AF: Alaska F-22 Crash Due to Pilot Error

In case you haven’t read it yet, it looks like the Air Force is blaming last December F-22 Raptor crash in Alaska on pilot error — with an oxygen generating system-related twist.

The service’s final accident report states that Capt. Jeffery Haney accidentally pointed his Raptor toward the ground while reaching for a switch to activate his jet’s backup oxygen system after the planes’ onboard oxygen generator system  (OBOGS) shut down.

As you know, the Raptor has been grounded for much of the year since that crash due to suspicions that problems with the OBOGS or bleed air systems are causing pilots to experience hypoxia-like symptoms. While the oxygen generating system on Haney’s jet didn’t fail, it did shut down because oxygen from the bleed air system, which feeds the OBOGS, was leaking into the engine spaces- a situation that can start a fire, according to the Air Force’s accident report. The bleed air system is designed to shut off automatically if it leaks air into the engine spaces — without the bleed air system the OBOGS can’t work. When this happened on Haney’s jet, he reached down to activate his emergency oxygen supply via a small ring tucked onto the side of his ejection seat; that’s when he accidentally nudged the controls and pointed the jet toward the Earth and crashed at Mach 1.1 31 seconds later, according to the accident report.

The report places blame on Haney for not activating his EOS fast enough to recover from the accidental dive, not on the problems with the bleed air system:

The board president found, by clear and convincing evidence, the cause of the mishap was the
MP’s [mishap pilot’s] failure to recognize and initiate a timely dive recovery due to channelized attention, breakdown of visual scan, and unrecognized spatial disorientation.

To be fair, the report also cites “organizational training issues, inadvertent operations, personal equipment interference, and controls/switches” as “factors that substantially contributed to the mishap.”

This goes along with emphatic comments that Air Force Cheif of Staff, Gen. Norton Schwartz made to a group of us reporters a couple of months ago, when he said the Oxygen system was not to blame for the crash. Click through the jump to read the report and sound off in the comments as to what you think of the verdict.

F-22CrashReport

  • Jazz ism

    Mmmmm I don’t see anything stating the pilot actually activated the inboard oxygen … To me if he’s slouched forward, he was already passing/passed out from the lack of oxygen. Yes?

    • mike j

      He attempted recovery with a 7.4G pull up 3 seconds prior to impact. He was conscious, but distracted.

      Seriously, read the report before you comment, please.

  • Brian

    ISTR that Raptor pilots have (more than once) successfully landed their planes whereupon it was discovered that the pilot was in a toxed-up condition. This is on planes that DIDN’T have a bleed-air system failure.

    I didn’t notice anything in the Mishap Review Board work that listed the blood chemistry of the pilot.

    I conclude that we don’t have enough data to conclude what condition the pilot was in when the mishap started (bleed system leak).

    Accordingly, the significance given to the “30 seconds without flight controls inputs” over-states what we really know.

    I wish he’d punched out.

    We have a few critical design flaws to fix on this bird:

    1: Bleed-air system shouldn’t leak absent battle damage.

    2: Shutting down one oxygen generation system must automagically activate the next backup in the chain.

    • blight

      Ejecting will automatically engage the oxygen bottle, whereas loss of OBOGS requires pulling that little pin.

  • blight

    “he reached down to activate his emergency oxygen supply via a small ring tucked onto the side of his ejection seat; that’s when he accidentally nudged the controls and pointed the jet toward the Earth and crashed at Mach 1.1 31 seconds later”

    Might poor layout of controls be responsible for a number of controlled-flight-into-terrain crashes over the years?

    • Charley A

      Possible, but it seems definite in this case that the ergonomics are not correct.

    • Splitpi

      And it seems like horrible oversight that the system cannot automatically fall back to the EOS when OBOGS shutsdown without operator intervention.

      I can understand operator intervention during critical systems failure… but the transition should occur automatically as it is critical to life support.

      • blight

        I’m trying to imagine if my car’s brakes required me to pull a small pin on my seat without taking both hands off the wheel. You know, say if I was driving through thick snow. Some things can be attempted one-handed, others should not.

        I guess they will redesign the cockpit to make it easier for the pilot to trigger these, or use more automated failsafe systems?

        • tiger

          I see your point, but to work a Emergency brake on a car you do it one handed?

          • blight

            Yeah, but you’re not moving at Mach 1 to pull a small pin on the side of the seat. In a car, you’re usually parked and pulling a large lever to engage that item.

  • seeker6079

    Okay, so the take away is, apparently: “Flaw in aircraft creates a situation which can be remedied by the pilot. Design of aircraft is such that a slight mistake by pilot in engaging remedy can result in crash of aircraft. Problem is not first design problem, nor second design problem, but pilot. Honour of aircraft is saved, and cookies for all except pilot. Bad pilot, bad pilot.”

    Man, I’ll bet that Harland and Wolff would have paid big money to have had these apologists writing their reports. “Titanic sinks! Nothing to do with hull or watertight containment!”

    • blight

      Accident report indicates that while evading the iceberg, helmsman accidentally failed to turn the wheel hard enough or to order the opposite side boiler to full power to successfully dodge the obstacle, causing the ship to hit the iceberg and sink N hours later

      It wasn’t us, it was a controlled-steerage-into-iceberg event.

      • blight

        Rephrase. Order full ahead on the screw on side closest to iceberg and reverse on the opposite to turn hard away.

        Titanic might’ve been saved by azipods, but the tech wasn’t around, so….

      • seeker6079

        Do tell.
        I’m still trying to get my head around the fact that somebody asserts — presumably with a straight face — that “a design flaw which can cause the engine to catch fire can be corrected at the risk of triggering another design flaw which can cause the pilot to fly into the ground, and it’s all the pilot’s fault, and not design”.

        These guys would blame the car driver for his vehicle falling off the bridge: http://www.youtube.com/watch?v=P0Fi1VcbpAI

        • Chuck

          No design flaw caused the pilot to fly into the ground. The pilot flew into the ground because he became too focused on the flaws, and ignored the flying part.

          • seeker6079

            So, there were flaws so pressing that they fatally distracted the pilot, but the flaws didn’t cause the crash?

          • Chuck

            No. The point is that the pilot needs to keep flying the plane even when dealing with something else. There was 30 seconds between when he first started dealing with the oxygen issue and when he flew into the ground. That’s an awful long time to lose situational awareness.

          • mpower6428

            you’re right, the airforce and its wonder plane are completely blameless in this fiasco……

          • DanS

            Last I checked, most people need a steady supply of oxygen to keep functioning. Unless this guy was a freediver in his spare time, I would expect a drop-off in O2 level would be a pretty significant reason to be distracted.

          • tiger

            Not long at Mach 1. At that speed, things went bad faster than It took me to type this.

          • Chuck

            If the radio in your car is hard to operate, and you crash because you were focused on messing the radio, it’s still not the radio’s fault that you crashed. Nor is it the fault of the radio designer. It’s your fault.

            Same thing here. Pilot’s job is to NOT fly into the ground. He is trained to NOT become so focused on a problem inside the cabin that he ignores the situation outside the cabin. Unfortunately, that’s exactly what he did. His fault.

          • Splitpi

            Chuck,

            A radio in your car is not a vital life support system to your survival while driving. A pretty significant difference….

          • Chuck

            Doesn’t matter what the system is, you can’t take your eyes off the road for 30 seconds while messing with it.

          • blight

            If he didn’t mess with the backup oxygen, he would’ve lost consciousness and crashed anyways: which was the original story. Alternatively he could’ve punched out somewhere in the Alaskan wilderness…

          • Chuck

            But he should be able to mess with the oxygen system without becoming so focused on it that he ignored the fact he was literally flying into the ground.

          • blight

            Is that the fault of trying to a pull a ring-pin instead of something easier to get at? Ejection seats are probably easier to activate than the backup O2 system?

    • Chuck

      The pilot should be able to reach down and operate a control without flying into the ground, even if (i) that control is not very well designed and (ii) the need to operate the control in the first place is because of a system failure.

      • seeker6079

        The pilot should be able to fly the aircraft without having to turn the oxygen system back on because it’s off due to avoid a prevent an engine fire caused by a design flaw.

        • Chuck

          May or may not be a design flaw. Even perfectly designed systems fail sometimes. The pilot needs to deal with it without flying into the ground.

        • Chuck

          One would prefer that the pilot not have to deal with this failure state. But a pilot should be able to deal with this situation without losing situational awareness. His tunnel vision focus on the failure, not the failure itself, caused the crash. That’s pilot error.

          • Mastro

            I guess it depends on how easy it is to engage the backup- if its the matter of hitting one button- yeah- the pilot was JFK JR on a cloudy day.

            If the damn thing didn’t work after repeated attempts- the system might be more to blame than the pilot.

          • tiger

            See above report. They have pictures. The ring & cord is on the side of the Ejection seat.

    • Mark

      As a pilot we are trained to always fly the aircraft and know our situational position. Even while auto pilot is on we peroidically check (once every second to 5 seconds) altitude, attitude and vertical speed indicator. He did error in a big way.

      • Dfens

        Yep, he’s dead and you’re alive, so you must be right. Pretty easy to second guess a dead guy.

      • blight

        The man had 600 hours in F-15s and 880 total (presumably suggesting the remainder would be F-22?). Not a total slouch.

  • jrexilius

    Maybe I am missing something, but if primary oxygen system fails and pilot has to MANUALLY engage the back-up, what happens when pilot is busy, say evading enemy fire and can’t trigger it right away (while he is breathing heavily and exerting himself)?

    Wouldn’t that cause hypoxia-systems?

    It seems all around bad design to me.

  • Ed!

    The plane is so stealthy, it can even hide flaws from its pilots!

    • seeker6079

      It doesn’t hide its flaws, it hides the solutions.

      • Black Owl

        In that aspect the F-35 has the F-22 beat.

  • Uranium238

    Ya’ll are a little too hard on this. Pilot error does happen and yes the F-22 has a serious OBOGS flaw. However, this should not negate the function and purpose of this aircraft. Nevertheless, they SERIOUSLY need to address this issue and I believe the design flaw may actually be associated with the filtration system itself. Cool it on the negativity; every jet has problems, see teething issues of the F-4 Phantom and F-104 for examples.

    • seeker6079

      I don’t disagree, Uranium238. But if the pilot is blamed and the flaws go unaddressed, then how can the problem be solved?

      • Uranium238

        It won’t be unless people realize that there should be easier ways to activate a backup system. We are all human here and make errors, but to blame the pilot on a system that failed to activate it complete BS to me also.

    • tiger

      The Osprey fan club is happy to pass the negativity torch to somebody else finally.

  • seeker6079

    If I had to summarize my concerns about the F-22 problem and this report it is that the USAF’s response is akin to religion or ideology, not scientific inquiry: “The Ideal cannot fail, it can only be failed.”

    • Chuck

      You obviously didn’t actually read the report. They have negative things to say about the aircraft design, but conclude that the aircraft’s problems would not have resulted in a crash without the addition of pilot error.

  • Riceball

    Sounds like to me the AF is saying that the accident was pilot error due to aircraft design fault. Seems to me that while the pilot was obviously ultimately responsible for crashing his plane at the same time flaws in the aircraft design seemed to be factor in the pilot error. It seems to me that the side of the ejection seat somewhere is not a very good place to place controls for any in flight system. Any control for something that might need to be accessed during flight ought to be put somewhere where the pilot can see quickly and easily and not have to grope blindly around for and be tempted (as apparently this pilot did) take his eyes off of his instruments and sky outside and look for the control.

  • JE McKellar

    31 seconds to crash? Seems like more than enough time to fidget with the switch, look up, realize you’re losing altitude, and then pull back on the stick. Am I missing something? I know the lack of oxygen might dull the reflexes a bit, but 31 seconds?

    • Guest A

      You would think that, but you cover alot of ground when your doing mach 1.1. Add to that he was flying at night over mountians, it’s real easy to get disoriented especially while flying with NVGs.

    • Guest A

      And at +51,000 ft if you start to lose O2 your in a BIG world of hurt…

    • Commisar12

      He was flying at Mach 1.1, at those speeds, even small course corrections can make big differences.

    • blight

      Which is precisely what the pilot did. It probably took N seconds to try and mess with the switch, a few more seconds to look at instruments and go “oh no” and then a few more to attempt a recovery. Wasn’t enough.

      I’m surprised nobody has used this moment as an opportunity to argue for two-seaters….

    • tiger

      He was already in a dive. See report copy.

    • blight

      Look at figure 15. He’s taking his eyes off everything to look at the darn ring.

      Trying to imagine driving on black ice in Minnesota winter and having to engage an essential vehicle system by pressing a button next to my seat belt buckle. Remove one hand, risk losing control, fumble around for something in an unintuitive place…

      This lesson has been paid for in blood. Do we redesign the ACES II seat (used in other aircraft too) to make it safer? The dead pilot had ~880.7 flying hours, ~600 in F-15’s. Doesn’t grow on trees.

  • mfo

    I can see how it could happen. OBOGS switches off. The dashboard warning system alerts the pilot. Pilot has right hand on ‘force-sensitive’ stick and left hand operating throttles. He reaches down with left hand to find EOS ring. He is concerned about a fire and lack of oxygen. He can’t immediately grasp the ring so turns his head to the left to try and see it. The movement inadvertently shifts the right side of his body forward pushing the stick forward. The aircraft dives.

    • Chuck

      They did a ground simulation and the simulator pilot made roughly the same control inputs as the incident pilot when they had him try to look down to see the ring. The ring pulls a little wire. If you pull the ring, fail to activate the system and accidentally drop the ring, it could fall down the side of the seat, making it hard to recover the ring in order to try again.

      • seeker6079

        Does that not undermine the concept of “pilot error”? It is arguably pilot error if a pilot makes an error in responding to a situation. If multiple pilots make the same “error” because of the technology does that not indicate that the blame lies with the technology. Put alternatively, if everybody burns their finger at the same point on the toaster, might it not be time to move how high the bread comes out?

        • Chuck

          The simulator pilot made the same input errors. BUT the input errors weren’t what downed that plane. What caused the crash was the 30 seconds between those inputs and the pilot’s next control inputs, to correct the dive. That’s where the pilot error is. That’s WAY too long for a pilot of a plane going Mach 1 to ignore his instruments.

          I don’t see why you’re being so obtuse about this. This guy accidentally put his plane into a dive and then didn’t notice it for 30 seconds while he screwed around with something inside the cabin. How is that NOT his fault? All he had to do was look up at his instruments every 10-20 seconds while he dealt with his oxygen issue and he’d be alive today.

    • Commisar12

      good scenario, plus the jet was going mach 1.1, and the pilot DID try to recover before he crashed, so he wasn’t unconscious

  • Dfens

    Hell yeah it was the pilot’s fault. The airplane has thousands and thousands of bureacrats making the case for why their airplane is perfect. The pilot has no one advocating for his side. What did you think was going to happen? The F-22 co ckpit is crap, anyway. It’s amazing more haven’t died. It’s amazing how the pilots never get credit for “not crashing” an airplane that frequently screws them. And, of course, if they complain it’s back to flying the 1970s model airplane, if not those of 1950s vintage.

    • Black Owl

      Too true.

  • Lance

    I find it funny that many pilots complain about problems with the Raptor’s oxygen system but when it came to accident due to one they BIG generals who championed it will blame the pilot instead of its multimillion dollar planes air system.

  • mfo

    To Administrator: Why? Are pilots forbidden from commenting?

    • Dfens

      There’s a 2000 character limit to postings. Did you over run that? It’s usually equivalent to 2 short paragraphs.

      • mfo

        Ah. Thanks Dfens. That’s probably what happened.

  • Neil

    No aircraft is perfect, no pilot is perfect, shit happens.

    • Commisar12

      true, but try telling that to all the armchair generals here :)

  • Dfens

    I’m having a hard time following the genius of the logic Lockheed used in determining what the airplane should do when it detects a leak in the bleed air system. I mean, it automatically shuts off the air the pilot is breathing? Is that because God forbid the airplane should burn but it’s perfectly ok if the pilot dies of asphyxiation? Hell, couldn’t they warn the pilot that there’s a leak in the bleed air system and let him get his back up system turned on before the air gets shut off, or is that just me thinking again?

    • Riceball

      The better solution would be shut off the OBOG then have the back up kick in automatically without the pilot needing to do anything at all.

      • Dfens

        Yes, you’re absolutely right.

  • Marsh

    By running system simulators(computer programs designed to simulate scenarios), it may have been possible to predict this event.

    • Dfens

      This should have been picked up by the Crew Systems or Human Factors people during the design phase of the program. The problem is the people who design the life support system are the first to decide what happens in cases like this. They have little insight into the overall functioning of the aircraft, so it seems perfectly reasonable to them to shut down their system if a bleed air leak is detected so there isn’t a fire. Final stage bleed air can be 800 - 1000 F, if that’s what they’re using. Crew station people typically have the bigger picture. They’re supposed to be the pilot advocates. They should have seen this and said, “hell no you’re not shutting off the pilot’s air supply.” Essentially the airplane made a catastrophe out of what should have been a routine situation. Given how screwed up the crew station design and human factors groups were on that program, I’m inclined to think they’re the ones who screwed up here, not the pilot.

      • blight

        Reminds me of people writing modular code that isn’t compatible. In any case, it sounds like the design teams didn’t communicate with each other, which doesn’t sound very Skunk Worky at all.

        “Strong but small project offices must be provided both by the military and industry.”

        “The number of people having any connection with the project must be restricted in an almost vicious manner. Use a small number of good people (10% to 25% compared to the so-called normal systems).”

        “The contractor must be delegated the authority to test his final product in flight. He can and must test it in the initial stages. If he doesn’t, he rapidly loses his competency to design other vehicles.”

        “The specifications applying to the hardware must be agreed to well in advance of contracting. The Skunk Works practice of having a specification section stating clearly which important military specification items will not knowingly be complied with and reasons therefore is highly recommended.”

        So what happened with “He can and must test it in the initial stages. If he doesn’t, he rapidly loses his competency to design other vehicles.”? I thought prototypes generally used OTS setups to save time and money..which would suggest having this switch where it was was perfectly normal. Alternatively, the cockpit was redesigned after winning the design contract.

        I thought either Kelly or Ben Rich attempted the google-esque no-cubicles and designers-near-the-shop-floor to ensure craziness was quickly found in the design. Perhaps things have changed a great deal since Kelly’s 14 Rules & Practices?

  • blight

    For reference for armchair people like me who don’t know F-22 ejection seats like the back of their hand:
    http://www.ejectionsite.com/acesiitech.htm

    This sucker is used on F-15, F-16, A-10, B-1B. (I guess everyone else uses Martin-Baker ejection seats?)

    This is what got the pilot killed.
    http://users.bestweb.net/~kcoyne/aceso2.jpg

    The text accompanying this picture is:

    “The emergency oxygen system consists of an oxygen bottle attached to the seat back, an automatic activation lanyard, and a manual pull ring (the green ring visible on the left hand seat pan side in this picture). As the seat rises up the rails, the lanyard activates the oxygen bottle and allows the crewman access to oxygen as long as he is still connected to the seat. During an in-flight emergency that does not require ejection, the oxygen bottle provides breathable air for enough time to return the aircraft to 10000 feet or below where the atmosphere is thick enough for the pilot to breath[e, sic].”

    Notes for ACES II for the F-22 state:

    “The seat also features a larger oxygen bottle for longer lasting emergency oxygen supply.[…] Due to the larger oxygen bottle, both disconnects for the canopy jettison system have been relocated to the right side of the seat.”

    Makes you wonder what were the consequences of moving things around. I’ve never seen an ACES II seat, so I can’t really say…

  • RCDC

    It’s probably a brain freeze

  • Commisar12

    If the jet was going Mach 1.1, it seems that even a short time when the pilot is not minding his controls and instruments means he could have easily lost control of the jet and crashed. Pilot error IS real, and while the backup Oxygen should have kicked in automatically, the pilot would not have suffocated instantly if he didn’t immediately turn on the backup. Sorry, but the amount of hate the F-22 is getting here is unacceptable.

    • TGR

      That is because people on here usually have no idea what they are talking about but feel compelled to share their opinions they believe to be fact.

      • Guest A

        I couldn’t have said it better. If they took the time to read the report attached to the story they would have a better understanding of the situation. Only God and the pilot know what he was thinking during this unfortunate chain of events.

  • RCDC

    I personally would recommend F-22 and F-23 but if there is something wrong with it, it needed to be corrected for the safety of our pilots, the jets and making sure it is in good working condition especially if they need to use it for defense.

  • Guest A

    I’m just going to throw my .02 cents in here and suggest that those of you not really involved in military aviation, look up and read a copy of Approach or the AF equivilant safety magazine to get a better understanding of the thought processes of aircrews and the decisions they make when an incedent occurs.

    • Dfens

      I’m going to suggest you didn’t work on the airplane and I did.

      • Guest A

        No, I didn’t work on this particular airframe. What’s your point?

        • Dfens

          My point is, who the hell are you? There is a very obvious flaw in this investigation. No one could figure out why the pilot’s attention was tunneled on trying to breathe? Are you kidding me? There is also an obvious flaw in the computer logic for dealing with bleed air leaks from the OBOGS system. Now maybe the obvious errors in the conclusions of this study were purely because of stupidity, or maybe they were a result of people coming up with the answer demanded of them. Either way, the system is broken.

          • Guest A

            Ok, I didn’t write the report, nor do I claim to be a subject matter expert on aircraft mishaps. The only person who knows what the pilot was doing in that aircraft was the pilot. The data they pulled from the wreck, and the other pilots testemony is all they really had to go on. What they concluded in the report makes sense to me, being that I’ve been involved in Naval Aviation my entire career and have seen and heard about similar mishaps. I’m not trying to change yours, or anyone elses opinion on here on what they believe was the cause of this mishap. So no need for you to get all butt-hurt about my comments, but since you are the SME on all things F-22, I concede the floor to you Sir…

          • Dfens

            It’s pretty damn easy to second guess a pilot who is dead. Frankly, I’m doing what I can to get that system fixed. It should not shut off the pilot’s air for any reason short of the introduction of a known, extremely toxic contaminant.

          • mfo

            I agree. The pilot should always get the benefit of the doubt. An emergency in a dark cramped cockpit with oxygen depletion. The pilot has to find the EOS ring and pull forward hard. Or the pilot may eject allowing the cord attached to the cockpit floor to automatically activate the EOS.
            Hypoxia is this: http://www.youtube.com/watch?v=_IqWal_EmBg

          • Dfens

            Damn, I’ve seen pilots turn on a crash victim too many times to count. I agree with you, the pilot should get the benefit of the doubt. After all, they often pay for the ride with their lives, and while turning on their fallen comrade might give a someone a comfortable sense of “this can’t happen to me” it is ultimately counter productive and makes aviation less instead of more safe. And frankly, at this point, it just pisses me off. It’s like a damn pack of dogs killing a member of the pack gone lame. It shows about as much class.

  • Matt Holzmann

    sheesh, what sure sounds like a major design flaw gets put down to pilot error. Yay Lockheed Martin!

    Another victory for the bureaucrats and the system over logic. Just another reason we’re losing mid-level officers and enlisted. The level of smoke and BS just keeps on rising.

  • coolhand77

    I’m just gonna say this. I’m not a pilot, nor in the aircraft industry. What I do know is SCUBA. The principle is the same in this situation. EVERYTHING gets put on the back burner when you can’t breath…thats why you dive with a buddy that can give you his spare or his primary in an emergency. I’m not familiar with aircraft O2 systems, but if its anything like a diver, if your air gets shut off accidentally, your first indication is on the next inhale…at which point you realize you have NOTHING to inhale. Doesn’t take a rocket surgeon to see that having a backup system you have to fumble with in the dark is bad juju at that point.

    • blight

      Indeed. Perhaps simulator training may need to include sudden flameouts and OBOGS shutdowns. We need to figure out now how to activate emergency systems, because one day it’ll be over enemy territory, and not just over Alaska.

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