Molehill or Mountain?

USAF C-130 crashes into the Rockies after virtually ignoring pre-takeoff planning


Telluride, Colo. Missoula, Mont. Kalispell, Mont. Jackson, Wyo. Aspen, Colo. Hayden, Colo. Sun Valley, Idaho. Welcome to the high and clean air of the Rockies.

Even if you havent been to Jackson, youve undoubtedly seen the pictures of the Tetons. Yes, they are very real, very gorgeous – and very high. The valley that houses the airport at Jackson is surrounded by high mountains that quickly reach over 13,000 feet. During a daylight approach in good weather, Jackson is gorgeous.

However, add night or bad weather and a place like Jackson is enough to make your blood chill. Back when I flew air ambulance, a co-captain friend of mine said he would hold his breath on the departures out of Jackson until the altimeter reached 14,500 feet, at which time he knew he had cleared the rocks. I didnt blame him – I think I did the same thing.

In Part 135 and Part 121 companies, airports such as Jackson are considered special qualifications airports. This means the pilots had to receive special training prior to operating into the airport. This included a complete familiarization with the arrival and departure procedures, the instrument approaches, special limitations and pitfalls in the instrument approaches, the navaids and limitations, the typical weather, the topography of the terrain and any other special hazards or procedures.

Many such training programs include photographs and videos taken of the actual approaches into these locations. Additionally, some of the airports required a checkout by an appropriately designated check airman prior to operating into these locations.

At such airports the commercial operators require the pilots to fly an instrument departure procedure for the runway in use. This is especially applicable to airports surrounded by high terrain.

Departure procedures, of course, can be governed by pilot navigation or radar vectors. For those used to flying over the oceans of concrete common in the Northeast, it may be surprising to learn that in the uncongested West, radar vectors are not available in many places, particularly in mountainous terrain.

Much of the West is covered by uncontrolled airspace, and even most of the airports with commercial air service do not have radar coverage. Since the critical back-up of an ATC radar controller isnt available to keep the airplanes out of the rocks, the pilot has even more responsibility to fly the appropriate departure procedure to ensure obstacle clearance while climbing to a cruising altitude.

On an August night in 1996, however, the precautions vanished like a snowflake in the tropics. The day earlier, the crew of an Air Force C-130 based in Fort Worth, Texas, assembled to plan the flight from Fort Worth to Jackson, Wyo., then to JFK in New York City. The purpose of the flight was to transport a U.S. Secret Service communications vehicle in support of a U.S. presidential visit.

According to the post-accident investigation, the major planning effort focused on the complex joint airborne air transportability training mission at Pope AFB, N.C., afterwards. This unit did not have special qualification procedures for a crew to operate into a place such as Jackson. The preparation for Jackson was treated like any other airport, except that the crew was unfamiliar with operations into a non-radar facility.

This was discussed with the operations officer for the squadron, however they figured that, since the airport was serviced by a precision instrument approach procedure and that the navigator had the proper arrival and departure chart, the airport did not raise any other special concerns.

If they had understood how to operate in a mountainous environment, they would have spent more time preparing and familiarizing themselves with the procedures for Jackson. Clearly they gave little thought to the preparation.

The aircraft arrived in Jackson using a visual approach and landed at 21:05. Since dusk starts arriving near this time of day in the Rockies, they should have at least seen the topography during the descent into Jackson and been familiar with the nature of the surrounding terrain. I know firsthand how clear the skies in Jackson were because I flew a crew of firefighters into Jackson that evening.

The aircraft commander had 1,744 hours of flight experience, of which 904 hours were in the C-130. He was an instructor pilot respected by his military peers and characterized as a by the book pilot. He had completed C-130 instructor school in March 1996, so accordingly, you would think this pilots performance should be at the top of his unit and he should serve as the example of how to do things.

The pilot also completed advanced airlift tactical training in April 1996, where he received instruction and actual flying experience in what the service considered to be mountainous terrain based around Little Rock, Ark.

The C-130 aircraft was crewed with an aircraft commander, a copilot, a flight engineer, a navigator, senior loadmaster, two loadmasters and an assistant crew chief.

While taxiing out, the captain asked the flight engineer if the assault takeoff procedures would be required, due to their concern about the airplanes takeoff performance and the available runway. An assault takeoff is somewhat similar to a short-field takeoff.

The runway length is 6,299 feet and the aircraft had a critical field length of 7,600 feet given its weight of 145,000 pounds, the field elevation of 6,445 feet msl and the current conditions.

The navigator performed the calculations and determined that an assault takeoff would be required for departure from runway 18.

A SkyWest Brazilia reported on the Unicom frequency that it was conducting a straight-in approach to runway 36 and was presently 17 miles from the airport. At the same time, a Delta Air Lines aircraft started to taxi from the ramp for a departure from runway 36. The pilot of the C-130 said, Why is everybody going to 36? Winds were out of the north at six knots.

No one in the USAF C-130 crew recognized that the decision to operate from runway 18, in addition to operating opposite to the traffic flow, also caused a tailwind situation where they were already worried about takeoff performance.

At 22:18:54, the navigator asked the pilot how he wanted the navigational aids set up for the departure. The aircraft commander replied, I am not really sure of what the course is and all that stuff out of here. I assume it will probably be set up Jackson (the VOR/DME located on the field) initially, but I dont know what course is defined off of.

Common Sense Solutions
The standard operating procedures used in most transport-category aircraft require the pilots to plan every departure using the standard instrument departure procedures. In my experience, company procedures (and just plain old common sense and good workload management) require pilots to examine the departure procedure before starting the Before-Start Checklist.

If you study the departure procedure, youll know what navigational aids to use and the courses to fly, and youll make sure the navigational aids are set up before you even start the engines.

The commercial charts available for the Jackson departure procedure graphically illustrate the nature of the terrain using various colors and contours. The courses to be flown are outlined in heavy black arrows that instantly attract the eye. The profile view of the departure is supplemented by a narrative section that outlines in words how to safely depart the airport with adequate navigational, communication and obstacle clearance capability.

At my previous companies, and in my pleasure flying, I would take the full set of charts, both IFR and VFR out of my case to review. I always carry the VFR charts in this country because it shows the nature of the terrain, including high terrain and the valleys. This allows me to form a more complete mental picture of the terrain and how the departure procedure climbs out through the high terrain. The commercial charts also have a section on the necessary climb gradient of the departure procedure to ensure adequate obstacle clearance.

You may also carry charts that list the maximum allowable takeoff weight given the temperature and runway. Those charts also indicate the maximum weight that will allow you to climb steeply enough to assure obstacle clearance. The most restrictive of these two numbers will usually be the maximum weight for departure. (There are other limitations, including tire speed, brake energy and structural limits, but the vast majority of the time the climb limit is going to be the most restrictive out of a place like Jackson.)

This crew used Department of Defense Flight Information Publications that included airport information, instrument approach procedures and instrument departure procedures. These charts are similar to the NOS charts, though the military version includes military bases. The bottom of the instrument approach plate for Jackson includes a white T symbol that is surrounded by a black triangle. This critical little symbol means that the airport had a special departure procedure. The military charts do not have the color contours that the commercial charts have, nor the terrain information in such a graphic nature.

Air Force regulations require pilots to review any published departure procedures in order to be familiar with the location of obstacles. This particular night was VFR, however it was moonless and the towering peaks surrounding Jackson were not visible. The FBO described the night as ink black.

The only ground reference lights that were available were just north of the accident site, way down deep in the valley. Ive flown into Jackson on many occasions under these conditions, and quite frankly, the term black hole is very fitting. Despite these black hole conditions, the crew never discussed the published instrument departure procedures.

The official report stated, the crew did not obtain obstacle-clearance data or the required climb rate for departure. It appears that the crew was not aware of the climb-out terrain and the obstacles on departure. The next time you see a movie or news report that shows pictures from a place like Jackson, try to imagine not considering the climb-out gradient and procedure for departure.

The Incomplete Question
At 22:26:46, the pilot asked the navigator about terrain off the end of the runway. The navigator replied, Its pretty much a mountain and valley terrain, rising to seventy three hundred feet about a thousand foot rise, 10 miles south of the field.

That wasnt correct though. The two ridgelines that rise above some scenic pastures are roughly five miles south of the field, and much taller ridgelines loom past those. Again, one look at a VFR chart or the Jeppesen IFR chart would have made this plainly clear.

The pilot said, All right, now if I need to turn, I need to turn right, correct? Oh, excuse me, left. The navigator said, Left turns. We would like a pretty sharp left turn and a pretty rapid climb rate.

Its unclear where the navigator obtained this information. The official USAF accident report goes on to state, There is no follow-up discussion about the reason for the rapid climb rate or how high the terrain is after the left turn. No one asks to see the navigators chart.

At no time did anyone in the crew ask what climb rate is required for departure, even though the navigator did state that a pretty rapid climb rate was required, even though the airport operator warned the Air Force crew that You cannot maintain your heading [eastbound] very long because of the terrain.

This was another clue to the crew that they needed to be worried about the terrain. It was the second time that they ignored clues from pilots who regularly operated out of Jackson, which raises questions about their CRM training to solicit input from all available resources.

Departing Jackson, characterizing the necessary performance as a pretty good climb rate is clearly insufficient planning.

The departure procedure for Runway 18 requires an initial climb to 11,000 feet tracking the 188 degree radial off the Jackson VOR, then a left climbing turn to the Jackson VOR, where the aircraft must be higher than the minimum crossing altitude to proceed on course.

For prudent transport operations, the pilots must be able to verify that the airplane is light enough to comply with the climb-out gradient – and to do so with one engine out. Thats just good planning for the what ifs.

Now in a single engine airplane, guess what? If the engine fails, youre going down. When Im over flat country, that doesnt bother me too much, but in the mountains I generally avoid flying single-engine at night. An engine failure at night leaves you with little hope of making an emergency landing in hospitable terrain.

Prudent pilots find it helpful to have the appropriate navigation charts immediately in front of them. American manufacturers of transport aircraft seem to agree with that policy because airliners have a nice big yoke clip right where it is easy to glance down and immediately review the charts. Most operators require the pilot to use them.

And guess what? Boeings clip is big, meaning you can position several charts on this clip. It helps keep the cockpit organized by putting the charts in order for immediate access. Clearly this C-130 pilot never had a good mental image of the terrain he needed to avoid, suggesting his yoke was clear of charts. The redundancy usually provided in a crew cockpit, when crewmembers double check each other, was lacking because only the navigator had the charts available for immediate viewing. This defeats part of the concept of having multiple flight crew members.

What Left Turn?
In fact, the commercial IFR departure procedure does not specify a rapid left turn, as the commander suggested. It also provides much more specific information about the required climb rate on course to provide adequate obstacle clearance than what the navigator communicated to the pilot of the C-130.

In fact, the graphic depiction of the departure procedure shows the rapidly rising terrain to the east. The minimum safe altitude in that direction is 12,800 feet, but no one in this crew asked about that important number. This is yet another critical preflight planning parameter that was never considered.

As a SkyWest Brazilia landed on runway 36, the Air Force C-130 taxied onto Runway 18 and at 22:46:08, the pilot applied power for takeoff. As they raised the gear, the pilot said, All right, Im going to go ahead and start a left-hand turn.

A charter pilot living near the end of the runway observed the takeoff and noted that the aircraft appeared to be flying very low. When I first saw the aircraft from my yard, they were about 100 feet over the tops of some trees. At that point, they were definitely in a left hand. I wondered what they were doing. I mentioned to my girlfriend that they were awful low and off course.

At 22:48:38, the copilot reported to Salt Lake Center that they were passing 8,000 feet for 19,000. The aircraft was too low to be detected by radar at this time. At 22:49:25, the pilot handed the aircraft over to the copilot and the pilot turned to a heading of 078 degrees, which differed dramatically from the 188 degree radial off Jackson outlined in the departure procedure.

This heading aimed the aircraft straight at Sleeping Indian Mountain, located in the high and steep Gros Ventra mountain range. At 22:50:25, the pilot said, My radar altimeter just died. Moments later, the aircraft struck the mountain at 10,392 feet msl. The aircraft and crew were destroyed on impact.

The official USAF accident report blamed the crash on crew error. The report said, Unfortunately, mountainous terrain in all quadrants … presented too great a challenge to crewmembers accustomed to flying in the flatlands of Texas. The crew failed to avoid mountainous terrain ahead. They were complacent and not situationally aware of their proximity to that terrain. Radar information, which would have been showing up on the navigators radar scope, was not correctly interpreted. Arrival/departure charts were not studied by the pilot/copilot and were incorrectly interpreted by the navigator.

The environment and task require the right pilot, right tools and right procedures. Environmental risk factors such as terrain, weather or darkness (not to mention non-radar areas) need to be adequately assessed and then you must determine whether you, the equipment and the proper procedures can match the task and the environment.

Those flying light planes, without the backup of multiple turbine engines and excess aircraft performance, who are content with less redundant systems and usually flying single pilot, are faced with even greater obstacles when operating out of these places.

-by Pat Veillette

Pat Veillette is an aviation researcher whose heart is tied to a J-3 and whose checkbook depends on a Boeing 727.


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