The NAVSAFECEN mishap investigations directorate was notified of a mishap on the USS Blue Ridge (LCC 19), which was operating off the coast of Okinawa, in January 2020. An MH-60S, assigned to Helicopter Sea Combat Squadron (HSC) 12, had crashed into the Pacific Ocean. While all crewmembers safely escaped the helicopter, the MH-60 sank, coming to rest on the ocean floor nearly 20,000 feet below the surface.
More than a year later, on March 19, the investigations team, led by Maj. Brett Papale, aviation safety investigator, spearheaded a recovery operation involving the Naval Sea Systems Command (NAVSEA), Supervisor of Salvage and Diving (SUPSALV) command, embarked on a commercial, dynamic-positioning (DP) ship Grand Canyon II. As lead investigator, Papale worked hand-in-hand with the HSC 12 AMB and SUPSALV’s deep ocean program manager, Bryan Blake, to coordinate the recovery.
The recovery operation broke SUPSALV’s own record for deep-water aircraft recovery and provides an opportunity for NAVSAFECEN investigators and members of the AMB to examine critical evidence needed to determine why the aircraft went down.
The ability to recover a downed aircraft, and any source of data information, provides NAVSAFECEN critical information to determine the cause and prevent further mishaps by uncovering possible equipment and systems issues that need improvement or require updated procedures or changes in how pilots respond in emergencies. Determining how to access the data faster after a mishap is critical. If there was an issue with a particular flight system, that information should pushed out to the Navy, Marine Corps and other armed services as soon as possible.
For the investigators, the overall goal is not about looking for who or what was at fault; rather, the focus is on collecting and examining all evidence to determine why something happened and what actions or steps can be implemented to prevent this type of mishap from happening again in the future. The investigation covers everything from changes to procedures, checklists, how aircrew or pilots respond in specific environments or console warnings and cautions ꟷ to complacency and compliance issues based on unit or command culture, as well as problems with the various equipment, systems and aircraft components.
According to Dave Clark, NAVSAFECEN aviation safety specialist and 20-year veteran of mishap investigations, there is always a desire to recover the aircraft and determine what actually went wrong, a process that requires interviews with everyone involved, reviews of maintenance logs and ideally, examination of the aircraft itself.
“The evidence immediately available would be from the crew and the maintenance history,” Clark said. “Had the crew not survived, we wouldn’t have anything to go on.”
By recovering the downed helicopter, investigative teams can take it apart and look at suspect components. Even more important, the recovery provides access to the one component on the helicopter that may tell the whole story, the non-volatile memory (NVM), or “black box,” that stores recorded data. NVMs retain data even when power to the box is lost, making their recovery invaluable in investigations and analysis. Accessing that information quickly is especially important in a scenario like this, where a component failure is indicated, as the component may have widespread use, not just in Navy and Marine Corps helicopter platforms, but in Army and Air Force aircraft as well.
“The data recovered from the aircraft is important overall and other services will be interested in the findings. It has wider implications than just a ‘helo crash’ in the Navy,” Clark said. “The data recorders help us determine precisely why something failed. And it’s that exactness, that helps us redesign components, change operating limits, change pilot inputs or procedures because, in the past, it was more of a guess as to what happened, but now, because of data recorders, it’s almost exact. The more quickly we get to the data, the more quickly we can get that information out to the Naval Enterprise and other services.”
Flight data recorders that deploy on impact and rise to the surface are gaining more traction in aviation fields. A Canadian CH-148 Cyclone helicopter crashed April 29, 2020, during routine flight operations with a NATO naval task force in the Ionian Sea, killing all six crewmembers onboard. The Canadian air force initially grounded the entire fleet after the incident, and while the investigation was expected to take at least a year, the flight data recorder auto-deployed and was recovered from the sea within hours.
The information pulled from the data recorder allowed Canadian officials to determine the circumstances of the crash ꟷ flight input conflict between the human pilot and autopilot function, which they released roughly six weeks after the crash. The fleet was cleared to resume operating at roughly the same time. While the U.S. Navy supported recovery operations that May, the focus was primarily on crewmember remains and parts of the helicopter that may inform the investigation, as the NVM recovery had already provided vital information on why the helicopter crashed.
The process from initial mishap notification to recovery is complex. Following an aircraft mishap, the governing fleet type commander assigns an active-duty officer, referred to as the “senior member,” with the responsible squadron to run the investigation. NAVSAFECEN’s Aviation Mishaps Investigations team coordinates with that senior member and provides guidance and support on the process of requesting a search for a downed aircraft and subsequent recovery operation planning.
“Investigators always want to retrieve the aircraft and NAVSAFECEN starts the coordination to see if it’s possible immediately after being notified of a mishap,” Clark said. “It’s a cross-organizational effort involving fleet commanders, SUPSALV and the senior member, among others. The first step is locating the aircraft and finding out if it is recoverable. The second is the decision process to recover the aircraft. Depth is a factor, as is whether or not the Navy has the equipment it needs. Other factors include the availability of a DP vessel, weather and season. As you’re recovering an aircraft, the ship has to stay right over the crash site.”
During the MH-60S search, it was determined the helicopter, located 19,075 feet below the surface, was at the maximum recovery depth (20,000 feet) of the Navy’s cable-controlled Undersea Recovery Vehicle (CURV-21), a deep-water, remotely operated vehicle (ROV). The CURV-21 has performed its deepest recoveries over the past three years and has worked multiple DoD and international salvage and recovery operations. The preceding deep recovery was a C-2A Greyhound in June 2019, recovered from a depth of 18,500 feet in the Philippine Sea.
NAVSAFECEN’s investigative team departed with SUPSALV and the DP vessel in Guam on March 11 and by March 17, the entire team was on station to begin the recovery effort. The helicopter was officially recovered and brought on deck March 19.
“Once it was on deck, we examined the suspect component as best we could, and documented other conditions of the cockpit, switches, gauges, etc.,” said Clark. “The gearboxes and dynamic components deteriorate in the ocean, exposing all the gears, which actually makes it easier to inspect in some cases.”
The helicopter was dropped off at Yokosuka, Japan, for further transport to Naval Air Facility Atsugi, Japan, for examination. From there, the suspect component will be shipped to the H-60 Fleet Support Team for an engineering investigation.
Knowing why a system failed or an aircraft crashes impacts all aircraft flying with similar components or systems. Without being able to access that data, investigators and those in the aviation community are missing a vital piece of the puzzle, and one that can have significant impacts on the lives of other personnel. Successful recovery efforts enable NAVSAFECEN to identify potential emerging risks and communicate that analysis to the fleet and other services.
For additional resources on safety awareness, visit the Naval Safety Center’s website, https://navalsafetycenter.navy.mil.