serious Incident Report)
The families of the lost aviators deserve the sincerest of condolences from all of us, first, foremost, and most importantly.....RIP.
I'd also like to say that the AIB reviews you do and the style you use in doing them, is the most intriguing part of your channel. It's not my favorite part certainly, but very informative given your background, so thank you for doing them.
As a non-pilot computer systems guy, one thing that stood out to me was their discussion of previous experiences with the initial alerts as being nuisance alerts. This really hit for me because I've seen prior false positives lead to people dismissing alerts in the past and it's sometimes made situations worse.
They are not false positives if there are chips in the detector. What good does an alert system do if it only alerts after the gearbox has already come apart?
@@blegi1245 you're focusing on the wrong part. There was conversation during the event about one of the crew having seen a similar alert once and that it was just a nuisance. Whether true or not, the perception is what matters - and a perception that it's a false positive does lead to people ignoring alerts
As a computer guy myself, that sort of response caused the network engineer to allow a ransomware attack to inundate our entire company... We're a hospital.
As an Ex UK military engineer, we had chip detectors in the RR Merlin engines but they could only be viewed during major engine inspections which included draining the oil system. Any metalic chips lead to an engine change. I question the use of chip burning off up to 3 or 4 times. Back to the swiss cheese,i would always favour on the Y22 immediate grounding on the first chip detection allowing for a detailed examination of the Propellor/ Engine oil system. The history on the Y22 suggests an aircraft operating at the extremes of flight with a surprising number of aircraft losses.
Gotta listen to your Flight Engineers… We are the system knowledge experts of the aircraft… I was an FE on both rotor and fixed wing…
Interesting, the Army only has "Practical" and "Possible". We treat "Possible" like the USAF "Immediately".
Up North we have 4, Continue Flight (stuff like degraded GPS), Land as soon as Practible (stuff like MFD failures), Land as soon as possible (stuff such as engine chips or hydraulic failures), and Land immediately (stuff like total loss of flight hydraulics or uncontrollable fire). For Land immediatelies, it's basically to get you on the ground right away, so that means putting it into trees or the water, whatever you can do to make sure the aircraft doesn't break apart with height.
The AH-64 has a LAND IMMEDIATELY in the checklist for primary hydraulic failure, but most aircraft in the Army (especially older ones) were only as soon as practicable and as soon as possible.
@@DanMcClinton thanks for the correction. 64s always have to be different 😜
@@bgroovin1343 well, in fairness, if you've lost hydraulics you've got about 3 strokes of the collective out of the emergency back-up....so immediately is probably warranted there.
@@DanMcClinton I'd say that goes for any helicopter that can't be flown without hydraulics.
The MDSO was a good buddy of mine…
I know you know this well Mover, but these AIBs are a lot harder to read when you know someone involved. Thank you for being respectful to the crew and the situation they were in. It’s easy to judge with hindsight, when you’re not actually in the aircraft dealing with it in real time. Policies have been modified and this crew’s sacrifice will make flying safer from now on.
Love you Jakey, and I miss you.
I can understand the initial computer reset caused so many incorrect warnings that can be ignored, so when they got a real one, they were thinking it's another nuisance but the book says not to ignore it, so they didn't ignore it but they didn't believe it either.
I can understand bypass the landing pad because the maintenance crew might need a C-130 or something to land parts or ???.
I can't understand self cancelling the immediate landing and doing it with the most power intensive method. You're going to maximize stress on the very gearbox that's about to die. Just throttle back and coast on in, telling everyone on the runway to get out of the way. You can apologize later if you find out it was all a bad computer chip.
Most modern aircraft computer systems are built quad redundant. This is great, until the crew gets used to the plane pushing through fails, and assume it will again.
@@kerbalairforce8802 The PRGB isn't a computer though. The pilots knew that.
@@stanislavkostarnov2157 a C-130J could land, stop, and take off without reversing on that runway
Mover
Thank You for this sad report . May they all RIP. Sending my deep heart felt Sympathy and Love to all family members friends coworkers and all the people who new them .
YT enqueued your video after I watched Ward Carroll's debrief on the same topic... and I am so ok with you saying that after all this is a really tough one... I am no real pilot, only the pilot of my own life... yet as a Navy guy to me it is a thin line between mission accomplishment and that safety thing that you should maybe listen to, but ignoring it might make the difference that you've been striving for and that one is a deeply rooted one... even under training circumstances or maybe even more... no one wants to fail others... so just as the theory goes, I am confident, the crew did definitely not want to fail anyone with what turned out to be hell of an edge case... - still I like your way to adress the case... and for you it is even closer and so much more intimate to rehearse what happened, to discern what went wrong and to make the loop back to what we might all have or not have done... lots of respect for that
Does anyone know how often those warning lights illuminate in normal V-22 ops? If it's a known false alarm, I'll cut them some more slack for not taking it seriously. Still, as an FE I can't imagine leaving the flight deck to look at a radio when there are potential issues with the gearboxes; aviate navigate communicate last.
I’m sorry, but if it was me, I’m landing As Soon As Possible if any of those warning lights come on. A runway was not necessary to land, so why ignore warning lights until you find a suitable strip? Thanks Pete!
According to the voice recording, only the MC had ever seen the chip burn caution, and I don’t think any of them had seen the full Chip warning.
I would assume it’s not a common failure.
I appreciate how you stick to the facts in your reviews! For context, because of the size of the rotors, the V-22 can’t takeoff or land in airplane mode. Nacelles have to be at 60° or greater for takeoff and 75° or greater for landing. 32:43
Given the flight characteristics of the CV-22 and the high percentage of fatalities with a gearbox failure, I would take absolutely every chip detection as a very serious concern, and certainly when it comes to an immediate landing situation being progressed to. All the process was in place, they had a chance. The fact that it functioned as long as it did is one good thing. Looking at it, you have to consider if the additional strain on the gearbox for a more vertical landing (very short field roll or helipad) sooner would have been preferable to the longer field, low-angle landing, but much later. Certainly the lack of urgency from the pilot at the third detection is a contributing factor and likely doomed them. Perhaps a reevaluation of the possible/immediate conditions and times to likely failure of components should be done.
That's one of the main things I find hard to believe. Even with all the crashes and problems they've had with the Osprey, these guys kept dismissing warnings until it was too late and didn't seem to think much of it.
Obviously, as a non-military and non-pilot, it's easy for me to say "I'd think that would be a cause for worry" but it did strike me as odd. I would think in a helicopter it would be scary enough, but the V-22 seems like something that pretty much can't stand to lose that engine, especially not at slow speed. With those massive engines on the wings, it's gotta be difficult to control in the worst of events.
@@Michael-ol2jn Definitely hard to believe as a person just on the sidelines, which was making me wonder the same thing about how frequently the detections go off. I haven't read through the entire report to see if the report mentions the frequency of these alerts, but it's something we have to deal with in cybersecurity.
Trying to find that fine line between over-alerting ourselves and also annoying the users with emails and warnings.
@@aaronwhite1786 Only two crew members had ever seen one.
@@chrismaverick9828 Sorry, that's just false. It does not have a high percentage of fatalities. Nor a high percentage of gearbox failure.
Thankyou for your comments and insight.
Thanks for your excellent discussion of this tragic crash... When you mentioned the multiple roll, my gut clenched!
It seems that the air force approach to training on the CV-22 is part of the "failure mode" here, as I understand, and many have commented, any failure in the drive mechanism in this aircraft leads to catastrophic asymmetry in lift, and any of the indicators of any drive failure can not be *assumed* to be "nuisance failures".... Damned awful that the failures in risk management just stacked up in this case. Our sympathies to the families, friends, and colleagues of the lost crew....
Mover, excellent reporting as usual.
That aircraft was trying to tell them right from the beginning that there were problems. Minor or not, ignoring even small problems can lead to catastrophic problems. I understand there’s risk in everything, but being afraid to ABORT is getting people hurt and worse…..
I think the issue is that every CV flying has something broken on it.
Having taught accident avoidance and risk mitigation to helicopter pilots, almost every accident has a string of events (the accident chain) that lead up to the accident. If the crew had broken that chain, the accident would never have occurred. This accident had several opportunities for the crew to avoid it and for whatever reason they failed to. We can only hope that others learn from it and the same things aren't repeated in the future. That's the only good that can come out of this.
Hey Mover, you ever looked into or considered doing an AIB review on Shell 77? KC-135 that went down in Kyrgyzstan in 2013... unfortunately all 3 crewmembers were lost. Being a former AF sheet metal guy at that bird's home base it literally hit close to home! Know you don't typically do heavies but just a thought! Love all the content you, Gonky and WOMBAT put out for us.
Perhaps part of the mindset of being the mission commander is acknowledging target fixation on the mission and therefore also making a decision to let the rest of your crew make other decisions, like about when to abort due to a mechanical issue.
To finish first you must first finish.
So I cannot be as nice to the pilots on this one. I maintained this aircraft for the last six years of my USAF career and I know the gamble that they took. In gambling terms this was an all in bet. There is no recovery if either PRGB fails as it will create either an unrecoverable roll or yaw input (depending on aircraft or helicopter mode) that the pilot cannot make up for. As soon as a PRGB lets go like this the other prop is the only one making lift and those prop diameters are HUGE. Just no way to recover from that level of imbalance. The pilot doing some things like passing over mission command I don't consider to be that big of mission go-itis. However assuming that a potentially fatal problem like this is a nuisance and not real and concentrating more on being the mission commands IS mission go-itis. That plus failing to know the airfields for emergency landings as well as not thinking of alternate ways of getting it done as pointed out doomed this flight and everyone in it. I was avionics and so if I knew about this as potentially fatal not even directly working on those components the pilots sure as hell knew it.
The engineer seemed to be the only one showing any real concern for this problem. Not hearing a peep from the co-pilot so this is where CRM failed as the pilot had mission go-itis and everyone but the engineer just let him roll with it. The fact that it is such a rare thing to see and they had it multiple times should have been the clue they needed to get that bird on the ground. Even if it had been a failed sensor the severity of it if it is real means you get that bird on the ground and let others pick up the slack. That is precisely why you factor in backups.
The last part was my thought exactly. I get the desire to complete the mission, but why have a #3 aircraft along with you in the flight if you're not going to use it when the situation warrants. I feel like there's probably a cultural component here as nobody wants to be the guy that scrubbed a mission and grounded his crew on an island because of a sensor fault. The problem is, at least that guy is breathing.
Appreciate you doing these.
Man as an engineer this hurts. It's like severe weather warnings. If they've been safely ignored in the past due to (mostly reasonable) inaccuracy, it can cost lives. RIP to the crew, thank you for your service.
I'm as guilty of leaning forward and hacking the mish as most of us, but there's a time and a place for that. Training missions aren't it. Agreed that CRM was lacking; as an FE I've seen it work and it kept me out of dangerous situations, even in combat zones.
As a load on the C-17, this happens to us too sometimes, whether it’s getting the mission done or get-home-itis. I like to think our safety culture is good but there’s nothing more true than when Mover says “but for the grace of God go I”.
Thank you for reviewing this. Very balanced; considering all "parties" Not an easy thing for you to do but so helpful to the public. Much appreciated.
Sorry for the loss of the families. I have always been uneasy about the Osprey it is such a fine line between flying and crashing.
You'd think that with the history of osprey all over the news continually, they would have set it down on the spot without hesitation.
Mover, when you were reading about the pilots' qualifications and experience, you skipped past the FE. All I could make out was he had 4 years flying, which should be enough for one of us to know the systems, learn the ins and outs, and be comfortable speaking up when things don't feel right. Could you post what the report said about the FE? Thanks.
I have the 935 page report with tabs downloaded from the official Marine FOIA website, I could probably look at the report and tell you. But first, what is FE?
@@Skank_and_GutterboyFlight Engineer
Interesting that the gearbox should have been considered a catastrophic single point failure scenario, with the associated urgency that could lead to aircraft loss. A failure that becomes catastrophic in six seconds leaves very little time for, and this failure case absolutely no margin for error. Ultimately, the CV-22 requires both gearboxes to maintain positive aircraft control. Unlike an engine failure of a twin engine aircraft, both gearboxes must remain operational throughout the flight. Crew procedures should be required to reflect the criticality of such a failure scenario. I would agree with you that some amount of helicopter experience should be a prerequisite for tilt rotor flight operations.
Even in a twin engine aircraft, single engine failure is extremely dangerous unless handled perfectly. the sudden asymmetric thrust can put you into a spin, especially if it's a prop engine and the dead one isn't feathered. Once an aircraft like that is in a spin, it's very difficult to get back due to so much weight being outside the CG.
Thanks for the great breakdown of the report. The crew was probably not familiar with the V-22's growing pains. Never had a lot of trust in that platform. After the second burn indication I would have went straight to Job 38:11 " You may come this far, but no further".
@@darrenkuehn8479 These were not flight school rookies.
Not a pilot myself, but I feel like in a rotorcraft, any indication of gearbox/transmission trouble should be a pretty big red flag.
As a generator mechanic instructor back in 1972 73 the Army was transitioning from scheduled oil changes to sending oil samples from each generator to a lab to be tested. Once a sample shows any significant signs of metal we would be notified to change the oil. If on the next sample after the oil change shows metal, then it was teardown time on the engine. The V-22 series looks like a failure ready to happen on every takeoff.
A few years ago the Air Force changed their training. Rotary wing used to go first to IPT on the T-6 at Columbus, etc. That is how it was when these pilots went through. Now, the pilot candidate decides before IPT, and they get sent directly to rotary wing. This change was made around 2020 or 2021.
Kanoya is a JASDF air base, and it was only 10 miles behind them when the third light came on. They should have gone directly to Kanoya. Unlike Kagoshima Airport (the next closest), they would have no commercial traffic to worry about. Also, being a military base, maintenance would probably be easier than a busy commercial airport.
I live in Japan and saw the local news coverage of this accident. My recollection is that the news never really said that the Osprey was trying to make an emergency landing, but rather that it just suddenly disappeared off the radar. Does the US military withhold even such information that a military aircraft had called for an emergency landing when such an accident occurs, until after an official report comes out? The local Japanese news was making a big fuss about how it just got lost but, as it turns out, the S&R teams found the wreckage pretty quickly. Just really tragic.
I was a CH-46 crew member. Twice we go an aft transmission chip light. Fisrt time we immediately landed at a construction site. The second time we were around the Philippine. Islands. We headed straight to a helipad that was closer than the boat. No hesitation by pilots. Each time it was just fuz on the sensor. Cleaned then took off again I currently fly a T-28 alpha if I get a chip light I do not care I head to ground. I would rather land and find no issue then keep going and kill myself and or others.
Great over view of the report
Been wondering when you'd bring us the deep intel
The engineer was the real safeguard position and while you critiqued the copllot for not speaking up, it was the engineer who should have fully understood the seriousness of the situation and gotten in the face of the pilot to tell him to forget the mission and fly the plane. He also should not have stepped out of his position to deal with other malfunctioning equipment. There were lots of failures here, and nearly all of them were human factors. The plane designers thought of this failure mode and gave the Service a redundant system to monitor for the failure mode and avoid this exact scenario. This was a 100% avoidable accident that shouldn't have happened and the entire Service should retool to train in risk management priority over all other tasks. There's no shortage of examples, but the best analyzed was the space shuttle o-rings failure. America has still not learned this lesson, decades after it discovered what it was doing wrong.
Thank you to each crew member for their service and sacrifice to this great country. May we learn from this so it never happens again and may they rest peacefully.
With regard to this mishap, I agree with the Army pilot. Anything that would be an indication of an imminent gearbox failure needs more attention. The aircraft actually gave the crew lots of time and several warnings that were not given proper consideration by the crew before finally failing.
On a different note, I would love to know your take on the 2008 F-18 incident when it flew into a residential neighborhood by Miramar.
I'd like to see a breakdown of one of the many MQ-9 AIBs from the last year. The one where the top 3 starts passing bad instructions was pretty rough. The really bad one was the overzealous test director that killed someone.
I'm not a pilot but I know enough about engines/transmissions in cars that chips in the oil mean something is going to go bye bye catastrophically if you don't sort it.
After a notification of Chips, does it occur to others that a hover adds significant additional stresses in torque load to the gear box?
I'm an Army-trained helicopter guy flying Hueys and Blackhawks, who later transitioned to fixed wing.
All helicopter guys know that certain failures will kill you. If you get an indication that one of those types of systems is not well, you don't muck about. You get the aircraft on the ground if at all possible. These guys treatedd that issue as if it wouldn't be a big deal if that gearbox failed. To me, it's a bit like a wing falling off. Why gamble on that?
Chip lights were a constant annoyance because 90% of the time, they were false warnings. I've had them. The attitude in the cockpit was, "dang, another chip light. It's probably fuzz. But, let's get her on the ground. " You don't futz around talking about continuing a TRAINING mission when you are facing real-life death.
That gearbox failure would lead to certain death if you were in helicopter mode. Why they chose that landing type, I don't understand. If you know you might have a failure like that, then you don't try to hover. A rolling-landing would be much more prudent -- I would think. I'm not a V-22 guy, obviously. But it seems like if that gearbox failed, you're basically single-engine and it's generally not too much of an event. If you lose thrust on one side and cannot transfer thrust from the other side in hover mode, that's unrecoverable. I think this accident shows that.
I think all V-22 guys should have helicopter training. Rotary wing track used to go to Rucker . They were there when I was there. They got extra pay because the Army BOQ sucked, but they got solid helicopter training.
Thank you so much for such a LEVEL HEADED analysis of this tragedy. I watched a video a couple days from another UA-camr who I won't mention who has quite a following and the difference is stark. I appreciate you taking the time and effort to put us into the possible mindsets of the pilot and crew, instead of just passing judgement on the pilot with perfect hindsight. Well done, and one of the many reasons you continue to be my preferred channel on military aviation.
Rest in peace crew of 10-0054.
The trouble with accident analysis is you come up with some pilot action that was bad, and tell everybody "This was bad. Don't do this" without understanding *why* they did what they did, which is the real issue.
As a prior Flight Engineer in the Air Force they have tried to blame the crew in multiple incidents. The one at Hurby on the Eglin range was not the crews fault but a bad chart said they were good to go.
So, very sad. In first responder roles all the way back in the 1940s when the first incident command system was in place in the forestry fire service, later on in building incident and unified command systems the safety officer became a important part of these systems. The rule of the safety officer is that while the IC is looking at the overall mission, getting the job done the safety officer looks at only the physical safety of the personnel and equipment making sure the FR's are using the right gear for the right job at the right time and that safety protocols ate being followed. Physical stress and FRs rehabbing and proper backups if something goes wrong really fast. PAR time of 20 minutes etc and making sure your RIT team is standing by and not being utilized for something else. Now, I know listening to you Mover Crew resource management is the glue that keeps the puzzle from disintegrating. The crew chief is a very important puzzle peice, that I do beleive since he/she is the plane/rotor wizard that the pilots need input the most from for conditions of the aircraft. While crew management, I would say, should utilize the crew chief in its decision-making at the highest level. Maybe they need to have that SAFETY factor as does first responders do in IC or unified command operations. It sounds as if the crew chief was pressing the fact of the seriousness of the chip master caution alerts. As like in FR scenes, the safety officer has the authority to stop all operations if he she deems that the operation is in danger of failure due to possible injury loss of life to personnel. That safety officer then can order the IC to make safety changes before operations continue.
While the pilot and co-pilot were using crew resource management effectively, the crew chief was like the odd third wheel, and his/her inputs were not rising to the level of importance as it should have.
Maybe in complex aircraft where there are crew chiefs is also designate them as the overall safety officer of the flight. Tunnel vision of the pilot pushing to get the mission accomplished in training didn't once weigh the fact outside his own mind that this was a training mission and that the load he was carrying i.e intelligence and more important medical personnel for the complete air operations if they are taken out, then there's no further support to the mission so it fails to complete. As you said in war, there's a different thought process, which I understand. But in training, you need to have that third man/woman who's thinking not of mission completion, but safety would had given this flight the best chance of surviving. Also, with safety officers, they are trained to be just that, for the overall safety of all life safety involved in operations. There are plenty of warnings that occurred that day for a safety officer to stop the exercise and make it safe, then continue the training operation. A safety officer is also protected from higher officers such as the IC by using life safety over operations template. Giving the crew chief that additional role as safety officer and that mandate of life-safety over mission protections , overruling the pilot in command by taking the mission out of the life-safety aspect in operations would had saved everyone and the aircraft involved in that specific order. The decision to continue with the training mission overuled the commonsense overall mission of life safety that day.
Tragic. May they rest in peace.
I did not realize that Air Force Osprey pilots didn’t receive both rotary and fixed wing training. Navy/Marine pilots in the Osprey pipeline would go from Primary in the T-6, to Intermediate rotary in the TH-57, to Advanced multi-engine fixed wing in the T-44, then to the RAG, then to the fleet. The Navy/Marine Osprey pipeline essentially blends the Hawkeye pipeline and Helo pipeline into one.
Everything I’ve heard about the Osprey is that it requires fixed wing skills and a rotary mindset. I can see how someone with only fixed wing experience would show less concern with the C&W they were receiving than a helo bubba might because in fixed wing if one engine is wonky, you know you still have single engine options. With helos, and with the Osprey, if one engine goes the entire thing goes. I wonder, faced with the same failure mode, if Navy/Marine pilots might approach it with a different mindset having had helo training.
The CV-22 is really neat in concept...It's both a helicopter AND an airplane. But that transformer capability comes at a high cost in that it's an especially dangerous aircraft in an emergency like the one this crew experienced. Condolences to the families...
Thanks for the walkthrough. Kudos to the aircrew to have the mission as top priority but unfortunately its not supported by this aircrafts' reliability. Maybe the hot-spare ship should have been used and the MA stay on the ground after that the 3rd restart. The maintenance team could then perform fault-finding (eg a common power supply failure might also have been impacting the gearbox). Maybe aircrew response to failures can be altered if "training" vs "in anger" (eg that leg mounted ipad to assist the aircrew ?). Sad to see the V22 still in this state after such a long development program.
This was tragic and I hope there loved ones get through the loss as well as possible. That said did anyone else notice there call-sign was GUNDAM!?
Even though it was a peacetime training mission remember that these guys are SOF so the pressure for currency is very high.
Something went really wrong with training and/or mission planning. When the third chip burn happened, Kanoya Air Base was just 10 miles behind them. This would have been the perfect place to land, since it is not a busy commercial airport, and as a military air base the maintenance could have been accomplished easily. In fact, the US Air Force occasionally uses Kanoya. Training should have strongly emphasized considering 360 degrees for available airport.
I think it's very interesting the heavy to Tilt rotor path, I feel like a rotary wing Pilot would be far less cavalier about gear box issues. Seems rotary wing would be a more appropriate lead in to a tilt rotor for a lot of reasons.
Absolutely horribly sad..
This aircraft has been a disaster since the drawing board! How many deaths does it take for it to be grounded permanently!??!
God rest their souls.
Nuisance light! no way man.....with all the gearbox related issues, specifically the clutch slip engagement issues, I'm landing that thing ASAP,
Any thoughts on if the rotation of the engine nacelle caused the final gear/drive shaft failure? So would the aircraft had crashed after the first chip alert anytime the nacelle was rotated?
These are tough to watch. The swiss cheese model is a real thing. I appreciate Mover for not sensationalizing these reports for clicks. Just the facts presented in a way that a civilian non-pilot like myself can somewhat grasp.
Hi, Mover. Was the reason the MA didn't simply land in a field or the helipad was that a VTOL landing would be considered high risk with a suspect engine? That's what it sounds like you're saying around 29:00 and later
They did a VTOL landing anyway so I have no idea.
Actually, they were coming in for a landing at the time. The question is, why did they ignore the several alerts? there were repeated warnings given by the aircraft.
The V22 can’t exactly land like a normal plane, as the blade length is longer than the height of the nacelles off the ground.
Depending on conditions they can do rolling takeoffs of landings with the nacelles at at partially horizontal angle, but usually they just land vertically.
The engine wasn't suspect the PRGB was. The engine can be working 100% and it doesn't help at all if the PRGB lets go as the PRGB is what transfers power from the engine to the props.
@@DeltaEntropy No it can that way for emergency landings. It can't land that way without destroying the props but it CAN land that way.
Crew had alot of warnings. At least 1 base was close to them to land.
a video was recently released of a Russian Su-34 escaping from a Patriot attack, a real recording from the cockpit, it would be interesting to see the reaction, the video is on the Command T channel with an English translation
For those of us who flew the Osprey, we recognize this loss was a tragedy that should have been avoided. Nothing more needs to be said publicly. For those flying Osprey's today, this report will be used as a lessons learned, as all AIB's are.
For those commenting in this thread, you are entitled to an opinion, as is protected by those who have, do, and will serve. That freedom to express isn't just reserved for those with experience in the aircraft, it belongs to all and unfortunately an overwhelming majority of opinions on the Osprey are made those who have no actual experience in the aircraft. This is why I never comment on topics involving the Osprey, because it is futile to those closed minds. I would like however to share one "retired" insiders perspective and perhaps inspire some to research prior to commenting.
I came out of the 130 world and started flying Osprey's in 2006 for AFSOC. The aircraft, from inception, was arguably one of the most politicized MDS to ever take to the skies. Everything in the V-22 was scrutinized to a level, honestly, I have never seen. The overwhelming majority of negativity was based on outside opinions, were narrative driven, and/or people that literally just wanted to "hate". I flew combat missions, in multiple theaters, austere conditions until my retirement in 2013. I went on to spend another three years with the same unit, same mission. I say all this for no other reason than to provide context from a "known" perspective.
The V-22 is a modern marvel. The concept of tiltrotor goes back to the 1950's. Operation Eagle Claw was the genesis of what would become the Osprey. With the advent of the microprocessor leading to fly by wire capabilities, the Osprey was born. There is something that is very important to realize when talking about the aircraft. It was the first of its kind, not just as an MDS, but more important, the ability to operate in an aerodynamic envelope never before achieved. When it was a "airplane", it flew just like an airplane and the same as a helo. However; between 1 & 89 degrees nacelle, it was a tiltrotor and those operational capabilities literally had to be written in real time. Heck, the first few years, we didn't have FAA rules so we used whatever was most advantageous for us for "flight mins".
People often try to compare the Osprey negatively to other MDS's. The reality is you can't. The aircraft can fly hundreds of miles (thousands with AR), operate off ships, perform multiple SOCOM mission req's, land on up to 9 degree slopes all flying
I have to say that coming from a COMPLETELY outside perspective I'm surprised about the "cavalierness" about the chips. Yeah, sometimes something inside might chip but by the time you hit 3 I'd be thinking...
"This engine is EATING ITSELF apart!"
And when that happens balances, tolerances, and metal casing integrity will only get worse. At 3 chips I'd be calling it and landing that thing at an airport ASAP. At 4 or 5 I'd be in "land or else" mode. Once I saw the issue with sensor I'd be thinking either its a sensor issue or the sensor is overloaded. IE... get ready to ditch. But I wasn't there. Lot in your lap in those situations. Total bummer.
From the engineering side of things, I would argue that having "nuisance alarms" is a design defect unto itself. If needed, duplicate sensors need to be installed so that a disagreement can be internally diagnosed and queued for service on the ground without pilot distraction. This also allows for actual notifications to be far more likely.
@@garrettkajmowicz it's not a nuisance. It's not a tire pressure warning in your car.
The fact that they treated a sensor telling them that they have measurable metal chips in their gear oil as a nuisance is the root problem here. Even if it is a faulty sensor, you are talking about a critical system that will kill you if it fails 100% of the time.
Maybe it's just me, but if you get a "Land As Soon As Possible" that should automatically trigger an Emergency Declaration if it's not in the checklist already.
When your oil pressure light comes on so often that you think the sensor must be bad, so you keep driving...
Not a reasonable decision 😢
Things separating from Military aircraft should not happen.
Only ordinance and defense contractors.
This read a lot like the B-1B mishap report...
Is it "legal" for ATC/operations officer to not give priority to an emergency aircraft?
This mishap could have turned an exercise into a realistic combat training moment.
A bird "goes down" for an emergency. How does the rest of the mission handle that? Makes me think of Op Eagle Claw and its failure that ironically restarted the VTOL program.
I recently retired from the USAF, spending most of my career at SOCOM deploying, leading & developing 19Z combat rescue officers & 1T2X1 pararescue specialists. I also begrudgingly wrote the CV-22 into several training & mission profiles including a mass cas. syllabi, personnel recovery training with the Joint Personnel Recovery Agency, and numerous JSOC C&C PJ infil profiles. Everything SERE scared out of me, the CV-22 put back in. 62 dead men across the services. I hate that bird with the fist of an angry god.
Yet the chinook that has killed hundreds in crashes is fine?
@@fraleo2192 War is Hell. But I don’t remember seeing you there.
Two thoughts.
1. Obviously they didn’t take the land asap as seriously as they should have bypassing multiple options and making turns in the hold. Even if you think it might be a nuisance your a land asap and you need to treat it that way. If they had they would all still be alive.
2. I’m not a MV-22 guy but I’m not buying the program level issue. It takes very little imagination to figure out what is going to happen if the gearbox on one side comes apart in helo mode. It’s going to be instantly fatal and unrecoverable. Thats just obvious and I find it hard to believe the community wasn’t aware of that. That perhaps indicates another lesson that needs to be learned. Knowing what your aircraft can do that will kill you. What sorts of failures can be fatal and what can you do to counter them. Chips in helicopter gearboxes are not a new phenomenon. So training/thinking about that problem and its potential outcomes should have been front and center.
There's no need for the PIC to also be the mission commander. They had 8 guys on board, the mission commander could easily have taken a back seat and had a pilot and copilot to fly the aircraft.
Trust the instruments. The pilots actions at the field is what killed these guys.
Any flight / control critical conponent such as this gearbox , that can fail this quickly makes this aircraft unfit for flight. It should never be permitted to start its engines or leave the ground as either of these could turn it into a death machine !
If you do some research it will really humble how stupid we are from a training standpoint. We lose 80ish personnel a year to training accidents. In fact we’ve lost more personnel from 2006-2018 from training deaths than KIA.
Yes, train as you fight but keep the big picture in mind as well.
Look at the military aircraft accident rates in the 50s and 60s. Things are far, far safer today. But still things happen.
All good points, but it could have been the transition to vertical flight that started the final gearbox failure, rather than Time of Flight.
The gear box failure was already in progress but I do think that that transition accelerated the process. The problem is, the only way to land that thing without rotating the nacelles is to destroy the props. With the PIC making an assumption that his warnings were a sensor fault, there is no way he would have considered that.
I think when your gearbox is starting to Injustice self , that's when you know time to get this thing down on the deck be it in the water or on the ground
You need to be honest about what the dead did in this case there's no way to discuss it without disparaging them because they screwed up big time and alot of people killed.
I find this perplexing. I strive to know as much as I can about the equipment I am operating - I'd imagine this would be even more pronounced with personnel operating aircraft, because of the potential risks involved. With how easy is to access information nowadays, I would think that every person riding in a V-22 would know about the multiple fatal accidents caused by gearbox failure - of all the warnings you can get, this would seem to be the one you really should not be dismissive about given the past record.
@@walterscientist You are mixing and matching situations. And if you looked at the actual record of crashes? Few have anything to do with the gearbox.
If ICAO (worldwide) uses Mayday Mayday Mayday to confirm an emergency, why doesn't the US Military (in this case- looking to land at civilian airports) use Mayday, and instead only say Emergency?
Seems counterproductive in a life threatening situation.
Does the Osprey glide? Or fly single engine in airplane mode? It looks to me, not having read the report or knowing anything about Ospreys, like the final hole in the cheese was knowing that there was a _potential_ issue around one of the gearboxes, & voluntarily putting the aircraft into a mode where if the gearbox actually fails, everybody dies, out of a mode where it's just a change of underwear if a gearbox fails...
Not all that well in aircraft mode. In transition or hover mode, it absolutely cannot. Both GBs are required for operation. The theoretical redundancy of 1 engine operation is made moot by the fragility and complexity of turboprop GB which makes both GBs single points of failure. The CV-22 also lacks ejection seats and an explosive bolt blade off system.
That suggests that if they had elected to stay in 'airplane mode' & take the runway normally, they might have ended up on the runway, or landed short in the sea at best glide, but that the latter would have been potentially survivable
Every time we review a Fire Service LODD report, I look to the causal factors to see if we have found a new way to kill Firefighters; we haven't. Clearly the Mission Commander's Span of Control was exceeded by the mission requirements and his develping emergency.
The CRM failure of strong leaders and peer pressure drawing crews into a position that they can't extricate themselves from has to be trained up to the "Unlawful Order" level. ANYONE should have a pass to call out a decision that puts the crew in jeopardy. Even an "explaine why we're doing this" can bring the issues back into a reasonable risk/reward analysis.
CV-22 Mishap Report Volume 3, episode 17.