This post has been updated to include additional information from the office of the Commander of Naval Air Forces.
The Navy determined that aggressive and unsafe behaviors by the instructor pilot and the student naval aviator led to a T-45C Goshawk training aircraft crash in October.
Despite the many rules and protocols that were broken during the flight event – and in many of the instructor’s previous flights, and in flights let by other instructors within Training Squadron 7 (VT-7) – the Navy did not recommend any punitive actions, since leadership at both the training squadron and training air wing level has since changed over. However, a number of corrective actions are being taken, including an effort to ensure all instructors are teaching the syllabus – no more and no less – in a standardized way, and an effort to check recorded in-flight data to ensure no unsafe behavior is taking place in the air.
The crash occurred on Oct. 1, 2017, with Lt. Patrick Ruth, 31, serving as the instructor pilot (IP) and Lt. j.g. Wallace Burch, 25, as the student naval aviator (SNA).
“The cause of the mishap was not due to mechanical, maintenance, or weather related issues. The cause of the mishap is not related to a physiological episode on the part of either the IP or the SNA nor due to inadequate written training procedures or directions. Rather this mishap resulted from individual pilot error, a culture within VT-7, and Chief of Naval Air Training (CNATRA) at large, which fostered IPs and SNAs flying their aircraft beyond the bounds of approved Naval Air Training Command (NATRACOM) curriculum, and a failure of leadership to oversee training operations to ensure strict adherence to all approved publications,” Chief of Naval Air Training (CNATRA) Rear Adm. James Bynum wrote in the Navy’s investigation report.
The pair were returning to Naval Air Station Meridian in Mississippi after a week-long event that included several Operational Navigation Low Altitude Awareness Training (ONAV LAAT) events.
“The IP was ‘flat hatting’ (flight conducted at low altitude and/or a high rate of speed for thrill purposes) during various parts of this particular cross country training event, and actively encouraged/instructed his SNA to follow his example,” Bynum wrote.
“The investigation further demonstrated that this IP was overly confident, nonchalant, and aggressive at low altitude training, with limited awareness of the performance capabilities of the T-45C in the LAAT environment. This attitude influenced the IP’s instructional style, and conditioned the SNA to fly the aircraft in an aggressive manner, without correction from the IP.”
Leading up to the crash, Ruth and Burch passed control of the aircraft back and forth to one another and dipped in altitude as low as 210 feet above the ground, when the rules state they must remain at least 500 feet above ground level. At 35 seconds before the crash, Ruth deviated from the required flight path to instead follow the terrain. He assumed control of the airplane 26 seconds ahead of the crash and “commenced a descending turn to demonstrate terrain following techniques. The IP (Ruth) nonchalantly returned the aircraft to the NSA (Burch) 10 seconds before the mishap, and then instructed the SNA to make a hard right turn. What neither the IP nor SNA knew was that they were too slow and too low relative to the rising terrain in front of them and that the attempted control input to recover was beyond the limitation of the aircraft. In response to their maneuvers the aircraft entered into a stall. By the time the aircrew realized they were in extremis, it was too late to eject safely.”
The report – with entries from Bynum, Commander of Training Air Wing 1 (TW-1) Capt. Nicholas Mungas, and Commanding Officer of VT-7 Cmdr. Steven Vitrella – notes several areas of concern, including Ruth’s qualifications as a flight instructor and the reckless culture found within some parts of the training community.
Bynum noted in his portion of the report that “Lt. Ruth was not qualified as a T-45C ONAV instructor since there is no documentation of him completing ground school as required.” Ruth had also never flown that flight path before, the report notes. Bynum also writes that Ruth was an E-2C pilot and therefore had no experience with dynamic flight regimes.
Still, “Lt. Ruth was comfortable with both himself and his student performing aggressive ridgeline crossings, descending turns, and flat-hatting maneuvers that violated the ONAV FTI (operational navigation flight training instruction) and other instructions. Many of the habit patterns and techniques he chose to use during low altitude flights were both violations of existing guidance and unsafe. Throughout the weekend LT Ruth and his student had numerous excursions right to the edge of the aircraft’s performance envelope, with no real understanding of the danger. LT Ruth’s failure to instruct the ONAV syllabus as designed, his fleet background, and his overconfident attitude left him unprepared to recover from the situation in which he put his student.”
Despite those findings, Bynum writes that the deaths, which a medical examiner found were caused by blunt force injuries from an aviation mishap, were “in the line of duty and not due to misconduct.”
Though the actions taken by Ruth and Burch directly contributed to the crash in the dense woods in Cherokee National Forest, the report also addresses leadership and accountability within the chain of command.
“Lt. Ruth and Lt. j.g. Burch did not exercise good [operational risk management] during the flight series between 29 September 17 and 1 October 17 as their procedures were unnecessarily aggressive and were not in accordance with the syllabus,” Bynum writes, but he also adds that “VT-7, Training Air Wing ONE, and CNATRA did not take sufficient action to identify the aggressive flying and deviations from the curriculum and guidelines” that instructor pilots were conducting.
Mungas, the TW-1 commodore, wrote in his section of the report that “VT-7 may have had an aggressive [operational navigation] culture that contributed to this mishap. As indicated by [automatic data recorder] data, a small number of VT-7 instructors were allowing maneuvers outside the [flight training instruction],” though Mungas specifically writes that he believes Ruth’s Instructor Under Training (IUT) teacher “was not part of an aggressive ONAV culture, and that he corrected LT Ruth’s inappropriate maneuver on his first ONAV IUT flight.”
To address leadership and accountability issues, the report recommends several changes to the training syllabus, such as more explicit accounts of the aircraft limitations while flying low-altitude profiles, as well as an effort to ensure standardization in training curriculum and to ensure the instructor pilots are adhering to that curriculum.
“During this investigation it was discovered that CNATRA T-45 IPs were training towards what they thought would best prepare SNAs for the fleet, which is unacceptable,” Bynum wrote, noting that many of the tactics that were taught outside of the formal curriculum were too advanced for the students in the entry-level training squadrons, who are just learning how to fly for the first time and have not yet begun to learn some of the platform-specific tactics that the IPs were teaching them based on their fleet experience in a fighter jet or a propeller plane.
“While instructor pilots within NATRACOM teach students using their fleet experience, they are not to teach advanced tactical maneuvers. … Fleet experienced IPs should explain to the SNAs why the approved curriculum is relevant and essential as the foundation that will enable them to start the development of tactical maneuvers at the Fleet Replacement Squadrons (FRS). The ONAV LAAT syllabus has a defined training syllabus and its critical objectives are clearly defined. It is built in stages that are designed for SNAs to grow with each successive step. The SNAs are expected to learn to aviate, navigate, and communicate from IPs that have successfully completed their own training to be instructors. In this case, the IP (Ruth) engaged in aggressive flying beyond approved training curriculum, to the edge of the performance envelop, and encouraged his student to follow his lead. Ultimately, they flew beyond the aerodynamic limits of the aircraft, which resulted in the mishap,” Bynum wrote.
“I have issued direct orders to all Training Air Wings and Training Squadrons that they fly and train in accordance with the curriculum as promulgated by CNATRA. This incident highlighted the need for intrusive inspections to ensure a uniform, standardized syllabus is being taught by properly trained IPs with auditable training jackets. We have stood up Flight Instructor Training Units at all Wings to ensure standardization, and the correct leadership is now in place within Training Air Wing ONE to ensure that my guidance is followed.”
Cmdr. Ron Flanders, a spokesman for the Commander of Naval Air Forces, told USNI News that “this tragic mishap underscored what can happen when we deviate from standards and our approved curriculum. CNATRA took immediate corrective actions as a result of this investigation to correct lapses in oversight.”
Prior to the crash, Flanders said, new instructors were trained within each squadron, whereas after the crash one of the corrective actions was the standup of the Flight Instructor Training Units.
“By moving the instructor training unit to the Training Wings, we are providing an arms-length, dispassionate third-party beholden to the Training Wing Commodores to hold the squadron instructor pilots to exacting standards while eliminating the pressure to expedite instructor training qualifications. This is in line with the way we use our Wing Weapons Schools in the fleet,” Flanders explained.
Flanders added that several corrective actions were taken and are still ongoing, including: an audit of all instructor pilots to ensure they have fully completed all requirements to serve as a certified flight instructor; a review of the T-45 instructor pilot training process to ensure that all pilots, regardless of aircraft background, are properly trained to instruct student naval aviators in the T-45; an update to all low-altitude training references to ensure they include references to airspeed limits and requirements, which should be completed this week; and an immediate review of the T-45 curriculum to ensure NATRACOM is properly preparing naval aviators for the fleet replenishment squadrons, which should be complete by June.
Additionally, the simulator that instructor pilots and student naval aviators both used do not include the same Terrain Awareness Warning System that the T-45C itself has, nor does the simulator include challenging treelines and other vertical considerations. The report recommends adding the TAWS to the simulator so the students get used to watching their altitude before actually flying in distant locations like Tennessee.
The report notes that Mungas had launched a “further investigation of an aggressive ONAV culture in TW-1. Should any instructors be found to have routinely violated the ONAV or LAAT FTIs, further action will be taken.”
The naval aviation training community took the crash investigation process as an opportunity to rededicate itself to the culture of safety and the strict adherence to standards that are the hallmark of the community. While the corrective actions and the self-reflection on the culture within the training squadrons are meant to prevent similar mishaps going forward, the report makes clear that the Oct. 1 incident was due to Ruth’s and Burch’s actions during their final mission together, which paint a picture of a flight instructor that Mungas calls “essentially a cowboy” and a student pilot trying to keep up with him.
“During the three ONAV flights prior to the mishap, LT Ruth made multiple comments directing LTJG Burch to execute ridgeline crossings or other maneuvers that do not contribute to ONAV training objectives. Examples just prior to ridgeline crossings include: ‘Let’s go dude, [email protected]#$ing love it,’ ‘We need to do this,’ ‘Oh yeah, big ol’ ridgeline crossing here,’ ‘Ready … Do it,’ and ‘Nothing good to do here, maybe coming up there’s one.’ After taking control to aggressively fly over a boat on a lake, LT Ruth stated, ‘Just gave that guy the show of his life.’ Approaching a boat on another lake with LTJG Burch at the controls, LT Ruth asked, ‘Gonna give him a good show?’ On at least four occasions, LT Ruth gave LTJG Burch sudden direction to execute a ‘hard pull’, and at one point teased LTJG Burch for not wanting to pull 4 or more G’s during turns.”
Mungas’s section of the report classifies some of the moves as “airshow maneuvers” and said that Ruth had no recognition that Burch had nearly entered a stall just two flights prior to their fatal one.
“His focus appeared to be on having a fun flight at low altitude, in particular maximizing aggressive ridgeline crossings that violated the [flight training instruction] and giving a ‘good show’ to witnesses of opportunity on the ground,” which the air wing commodore concludes “served no training purpose.”