United States Air Force C-17 Crash 28 July 2010
Joint Base Elmendorf -Richardson, Alaska

Carnell E. Chappelle Jr

Commercial Aviation Safety
Tom Stein
9 April 2011
USAF C-17 Crash

Abstract
On the 28th of July 2010, an Air Force C-17 took of from Joint Base Elmendorf-Richardson in Alaska so it could practice for an air-show that was to happen later on in the week. During the first minute of flight that included takeoff, a steep climb followed by an aggressive left turn and as planed the aircraft executed another aggressive right hand turn so he could line up with runway 6 for a high speed low pass, It was during this right hand turn that the aircraft entered into a low altitude stall and crashed killing all crew onboard. It was found that pilot error was the cause of the crash.

On the 28th of July around 1800, an Air Force C-17a with a total of 4 crew members to include the load master, took off on runway 06 at Joint Base Elmendorf-Richardson in Alaska. It was a schedule practice flight for the aircrew so they could practice for the Arctic Thunder airshow that was to happen a few days later on the 31st of July. The flight was intended to show the crowd the extreme maneuverability of the C-17. The practice flight included a maximum climbout followed by a steep left turn. After the left turn, the aircraft was to inter another steep right hand turn that would allow the C-17 to line up with the runway that it just took off from and inter into a low altitude high speed pass. The C-17 did a “short field” takeoff followed by a steep climb. After the climb, the aircraft leveled off followed by an aggressive left hand turn so he could set up for a 260’ right hand reversal turn so the aircraft could line back up with the runway and inter a low altitude high speed pass. During the right hand reversal turn, the C-17 entered into a stall with the pilot making a late try at stall recovery that was unsuccessful and thus the aircraft crashing in a wooded area about a mile and a half from the base. All four aircrew onboard where killed instantly and a partition of the Pacific Railroad was destroyed. The whole accident sequence was recorded by a remotely mounted camera on the air traffic control tower. The aircraft was a C-17a T/N 00-0173 belong to the 3rd Airwing. It was operated by 517th Airlift Squadron and the 249th Alaska Air National Guard squadron. The Pilot, Safety Officer and Load Master where all National Guardsmen. The Copilot was the only Active Duty member.

The day before the practice flight, the pilot, copilot and safety officer flew the predetermined airshow profile in the C-17 simulator. The training lasted for about an hour and half and ended with the aircrew performing their mission planning for the practice flight the next day. The following day, all the aircrew briefed and completed an Operational Risk Management formula to evaluate the possible risk for the demonstration flight. All crewmemebers determined that the mission had some risk but it was safe to fly. The aircraft preflight was normal. The original aircraft that they where going to use was down due to maintaince so they planed to “hot seat” with an aircraft that was returning from another sortie that was unrelated to the airshow demonstration flight. The accident aircraft returned and a normal one for one swap of aircrew was performed. The outgoing aircrew noted no know matainnce descpencys with the aircraft. The accident aircrew to control of the aircraft with the callsign Sitka 43. The aircraft took of for a 9 minute weather observation flight around the airfield. After that flight, the aircraft landed and it was determined that the weather was clear and safe to fly for the airshow practice. After it landed and a 30 minute wait, the aircrew filed a VFR flight plan and taxied for take for the practice flight. The Air Force has four predetermined airshow profiles just for the C-17 to chose from. All of them range from just a few minutes to 12 minutes in length with one of them including an aerial drop of troops and equipment. All four profiles are clearly outlined in the Air Force instruction tilted: 11-246, Vol. 6. The crew chose the #3, 12 minute flight profile to fly for the airshow. The normal procedures for the #3 flight demonstration profile start out with a Maximum performance climb to which the aircraft takes off and climbs at a steep angle to clear an obstacle while maintaing an airspeed that is published for a single engine failure (simulating the aircraft has 3 good working engines). The targeted speed for the climbout should be around 133kts. After the climbout the aircraft would level off at around 1,500 feet AGL and make a left 80 degree turn, flying wings level, pick up speed and then set up for the right 260 degree turn to the right and start a decent from 1,500 feet AGL to 500 ft AGL and pass “Show Center” at around 25o kts at 500 feet AGL.

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The aircrew released breaks and took off from runway 6. The aircraft rotated and climbout at a 40 degree angle nose up and at an airspeed of 107 kts, well below the target speed of 133 kts. As the aircraft was climbing through 800 feet, the piloted started his 80 degree turn to the left using 57 degrees of bank in the turn. As the plane went wings level from the turn, it then leveled out and started to accelerate at an altitude of 825 feet and not the predetermined 1,500 feet. As the aircraft leveled out, the copilot retraced the flaps that where used for the takeoff. The minimum speed the aircraft needs to be at before flap retraction is 150 kts, the copilot retracted them when the aircraft was passing through 151 kts. The pilot keep the aircraft level and at a steady heading as he waited for the flaps to fully retract. The pilot then started his right hand 260 degree reversal turn. Again the pilot used 57 degrees angle of bank. While in the right hand turn and at 188 kts, the copilot retracted the slats which was below the minimum 193 kts slat retraction speed. After a few seconds into the turn, the aircraft stall waring system activated letting the pilot know that his aircraft is currently in a pre stall condition. This type of aircraft stall waring activates a “Stick Shaker” to physically let the pilot know of the impending stall. At this time, the aircraft was still in the right hand turn with the pilot using full right rudder and full aft pressure on the control stick. During the stall warning the aircraft was flying at 199 kts which is 6 knots below the aircrafts 205 kts stall speed. During the stall warning, the copilot called out “ acknowledge crew, temperature, altitude looking good.” The pilot continued the right hand turn using full right rudder and that caused the aircraft to increase its angle of bank from 57 degrees to 62 degrees. The C-17 maximum angle of bank is 60 degrees. While still in the 62 degree bank turn, the pilot was using full aft stick pressure and at that point the pilot, aircraft, and crew where expecerering 2.4G’s. The aircrafts deep stall protection system became active. This system limits the pilots elevator input so that the aircraft dosent have a noise high condition and allowing the aircraft to accelerate so it can come out of the stall. The pilots inputs where so aggressive, that it overrid the system allowing the pilot to contion with his maneuver. The aircrafts bank angle increased to 82 degrees and the aircraft started to loose altitude at a rate of 9,000 thousand feet per minute. The aircraft speed also decreased from 199 kts to 183 kts. Once the aircraft was into the heavy stall condition, the copilot called out “ watch your bank angle brother” and the safety pilot called out three times “watch your angle of bank.” The pilot inceated full left ailerons and full left rudder but he kept in full aft stick pressure. A few seconds prior to impact, the slats fully retracted and the aircraft started a roll back to the left but it was very minimal due to the stall. Once the stall and deep stall waring system activated, they stayed on and active all the way to impact. The aircraft crashed into heavily wooded terrain north and west of the airport. At the time of impact, the aircraft was in a 63.6 degree right hand turn and 16.9 degrees nose low with an airspeed of 184 kts. The aircraft exploded and was destroyed and a fire ensued for 3 days.

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Post Crash investigation reviled that the aircraft and aircraft system where all operating normally before impact. They where also able to rule out any weather or other conditions that would have caused the aircraft to crash. It was then determined that the cause of the crash was pilot error. The pilot flew the aircraft outside of the aircraft flight envelope and when the aircraft started to stall, the pilot didn’t make the proper corrective actions to recover the aircraft. During the crash investigation, it was reviled that the accident pilot was known for flying the C-17 in an aggressive manner during airshow performances. He also taught other pilots that the aircraft stall warning systems were premature in activating and that you could fly the aircraft safely outside of the known published speed and angle of bank numbers. He routinely deviated from the Air Force written airshow guidelines that have been prescribed for the C-17. Unltamtily it was the pilots over confidence and failure to recognize and react to proper stall recovery techniques that caused the C-17 to crash. The other contributing factors to the crash were the copilots early retraction of the flaps and then the slats that caused the aircraft to loose lift and aggravated the stall.

5M Fish Bone
Five “M” Analysis of the crash:
Man:
All four crew members qualified for demonstration flights. All crew in good health and current flight physicals. Accident crew and maintenance ground crew passed drug tests post crash. 6,143.2 total C-17 flight hours among flight crew. Pilot error sited for cause of crash. CoPilot error due to early retraction of flaps and slats. Pilot overconfidence /overaggressiveness. Incorrect aerial demonstration techniques. Late/improper stall recovery.

Medium:
9 minute flight to check weather. Winds 240 Degrees @ 4kts broken at 2500 AGL 10 miles visibility. Weather within demonstration limits. Filed VFR flight plan. Weather wasn’t a factor in crash.

Mission:
Demonstration flight for airshow. Written pre-approved demonstration flight profile. Aircrew flew #3 demonstration flight profile in simulator day before. ORM checklist completed.

Machine:
Total aircraft time: 13,361.6 hours. 4 operating Pratt and Whitney engines @ 92.5 % N2 till crash. No outstanding aircraft or inspections due. All control services and system working properly. No fuel, oil or hydraulic contamination. No unscheduled maintenance.

Management:
C-17 belonged to the 3rd aircraft wing. Operated by the 517th airlift and 249th ANG Squadron. High Operation Tempo/overtasking not a factor in mishap. Confusion among demonstration program managers. Crew utilized unapproved checklist. Unapproved checklist use widespread in the 3rd Airwing. Unapproved checklist not a factor in mishap.

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