Pilot error blamed in crash of OH-58 Kiowa helicopters

JBLM: Report also says communications problems contributed

May 1, 2012 

A veteran Army pilot should have seen and avoided another helicopter in a Joint Base Lewis-McChord training area in rural Thurston County just before he crashed into it, according to the Army’s first investigation into a December accident that killed four soldiers in two OH-58 Kiowa helicopters.

Yet pilot Chief Warrant Officer Shan Satterfield’s failure to identify the other aircraft was not the sole cause of the accident, according to the document released Monday.

An Army investigator found systemic communications problems in the undeveloped area where the nighttime crash took place – problems that Lewis-McChord officials were aware of early last year. Radio transmissions and radar signals are blocked from reaching an important training area for Lewis-McChord’s growing combat aviation units.

Those dark spots contributed to the Dec. 12 accident in that they prevented an airspace manager from providing accurate information to the two crews during their routine training missions.

Killed in the crash were all four crew members: Satterfield and Chief Warrant Officer Lucas Sigfrid in one helicopter; Capt. Anne Montgomery Rockeman and Chief Warrant Officer Frank Buoniconti, a decorated veteran pilot, in the other.

The investigator also found that the personnel working in the air traffic control center – called Bullseye Radio – did not relay updated information to the crews about their locations when Satterfield changed and apparently deviated from his planned route.

The prudent action would have been for Bullseye Radio to attempt to re-establish contact directly with (Buoniconti and Montgomery) or relay messages through (Satterfield and Sigfrid) in order to prevent the collision,” the investigator wrote.

The dark spots for aviation communications were known to Lewis-McChord leaders. They had been discussed at aviation safety meetings led by garrison commander Col. Thomas Brittain earlier in 2011.

It was called a “high risk” issue in January 2011, but it did not lead to improvements that year.

Lewis-McChord officials were not available to comment on the investigation Monday because the Army is conducting a second inquiry into the accident. That one is being carried out by the Army Combat Readiness and Safety Center at Fort Rucker, Ala.

The first investigation was completed by an officer in Lewis-McChord’s 16th Combat Aviation Brigade, which oversees the aviation squadron that contained the Kiowa crews. It was first reported by Public Radio Northwest News Network.

The crash rattled the South Sound military community just four months after Lewis-McChord welcomed the new aviation brigade. The unit brought more oversight to Lewis-McChord’s existing aviation units, and another 44 helicopters. The base now has 143 in its active-duty fleet.

Buoniconti was a highly decorated aviator who joined the Army in 1994. He had served on four deployments to Iraq and Afghanistan. Satterfield had deployed twice to the war zones.

Sigfrid joined the Army in 2008 and was expecting a child. Montgomery was a West Point graduate who had married another Lewis-McChord helicopter pilot a year before her death.

All of them had the chops to be in the air training at Lewis-McChord, the investigator wrote.

“Buoniconti and Satterfield were … instructor pilots with extensive flight experience and (hours flying with night vision goggles),” the investigator wrote. “The aviators they were training, Montgomery and Sigfrid, were both low time pilots progressing to readiness level 1. These junior aviators were fully qualified to be conducting the training outlined in the flight plan.”

On the night of the accident Buoniconti and Montgomery left Lewis-McChord’s Gray Army Air Field for the training area at 7 p.m. and were operating there at 7:30 p.m.

Satterfield and Sigfrid left the air field at 7:07 p.m. They called Bullseye Radio at 7:36 p.m. to report that they would be moving into the area where Buoniconti and Montgomery were flying.

They acknowledged that at least two other helicopters were in that training zone. Buoniconti and Montgomery did not signal back to confirm that they heard Bullseye Radio’s advisement that another Kiowa would be approaching.

The last transmission to either crew took place at 7:41 p.m. They were reported “overdue” at 8 p.m., and a search crew went looking for them at 8:22 p.m.

Civilian and military personnel who monitor the aviation training site said they rely on dispatches from pilots to track the helicopters. Sometimes, one civilian said, pilots do not report all of their landings in the training areas and they do not describe their positions accurately.

The investigator appeared troubled by a near-miss incident in which two Blackhawk crews were surprised by another helicopter in November 2011. The investigator learned that other near-accidents such as that one usually go unrecorded.

One pilot recommended beefing up the communications gear in the helicopters, such as providing satellite radios to use when traditional radios fail.

“If there was a method to more accurately track aircraft location in the tactical training area, that would provide air traffic control and participating aircraft with more situational awareness,” the pilot told the investigator.

In the wreckage, it was not clear to other aviators how many helicopters went down. One was found at 8:49 p.m. It took another hour to identify the helicopter that held Buoniconti and Montgomery.

Some of the aviators who spoke with investigator kept their comments brief. Others revealed the pain of finding the bodies of their fellow soldiers.

One pilot got to Satterfield’s helicopter and could not identify the corpse he found. He shook the body, and felt for a pulse. The pilot saw dog tags.

“I was shaking and could barely read the text on the tag, but then was able to see that it said, ‘Satterfield, Shan,’” the pilot told the investigator. “I began yelling Shan’s name to see if he would respond but didn’t get any response.”

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