Read: Case Study:
CRM During DCS Episode (DOCX)
An important part of this case study is the fact that once the incident was identified, it was operational CRM that enabled a successful outcome.
Discuss how all available resources were used in this incident in order to successfully bring Lt. Colonel Henry back safely.
Be sure to use APA format for any citations and references if applicable.
CRM During DCS Episode 8
In March, 2006, Lt Col Kevin Henry experienced one of the worst things that can happen to a single-seat pilot. He was suffering from decompression sickness, and literally losing his mind. As his mental capability continued to degrade, a world-wide team worked together to guide him to a safe landing and the medical attention that would save his life. The different teams involved were separated by continents as well as being from different nations, but all worked together to do whatever they could. This effort demonstrates many of the principles of cockpit resource management and shows how important having all resources available working together can be in an emergency situation.
CRM During a Decompression Sickness Episode
In March 2006, Lt Col Kevin Henry experienced one of the scariest and most serious malfunctions possible while flying an operational reconnaissance mission over Afghanistan. His brain was malfunctioning. Due to a buildup of nitrogen bubbles in his brain, he was losing the ability to think and perform normal aircraft procedures. By the time he got back to his recovery base, he was losing portions of his eyesight and even lost consciousness several times. Eventually, he was able to land the aircraft and was rushed to receive critical medical care that would save his life. The sequence of events that led to his recovery demonstrate many aspects Human Factors and Cockpit Resource Management (CRM) and demonstrate how they apply in a critical situation.
Flying the U-2S Aircraft
The U-2 aircraft first flew in 1955. The U-2 that is flown today is different in many ways, but shares some similarities with those early models. It is still a tailwheel aircraft that leaves its outrigger gear (called pogos) that hold the wings off the ground behind when it takes off. This requires the pilot to not only carefully land the aircraft in or near a full stall, but to also balance the wings and fly them to prevent contact with the ground during landing. The current model, the U-2S, is bigger than the original U-2s, has a new engine, has had a glass cockpit installed, and has state-of-the art sensors onboard to fulfill its reconnaissance mission. U-2s are deployed world-wide, gathering the intelligence data for use at all levels of US decision-makers.
The pilots that fly the U-2 are a special group. They all volunteer to fly the U-2, and submit an application package once they have enough experience flying other aircraft. They can come from any aircraft in the US Air Force, as well as from any of the other US military services. If selected for an interview they go to Beale AFB, California, for the interview, including three flights in a training model of the U-2 to see if they will be able to master the aircraft known as the DragonLady, the hardest aircraft to fly and land in the US Air Force. Due to the difficulty of landing the aircraft, especially after long missions, the U-2 pilot has another pilot, referred to as the “Mobile,” drive out behind the aircraft during the approach to landing to advise the pilot on landing the aircraft. The mobile also preflights the aircraft while the pilot is getting suited up and pre-breathing, as well as acting as a safety observer and wingman while the pilot is in the local area. Like many other USAF platforms, the U-2 also has a supervisor of flying (SOF) during all operations. The SOF is an experienced instructor that can provide advice and assistance, as well as providing liaison between other agencies, such as the weather office, and the pilot-mobile team.
The operational ceiling of the U-2 is classified, but it flies over 70,000 feet. Due to the extreme altitude, pilots wear a full-pressure suit (FPS) for flight. This is basically the same suit the space shuttle astronauts wear for launches. The FPS is necessary as a backup to cockpit pressurization. Armstrong’s line is at approximately 63,000 feet; above this altitude blood boils at body temperature. A loss of cabin pressure would be deadly without the backup provided by the FPS. The FPS is rather bulky and tends to reduce the tactile feedback the pilot get during flight, as well as providing barriers to communication and doing normal activities. This is something the pilots adjust to during training. The cockpit of the U-2 is pressurized only to about 29,000 feet, necessitating the pilot pre-breathe 100% oxygen for least an hour before flight. This washes nitrogen out of the bloodstream and body tissues to minimize the chances of getting decompression sickness (DCS). DCS can take many forms, from the Bends that many divers are familiar with, to skin rashes, bubbles in the lungs causing difficulty breathing (the Chokes), or bubbles along the spine or in the brain known as a central nervous system (CNS) “hit.” A CNS hit is one of the most serious problems that can happen to a pilot, but can be one of the hardest to diagnose. Due to the pressure or blockage of blood flow to different parts of the CNS, symptoms can vary from minor to life-threatening. They can also present as almost anything, from tingling feelings to loss of eyesight, loss of cognitive ability, and death.
Lt Col Henry was filling in for the commander of the deployed squadron he was at in March 2006. On the morning of the incident, he took care of a few duties and went to get suited up in his FPS for the flight. He had trouble getting a good seal around his face when he put the helmet on. The poor seal was allowing ambient air from the suit into the cavity around his face, meaning he wasn’t getting 100% oxygen and that nitrogen from the ambient air was able to enter his system. He thought he fixed the problem, but was somewhat rushed trying to ensure he would be able to make an on-time takeoff. The rest of the preflight and the beginning of the mission were normal (Alyworth, 2006a).
Approximately two hours into the flight, Lt Col Henry had the first signs of trouble. He began to feel tired and developed a serious headache. At first, he didn’t recognize these symptoms as a major problem. He thought perhaps he was just dehydrated (Cloutier, 2006). By three hours into the flight, serious symptoms began to manifest themselves. He began having trouble breathing, probably the results of the Chokes, although he thought he was just hyperventilating. Then he saw the aircraft go into a 30 degree roll. Although it was just a hallucination, Lt Col Henry didn’t realize that at the time, he just knew something was wrong. Since he was also having trouble breathing, he decided to activate the backup oxygen system. This requires pulling a small green knob with 10-15 pounds of pull. It took him two hands to do it. At this point, he needed to transfer navigation files to head home. Lt Col Henry couldn’t remember how to transfer the files using the glass cockpit (Alyworth, 2006a). By this time it was clear to him that he needed help.
For the missions that Lt Col Henry was flying in March, the aircraft uses a data and voice link that allows communication to intelligence personnel back in the US. This would provide a critical link to his recovery. He confessed over the link to the mission operations commander (MOC), an intelligence Captain in the US that he was having problems. The MOC was able to get in touch with Lt Col Russell, the commander of one of the U-2 squadrons at Beale, and have him come in (Cloutier, 2006). Initially, Lt Col Russell didn’t know what was happening, just that he was called in the middle of the night because there was a problem with a flight on the other side of the world. When he began talking to Lt Col Henry, he quickly realized how serious the situation was. He couldn’t comprehend even simple instructions, like “Turn south,” much less more complicated instructions on working the navigation system. Lt Col Russell had to give directions on flying back to base and avoiding overflight of unfriendly countries by telling Lt Col Henry, “Turn right” and “roll out” (K. Henry, personal interview, January 12, 2007).
The trip home was several hours long, and saw a worsening of problems. Lt Col Henry vomited in his helmet, and after opening it to try to clean off his visor so he could see, he couldn’t get the visor to close properly. This meant that ambient air was mixing with the 100% oxygen he was supposed to be breathing, leading to hypoxia in addition to the DCS symptoms. He lost his ability to see colors and could no longer interpret the basic instruments he was used to flying. He was flying back across the Indian Ocean slumped against the side of the cockpit, blindly following instructions from Lt Col Russell. All this time, Lt Col Russell and the intelligence personnel were in contact with the deployed location over the phone and internet chat, keeping them informed on the situation. The personnel at the deployed location notified their leadership as well as the Host Nation (HN) personnel (K. Henry, 2007).
When it became time to lower the gear to begin descending from altitude, Lt Col Henry couldn’t see the gear handle. He was developing blind spots. In the descent, he lost the ability to see that airspeed indicator, but got a warning that his airspeed was high, so he leveled off with the throttle at idle. Soon he was in a stall and didn’t even realize it (Alyworth, 2006b). The HN had launched some fighters to escort Lt Col Henry, so Lt Col Russell suggested that the HN fighters buzz Lt Col Henry to try to get his attention and lead him to the base. Records later showed that the aircraft was in a full stall for over 3 minutes. The noise of the Mirages flying by closely in afterburner woke him out of his stupor. Lt Col Russell told Lt Col Henry to follow the Mirages (K. Henry, 2007).
As he was approaching the base, Lt Col Henry vomited again, shorting out his microphone. From this point on, Lt Col Henry could not talk to anyone, but he could still hear. Lt Col Russell kept talking to Lt Col Henry throughout the rest of the flight, trying to calm him and get him to land the aircraft. Although he was able to follow the Mirages to the field, Lt Col Henry proceeded to fly around the pattern for the next 45 minutes, flying within feet of the ground and even between hangars (Alyworth, 2006b). The SOF and mobile attempted to give Lt Col Henry directions, but he could not follow them. After almost crashing, Lt Col Henry woke up, and Lt Col Russell told him that he either needed to get it together and land the aircraft, or eject from the aircraft (K. Henry, 2007). At this point, Lt Col Henry was able to perform a textbook pattern and landing, incredible considering his condition. After landing, the mobile instructed Lt Col Henry to stop on the runway and shut down his engine. By the time they were able to open the cockpit, Lt Col Henry was unconscious and unresponsive.
Luckily for Lt Col Henry, the chief US doctor deployed to this location at that time just happened to be the USAF expert on DCS. In fact, he had earlier that day, before news of Henry’s problem, initiated an exercise to test how to respond to a DCS case (Alyworth, 2006c). Now those procedures were put to the test. The HN base commander had offered a helicopter to be on standby when he heard of Henry’s condition. As soon as he was out of the aircraft, they loaded him into the helicopter and flew him to a HN facility that had a dive chamber to attempt to get the nitrogen in Lt Col Henry’s brain to absorb back into his tissues and blood. It took four dives in the chamber, but eventually Lt Col Henry recovered.
This paper only touches on the CRM principles demonstrated during this DCS episode; an entire book could probably be written detailing it all. From this brief overview, many of the principles become evident. From the organizational culture, team performance, communication, decision making, leadership and followership, theory of the situation, situational awareness, to risk assessment and analysis, all can be demonstrated during the reaction to this incident. Even though many of the examples are not of the traditional, pilot-directed communications, but of the rest of the involved teams using CRM principles to recover the pilot and aircraft, the fact remains that the principles taught in CRM training can be critical to the safe return of aircraft and the saving of lives.
Cochran, C. (2004). Crew Resource Management: Single Seat, but Not Alone. Approach, May/June, 28-29
Fiorino, F. (2006). Fighting Human Error. Aviation Week & Space Technology, 165, 22, 47.
Fowler, R. (2003). CRM And The Single Pilot. Plane and Pilot , September, 58-61
CASE STUDY ANALYSIS GUIDANCE
The case study provides examples of how CRM can break down in an operational environment. List as many examples as you can find, numbering them 1, 2, 3, etc.
When you finish you will be able to identify the HFACS areas that contributed to the DCS episode.