Astro14 said: I’ve talked about Kara Hultgreen’s mishap at length in my F-14 thread. I was involved in the investigation.
How's that are you qualified as an investigator...never heard that before a Navy pilot. I maybe wrong but try to explain?
I’ve been involved in several mishap investigations.
The Navy investigates their mishaps, not the NTSB or other external agencies, unless specific expertise is requested.
Governance of those efforts is found here:
https://navalsafetycommand.navy.mil/Resources/Instructions-Policy-Guidance/
For every aircraft accident, there are three parallel investigations:
1. Safety - root cause, non-attribution, with protected testimony and evidence.
2. JAG - legal culpability and determination of “in the line of duty”.
3. FNAEB - Field Naval Aviator Evaluation Board - determines if this pilot should continue flying.
The three investigations have different purposes, and different protections (or not) for the witnesses and sworn testimony.
They can share physical evidence (basic photos, wreckage, documents describing events) but not testimony or interviews, because the safety investigation protects people from consequence for what they say, and the other two do not. The point of that protection is to encourage honest, open contributions from those involved by protecting them from career, disciplinary, or other consequences.
I’ve done all three types, several of each. Reviewed many when on the staff of a higher headquarters. On more than one occasion, buried in the details of raw evidence, I found something that changed the course of the other investigations. An eye for detail is important.
The three investigations can arrive at different conclusions. The safety investigation may say that the pilot was at fault, while the JAG investigation may say that they were not guilty of misconduct and they performed in the line of duty, and the FNAEB can recommend that they not fly again.
All three, different opinions can be simultaneously true. Someone could have screwed up, but it was not willful misconduct, for example. They also are based on differing evidence.
Our intrepid pilot could tell the safety investigation that they had fought with their wife on the phone the night before, and didn’t sleep well because their wife was threatening divorce over the fact that their girlfriend was pregnant, etc. No repercussions. Sleep was a factor. Distraction was a factor.
They may provide evidence to the JAG that they were back at the hotel by 10PM, the mission was briefed at 08:00, and that they had an adequate window for sleep. The command provided sufficient sleep opportunity and the pilot reported simply that they didn’t sleep well. The JAG determines that the pilot made an error but was performing their tasks in the line of duty, in accordance with SOP, and did not willfully screw up, so they are not guilty of misconduct.
The FNAEB may reach an entirely different conclusion and determine that this pilot is unfit for flying fighters, because they lack the ability to focus and compartmentalize.
In the case of Kara Hultgreen, the JAG investigation was “leaked” to the press. It found that the mid compression bypass valve was stuck closed, and made the engine more susceptible to compressor stall in the landing configuration. It found that she was not guilty of misconduct, that is, that she was not guilty of willfully ignoring procedure.
The press, and public, grabbed on to that investigation as exoneration.
It was not.
The safety investigation found a pattern of poor flying. She frequently was too close to the ship when landing, requiring a much steeper turn (not good), so she “skidded” the airplane by using left rudder (even worse) and induced the compressor stall. She then failed to recognize the compressor stall, failed to apply single engine failure procedures, failed to counter the thrust asymmetry with proper rudder, failed to fly the airplane at the proper angle of attack, and allowed airspeed to decay and then lost control.
All pilot error. Huge, compounding, fundamental errors that caused her death and loss of the airplane.
Matt initiated ejection when she lost control. RIO ejects 0.3 seconds before the pilot and that 0.3 seconds saved his life.
The public thinks she is a “hero” who was done in by a complex airplane.
The pilots think something different altogether.
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