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Key Takeaways:

  • A C-5B transport, returning to base with one engine secured, crashed after the pilot inadvertently advanced the throttle for the secured engine while leaving another good engine at idle, resulting in the aircraft operating on only two engines instead of three.
  • This critical throttle error, compounded by an early selection of full flaps and a low approach profile, went unnoticed by the entire six-person, highly experienced crew despite clear instrument indications.
  • The investigation cited human factors such as inattention, complacency, and a breakdown in crew resource management, where a "collective inertia" prevented any crewmember from identifying and correcting the multiple deviations.
  • The incident underscores the vital importance of "eternal vigilance" and constant, alert attention in aviation, as established procedures and warnings are ineffective without active human monitoring to prevent catastrophic errors.
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On a cloudless morning in April of this year, a C-5B transport of the 436th Airlift Wing took off from Dover AFB in Delaware, bound for Ramstein Air Base in Germany on a routine supply mission. The C-5 is the United States Air Force’s largest transport; this one’s takeoff weight was 742,000 pounds, including a quarter-million pounds of fuel. Aboard were 17 people; the crew included three pilots and three flight engineers, collectively representing more than 26,000 hours and 92 years of C-5 flight experience.

Shortly after takeoff the crew observed an intermittent warning light for an unlocked thrust reverser on the number two engine, the inboard engine on the left side of the aircraft. An unlocked reverser is a potential hazard-there is a chance of unexpected deployment in flight-and so after due deliberation and cross-checks the crew secured the engine and turned back to Dover. They did not declare an emergency, but did request an expedited approach. They anticipated a routine landing, though at a higher than usual weight; they had, after all, three good engines and a perfectly functional aircraft. A few minutes later, the C-5 lay, a mangled wreck, a third of a mile short of the Dover runway. Thankfully fire did not break out and all aboard survived, although some were seriously injured. Newspaper reports the next day hailed the fatality-free crash as a miracle.

Peter Garrison

Peter Garrison taught himself to use a slide rule and tin snips, built an airplane in his backyard, and flew it to Japan. He began contributing to FLYING in 1968, and he continues to share his columns, ""Technicalities"" and ""Aftermath,"" with FLYING readers.

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