Two Army investigations into a deadly 2011 helicopter crash at Joint Base Lewis-McChord cited pilot error as the primary cause of the accident, but both paved the way for improvements that could help prevent another tragedy.
The crash took the lives of Chief Warrant Officer 3 Frank Buoniconti, Capt. Anne Montgomery, Chief Warrant Officer 3 Shan Joseph Satterfield and Chief Warrant Officer 2 Lucas Daniel Sigfrid.
It took place just as Lewis-McChord officials were evaluating helicopter safety procedures to prepare for a big expansion of their aviation forces. Officers said the crash investigations shaped some of the ways they revised policies for the incoming helicopter units.
“The accident may have caused us to reflect on some areas we didn’t see,” said Col. William Gayler, deputy commander of Lewis-McChord’s 7th Infantry Division. He oversees the largest helicopter unit at the base, the 16th Combat Aviation Brigade.
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According to the reports, Buoniconti and Montgomery were flying in a training zone when Satterfield and Sigfrid moved into the area some time before 8 p.m. on Dec. 11, 2011. All four were experienced pilots qualified to be in the air that night.
No one knows if the two helicopter crews communicated with each other. It’s also not clear what they heard from air traffic control at Gray Army Airfield, according to one of the investigations, because the helicopter piloted by Buoniconti and Montgomery might have been flying too low to get the notice about Satterfield and Sigfrid’s path.
Air traffic control had limited visibility of aircraft on radars when they flew below 600 feet; radio transmissions also were spotty in the challenging, wooded terrain of South Sound Army training areas.
Both investigations identified several contributing factors to the accident that, if fixed, would improve safety for pilots.
The first investigation, conducted by an aviation brigade officer for Lewis-McChord’s I Corps, urged commanders to:
• Clarify exactly when they expect pilots to speak directly to each other while in the air.
• Follow through on plans to buy equipment letting air traffic controllers see helicopters when they dip below 600 feet.
• Require more frequent communication from air traffic control to pilots.
The officer noted that representatives from the base’s aviation units had listed the limited communication between helicopters and air traffic control at low altitudes as a “high risk” problem since early 2011.
“This created an unsafe training environment for the aircrews,” the investigating officer said.
A second, more extensive investigation was carried out by experts from the Army Combat Readiness/Safety Center at Fort Rucker, Ala. The News Tribune obtained the report through the Freedom of Information Act, but it was so heavily redacted that reporters could not glean much usable information from it.
Gayler said it mirrored the I Corps report by citing pilot error as the primary cause of the accident while acknowledging other factors.
The aviation command at the base responded to the critique by:
• Relocating some exercises to the open expanses of the Yakima Training Center.
• Revising flying regulations on Lewis-McChord.
• Better defining terms in flight rules.
• Improving radio transmissions so pilots can communicate with air traffic control at lower altitudes;
• Taking steps to buy radar sensors to fill in the dark spots at air traffic control. The radar equipment should be operational late next year.