Sunday, December 20, 2009

To teach a dinosaur.

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Fly the airplane
Silence the bell.
Confirm the emergency.
These memory items should be familiar to everyone
who flies most large aircraft.It was Presidents' Day, and for most Navy folk in the continental U.S., this meant a well-deserved holiday. For those of us in logistics, it meant yet another day of getting people where they needed to be, when they needed to be there. I fly the DC-9/C-9B, a soon-to-be dinosaur; it's being replaced by the C-40, a newer, more efficient 737. My squadron is one of the last hanging on to the mighty Skytrain II, a bird that has served all the armed services worldwide for three decades.

On this Monday, while most people were asleep, dreaming of barbeque and a favorite beverage, my crew of five were up at 0400 and briefing at 0515. We expected as routine a day as it gets: Take 17 people and their cargo from NAS Whidbey Island to NAS North Island, then pick up 20 people and take them home to Whidbey.

The crew consisted of full- and part-time reservists. The transport safety specialist was an experienced P-3 flight engineer with a ton of hours but new to C-9s. The loadmaster had more than 20 years' experience just in VR-61. Our crew chief was the youngest salt of the bunch but still had more than 3,000 hours in the C-9. The copilot was a newly qualified second pilot (2P) but had been a P-3 patrol-plane commander. I was just a dinosaur flying a dinosaur. I've been with VR-61 for almost 11 years and have had more than 2,400 hours in the C-9, with more than 9,000 hours total. All this experience would come in handy in a mission that would last almost two days.

The weather in San Diego was unusually bad: windy, rainy, and clouds down nearly to the ground, which required an alternate. I've always been a fan of working with Mother Nature, and this was just another day she had said, "Take me into consideration." This trip would require more than the usual fuel, which also would become a crucial factor in something most of us take for granted: time.

Shortly after departing NAS Whidbey, on the uplatch check (a routine check to make sure the gear system is working), the copilot said, "Huh, that feels funny." He tried it again. This time the lever went to the correct position with the correct result, so we considered it a good check. It turned out not to be so funny.

When we arrived in the San Diego terminal area, we were vectored for the PAR into North Island. Everything was routine until the controller said, "Your wheels should be down."

We answered, "In transit."

But, when my copilot reached to select the gear lever to down, he only could move the lever to the halfway position; the gear wouldn't go down. He tried it again with the same results. Then standard training kicked in. We requested a go-around and delay vectors over the ocean between San Diego and Mexico.

I instructed my copilot to "break out the book (NATOPS)," and added, "I'll fly the aircraft and take the radios. You guys work the problem,"

We were instructed to turn left to the south, climb and maintain 2,000 feet.

We explained our problem to air-traffic control, and they replied, "Say fuel in pounds and number of souls on board."

We had 8,600 pounds of fuel. We are required by standard operating procedure (SOP) to plan on landing with 6,000 pounds, but today, we had that extra fuel for our alternate.

My crew chief opened "the book" to the emergency "Landing Gear Lever Stuck in the Up Position," which led us to the "Free Fall Checklist." Our crew chief and copilot worked in flawless unison on the checklist, while I monitored. The landing gear still wasn't down and locked. We could hear the sound of gear doors falling into the wind, but the aircraft failed to do the normal slowdown. We didn't need the additional power that normally comes with lowered gear. It just didn't feel right, and the indicators still displayed an unsafe condition.

After the failure of the free-fall checklist, it came time to improvise. We discussed several things. Did we have an indication problem? We pushed the pencil bypass and reset the circuit breaker for the landing-gear horn.

Was the wind stream keeping the gear from falling all the way? We slowed to 122 knots and slats 50. When the circuit breaker was reset, we showed three red (unsafe) lights and got the warning horn, meant the landing gear were not down. We pulled the breaker, and the horn went away.

Was residual hydraulic pressure holding up the gear? We secured engine-driven hydraulic pumps and the electrical aux and transfer pumps. System pressure on the right side bled to zero. On the left, it went down to 1,100 psi--normal pressure is 3,000 psi. We reset the breaker but still showed three red lights and got the horn. We concluded there was no indication problem, and the mechanical-hydraulic bypass from the freefall handle probably was working fine. Fuel status was 7,400 pounds.

So, what was the emergency? Obviously, the gear was the problem, but what was causing it? A fire causes a fire light. An electrical failure causes an electrical-failure light. A procedure is designed to respond to cause. We needed to respond to a cause. Fuel status now was 6,900 pounds.

ATC updated our winds to 200 degrees at 20 knots. They had removed the arresting gear on runway 29 and asked, "Would you like the arresting gear removed from runway 18, as well?"

Of course we said, "Please do."

Normally, our aircraft has no problem rolling over the gear with our large tandem tires, but with the possibility of landing without our gear down and locked, we could catch a gear door on the wire with nasty results. We could have a belly, or gear-up, landing. The arresting gear could introduce one more variable we didn't need.

We discussed diverting to MCAS Miramar, a longer runway that faced more into the wind. The problem was the commute time would have consumed a lot of gas better used buying us time to get down the gear while over North Island. If we really needed to land into the wind, the runway at Lindbergh Field (San Diego International) was another option. I was confident we could get into North Island with the current weather, having broken out of the clouds earlier on the first approach.

But, there was another curve. Lindbergh Field ceiling (cloud base) was down to 500 feet. This ceiling would have been fine for a precision approach, but to shoot the approach to runway 18 into North Island, you use the localizer course runway 27 into Lindberg, and then execute a left 90-degree turn from 830 feet to land on runway 18.

We discussed contacting North Island base operations to get a phone patch to our maintenance department to ask if they could come up with any more ideas. Oops, it was a holiday, and we were faced with holiday routine. No one would be in the spaces until our scheduled return time in three hours; we were on our own. Fuel status now was 6,300 pounds.

We began to prepare the cabin and passengers for an emergency landing.

Our crew chief astutely made us aware that the front instrument panel (immediately to the left of the gear handle) had had some work done to it that weekend for a fuel-flow indicator. This part had been written up in the aircraft-discrepancy book (ADB), but, to a pilot reading the gripe, it appeared just to be a gauge change. To my crew chief, however, it meant something more. He told us the procedure required the removal of the entire front instrument panel. When I asked him if the plane had flown since the maintenance action, he replied, "No, this is the first flight."

Our attention immediately shifted to the possibility of FOD behind the panel, which might prevent full motion of the handle. The copilot and crew chief took the flashlight and checked for objects by looking through the slot the gear handle glides through. Fuel status now was 5,600 pounds.

Earlier, when I had tried to lower the gear handle, I had noticed a slight bulging to the left of the handle as it was moved through the 90-degree position from the front panel. It moved freely to almost 90 degrees, and then I heard a "thud."

We were confident we were making progress.

I suggested, "Get a screwdriver. Let's pull the panel." The crew chief made a beeline to the cruise box, retrieved the tool, and turned the four screws on each corner required to pull out the center instrument panel. When he twisted the two screws on the right side, the panel popped rearward, as if pressure was present on its back side. Once the panel was released from the screws, I said, "Try dropping the gear again."

The copilot grasped the loose panel with his left hand, and the gear handle with his right. He completely placed the gear handle to the down position. Within moments, we had three glowing green lights. I immediately told ATC we had three-down-and-locked and requested short vectors for the PAR 29 for the full stop; ATC complied. We broke out of the clouds at 1,000 feet. On short final, tower reported winds from 200 at 25. We continued into runway 29 and landed. Fuel status was 4,800 pounds.

The crew chief and some maintainers on board troubleshot the problem and discovered the center instrument panel hadn't been installed properly. It was resting on top the tracks instead of inside the tracks. They proceeded with removing all 23 gauges and both FMS boxes, so they could remove the center instrument panel and reinstall it.

This two-hour process, when completed, was successfully tested: Engines started, all gauges worked, gear pins were installed, and gear handle was moved up and down repeatedly with no binding. We felt we successfully had identified the handle problem. As for the mystery of why the free fall did not work, we, with VR-61 maintenance, determined a full gear swing should be accomplished to further troubleshoot and determine we had a good fix.

We left the hangar at 2200 after a 17-hour workday, tired but thrilled it was a job well done. Our rescue aircraft, 115, would take a crew overseas the next day, and the squadron would have an up asset the next day for tasking.


An accident or incident happens as a result of a chain of events. The onus is on every one of us to break the chain.

In this incident, the chain started in 1975 when McDonnell Douglas discovered if the center instrument panel was not installed properly into the rack grooves, the gear handle could jam in the up position. Service Bulletin 31-37 recommended removing a portion of rack spar that would interfere with the landing-gear-handle linkage. But, only four of 27 of our wing C-9s received the modification. The aircraft in this story came from Iberian Airways in Spain, and it is uncertain if they ever got the bulletin.

Between NATOPS revisions, our wing supplies standardization notes to inform squadrons of current flight concerns on all models. A 2005 note refers to the need to reset the landing-gear-circuit breaker to get a positive indication of down and locked. This has not been corrected in the current NATOPS and could lead another crew to think all is well after the free fall checklist is complete. That would be disastrous.

In our case, the squadron is looking closely at what went wrong. Was the problem the result of a trainee doing the work or checklists not followed? Maybe some of us weren't fully engaged in our work because of personal problems or lack of administrative support. We need to also consider fatigue: working in the middle of the night without enough rest.

How many risk factors faced this aircrew? Old aircraft, routine flight bordering on the mundane, holiday weekend, and unusually poor SoCal weather round out the contributing factors. Even add a recently completed maintenance action on the instrument panel. Each factor was manageable, but the addition of a looming fuel emergency complicated everything. This crew was spot-on with their CRM execution, as well as their attention to the maintenance details which preceded the flight. No flight is routine.--LCdr. Paul Wilson is the C-9 analyst at the Naval Safety Center.

Cdr. Blanchette is a reservist and flies with VR-6.

Source Citation
Blanchette, Joseph K. "To teach a dinosaur." Approach 53.3 (2008): 20+. Academic OneFile. Web. 20 Dec. 2009. .

Gale Document Number:A201211906

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