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​This photo from the Air Force Accident Investigation Board Report on the WC-130 crash shows the accident site on Georgia State Highway 21. USAF photo.

A series of pilot and aircrew errors brought down a Puerto Rico Air National Guard WC-130H in May, killing all nine on board, the Air Force determined in a recently released investigation into the crash.

However, the Accident Investigation Board report on the Savannah, Ga., crash also details a long series of systemic issues inside the wing, including a disregard and lack of knowledge of maintenance practices and a “good enough” mentality on an aircraft that was headed to the bone yard after flying in a unit that considers itself not connected to the broader Air Force mission.

At about 11:25 a.m. local time on May 2, the WC-130H from the Puerto Rico ANG’s 156th Airlift Wing, took off from Savannah/Hilton Head International Airport en route to Davis-Monthan AFB, Ariz., where tail 65-0968—one of the oldest C-130s in the Air Force’s inventory—was to be retired.

According to the Air Mobility Command investigation, the aircraft’s first engine fluctuated and did not provide the normal revolutions per minute when advanced for takeoff. That fluctuation continued as the aircraft advanced down the flight line, eventually losing thrust and pulling the WC-130 to the left and almost off the runway into the grass. Still, the pilot was able to pull the aircraft into the air, and banked right to try to maintain runway centerline before raising the landing gear.

Fifteen seconds into flight, the pilot asked the co-pilot to shut down one of the left engines because it continued to fluctuate and the power was low. At about 430 feet, he then banked left instead of accelerating to the climb speed dictated for three-engine flight.

The board found that the pilot and crew were able to successfully shut down the engine at about 600 feet, but they did not complete proper procedures for takeoff after engine failure or for engine shutdown, and they did not complete the “After Takeoff” checklist. If completed, these steps could have helped the crew maintain control by retracting flaps, which could have decreased drag and helped the aircraft accelerate, according to the AIB.

The pilot varied rudder inputs as the aircraft continued to climb, but failed to retract the flaps or achieve the three-engine climb speed. At about 900 feet, the aircraft skidded to the left, lost thrust on its left side, and departed controlled flight.

The WC-130 dove at a maximum 52 degrees, did a left barrel roll, and crashed directly onto Georgia State Highway 21, about 1.5 miles from the airport. The crash killed pilot Maj. Jose R. Roman Rosado, navigator Maj. Carlos Perez Serra, co-pilot 1st Lt. David Albandoz, mechanic SMSgt. Jan Paravisini, MSgt. Jean Audriffred, flight engineer MSgt. Mario Brana, MSgt. Victor Colon, loadmaster MSgt. Eric Circuns, and SrA. Roberto Espada. The aircraft was completely destroyed.

A CULTURE OF 'APATHY AND LOW MORALE'

Accident Investigation Board President Brig. Gen. John Millard wrote in the report the main cause of the crash was the pilot’s improper application of the left rudder, causing the skid and loss of control. Additionally, the crew didn’t prepare for emergency actions before takeoff, didn’t reject takeoff as the engine fluctuated its RPM, and didn’t execute the checklists and procedures.

Maintainers failure to diagnose and repair the engine prior to the flight, combined with a culture of “apathy and low morale” within in the wing were “substantially contributing” factors in the crash. Crews interviewed during the investigation outlined several issues plaguing their unit:

  • The unit flies the oldest C-130s in the Air Force, and there is a belief the wing is an afterthought to USAF planning.
  • The wing’s aircraft are not combat-coded, so members do not feel they are a part of the Total Force.
  • There is no direct connection to a mission. During interviews, many senior leaders at the group and squadron level could not “accurately describe the mission of the unit.”
  • The wing’s base, Muniz Air National Guard Base, is old and in poor condition. The wing believes there was a lack of urgency to repair, replace, or fix damage after Hurricane Maria in September 2017.
  • The wing, because they are remote, has trouble getting spare parts so aircraft have long repair times and a low mission capable rate.
  • The wing has manning challenges, with prolonged vacancies and inadequate replacements.
  • There is a lack of pride, with the concept of a “citizen airman” twisted into the excuse that “I am just a (Traditional Reservist).”

The commander of the 156th Operations Group believed the aging WC-130 was actually “one of the better aircraft” in the wing, and that the crew was fully capable of getting it safely to the boneyard, according to the investigation.

However, the investigation found the Operations Group’s processes appeared “to be broken,” citing discrepancies in training and maintenance forms provided to the board. The pilot involved in the crash was recently listed as Duties Not Including Flying, though he continued to fly. Also, while training records state maintainers were qualified, many in the wing could not say if they had attended Maintenance Resource Management Training and were not sure what the training included. Additionally, a propulsion shop lead on the aircraft did not know the difference between back shop and in-aircraft manuals, and maintainers on the aircraft did not realize there were troubleshooting guides in on-aircraft manuals. One maintainer could not define his role during a maintenance engine run.

MISDIAGNOSING THE PROBLEM

The aircraft first arrived in Savannah on April 9 on a ferry flight from Puerto Rico for fuel cell maintenance, and during that flight the aircrew noticed a similar RPM issue with engine one and reported it for troubleshooting and repair.

From April 10 to April 23, five fuel cell problems were addressed and fixed on the aircraft. On April 24, two maintainers from the 156th conducted engine runs to diagnose the RPM issue.

However, the maintainers did not have a precision tachometer required to accurately test the RPM of the engine. The maintainers checked out a different tachometer from the 165th Airlift Wing at Savannah, but it wasn’t the same model and did not have the same connection plugs to use on their aircraft. There was an adapter that would have allowed them to use this piece of equipment, but the maintainers were not aware of it, according to the AIB.

The maintainers conducted two engine runs to check the RPM, using gauges inside the cockpit instead of the precision meter. During the first, the gauge showed the RPM was running low at about 96 percent instead of the required 99 percent. The maintainers swapped the engine one gauge with the engine two gauge to test its accuracy, a common move by maintainers outlined in task order guidance. However, they did not shut the engine down, which is outlined in guidance. During the second run, the gauge showed the same reading. The maintainers then adjusted the engine’s valve housing, which causes an increase in the engine’s RPM, according to the investigation. Following the adjustment, the maintainers said the engine was producing 99 percent RPM, however the aircraft’s data recorder showed that the engine during the test never went above 96, according to the AIB. The engine should run at 100 percent RPM, but the maintainers believed the 99 percent reading they saw was sufficient.

“Thus, the mishap maintainers never corrected the engine one discrepancy and did not resolve the RPM issue, not just because they stopped at what they believed was a sufficient engine speed of 99 percent RPM, but because, in actuality, the engine only made it to 96.8 percent sustained speed during the runs ...,” the report states.

The crash at the time was the latest in a series of high-profile incidents in the Air Force. Six days after the crash, USAF Chief of Staff Gen. David Goldfein ordered a one-day stand down and review of organizational safety for all units.