CRM During DCS Episode 1 CRM During DCS Episode 8 Abstract In March, 2006, Lt Col Kevin Henry experienced one of the worst things that can happen to a single-seat pilot. He was suffering from decompression sickness, and literally losing his mind. As his mental capability continued to degrade, a world-wide team worked together to guide him to a safe landing and the medical attention that would save his life. The different teams involved were separated by continents as well as being from different nations, but all worked together to do whatever they could. This effort demonstrates many of the principles of cockpit resource management and shows how important having all resources available working together can be in an emergency situation. CRM During a Decompression Sickness Episode In March 2006, Lt Col Kevin Henry experienced one of the scariest and most serious malfunctions possible while flying an operational reconnaissance mission over Afghanistan. His brain was malfunctioning. Due to a buildup of nitrogen bubbles in his brain, he was losing the ability to think and perform normal aircraft procedures. By the time he got back to his recovery base, he was losing portions of his eyesight and even lost consciousness several times. Eventually, he was able to land the aircraft and was rushed to receive critical medical care that would save his life. The sequence of events that led to his recovery demonstrate many aspects Human Factors and Cockpit Resource Management (CRM) and demonstrate how they apply in a critical situation.Flying the U-2S Aircraft The U-2 aircraft first flew in 1955. The U-2 that is flown today is different in many ways, but shares some similarities with those early models. It is still a tailwheel aircraft that leaves its outrigger gear (called pogos) that hold the wings off the ground behind when it takes off. This requires the pilot to not only carefully land the aircraft in or near a full stall, but to also balance the wings and fly them to prevent contact with the ground during landing. The current model, the U-2S, is bigger than the original U-2s, has a new engine, has had a glass cockpit installed, and has state-of-the art sensors onboard to fulfill its reconnaissance mission. U-2s are deployed world-wide, gathering the intelligence data for use at all levels of US decision-makers. The pilots that fly the U-2 are a special group. They all volunteer to fly the U-2, and submit an application package once they have enough experience flying other aircraft. They can come from any aircraft in the US Air Force, as well as from any of the other US military services. If selected for an interview they go to Beale AFB, California, for the interview, including three flights in a training model of the U-2 to see if they will be able to master the aircraft known as the DragonLady, the hardest aircraft to fly and land in the US Air Force. Due to the difficulty of landing the aircraft, especially after lo.

1. CRM During DCS Episode 1
CRM During DCS Episode 8
Abstract
In March, 2006, Lt Col Kevin Henry experienced one of the
worst things that can happen to a single-seat pilot. He was
suffering from decompression sickness, and literally losing his
mind. As his mental capability continued to degrade, a world-
wide team worked together to guide him to a safe landing and
the medical attention that would save his life. The different
teams involved were separated by continents as well as being
from different nations, but all worked together to do whatever
they could. This effort demonstrates many of the principles of
cockpit resource management and shows how important having
all resources available working together can be in an emergency
situation.
CRM During a Decompression Sickness Episode
In March 2006, Lt Col Kevin Henry experienced one of the
scariest and most serious malfunctions possible while flying an
operational reconnaissance mission over Afghanistan. His brain
was malfunctioning. Due to a buildup of nitrogen bubbles in
his brain, he was losing the ability to think and perform normal
aircraft procedures. By the time he got back to his recovery
base, he was losing portions of his eyesight and even lost
consciousness several times. Eventually, he was able to land
the aircraft and was rushed to receive critical medical care that
would save his life. The sequence of events that led to his
recovery demonstrate many aspects Human Factors and Cockpit
Resource Management (CRM) and demonstrate how they apply
in a critical situation.Flying the U-2S Aircraft
The U-2 aircraft first flew in 1955. The U-2 that is flown today

2. is different in many ways, but shares some similarities with
those early models. It is still a tailwheel aircraft that leaves its
outrigger gear (called pogos) that hold the wings off the ground
behind when it takes off. This requires the pilot to not only
carefully land the aircraft in or near a full stall, but to also
balance the wings and fly them to prevent contact with the
ground during landing. The current model, the U-2S, is bigger
than the original U-2s, has a new engine, has had a glass
cockpit installed, and has state-of-the art sensors onboard to
fulfill its reconnaissance mission. U-2s are deployed world-
wide, gathering the intelligence data for use at all levels of US
decision-makers.
The pilots that fly the U-2 are a special group. They all
volunteer to fly the U-2, and submit an application package
once they have enough experience flying other aircraft. They
can come from any aircraft in the US Air Force, as well as from
any of the other US military services. If selected for an
interview they go to Beale AFB, California, for the interview,
including three flights in a training model of the U-2 to see if
they will be able to master the aircraft known as the
DragonLady, the hardest aircraft to fly and land in the US Air
Force. Due to the difficulty of landing the aircraft, especially
after long missions, the U-2 pilot has another pilot, referred to
as the “Mobile,” drive out behind the aircraft during the
approach to landing to advise the pilot on landing the aircraft.
The mobile also preflights the aircraft while the pilot is getting
suited up and pre-breathing, as well as acting as a safety
observer and wingman while the pilot is in the local area. Like
many other USAF platforms, the U-2 also has a supervisor of
flying (SOF) during all operations. The SOF is an experienced
instructor that can provide advice and assistance, as well as
providing liaison between other agencies, such as the weather
office, and the pilot-mobile team.
The operational ceiling of the U-2 is classified, but it flies over

3. 70,000 feet. Due to the extreme altitude, pilots wear a full-
pressure suit (FPS) for flight. This is basically the same suit
the space shuttle astronauts wear for launches. The FPS is
necessary as a backup to cockpit pressurization. Armstrong’s
line is at approximately 63,000 feet; above this altitude blood
boils at body temperature. A loss of cabin pressure would be
deadly without the backup provided by the FPS. The FPS is
rather bulky and tends to reduce the tactile feedback the pilot
get during flight, as well as providing barriers to
communication and doing normal activities. This is something
the pilots adjust to during training. The cockpit of the U-2 is
pressurized only to about 29,000 feet, necessitating the pilot
pre-breathe 100% oxygen for least an hour before flight. This
washes nitrogen out of the bloodstream and body tissues to
minimize the chances of getting decompression sickness (DCS).
DCS can take many forms, from the Bends that many divers are
familiar with, to skin rashes, bubbles in the lungs causing
difficulty breathing (the Chokes), or bubbles along the spine or
in the brain known as a central nervous system (CNS) “hit.” A
CNS hit is one of the most serious problems that can happen to
a pilot, but can be one of the hardest to diagnose. Due to the
pressure or blockage of blood flow to different parts of the
CNS, symptoms can vary from minor to life-threatening. They
can also present as almost anything, from tingling feelings to
loss of eyesight, loss of cognitive ability, and death.DCS
Episode
Lt Col Henry was filling in for the commander of the deployed
squadron he was at in March 2006. On the morning of the
incident, he took care of a few duties and went to get suited up
in his FPS for the flight. He had trouble getting a good seal
around his face when he put the helmet on. The poor seal was
allowing ambient air from the suit into the cavity around his
face, meaning he wasn’t getting 100% oxygen and that nitrogen
from the ambient air was able to enter his system. He thought
he fixed the problem, but was somewhat rushed trying to ensure

4. he would be able to make an on-time takeoff. The rest of the
preflight and the beginning of the mission were normal
(Alyworth, 2006a).
Approximately two hours into the flight, Lt Col Henry had the
first signs of trouble. He began to feel tired and developed a
serious headache. At first, he didn’t recognize these symptoms
as a major problem. He thought perhaps he was just dehydrated
(Cloutier, 2006). By three hours into the flight, serious
symptoms began to manifest themselves. He began having
trouble breathing, probably the results of the Chokes, although
he thought he was just hyperventilating. Then he saw the
aircraft go into a 30 degree roll. Although it was just a
hallucination, Lt Col Henry didn’t realize that at the time, he
just knew something was wrong. Since he was also having
trouble breathing, he decided to activate the backup oxygen
system. This requires pulling a small green knob with 10-15
pounds of pull. It took him two hands to do it. At this point, he
needed to transfer navigation files to head home. Lt Col Henry
couldn’t remember how to transfer the files using the glass
cockpit (Alyworth, 2006a). By this time it was clear to him that
he needed help.
For the missions that Lt Col Henry was flying in March, the
aircraft uses a data and voice link that allows communication to
intelligence personnel back in the US. This would provide a
critical link to his recovery. He confessed over the link to the
mission operations commander (MOC), an intelligence Captain
in the US that he was having problems. The MOC was able to
get in touch with Lt Col Russell, the commander of one of the
U-2 squadrons at Beale, and have him come in (Cloutier, 2006).
Initially, Lt Col Russell didn’t know what was happening, just
that he was called in the middle of the night because there was a
problem with a flight on the other side of the world. When he
began talking to Lt Col Henry, he quickly realized how serious
the situation was. He couldn’t comprehend even simple

5. instructions, like “Turn south,” much less more complicated
instructions on working the navigation system. Lt Col Russell
had to give directions on flying back to base and avoiding
overflight of unfriendly countries by telling Lt Col Henry,
“Turn right” and “roll out” (K. Henry, personal interview,
January 12, 2007).
The trip home was several hours long, and saw a worsening of
problems. Lt Col Henry vomited in his helmet, and after
opening it to try to clean off his visor so he could see, he
couldn’t get the visor to close properly. This meant that
ambient air was mixing with the 100% oxygen he was supposed
to be breathing, leading to hypoxia in addition to the DCS
symptoms. He lost his ability to see colors and could no longer
interpret the basic instruments he was used to flying. He was
flying back across the Indian Ocean slumped against the side of
the cockpit, blindly following instructions from Lt Col Russell.
All this time, Lt Col Russell and the intelligence personnel were
in contact with the deployed location over the phone and
internet chat, keeping them informed on the situation. The
personnel at the deployed location notified their leadership as
well as the Host Nation (HN) personnel (K. Henry, 2007).
When it became time to lower the gear to begin descending
from altitude, Lt Col Henry couldn’t see the gear handle. He
was developing blind spots. In the descent, he lost the ability to
see that airspeed indicator, but got a warning that his airspeed
was high, so he leveled off with the throttle at idle. Soon he
was in a stall and didn’t even realize it (Alyworth, 2006b). The
HN had launched some fighters to escort Lt Col Henry, so Lt
Col Russell suggested that the HN fighters buzz Lt Col Henry to
try to get his attention and lead him to the base. Records later
showed that the aircraft was in a full stall for over 3 minutes.
The noise of the Mirages flying by closely in afterburner woke
him out of his stupor. Lt Col Russell told Lt Col Henry to
follow the Mirages (K. Henry, 2007).

6. As he was approaching the base, Lt Col Henry vomited again,
shorting out his microphone. From this point on, Lt Col Henry
could not talk to anyone, but he could still hear. Lt Col Russell
kept talking to Lt Col Henry throughout the rest of the flight,
trying to calm him and get him to land the aircraft. Although he
was able to follow the Mirages to the field, Lt Col Henry
proceeded to fly around the pattern for the next 45 minutes,
flying within feet of the ground and even between hangars
(Alyworth, 2006b). The SOF and mobile attempted to give Lt
Col Henry directions, but he could not follow them. After
almost crashing, Lt Col Henry woke up, and Lt Col Russell told
him that he either needed to get it together and land the aircraft,
or eject from the aircraft (K. Henry, 2007). At this point, Lt
Col Henry was able to perform a textbook pattern and landing,
incredible considering his condition. After landing, the mobile
instructed Lt Col Henry to stop on the runway and shut down
his engine. By the time they were able to open the cockpit, Lt
Col Henry was unconscious and unresponsive.
Luckily for Lt Col Henry, the chief US doctor deployed to this
location at that time just happened to be the USAF expert on
DCS. In fact, he had earlier that day, before news of Henry’s
problem, initiated an exercise to test how to respond to a DCS
case (Alyworth, 2006c). Now those procedures were put to the
test. The HN base commander had offered a helicopter to be on
standby when he heard of Henry’s condition. As soon as he was
out of the aircraft, they loaded him into the helicopter and flew
him to a HN facility that had a dive chamber to attempt to get
the nitrogen in Lt Col Henry’s brain to absorb back into his
tissues and blood. It took four dives in the chamber, but
eventually Lt Col Henry recovered.
Conclusion
This paper only touches on the CRM principles demonstrated
during this DCS episode; an entire book could probably be

7. written detailing it all. From this brief overview, many of the
principles become evident. From the organizational culture,
team performance, communication, decision making, leadership
and followership, theory of the situation, situational awareness,
to risk assessment and analysis, all can be demonstrated during
the reaction to this incident. Even though many of the examples
are not of the traditional, pilot-directed communications, but of
the rest of the involved teams using CRM principles to recover
the pilot and aircraft, the fact remains that the principles taught
in CRM training can be critical to the safe return of aircraft and
the saving of lives.
References
Cochran, C. (2004). Crew Resource Management: Single Seat,
but Not Alone. Approach, May/June, 28-29
Fiorino, F. (2006). Fighting Human Error. Aviation Week &
Space Technology, 165, 22, 47.
Fowler, R. (2003). CRM And The Single Pilot. Plane and
Pilot , September, 58-61
CASE STUDY ANALYSIS GUIDANCE
The case study provides examples of how CRM can break down
in an operational environment. List as many examples as you
can find, numbering them 1, 2, 3, etc.
When you finish you will be able to identify the HFACS areas
that contributed to the DCS episode.