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news/2008/10/navy_53crash_101208w

Report: Fog, confusion led to January crash


By Andrew Tilghman - Staff writer
Posted : Tuesday Oct 14, 2008 9:02:24 EDT

Foggy weather and crew confusion led to a fatal helicopter crash near Naval Air Station Corpus Christi, Texas, according to a Navy investigation.

The crew probably misinterpreted the navigation equipment on its MH-53E Sea Dragon, which was flying a training mission after dark, when it struck a 1,000-foot television tower, according to the report obtained under the Freedom of Information Act.

Killed in the Jan. 16 crash were co-pilot Lt. Joshua Gross, 30, of New York; Aviation Warfare Systems Operator 2nd Class Alexander LeMarr, 25, of Colorado; and AW2 David Davison, 22, of Oklahoma.

The pilot was the crash’s only survivor. Lt. Cmdr. Howard B. Fabacher, 36, was seriously injured and has not been returned to flight status.

Cloudy weather severely limited the crew’s visibility and forced them to rely solely on their navigational instruments, the report says.

Radio transmissions from the helicopter showed that the crew believed the helicopter was nine miles closer to town and clear of the tower.

Misread indicator

The crew may have misinterpreted the cockpit’s Horizontal Situation Indicator, a “crew preventable error” that indicates a breakdown in “crew resource management,” according to the report.

At 8:05 p.m., about one minute before the crash, the crew radioed in to say they had switched to instrument-only controls.

Air traffic controllers warned the crew that radar data showed they were near the tower.

“If you are off the one-ninety radial, you are around the antennas. Do you have them in sight?” the approach controller asked.

The crew did not respond.

A witness about two miles from the crash site heard an explosion, saw a fireball rise into the air and heard a sudden halt to the aircraft’s flight noise, the report says.

Shortly after the crash, the local public television station’s broadcast was disrupted.

First responders from 11 agencies came to the crash site, where the cockpit’s cabin was engulfed in flames about 400 feet from the tower.

Debris from the aircraft was spread over an area of 700 feet, the report says.

Fabacher, the only survivor, was found about 15 feet away from the nose of the helicopter, still strapped to his seat and wearing his helmet.

Responders described him as “conscious but not coherent,” the report says.

The report from the Judge Advocate General’s office recommends that instructors use this crash and its investigation report as part of the annual helicopter crew resource management training. It also recommends stepping up training procedures for “inadvertent IMC Recovery procedures,” referring to conditions that require instrument-only navigation in bad weather.

LT. CMDR. JOHN L. KLINE / NAVY An MH-53E Sea Dragon, from Helicopter Mine Countermeasure Squadron (HM) 15, performs mine countermeasure training Nov. 12 aboard the multipurpose amphibious assault ship USS Wasp (LHD 1) in the Persian Gulf. A similar helicopter crashed in January near Corpus Christi, Texas. The accident was blamed on weather and crew confusion.

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