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How CRM saved my jet.

One afternoon during Air Wing Fallon (AWF), I took part in a large force strike. The strike consisted of 26 aircraft. I was Dash 2 in the division of strikers. The overall mission commander was also the lead of my division, and my squadron CO was Dash 3. Since it was the third week of AWF, the flight was complex, but as a division we managed to make it to the target unscathed to deliver our ordinance.

We immediately turned east and descended to the deck in an attempt to outrun a recently launched air threat. We were fast, more than 500 knots. We followed the terrain as it tapered off into Dixie Valley. Then the first big test of my aviation career began.

"Bleed air left, bleed air left. Bleed air right, bleed air right." My jet raced toward the valley floor. "Aviate. Navigate. Communicate." I thought. I looked in the cockpit and saw the red bleed warning lights. I immediately began a climb and slowed down, all while my left DDI began to fill with cautions.

I made a radio call to my lead that I had an emergency and would be turning around direct to NAS Fallon. My lead quickly decided to detach my CO, who chased me down and helped manage navigation and communication for our flight back to the airfield. The cautions that quickly began to populate on my display (L Bleed Off, R Bleed Off and Gun Gas) indicated that the bleed-air leak-detection system was working to prevent further bleed air leaks.

We navigated the mountainous terrain back to the airfield, staying below 10K cabin altitude because of the lack of pressurization. I had finished the NATOPS immediate action items for a dual bleed air warning, but both bleed air warning lights remained illuminated. I had my PCL out and began going through the non-memory items for my emergency. By executing the NATOPS procedures, the warning lights should have gone out. The NATOPS manual states that bleed air warning lights indicate: "Bleed air leak or fire detected in common ducting and the overheat condition still exists." Just as I began to process the magnitude of that statement, my airborne emergency became even more complex.

"Engine fire left, engine fire left." We were only a minute and a half into the bleed-air emergency and still 30 miles from the airfield. I began to execute my single fire light procedures by first shutting down the left engine and pushing the left engine fire light. Before I could execute the next step, I heard: "Engine fire right, engine fire right." I now had dual bleed warning and dual engine fire lights; I had never even had a simulator this complex!

I CONFERRED WITH MY WINGMAN, and he reported that smoke was coming from the left side of my aircraft. We decided to continue with the left-engine fire procedures. I discharged the fire extinguisher bottle, the only one in the F/A-18. However, both fire warning lights remained illuminated, and for the first time during my short career I began to think about ejection.

NAS Fallon lay beyond one last ridgeline as I set up for an arrestment. The jet kept flying and I was able to make a successful arrestment. As I climbed out of the jet, I looked back to see smoke billowing from the turtleback above the engines.

Later, when reflecting on the incident with my skipper and safety officer, I began to realize how much Crew Resource Management (CRM) contributed to my safe recovery. Since my first day as an SNA, I learned the principles of CRM, which are incorporated into every fleet NATOPS check. During my career I have participated in CRM case study discussions, but I never imagined that those seven principles would be so instrumental in preventing a catastrophic mishap.

The Hornet community takes pride in being single-seat aviators, but we stress using our wingmen and squadron representative for CRM.

After the onset of the emergency, I was assertive in my decision to terminate and make the 180-degree turn direct NAS Fallon. Because of my concise communication to my flight lead about the nature of my emergency, he had the situational awareness to detach the other F/A-18C in our division to accompany me back to the airfield. As the only person who knew the severity of the initial emergency, I assessed that training had to cease and the priority was to get my aircraft safely on deck. Applying CRM to the early phase of my emergency enabled me to land within 10 minutes of the initial cockpit warnings and helped prevent catastrophic loss of the aircraft.

As my skipper and I navigated back to NAS Fallon and the emergency increased in complexity, clear and concise communication, combined with taking action based on situational awareness, became instrumental in successful CRM within our section and later, the SDO. At the onset of the second fire warning light, my skipper and I efficiently worked together to diagnose the problem and develop a game plan. Prior to the dual-engine fire, my skipper switched us to the base frequency and brought the SDO into the discussion. As a side note, at NAS Fallon, multiple squadrons share a base frequency, but good headwork by other CVW-2 squadrons helped keep that frequency, which then doubled as our tactical frequency, clear for us.

The SDO displayed exceptional situational awareness by following along in the big NATOPS passively, since we clearly communicated that all NATOPS steps had been completed.

Finally, understanding the level of concentration in my cockpit needed to fly the airplane while competing with multiple emergencies, my wingman took the navigation and communications lead. The combination of smart communications and timely decisions with the situational awareness to prioritize actions between various actors throughout the event was crucial to helping me solve the complex problem that I encountered.

The leadership of my wingman not only helped keep me calm as we went through the dual bleed air warning and dual fire lights, but it also helped me steer clear of terrain while flying the shortest distance to the runway.

As we approached NAS Fallon, in a decision that would ultimately prevent catastrophic loss of the jet, he described the fire to NAS Fallon tower and asked for the crash crew to be standing by on Runway 25.

The post-mishap investigation revealed that hydraulic fluid had leaked into the aft keel area and ignited when it came into contact with the outside of the bleed air secondary pressure regulating and shut off valve. Thermal blankets that tested positive for hydraulic fluid contamination then sustained the fire in the keel of the aircraft, which has no fire suppression. The fire extinguisher line, which routes through the keel on its way to the engine bays, melted in the heat. So when I had tried to discharge the fire extinguishing agent into the left engine, it actually discharged into the keel through the severed line. That bought me the time I needed to get on deck.

All personnel involved in my flight practiced sound principles of CRM. If any of the tenets of CRM had fallen out during this complex evolution, I probably would have lost the jet.


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Author:O'Neil, Conor
Date:Mar 1, 2015
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