Who Killed Sergeant Henderson?

Two pilots from Service Test, Naval Air Test Center, Patuxent River, Maryland did their preflight on an old CH-53A helicopter at the Naval Air Station. The aircraft had just had its transmission changed and this flight would be a test flight. The pilots were graduates of the Naval Test Pilot’s School and were assigned duties as program pilots for tests involving Night Vision Goggles. The crew chief on this flight was Sergeant Henderson. The aircraft taxied to a location just off the runway where helicopter hover tests were conducted. As the aircraft came to a hover, the aircraft came apart in many pieces killing Sergeant Henderson. Both pilots survived, but one was critically injured. The aircraft was a total loss. If this was a preventable accident as all accident are, then who killed Sergeant Henderson? We need to start with some history to answer that question. The Vietnam War was ending and we had too many Marines. The Marine Corps had promoted several hundred non-commissioned officers to commission rank during the early years of the war and it was time to thin the ranks. I was going to be part of that planned Reduction In Forces. With seventeen years of service, my choices were to go back to enlisted status or accept $15000 and get out. I was currently serving as the Squadron Maintenance Officer aboard a ship off the coast of Viet Nam. It was a shock to get the bad news while we were still fighting a war. Anytime you talk to someone at Headquarters Marine Corps about something complicated, they tell you to send it to them in writing. That was a little difficult to do from the South China Sea. Because of the time differences, I talked to them from a phone in a bar in Manila, Philippines. I could have saved my money because they couldn’t tell me anything that I didn’t already know. It did turn out that they had it wrong and I was an exception to the rule. I was going to go back to my previous Warrant Officer rank at my next duty station. My next assignment was NAS, Patuxent River, Maryland as an Avionics Engineer. Working as an engineer at Weapons Test would have been interesting. On arrival, I was propositioned for another job. They knew about my experience and background in helicopter maintenance. The helicopter accident rate at the Test Center was one accident per month. Personnel were dieing at a rapid rate and something had to be done. The people running the show thought the answer might be me. The avionics job would have been very interesting and the transition from Captain to Warrant Officer would have been easiest in that technical position. Helicopter maintenance was my thing and they needed me so away I went. My position would be Helicopter Maintenance Officer, Flight Test, NATC, NAS, Patuxent River, Maryland. When I got there, we had one of everything, an H-1, H-2, H-3, H-34, H-46 and a H-53. We sometimes had two of the same type of helicopters in our inventory. We only had eight mechanics to handle the maintenance on all of those aircraft. With the war still being waged in Southeast Asia, our supply priority was very low. We were tasked with doing the maintenance on aircraft that were used to develop most of the new helicopter technologies used by the Navy. The H-53 mine sweeping squadrons got their research and development done at the Test Center and so on. Sometimes we would get aircraft on loan for special purposes like the Night Vision Goggle Project. In some cases, we would also get personnel to support those projects. I came up with a plan to stop the accidents caused by poor aircraft maintenance. We had to keep the aircraft flying, but no maintenance mistakes would be tolerated. The only way to do this was with checks and balances. In the Navy and the Marine Corps it’s a system called Quality Assurance or QA. QA is based on an inspection system that uses completed paper work as a fail-safe method to prevent accidents. A pilot or a maintenance shop initiates the paper work and the aircraft is not flyable until it is completed. The completed paper work includes a physical inspection in most cases. This plan is nothing new. It’s a standard throughout aviation, both civilian and military. What made our situation unusual was the lack of resources and the variety of aircraft. A solution to the personnel problem was to draw personnel from other shops to get the job done. Someone at the shop level had to be in charge and responsible for the paper work. That would insure that everything got done including QA and someone would be responsible. Mechanics and technicians in both the Navy and the Marine Corps are trained by aircraft type. A qualified H-2 mechanic knows the H-2, but not necessarily any of the other helicopters. Walking by a machine on the hangar deck doesn’t qualify a person in that type of machine. You can be a helper, but not a qualified technician. For the next two years, we had zero accidents from maintenance caused errors. How did that happen? I could say smoke and mirrors and be close to being right. The real reason was leadership. Picking the right person for the job, utilizing contractor personnel and factory technical representatives and borrowing people from other organizations. Getting my hands dirty when my help was needed to make an aircraft fly. This made it work well for two years and maybe a little longer. My troops knew we were a team. The aviation Night Vision Goggle Project came along with the creation of that technology. It was a joint project between all the services with the Navy in the lead. They needed an aircraft and an H-53A was available from a Marine Corps Reserve Unit. I’m sure they picked that aircraft for a reason. A third pilot was going to fly the aircraft from the cabin using a TV camera and receiver. We had a resident H-53D, but it wasn’t available. The “A” model’s flight controls had to be modified to add control input from the cabin. They still needed a crew chief and some maintenance help to maintain the aircraft. The closest source of H-53 help was HMX-1 at Quantico, VA. They used the big aircraft to ferry the President’s luggage and the press when required. Sure enough, they had an ample supply of H-53 crew chiefs and they were willing to send us one on temporary duty. That’s when I met Sergeant Henderson. H-53As are known for being unreliable. That was the aircraft that didn’t do well in the dessert when they tried to pick-up the Iranian hostages. Sergeant Henderson was doing well with the old bird. Not flying that much at first because the modifications took time to incorporate. After every modification, a test flight was required. Somewhere along the way, the Project Officers decided that they were not getting enough flight time. The aircraft was down and not flying as much as it should. Two Project Officers and their Boss showed up at my office and suggested that I change my maintenance plan to the one that they used at Test Pilot School. Test Pilot School aircraft were all the same and they had more maintenance personnel per aircraft than we did. When all your aircraft are of the same type, you can cannibalize parts from one to the other and improve availability. They didn’t use my shop method to maintain responsibility. All of their personnel worked on all the discrepancies as a group. I told them that I wouldn’t do that. I was transferred to another position soon after that meeting. I was hoping that they would remember the two years before when their aircraft were falling out of the sky and let me continue with my safety of flight procedures. Apparently, they didn’t remember or didn’t care. The old H-53A had a record of fifty percent availability, but they wanted more. Who killed Sergeant Henderson? Was it the young inexperienced pilots who pushed the system too far and too fast? Was it the older Project Boss who should have known better and didn’t? Should I have argued better and longer to keep a safe system? Sergeant Henderson purchased my Warrant Officer bars at the Post Exchange, Quantico. He went home to Quantico every weekend when he could. One day I was a Captain, the next day a Staff Sergeant and the day after that, a Warrant Officer. I didn’t have a uniform for Staff Sergeant, so they gave me the day off. This reduction in rank made doing business with the Navy at Patuxent River more difficult. The Navy pulled rank on me more as a Warrant Officer. I was transferred back to Marine Aviation shortly before Sergeant Henderson died. I wasn’t there when it happen. I still wonder today if I could have done something that would have prevented the accident? All I know for sure is that Sergeant Henderson didn’t kill himself. An organization that wanted too much from too few may have been the culprit. We call them accidents, but there isn’t anything accidental about an aircraft accident. I think I know what killed Sergeant Henderson. Every aviation organization needs a problem solver. This is an individual that has lots of training, experience and intelligence. Sometimes the Navy and the Marine Corps identify these individuals locally and put them in a position to save lives. The Services as a whole do not. They use rank as a substitute for training, experience and intelligence. Sometimes rank works and sometimes it doesn’t. I don’t think the Sergeant had a qualified QA inspector or a problem solver available for his transmission change. One set of eyes on a job like a transmission change isn’t enough. He was on his own. He also didn’t have a buffer between the maintenance being done on the aircraft and the program pilots. These groups operate at different speeds. The pilots want to do everything quickly and aircraft maintenance has to be done slowly and with great precision. The pilots were waiting on a transmission that had to be obtained though a slow supply system. When the new transmission arrived, Sergeant Henderson went from doing nothing to hurry up and get it done yesterday. He needed a buffer to shield him from his pilots. I did that job for two years and it worked pretty well. Who killed Sergeant Henderson? It was the organization that killed Sergeant Henderson. The organization was formed and operated by individuals and they killed Sergeant Henderson. Most “Aviation Accidents” are the result of bad circumstances surrounding the accident’s environment. An Accident Board will blame a part or a person for an accident. In reality, some accidents are caused by bad decisions before the accident. In this case, I think Sergeant Henderson lost the support he needed to maintain and fly his H-53. The Government got rid of the Naval Test Facility several years ago. They let the builders do the testing with the builders paying the bills. I'm not sure that's a good idea.