ASAP: Lessons Learned at 500 Feet Above the Ground

As a C-17 Instructor Pilot and the Pilot in Command (PIC), Maj Katherine Miller had an incredible responsibility to ensure the aircraft and everyone on board remained safe during a recent sortie. With the addition of variables such as a fini flight for a senior officer, deteriorating weather, and unexplained alert messages, she had her hands full managing the situation.

Although the senior officer on board for his fini flight was happy just to be there, Miller still felt pressure to make it a memorable experience out of respect for his many years of service. The first part of the flight, which included airdrop training, went well. All 30 jumpers and the airdrop cargo made it on the drop zone safely. Then the weather turned.

“We were unable to maintain VMC [visual meteorological conditions], which meant that our formation, just us and one other jet, would be unable to practice the visual maneuvers we had hoped to accomplish,†Miller said.

Miller’s C-17 and the second jet then “linked up†using the C-17 Formation Flying System data link for a short while but decided to scrap the rest of the plan and head home when the weather did not improve. It was the right call for the safety of the flight for both aircraft.

Also, with no apparent cause, the pilots in Miller’s jet received a flurry of messages that indicated “No CAT II, [Category II Instrument Landing System], No LAPES [low-altitude parachute extraction system], and No SAAF [Short Austere Airfield]†that had no accompanying checklist message. Because those error messages typically come with other indications that point to a checklist, Miller and the other pilot were uncertain when considering the next course of action. Everything seemed to be working normally, so they decided again that returning home was the safest thing to do.

On the trip back to their home station, in one final attempt to allow the senior officer to sit at the controls for his fini flight, Miller sat on the left and coached the officer into the landing. The flight crew was only 500 feet from the ground when they realized the landing gear had not been lowered. A Ground Proximity Warning System/Central Aural Warning System signal that said “too low, gear†alerted the pilots to the possible catastrophe. They also had not completed the Before Landing Checklist. “I immediately took over and initiated a go-around maneuver. We reentered the radar pattern, swapped out the senior officer for my qualified copilot, and I landed the jet [and] taxied back to parking uneventfully,†said Miller.

“Habit patterns can be easily disrupted when doing nonstandard/unbriefed things, so extra attention must be paid to ensure checklist discipline is enforced and critical steps are not missed,†Miller said.

“I happened to work for this senior officer at the time, enjoyed working for him, and really wanted to make his C-17 fini flight a little special,†Miller said.

“Critical thinking must be applied when dealing with ‘dumb, dangerous, or different’ situations. Putting the SOQ in the seat was definitely different under the circumstances and, in hindsight, probably should not have happened,†Miller said. “Due to the circumstances explained above, and after a tiring day of multiple actual airdrops, we probably should have kept the fully qualified pilots in the seat and finished out the day, rather than trying to make something happen for the fini flight.â€

With eyes on the future, Miller submitted an Airman Safety Action Program (ASAP*) report about her experience to prevent a similar mishap by other Airmen.

Critical thinking must be applied when dealing with ‘dumb, dangerous, or different’ situations.

Maj Katherine Miller

“I’ve sat through many, many safety briefings in my over eight years of flying the C-17, so I won’t say that everyone should ‘know their limits’ or ‘it can happen to anyone.’ Even though those things are very true and important to remember, the thing that really snuck up on me was how insidious all the little links in the chain of events were,†Miller said. “So, my advice would be, don’t ignore the little things because they add up. No flight is perfect, but there is certainly a point where things can get a little too far off the game plan. Think about and discuss that point with your crews.â€

As Miller notes, “flying is dangerous,†but her advice is not to stay on the ground. It is about making smart decisions on when to call it off or when to go ahead.

“Crews should talk about where that line is for that level of experience, for that training profile, for that mission. Even though we had a lot of experience on my jet, we still got into trouble because we just pushed through all the changes of [the] plan; we tried to make it work,†Miller said.

ASAPs can be submitted on an aircrew’s electronic flight bag, at https://asap.safety.af.mil/, or by downloading the Airmen Safety app on Apple or Android devices.
*ASAP submissions are identity protected. Names have been changed to protect the identity of submitted an Airman Safety Action those involved.