An Army investigation blamed simple pilot error for a UH-60 Black Hawk crash that killed four soldiers last year, but investigators discovered a glaring problem with Fort Hood's search and rescue system in the process.
After the helicopter failed to check in at the prescribed 30-minute mark on the evening of Nov. 23, it took hours to declare the aircraft missing and send out a search and rescue team to look for it, according to the AR-15-6 investigation into the crash.
"The fact that it took over two and a half hours after the overdue aircraft was declared before notifying Search and Rescue lends credence to the overall atmosphere of complacency and lack of sense of urgency when an overdue aircraft is declared," an investigator, whose name is redacted, wrote in the report's final recommendations.
Army Times obtained the report via a Freedom of Information Act request.
On top of the hours it took to launch a rescue party, the investigation found, at one point the unit in charge of search and rescue claimed that finding a missing helicopter wasn't their problem.
The incident prompted a thorough review of Fort Hood flight operations procedures and, according to recommendations, a safety update to flight training.
Some changes were implemented immediately, according to the investigation, while some are still in the works, according to a statement from First Army Division West commander Maj. Gen. Jeffrey Colt.
"Tragically, this accident was caused by human error," he told Army Times. "The investigation, however, provided us the opportunity to look within our organization at processes and procedures and make applicable changes, in order to mitigate future risks."
Killed in the crash were Sgt. 1st Class Toby Childers, Chief Warrant Officer 3 Stephen Cooley, Sgt. 1st Class Jason Smith and CW3 Michael Tharp.
All four soldiers were assigned to 2nd Battalion, 291st Aviation Regiment, First Army Division West.
'Not in our lane'
On Nov. 23, the aircrew with 2nd Battalion, 291st Aviation Regiment was out on a routine training flight with an aircraft from 7th Battalion, 158th Aviation Regiment around the Texas post when the pilot lost control during a hard turn, the investigation found.
He banked at an angle of 70 degrees, 10 degrees over the recommended limit, causing a stall that he couldn't recover from. The helicopter crashed into some trees before splitting in two, instantly killing the two pilots and two aircrew inside, according to the investigation.
But the post's response to the crash disturbed investigators and prompted a list of recommendations to revamp the way Fort Hood follows up with missing aircraft.
The Black Hawk last checked in at 5:19 p.m. on Nov. 23. According to the report, Hood Radio -- the post's air traffic control center -- should have declared the aircraft overdue and begun procedures to make contact or recover the helicopter if it didn't make contact every 30 minutes.
But 5:49 p.m. came and went. Hood Radio reached out at 5:56 p.m.
At 6:00 p.m., the Black Hawk was declared overdue. Hood Radio notified Robert Gray Army Airfield's base operations, known as Gray Ops, to try to initiate communications and check if the helicopter had just landed back at the unit without radioing in.
Gray Ops spent the next hour or so trying to call the unit's flight operations center, finally getting through at 6:50 p.m. They also tried one of the pilots on a cell phone number, but couldn't get through, and sent an AH-64 Apache that was already in the air to do a search.
When that turned up nothing, Gray Ops called up the installation operations center at 7:40 p.m. to report the helicopter missing and request a search and rescue team.
Sgt. 1st Class Toby Childers (clockwise from top left), Chief Warrant Officer 3 Stephen Cooley, Sgt. 1st Class Jason Smith and CW3 Michael Tharp were killed when their helicopter crashed on Fort Hood. They were assigned to 2nd Battalion, 291st Aviation Regiment, First Army Division West.
Photo Credit: Images via U.S. Army
The lag time is due to a couple of factors, according to the investigation.
"The responsible parties executed one step at a time and waited until completion of the prior step before initiating the next one," the lead investigator wrote.
There was also the sense of complacency, he added, because Fort Hood has nearly 100 overdue aircraft every year, and it's rare that one of them has crashed.
"Due to the high number of overdue aircraft, the culture at Gray Ops has been to not consider an overdue aircraft an emergency situation," he wrote.
Once Gray Ops got in touch with installation operations center, the person on the other end told the dispatcher that it was up to the unit to go find its own helicopter, against standard procedures, saying that it "wasn't in their lane."
It wasn't until 8:30 p.m. -- following calls to III Corps and the Department of Emergency Services -- that the installation operations center finally accepted its responsibility and launched a helicopter, which took about an hour to find the downed Black Hawk.
The various units in that communication chain had different methods of documenting the events and different standard operating procedures, the investigation found, adding to the complexity of the situation and prolonging any efforts to find the air crew.
"Since the accident, overdue aircraft procedures have been updated to include a timeline and overlapping initiation of required steps," the investigator wrote.
Further, the units typed up the facts of the story after the recovery and signed them off on the same time and date, rather than writing down what had happened in real-time.
Recommendations included a top-to-bottom review of overdue aircraft procedures, including regulations, standard operating procedures and paperwork forms to make sure everyone is on the same page and there aren't any outdated or obsolete regulations in play.
The investigator also recommended instituting a hard deck -- a minimum altitude -- for combat maneuver training, to ensure helicopters making sharp turns are high enough off the ground to recover if they stall or lose control.
"Readiness remains our No. 1 priority, and we strive to conduct safe, realistic training with the welfare of our soldiers paramount at all times," Colt said.
Meghann Myers is the Pentagon bureau chief at Military Times. She covers operations, policy, personnel, leadership and other issues affecting service members.
