super hornet crash - north arabian sea

8/13/2019 Super Hornet Crash - North Arabian Sea

1/30

DEP RTMENT OF THE N VYCOMMANDER NAVAL AIR FORCE ATLANTIC

1279 FRANKLIN ST.NORFOLK VIRGINIA 23511-2494

Mr . Daniel G. LamotheNat ional Secu r i t y ForeignPol i cy Magazine11 Dupont Circ le NW Ste 600Washington DC 20036Dear Mr . Lamothe:

5720Ser N01L/ 284Dec 12, 2013

This l e t t e r responds to your Freedom of Informat ion Act(FOIA) emai l reques t o f November 1 , 2013 seeking a copy theJAGMAN I n v e s t i g a t i o n i n to the Apri l 8 , 2013 c rash o f the Class Amishap i nvo lv ing an F- 18F j e t t h a t was l o s t in the Arabian Sea.Your reques t was rece ived by t h i s o f f i c e on November 18 , 2013 andass igned case number CNAL2014F000007 . Subsequent c l a r i f i c a t i ono f your reques t i n d i c a t e d t h a t you w i l l accept the bas ici nves t iga to ry ma te r i a l s a t t h i s t ime with t he oppor tun i ty too b ta in copies of the enclosures i des i r ed a t a l a t e r date .

The i n v e s t i g a t i o n has been pag ina ted a t the bottom r i g h t handcorne r fo r eas i e r re fe rence .

The enc losed pages have been reviewed under app l i cab lepor t ions o f t he FOIA s t a t u t e 5 U. S.C . 552) and Secre t a ry o f theNavy In s t ru c t i o n 5720 . 42F . This review ind ica ted a requirementto de le t e the names , ranks and emai l addresses o f mi l i t a r ymembers under 5 U. S . C . 552 b) (6) . Release of t h i s i n fo rmat ionwould r e su l t in a c l ea r l y unwarranted invas ion of personalp r ivacy . Dele t ions have been ind ica ted by plac ing an exemptioncode in place o f the redac ted mate r ia l .

By withholding par t s of the i nves t iga t ion , your reques t hasbeen p a r t i a l l y denied . Because your reques t has been p a r t i a l l ydenied , you are adv i sed o f your r i g h t to appea l t h i sdeterminat ion in wr i t ing to the Judge Advocate General , GeneralL i t i g a t i o n Code 14) , 1322 Pa t te r son Avenue , Su i t e 3000 ,Washington Navy Yard , DC 20374 - 5066 . I am the o f f i c i a lrespons ib le fo r the p a r t i a l den ia l o f your reques t .

An appeal must be postmarked no l a t e r than 60 ca lendar daysa f t e r the da te o f t h i s l e t t e r to be cons ide red . A copy o f t h i sl e t t e r should be enc losed along with a s ta tement exp la in ing whyyou be l i eve your appeal should be gran ted . I t i s recommendedt h a t both the l e t t e r o f appeal and its envelope bear thenota t ion , Freedom of In format ion Act Appeal .


2/30

5720Ser NOlL 28 4J ec 12 2013

There re no fees s s o c i t ed with the p rocess ing o f yourr eq u es t .

n e w ~J . WELSHpta i n J GC U S Navyy di rec t ion ofthe Commander

Enclosure : 1 . Repor t o f I nves t ig t i on w/o encl

2


3/30


4/30

Subj : ACTION OF THE FINAL REVIEWING AUTHORITY REGARDING THECOMM ND INVESTIGATION INTO THE FACTS ND CIRCUMSTANCESSURROUNDING THE AVIATION MISHAP THAT OCCURRED ON08 APRIL 2013 IN THE NORTH ARABIAN SEA

4. In accordance with section 0223 b ) of reference b), acomplete copy of t he investigation i s . forwarded to Commander,Naval Safety Center.5. Point of contact for t is matter i s

b ) 6)

Copy t o:COl iNAVSAFECENCOMUSNAVCENT/COMUSFIFTHFLTCS FWLVFA 122COMCARSTRKGRU 8CVW 7VFA 103USS DWIGHT D. EISENHOWER (CVN 69)

(b ) 6)

2

b) 6)

b ) 6)

000002


5/30


6/30

- - - - - - - - ,. -. - . - - - - --,----------.-: -

: ' .. 0 ' I "

: . . : ... . II . ... ~ E ' .DEP RTMENt OF T H E N VY. COMMANDe.R. C RRiER IR WINOSBVEN. t1NlT 60108 . . .FPC AE 6950M4os .5800Ser: NOQ/113 .30 Apr 13 :

: .

. ::.

.. ...

. ...

/

..-..

:' ;

-FIRST ENDORSEMENT ON (b)(6.) ,_usN 1tr ssqo .of 23.Apr 13From: Commander, Carri er Air Wing SEVEij:To : Commander, Naval Air Force, Atlant icVia: Commander, Carr ier St-rikeGroup E:iGHT

Subj: COMMAND. . INVESTIGATION INTO CLASS A MISiiAP OF VFA..:.H)3 F/ l6FBONO n 66616 THAT OCC)JRRED AT 1320 :oN .aAI?E\ .I. '2.013 . .1. R e a ~ d r e s s e d and forwarded. ,2. On 9 April 2013 l r ~ q u e s t e d (b)(6) _ to. con'cluct a J A G M A ~investigation inquidng int'o the tact and ciicumstai:lces of YFA-103's Class

.. ''A" .Mishap of .a April 2013. (b)(6) reviewed a l l ,relevant evidence, .. .. , i 'lterv i ewed numero1,1_ wi tnessesJ and coo,rdl nated with (b_)(6) for legal advice and inves't igat ive . support ' durihg the c6urse o.f the'i nvestigation. The. results of the i r r v : ~ s t . : i were wi.thin the sctJpe and measure of my request and the: f inal product submitted: to me today .i s well .rece i -ved. I have no disagreement with his f inqings of Fact, Opini_ons orRecommendations as 'stated in enclosure l ) . As stated i n the results , (b)(6) . concluded. that .. th.e cause of the .... rnis l)ap was. the inab i l i ty .to in-fl,i .ght refuel (-IFR) a.nd fuel ~ t a r v a t i o n dt1e . tetrapped fuel. Significant .factors included a fai lure of the aircraf tcommander. to -properly asse.ss ai rcraf t . Qamage a f t ~ r _lmpa_ t ing the -IFR k e t , compounded by n g e s t ~ o n of a large amount of fuel t:h;rough the engine intake

. and fai l i ng to associate the PERF 90 caution with a damaged engine. .., :

.

Recotmlendations incl uded. CVW-7 emphasis and r.evj,.&w pQ];,icy .regarding a,i rcraft ' . ." l


7/30

5800From: b) 6) , USNTo: Commander, Carrier Air Wing SEVENSubj: COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA .Ref: a) Chapter I I JAGMAN 2012 ed.)Encl: 1)

2)3)4)5)6)7)B9)10)

11)12)13)14)15)16)17)18)19)20)21)22)23)24)25)26)27)28)29)30)31)32)33)34)35)36)37)38)39)40)41)

Carrier Air Wing SEVEN l t r 5830 Ser N00/078 of 9 Apr 13Letter from b) 6) , USN, dtd 14 Apr 13Mishap t ranscript from CATTC/ILART of 8 Apr 13Xray Papa Watch log of 8 Apr 13USS DWIGHT D EISENHOWER CVN 69) Tactical Action Officer TAO) logof 8 Apr 13

b) 6) , USN, l t r of 17 Apr 13VFA- 103 Flight Schedule of 8 Apr 13Costs associated with los t aircraf t and equipmentUSS DWIGHT EISENHOWER CVN 69) Air plan for 8 Apr 13Statement of b) 6) , USN, dtd 13 Apr 13Statement of b) 6) , USN, and notes from interview dtd12 Apr 13

b ) 6)Statement of , USN, Aircrew summary dtd 11 Apr 13b) 6)Statement of

b) 6), USN, . USN, Fl i ght Surgeon dtd 20 Apr 13Aircrew summary dtd 12 Apr 13Statement of b) 6)b) 6)Weather forecast for 8 Apr 13

USN, dtd 13 Apr 13, USN, dtd 13 Apr 13Statement of _ b) 6) . USN, and e-mail dtd 13 Apr 13Statement ofstatement of

15 Apr 13 andStatement ofb) 6) , USN, dtd 10 Apr 13b) 6) , USN, and summary of interview dtd

email dtd 22 Apr 13b) 6) _, USN, dtd 14 Apr 13b) 6) , USN, dtd 12 Apr 13, and email dtdtatement of22 Apr 13

Summary of interview with b) 6) , USN, dtd 15 Apr 13Summary of Miser and Pyramid communicatio ns f r om 8 Apr 13Statement of b) 6) USN, dtd 15 Apr 13Statement of b) 6) , USN, dtd 18 Apr 13Statement of b) 6) , USN, dtd 17 Apr 13Compact Disc CD) containing a copy of Aircraft 206 DeployableFlight Incident Recorder Set . DFIRS) data from 8 Apr 13Email from b) 6) 1 USN, dtd 12 Apr 13NATOPS excerpt V-ib-1NATOPS excerpt V-15-1NATOPS excerpt V-15-3NATOPS excerpt I-2-47Emails from b) 6)NATOPS excerpt I-2-14NATOPS excerpt V-16-8

and b) 6) dtd 16 -17 Apr 13Statement of b) 6) , USN, undatedVFA-103 Aircrew l i s t of 8 Apr 13Statement of b) 6)NATOPS excerpts miscellaneous) 1 USN, dtd 18 Apr 13

b) 6) Memorandum for the Record of 15 Oct 13000005


8/30

Subj: COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAPRELIMIN RY STTEMENT

1. Pursuant to enclosure 1) and in accordance with reference (a), a CommandInvestigation was conducted to inquire into the facts and circumstances of aClass A aviation mishap involving the loss of an F/A-18F Super Hornet thatoccurred on 08 April 2013 while conducting routine operations in the NorthernArabian Sea. Both the mishap pi lo t {b) 6) USN, and the mishapWSO, {b) 6) USN, were recovered at sea after a successfulejection from the ai rcraf t . Each sustained minor injuries.2. I am qualif ied to conduct this investigation in accordance with 10 U.s . c. 2255 and A-2-n of reference (a). I am a graduate of the Naval Aviation SafetyCommand Course.3. I have met each of the Convening Authority s directives. I haveinvestigated the cause of the accident and provided my opinions as to anyfault , neglect or responsibi l i ty. I have also provided recommendations tomitigate the possibil i ty of this type of mishap happening in the future.4. USS DWIGHT o. EISENHOWER CVN 69) was on. the 46th day of deployment whenthe mishap occurred. The ship was conducting routine operations in theNorthern Arabian Sea while on her 2013 deployment in support of OperationEnduring Freedom OEF) .5. All relevant information was collected . The original USS DWIGHT D.EISENHOWER CVN 69) Air Department and Operations Department records areretained by the Air Department and Operations Department onboard. All recordsregarding Mishap Aircraft and Mishap Aircrew, to include the Maintenance log,are re ta i ned by Strike Fighter Squadron 103 (VFA-103), homeported at NASOceana, Virginia. All documentary evidence enclosed is either the original ora true representation of the original document.6. . b) 6) , USN, assis ted me in this investigation.7. There were no extensions of time requested.8. All times given are l i s ted in both Zulu Z) and Local (L) time. This wasdone to synchronize the differences in time l i s ted in the substantiatingenclosures or provided by witnesses in their statements.9. References to the mishap aircraf t varied according to the witnesses. I twas alternatively identif ied as VFA-103 Aircraft 206, BEARCAT 21, and VICTORY206. For consistency arid clar i ty purposes, i t is referred to as VICTORY 206throughout this report10. Witness recollections varied significantly as to the timing and sequenceof events following VICTORY 206 s refueling . This was part icular ly true in thelas t 30 minutes leading up to the aircrew s ejection; witness recollections asto fuel states, projected overhead or divert fuel s ta te , communications andother events differed signif icantly. For obvious reasons enclosure (3) thet Iranscr1pt of CATCC/ILART recordings of radio transmissions on 8 April 2013 wasused as a b a ~ e l ~ n e a?ainst which other witness statements, often captured da ysaf ter the av1at1on m1shap occurred, were reconciled. Moreover , i t i s

7 e c o g ~ i z e d that .not al l of the radio transmissions were captured or ref lected~ n t h 1 ~ t r ~ n s c r 1 p t Accordingly, the findings of fact contained in this1nvest1gat1on required the Investigating Officer to reconcile the differences

2 000006


9/30

- - -Subj: COMM ND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAin testimony to reconstruct the mishap sequence of events. In any event, theexact sequencing of events did not preclude the Invest igat ing Officer fromdetermining the underlying cause of th is mishap.11. Findings of fact in i t a l ics contain background information that isnecessary for a complete understanding of th is mishap. This includesinformation regarding operation of the F/A-18E/F as well as informationinf luencing decisi6ns made on 8 April 2013.

FIN INGS OF F CT

I. INTRODUCTION1. Aircraf t side number 206, BUNO 166616, was los t at sea a t approximately0920Z/1320L on 8 April 2013 in the North Arabian Sea NAS), approximately 1.5NM aft of the DWIGHT D. EISENHOWER CVN 69) (hereinafter referred to as IKE ).[Encls (2), (3), 4) , (5), (6), (10), i l ) , (15), i 6 ) , (19), (20), (21), (22),

26), 27), 29) and 37)]II . BACKGROUND

Aircraf t 206 , BUNO 166616 Lot 27)2 . The ai rcraf t involved in the mishap was F/A-.18F Super Hornet, side number206, assigned to Str ike Fighter Squadron ONE ZERO THREE VFA-103). [Encls 2) ,7) , 10 ) , 11) and (21)]

3. VFA-103 was in compliance with a l l required and pert inent maintenancedirec t ives for Aircraf t 206. [Encl (2))4. Aircraf t 206 had flown 38 hours since the l as t phase inspection and had3,371.5 to ta l hours on the airframe. The f l ight hour threshold for ai rcraf trework had not been reached . [Encl 2 ) )5. There were no recent codes noted during pref l ight and servlclng for bothengines was well within l imits. Likewise, there were no outstanding gripes onthe engine . The r ight engine had 3, 322.4 hours and the l e f t engine had4, 119. 4 . [Encl 2) ]6. There were no outstanding maintenance actions or issues related to the fuelsystem, engines, or hydraulic systems for ai rcraf t BUNO 166616 when i t wasaccepted for f l ight on 8 April 2013. [Encl (2))

The F/A- 18E/F Sys tems7. The F-18 is f i t t ed with four in ternal fuselage tanks Tanks 1 through 4),two in ternal wing tanks le f t and r ight. Tanks 2 and 3 are ehgine feed tankswhile Tanks 1, 4, and the wing tanks are t ransfer tanks. The plane ' s fuelcapacity can be increased by adding up to four 480 gallon external fuel tankson the center l ine, inboard or midboard pylons. (Enol (40)]8. The F-18's fuel system is composed of the following subsystems: enginefeed, motive flow, fuel t ransfer , tank pressurizat ion and vent , therma lmanagement, refuel ing, fuel dump, fuel quantity indicat ing, and fuel lowindicat ing. [Encl (40)]

3 000007


10/30

Subj: COMM ND INVESTIGATION INTO THE FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA9. Fuel is t ransferred from the wing tanks to Tank 4 by two motive flowpowered ejector pumps, one in each tank. When Tank 4 is less than fu l l theSignal Data Computer opens both wing motive flow control valves, which directmotive flow to the ejector pumps and t ransfer fuel from the wing tanks to Tank4. When Tank 4 is fu l l the motive flow control valves are closed and normalwing t ransfer is inhibi ted . If motive flow is los t on one side single engineshutdown), the cross-motive shutoff valve opens so that one motive flow systemcan power the ejector pumps in both wing tanks. I f both motive flow systemsare los t the wing tanks gravity transfer to Tank 4. Barik angle changes . orsteady sidesl ip may be required to gravity t ransfer a l l available wing fuel .[Encl 35))10. External fuel, including from the center l ine tank, is t ransferred byregulated engine bleed ai r pressure applied to a l l instal led external tankswith weight off wheels. External tank pressurizat ion i s terminated forinf l ight refueling PROBE -switch in EXTEND). [Encl 40)]11. The EXT TANKS t ransfer switches are for the pylon tanks and the center l inetanks. With the external tanks pressurized, fuel t ransfers when the FUEL LOcaution is displayed regardless of the position of the EXT TANKS t ransferswitches. When in the ORIDE posit ion, pressurizat ion is applied and f ~ l istransferred from a l l external tanks for which the switches are not in STOP . Inthe NORM position, normal t ransfer and refueling of controlled external tank s)is permitted. In the STOP position, t ransfer and refueling of controlledexternal tank s) is prevented except with a FUEL LO caution. [Encl 40))12. During refueling, the soc opens al l refuel valves, allowing fuel tot ransfer into al l internal tanks. External tank pressurization is terminatedwhen the probe is extended, allowing the refuel/defuel l ine to f i l l a l lins ta l led external tanks EXT TANKS switch es) not in STOP). With the PROBEswitch in EXTEND or EMERG EXTD, normal in ternal wing t ransfer is not available.Gravity t ransfer i s s t i l l available. [Encl 40))13. Motive flow t ransfer from the wings is disabled with the IFR probeextended. Transfer will happen only through the gravity check valves when th e pi lo t ro l ls the wings at leas t five 5) degrees. The t ransfer rate thendepends on the amount of fuel in the wings and the amount of ro l l induced inthe aircraf t for gravity feed. The NATOPS specif ical ly states: a) with thePROBE switch in EXTEND posit ion, normal in ternal wing transfer is notavailable, but gravity t ransfer is s t i l l available; b) wing tanks will gravi tyt ransfer to Tank when motive flow systems are los t ; and c) bank anglechanges or a steady s l ides l ip may be required to gravity transfer a l l availablewing fuel. NATOPS does not contain any information regarding the rate fuelwill t ransfer from the wings via gravity feeding. [Encls 34) and 40))14. The APU i s a small gas turbine engine used to generate a source of a i r topower the Air Turbine Star ter ATS) for normal engine s ta r t . A hydraulic motorpowered by the APU accumulator is used to s tar t the APU. The APU receives fuel

f r o ~ the le f t engine feed l ine upstream of the l e f t engine feed shutoff valve,Dur1n? n o r ~ l operation, the APU shaft turns a separate compressor whichsuppl1es a1r for main engine s ta r t . Encl 40))15. The . hydraulic.power supply system is a dual pressure system 3,000 and5,000 ps1), The a1rcraft uses hydraulic power to actuate primary f l ightsurfaces and to run several ut i l i ty hydraulic functipns, such as the landinggear and the refueling probe. Two hydraulic accumulators provide emergency

000008


11/30

Subj : COMl AND INVESTIGATION INTO THE FACTS AND .CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAhydraulic power for cr i t i ca l u t i l i t y functions. The hydraulic power supplysystem incorporates two independent hydraulic systems, HYD 1 (powered by thel e f t engine) and HYD 2 (powered by the right engine). Each system is dividedin to two branches providing four independent hydraulic ci rcui t s . HYD 1ci rcui t s are dedicated solely to f l ight controls. HYD 2A powers both f l ightcontrols and most u t i l i t y hydraulic functions. HYD 2B powers the f l ightcontrols and arrest ing hook and pressurizes both the APU and emergency brakeaccumulators. [Encl (40)]16. Two hydraulic accumulators are provided in the HYD 2B ci rcui t : the APUaccumulator and the brake accumulator. The APU accumulator provides hydraulicpressure to s ta r t the APU las t alternative to res tar t an engine airborne).With a HYD 2 fa i lure (inoperable righ engine), pressure from the APUaccumulator can also be used to emergency extend the landing gear or therefueling probe inf l ight . [Encl (40))

Aircrew17. The Aircraf t Commander {pilot) : b) 6) 1310)(hereinafter referred to as the mishap pilot ) was commissi-oned through theUSNA and designated a Naval Aviator on 27 AUG 2004. b) 6) completedFRS t ra in ing at Str ike Fighter Squadron ONE TW9 FIVE VFA-125) and has deployedmultiple times to the Middle East in support of Operation ENDURING FREEDOMOEF). He has 1959.7 to ta l f l ight hours, 649.6 hours in F/A-18 E/F and 980.7hours in F/A-18 C/D and has flown 55 f l ights in Afghanistan in support of OEF.[Encls (6), (10), 12) and (41))18. At the time of the mishap, the mishap pi lo t had a current Medica l Up Chit,was current and NATOPS Qualified in the F/A-18F, had a current and validInstrument Check, and was a qualif ied Mission Commander. [Encl (12))19. The mishap pi lo t s ta ted that he had approximately 8 hours of sleep thenight pr ior to the mishap. (Encl (41)]20. The Weapons Systems Officer (WSO): b ) ~ )1320) (hereinafter referred to as the mishap WSO ) was commissioned throughthe USNA and designated a Naval Flight off icer on 31 July 2008 . b) 6)completed FRS t raining at Str ike Squadron ONE ZERO SIX VFA-106) in July of2009 and is on his second deployment to the Middle East in support of OEF. Hehas 1262.3 to ta l f l ight hours, 1077.7 hours in the F/A-lBF and 13.1 hours inthe F/A-l8B/D and flown 43 f l ights in Afghanistan in support of OEF. IEncls14) and (41))21. At the time of the mishap, the mishap WSO had a current Medical Up Chit ,was current and NATOPS Qualified in the F/A-18F, had a current and validInstrument Check and was a qualif ied Mission Commander. [Encl (14))22. The mishap WSO s ta ted he had an ample 5 hours of sleep the night pr io rto the mishap and that he averages 5-7 hours of sleep a day. [Encl (11))

III . 8 APRIL 2013Preflight to Refueling Incident

23. The Mishap Sortie was scheduled and approved for f l ight by Command i ngOfficer, VFA 103. The f l ight was scheduled for a 0400Z /0800L launch and a

5 000009


12/30

Subj: COMM ND INVESTIGATION INTO THE FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA

lOOOZ/14001 recovery in support of an OPERATION ENDURING FREEDOM Close AirSupport (CAS) mission over Afghanistan. [Encls (6), (7), (8), (9), (2-1) and24)]

24. The Mishap Sortie was scheduled in support of IKE s 8 April 2013 Air P l a ~ .[Encl (9)]25. The weather brief for the morning mission was as follows: The weatherforecast at launch was Visual Meterological Conditions (VMC). At launch, fewto scattered clouds at 3,000-5,000 feet and scattered clouds at 8,000 feet.Visib i l i ty was forecasted as 4-6 nautical miles (NM)/2-4 NM in dust. Windswere west-northwest at 10 knots gusting to 15. Thunderstorms up to 45,000 feetwere forecast for the Boulevard (the transit corridor from the North ArabianSea to Afghanistan) and southern areas of Afghanistan. Moderate turbulencebetween 28,000-32,000 feet was forecast for the Boulevard and Iran/Pakistanborder. No turbulence was forecast in the area of Afghanistan that BEARCAT 21and 22 would be conducted airborne refueling . [Encl (17))26. The mishap pi lo t and mishap WSO stated they received a good, standard OEFmission brief from CVIC with weather being the main focus of the brief Themishap pi lo t recalled thunderstorms ~ e r e briefed from the o u l e ~ a r d throughcentral/eastern Afghanistan. The mishap WSO stated the expectations were forlayers and thunderstorms on the northern half of the Boulevard info Afghanistanand multiple layers in the south and east Afghanistan.. Divert weather wasbriefed, but not discussed. [Encls (10) and (11))27. VICTORY 206 launched at 0800, completed standard checks and reported readyfor mission. VICTORY 206 was assigned the OEF mission calls ign of BEARCAT 21.The original lead je t experienced a lef t generator fai lure and r e t u r n ~ d to IKE,resulting in the launch of the spare, VFA-143 Aircraft 112, calls ign BEARCAT22, flown by b) 6) , VFA-143 b) 6) (hereinafter referredto as BEARCAT 22 ). [Encls (4), (6), (10), (11) and (18)]28. The mishap pi lo t and mishap WSO reported the weather on the Boulevard wasnot an issue. Enroute to the ir f i r s t tanker, during the t rans i t throughPakistan and into the southern port.ion of Afghanistan, they encounteredthunderstorms up to 31,000 feet and spots of rain up to 45,000 feet. Once thecontrolling agency gave clearance above the weather, a Climb to 33,000 f t , theweather was workable and below the aircraf t The aircraf t were able to descendto below 30,000 for the ir f i r s t refueling. Light turbulence was encounteredduring the f i r s t tanking evolution but i t i not affect the refueling.However, BEARCAT 22 stated he could see storms developing in the area and tothe west. [Encls (10), (11), (18) and (41))29. For the ir mid-cycle tanking evolution, the aircraf t used the same tankertrack as they used for thei r in i t ia l refueling. With cloud layers atapproximately 23,000 feet, no turbulence and clear weather at tanking alt i tude,~ I ~ O R Y 206 joined up and connected with SHELL 73, US Air Force KC-135 , without1nc1dent. [Encls (10), (11) and (18))30. The f i r s t s minutes of th is refueling evolution, during which Victory 206took on a p p r o x ~ m a t e l y 14,800 pounds of gas , likewise was without incident.

H o w e v ~ r SHELL 73 and VICTORY 206 hi t a section of clear ai r turbulence uponenter1ng t ~ e southern part of the track, signif icantly jarr ing both the basketand refuel.lng boom. [Encls (10), 11) and (18))

0000106


13/30

Subj: COM1 1AND INVESTIGJ\TION INTO THE FJ\CTS 1\ND CIRCUMSTJ\N.CES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA31. 1\fter approximately 2 minutes of tanking in signif icant turbulence andreaching 15,300 pounds of gas, the boom unexpectedly moved below the nose ofVICTORY 206 and then back up , resulting in the hose becoming wrapped around thebasket. (Encls 10) and (11)]32. The mishap pi lot brought the throttles to id le to back out of the basket;when simultaneously, the boom returned back above the nose and the hosedetached from the basket. [Encls 10) and (11))33. BEARCAT 22, flying port observation at the time of the drogue separation,did not notice any signif icant deviations between VICTORY 206 and SHELL 73 orobserve the boom movement or the basket separate from the boom. [Encl 18))

Land as Soon as Practical vs. Possible: The In i t ia l Divert Decision34. After backing away from SHELL 73 , the VICTORY 206 aircrew recognized thatthe tanker s refueling basket was s t i l l attached to VICTORY 206 s inf l ightrefueling(IFR) probe and fuel was pouring out of the hose in the direction ofthe r ight intake. They surmised that a significant amount of fuel from thenow-separated refueling hose had entered the r ight engine intake of the mishapai rcraf t [Encls 10) and (11))35. The aircrew then received a R ENG caution with aural tone, a FullAuthority Digital Engine Control FADEC) advisory, channels A and B on ther ight engine lined out and PERF 90 in red on the engine page. [Encls 10) and11))

36. The FADEC, mounted on each engine casing, controls engine operation. EachFADEC computer has two central processor units , channel A and channel B, and i sintegrated with the mission computers, f l ight control computers and thro t t lesNormally, both FADEC channels monitor engine and control system operation withone channel in control and the other in standby.a. Engine status i s reported by the FADEC and appears on the ENG STAUTSl ine of the ENG display. These include NORM, PERF90 , AB FAIL, THRUST, IDLE andSHUTDOWN.b. FADEC/engine degrades fa l l into two categories: minor fai lures which donot affect engine operabi l i ty and significant fai lures that do affect engineoperabili ty.

1) Due to a high level of redundancy, most minor control systemfai lures do not cause any degradation in engine pe rformance ENG STATUS remainsNORM) Inf l ight cockpit indications for these types of failures include: FADECand BIT advisories.2) Significant fai lures which do cause degradation in engineperformance ( inflight and on the ground) include: L or R ENG caution and voice

~ l e t ; :ADEC and BIT advisories; ENG STATUS change on the ENG display; DEGDlndlcatlon for the affected engine channel on the BIT/HYDRO MECH display; andboth CH A and CH B lined out on the ENG display.[Encl (40)]

0000117


14/30


15/30


16/30

Subj: C O M ~ N D INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA

anticipated to be overhead IKE at OBOOZ/12001 . The time of BEARCAT 22 scommunications were at 0718-19Z/lll8-19L.[Encls (10), (11), (15), 18) and 24)}51. The CAOC relayed to IKE that VICTORY 206 was returning early because i tsustained probe damage while refuel ing and was unable to refuel and that i twould be overhead a t approximately 0800Z/1200L, and then corrected the overheadtime to 0845Z/1245L after an update from VICTORY 206. Overhead fuel sta te wasanticipated to be 4500 lbs This information was passed approximately 30minutes prior to the corrected overhead time 45 minutes la ter ) and was wiqelydisseminated to appropriate persons. I t was not passed that the refuelingbasket was s t i l l on VICTORY 206 s IFR probe. [Encls 11), (15), (16), (20),22 ) , 2 4 ) , 25) and 2 6 ) )52. A bingo prof i le of 4700 lbs to Masirah was originally calculated. Whentold that VICTORY 206 would be close to BINGO when they reached IKE the IKE codirected IKE Air Ops Officer that VICTORY 206 was to diver t immediately toMasirah i f they could not arr ive with a minimum of 4700 lbs . Time of th isconversation t ook place pr ior to 0830Z/1230L. There is no indication that thiswas passed to VICTORY 206. [Encls (15), (20), (22), 25) and (26)]

Centerline Tank not Transferring53. Approximately halfway down the Boulevard, the mishap pi lo t and mishap WSOnoticed that the center l ine fuel tank was not transferring. The mishap pi lo tplaced the EXT TANK switch in to the ORIDE position, and the center l ine fueltank began transferring normally. [Encls 10) and (11))54. Th e r ight engine then experienced a momentary compressor s tal l whichstopped after the mishap pi lo t retarded the r ight thro t t le [Encls 10) and{11)) .55. Around th is time, the mishap WSO also noted and informed the mishap pi lo tthat the r ight engine in le t temperature was high. [Encl (11)]

Wing t ransfer i ssues56. The mishap pi lo t and mishap WSO also noticed that fuel from the wing tankswas transferring slower than normal. The mishap pi lo t recalled that each wingtank had approximately 1,500 lbs of fuel. They stated they noticed th isapproximately 200 N from IKE or two-thirds of the way down t he Boulevard andabout the time they established sol id communications with XP (Air Wingrepresentat ive in CVIC, a separate space on the ship from CATCC where squadronrepresentatives are located) . [Ehcls (10), (11)]57. The mishap pi lo t assumed the fuel in the wings was gravity feeding, andattempted to aid the gravity feed by sl ipping and cross controlling forapproximately 15 minutes. [Encl (10)]58. NAVAIR F-18 engineers subsequently calculated that the t ransfer rate for?ravi ty feeding fuel in wing tanks is about 10 pounds a minute. In th is case,

w ~ u l d have ~ k e n up to 40 minutes to t ransfer al l of the useable fuel fromt he ~ ~ t e r n l w1ng tanks in a best-case scenario, and would have in vo lved flyingthe ~ r c r f t for 15 minutes continuously a t an angle of bank greater thandegrees and in a sides l i p. This would have to be done for each wing and would

00001410


17/30

Subj: COMM ND INVESTIGATION INTO THE 'FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA

have transferred a l l but 150 pounds of fuel out of the wing tanks. [Encls (34)and ( 41) 1VICTORY 206 Communications with XP

59. VICTORY 206 informed XP they would be overhead IKE with 4,500-5,000 lbs .offuel with expectation of being able to attempt one Case I I I approach and thenexecute a divert to Masirah . The mishap aircrew also asked XP to ass is t withthe BINGO profi le numbers to Masirah, which they expected would be around 4,500lbs of fuel. The mishap aircrew stated that they had discussed with XP theslow t ransfer of fuel out of the wing tanks, 10-20 lbs per minute, and askedfor any techniques to increase wing t ransfer . (Note: The mishap WSO recal l edinforming XP they would be at 4 800 lbs of fuel on the ball . ) [Encls (10) ,(11) 1 (15) (21) 1 (22) 1 (25))60. b) 6) , airborne as the WSO in VICTORY 210 being flown byb) 6) . (hereinafter CSG Commander ), recalledhearing VICTORY 206 provide the update to XP along with the PERF 90 indication .b) 6) came up on MIDS A (a separate communications frequency) andasked VICTORY 206 to confirm the damage to the refueling probe was the reasonthey would be unable to conduct an airborne refueling. VICTORY 206 repliedthat there was damage to the probe, but did not specify the nature of thedamage or that the refueling basket was stuck on the probe. [Encls (21))61. Aboard IKE, the bingo profi le to Masirah was recalculated to 4500 lbs(4.5) based upon a 70-knot headwind and using a 100, vice 150, drag count.[Encls (15), (22) and (27)]62. With the new profi le, the decision was made to give VICTORY 206 one passat IKE before diverting to Masirah. [Encls (16) and (22)]63. VICTORY 206 was then instructed by XP to contact the CATCC squadronrepresentative (SR) on Button 18 . [Encls (10) and (27)]

VICTORY 206 Communications with SR. 64. VICTORY 206 provided the SR with an overview of the si tuat ion. The mishappi lo t informed him that they were approximately 130 NM from IKE with 6,200 lbsof fuel and estimated they would be overhead IKE with probably about 4,600 or4,700 lbs . The mishap pi lo t also briefed the r ight engine issues (FADECadvisory, PERF 90 condition possibly due to fuel ingestion, and engine surgi ngslightly) and that they had incurred probe damage and thus would not be able torefuel while airborne. No indication was given that the drogue was s t i l l onVICTORY 206's IFR probe or any other indication of engine problems.

0834Z/1234L-0835Z/1235L. [Encls (3), (15), (19), (20) and (27 ) )65. VICTORY 206 was then briefed i t would get one pass at IKE and would divertt o Masirah i f the landing attempt was unsuccessful . VICTORY 206 was alsobriefed that the bingo to Masirah was 4.5 with a 70- knot headwind. Normalbring profi le, when flown correctly, has the aircraf t on deck with a fuel stateof 2.0 . 0836Z/1236L. [Encls (3), (15), (16), (19), (20), (22), (27 ) )66. ~ h e m i s ~ a p pi lo t then passed that there was approximately 1,100 lbs of

f u ~ l 1n the 1nternal wing fuel tanks , tanks 1 and were empty, and Tanks 2 and3 U ~ t under 2000 lbs. He also stated the assumed the tanks were gravityfeed1ng, going down about 10-20 lbs every minute. [N ote: t ranscript has 10 lbs

00001511


18/30

Subj: COMM ND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAevery 20 seconds, but other witness statements put i t at 10-20 lbs per minute.][Encls (3), (11), (19), (20), (21), (27))67. VICTORY 206 was advised to check to make sure the INTR WING control (usedto isolate the wing tanks) switch in the NORM posit ion (normal t ransfer fromand refueling of internal wing tanks permitted), and not the INHIBIT position(normal t ransfer from and refueling of the wing tanks is prevented) . [Encls(3), (11) and (40)]68. Twenty seconds la ter the mishap pilot was asked what would you cal l your'usable' fuel ? The mishap pi lo t replied, 3,700 lbs, i f no additional fueltransferred from the wings. At this point, the mishap pi lo t -stated heunderstood he had to change his assumptions regarding fuel status. From th ispoint forward, he began only refe-rr ing to the fuel in tanks 2 and 3, excludingthe fuel in the wing tanks. The mishap pi lo t la ter ref lected that th is waswhen he f i r s t real ized that VICTORY 206 .was in any in-extremis si tuat ion.0836Z/1236L. [Encls (3) and (10))69. VICTORY 206 was then directed to monitor the ir wings for about 5 minutes,at which point they would decide whether they needed to divert to Masirah whilethey would begin reviewing the NATOPS to investigate the wing t ransfer rateissues. [Encls (3), (21) and 27)]70. VICTORY 206 was not displaying a FUEL XFER caution l ight at th is time.[Encl 3) ]

The CSG Commander Intervenes71. A few seconds la ter the CSG Commander, s t i l l airborne and monitoring thedialogue between VICTORY 206 and the SR, came up on Button 18 and said, I wantyou to send 206 to Masirah r i ~ t now . The time was 0838Z/1238Z. [Encls (3),(10), (11), (15), (19), (20), (21), (22), (25), (26) and (27) J72. The IKE CO heard the CSG Commander's order, but did not know why he hadordered VICTORY 206 to divert . The CO stated he had been waiting to see i fVICTORY 206 was going to be able to arrive on f inal approach a t or above thebingo amount. [Encl (26))73. The CSG Commander, (b)(6)(b)(6) and was u u ~ exper1encea 1n maKing divert decisions, explainedthat two courses of action (COA) came to mind as .he monitored the conversationbetween VICTORY 206 and the SR: COA 1 would be for VICTORY 206 to attempt anapproach to IKE and i f unsuccessful, divert to Masirah; and COA 2 was to makethe decision to divert while VICTORY 206 was s t i l l at al t i tude, thereby notexpending the fuel on an approach. The CSG -Commander directed COA 2 for thefollowing reasons: the stated fuel on deck at Masirah was 1.3, which, while

l e s ~ than the amount specif ied by the NATOPS, was s t i l l enough to sustaineng1ne thrust ; the unknown s ta tus of the wing fuel quantity and transfer; lessthan two miles of vis ib i l i ty at IKE; the BINGO profi le needed to be executedperfectly in l ight of the distance and the headwinds; and f inal ly, the HailMary n a ~ u r e of the ship approach in that i f the mishap pi lot was unsuccessfu l~ t h i s f 7 r ~ t . a t t e m p t the aircrew was now committed to the aircraf t remaining1n the v1c1n1ty of the ship with no possibi l i ty of diverting or refue l in g .(b)(6) viewed th is option as a plan Of las t resort with very high r isk inthat l t would be a potential b a r r i c a d e ~ a s s i s t e d landing or controlled ejection[Encl (19) J

00001612


19/30

Subj: COMM ND INVESTIGATION INTO THE FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN . THE NORTHERN ARABIANSEA

74. The CSG Commander stated having decided upon COA i2 based upon theinformation available at the time, he acknowledged his role as the CSGCommander and associated r isk with his decisions, but wanted to preclude anyindecisiveness by the representatives in AIROPS; therefore, he directed what hethought was the safes t COA, a divert to Masirah. This was his only radiotransmission during the ent i re evolution. He pointed out that no one rebuttedhis decision on the radio or did VICTORY 206's mishap pi lo t state that he didnot have enough fuel to make the divert . [Encl (19))75. The SR acknowledged the CSG Commander s order and immediately orderedVICTORY 206 to diver t to Masirah. The time was 0838Z / 1238L. [Encls (3), (10)and (27)]

Changes to the Divert Field76. VICTORY 206 acknowledged the order to divert to Masirah, approximately 250NM away, and commenced climbing to 42,000 feet, the alt i tude specified for theBINGO profi le. b) 6) believed they were within 10NM of IKE's positionat th is time. [Encls : j ) , (10) and l l)]77. VICTORY 206 inquired about diverting to Muscat, but was denied. Muscat,although 84 miles closer than Masirah (from the end of the Boulevard), is notthe diplomatically preferred divert . C G OPS stated that, per .the Defense

t t a c ~ t o the US Embassy in m a n ~ t h e r e are significant sensi t iv i t iesregarding diverting US mili tary aircraft , even unarmed, into Muscat. Tacticalaircraf t diverts are almost always sent to Masirah, which s about twice as faraway as Muscat, even though Muscat is briefed as an option. Thus, when i t wasthought that VICTORY 206 was just a normal divert and could make t toMasirah with at least 2,000 lbs of fuel, Muscat was not considered as anoption. 0840Z/1240L. [Encls (3), (10), (11), (18), (20), (22) and (41)]78. As VICTORY 206 passed 39,000 feet, the mishap pi lo t informed the SR thatthey were unable to maintain the BINGO profi le airspeed of 200 KCAS. Hereported the wing fuel continued to t ransfer very slowly, and that they weredown to about 2,600 lbs of usable fuel. The mishap pi lo t stated theycalculated they would reach Masirah with 1,200 to 1,300 lbs of fuel, comparedto 2, 000 lbs i they diverted to Muscat. 0851Z/1251L. [Encls (3), (10), (11),(15) I (19) I {20) (21) I (22) I (26) and (27)]79. VICTORY 206 requested to diver to Muscat, and at 0853Z/1253L, was directedto proceed to Muscat. He was also directed to jett ison his ordnance, but tokeep his centerline fuel tank. The IKE CO stated VICTORY 206 was overhead thecarrier at this time . [Encls (3), (10), (11) 1 (15), (19), 2 0) , {21), (22),{26), (27) and (29)]80. In order to jett ison i t s ordnance, VICTORY 206 was told that i t would need

clear the sea space below them to the best of their abili ty eitherv ~ s u a l l y or by using the ir surface search radar or FLIR. [Encls (3) 1 (11),(15) 1 (20), (21) and (22)]81. V I T O ~ Y 206 replied that i t did not have the abi l i ty or the fuel to getdown from ~ t s current al t i tude of 38,000 feet to a ~ m o r e reasonab le alt i tude toSEL J E ~ the ordnance. CO, IKE then informed them that the airspace and seaspace ~ h e vic in i ty were clear based upon radar and other ship 's naviaationand t r a c k ~ n g systems SSDS and GCCS-M). At th is point, VICTORY 206 was'

13 000017


20/30


approximately 25 NM north of IKE. 0853Z/1253L-0856Z/1256L. [Encls (3) (11)(21); (22), 26) and (27))82. The SR then discussed Selective Je t t i son SEL JET) procedures with theaircrew. [Encls (3), (11), (19), (21) and 27)]83 . In the process of discussing SEL JET .procedures with VICTORY 206, the SRreceived word that Muscat had fal len below weather minimums (below 1 milvis ib i l i ty with a ceil ing of less than 100 feet) , and re-directed VICTORY 206 sdivert to Masirah. Victory 206 executed 1 50 to 60 degree le f t heading changeback towards Masirah. 08S7Z/1257L. [Encls (3)1 (10), (11), (15), (19), (20),(21), (22), (27) and (29))84. Divert weather conditions were updated and posted at 08855Z/1255L, andshowed the following conditions: Masirah - winds 250 at 13 knots and 2 milesvis ibi l i ty from dust (0600Z/1000L observation). Muscat- winds of 030 at 11knots and 1 s ta tu te mile of vis ib i l i ty due to dust (0850Z/1250L observation) (Note: The updated weather conditions for these diverts did not l i s tinformation on ceil ings.) [Encl (17)).85. At 0858Z/1258L, VICTORY 206 reported that i t had je t t isoned i t s air - toground ordnance: a GBU-32, a GBU-38 and a GBU-51 1 a total of 2,199 lbs . [Encls(3), (8), (10), (11), (15), (19), (20) and (41))

The Loss of One Engine86. At 0901Z/1301L1 VICTORY 206 reported R STALL, R ENG and R ENG FLAMEOUTcautions with the r ight engine RPM stuck at 67 . A few seconds la ter VICTORY206 reported the flameout went away, but they were gett ing intermittent s ta l l swith the throt t le at about 70 . [Encls (3), (10), (11), (15), (19), (20),( 26) ( 27) and (29) )87. VICTORY 206 also stated i t would be unable to make i t to Masirah [Encls(3), (10), (11) and (22)]88. VICTORY 206 was instructed to jett ison centerline tank and move thethro t t le to idle . 0902(13)Z/ 1302(13)L. [Encls {3) 1 (11), (15) and (20))89. VICTORY 206 reported the je t t ison of the center l ine fuel tank 39 secondsla ter . [Encl (3), {11), (15) and (22))90. At 0903Z/1303L, the SR began walking VICTORY 206 through the Single EngineFlameout procedure. The f i r s t part of th is procedure called for to attempt anauto res tar t of the engine. [Encls (3), (10), (21) and (27)]91. The optimum res tar t envelope is below 25,000 feet. [Encl (31)]92. At 0904Z/1204L, the mishap pi lo t reported the engine had failed tores tar t . Engine was a t 67 with exhaust gas temperature around 850-900Celcius. The SR then informed VICTORY 206 that t would now be a single enginebingo and tha t IKE would recalculate the bingo requirements. [Encl (3)]93. VICTORY 206 reported i t s usable fuel as 1400 lbs with 900 lbs in each wingtank that was s t i l l transferring slowly. 0904Z/1304L. [Encl (3))

18


21/30

Subj: C O M ~ N D INVESTIGATION INTO THE FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAReturn to IKE

94. Aboard IKE, i t was determined that VICTORY 206 would only have 800 lbs offuel on deck Masirah, well below the single-engine bingo minimum of 1800pounds, and Muscat weather precluded a divert to that ai r f ield. At th is point,t was determined to have VICTORY 206 RTB to IKE. [Encls (10), (11), (15),(16), (20), 22) , 25), (26), (29))

95. I t was calculated that VICTORY 206 s fuel rema1n1ng, i f successfullylanding on IKE on f i r s t pass, would be 1400 lbs. [Encl (26))96. VICTORY 206 was estimated to be approximately 40 NM from IKE and iSO NMfrom Masirah and a t a very high alt i tude most l ikely s t i l l around 39,00Dfeet) . Encls (15), 20) and (22))97. At 0905Z/1205L, VICTORY 206 was directed to turn back toward IKE and wasinformed that IKE was going to take them for an approach. Although th isreversal of course was the fourth destination change for VICTORY 206, theprevious adjustments to diverts had a l l been done with the aircraf t at alt i tudeand with re la t ively small heading changes required (e.g, less than 60).(Encls (3), (10), (11), 22) and (27)]98. Having turned towards IKE, the mishap pi lo t continued maneuvering theaircraf t with wing slices and wing dips in an effort to expedite graviiy feedof the fuel from the wing tanks. [Encl (11)]99. Additionally, having begun his descent, the mishap pi lo t then attempted tores tar t the r ight engine by crossbleeding. There i s no indicat ion that hediscussed his intention to do th is with the mishap WSO or the SR. Theattempted crossbleed yielded 0 RPM with the crank switch returning to the OFFposition. (Encls (3), (10), (11), 27) and (34)).100. The mishap pi lot recalled his fuel state at th is point as 900 lbs ofusable fuel with 1000 lbs in each wing tank. [Encl (10)]101. When the attempted crossbleed proved unsuccessful, the mishap pilot thenattempted an Auxiliary Power Unit APU) engine res tar t via the APU switch. Hedid not discuss th is with the mishap WSO or the SR who was backing them up onNATOPS procedures. [Encls (3), 10), 11) and (27)]102. An APU res tar t is the las t al ternat ive for restar t ing an engine andu ti l izes the APU accumulator to s ta r t the APU, The prescribed APU restartenvelope is below 10,000 f t and below 250 KCAS. Finally, s tar t i ng the APUwhile airborne may result in Bleed Air Leak Detection BALD) shutdown due toingestion of exhaust gasses into the APU ducting. The BALD system i s designedto protect the aircraf t from damage resulting from a bleed a i r leak. [Encls31 ) and 40) ]

103. Normal landing gear extension requires an operable r ight engine to~ r o v i d e hydraulic pressure to lower the gear. Emergency landing gear extensionlS a back to normal gear extension and also uses the APU accumulator. Withoutan operabl e r ight engine, once the APU accumulator is depleted in an attempt to

r e s t a r ~ a failed engine airborne, i t is not available for emergency geare x t e n s ~ o n [Encl (40))

15 000019


22/30


104. The mishap pi lot held the APU switch in place for approximately 20seconds, and then shut i t off without bringing the APU online. VICTORY 206 wasdescending through approximately 3 , 000 feet . (Encls (10) and (11))105 . After the APU switch shut off, VICTORY 206 received dual bleed warnings,which were automatically extinguished via the BALD sy s tem . [Encls (10) and11) J

106. Both aircrew pulled thei r green rings to provide emergency oxygen.[Encls (10) and 11)]Final Approach

107. At 0908Z/1308L, the SR talked VICTORY 206 through the Single EngineApproach and Landing and Emergency Extension of Landing Gear procedures. TheSR briefed that t was going to be a half - flap . approach and that they we r egoing to have to blow your gear down (e.g. , extend gear via e r n ~ r ~ e n y m ~ t h o d susing APU accumulator). (Encls (3), {10), (11), {15) , l6) , (20), {21) and(27)]108. VICTORY 206's fuel state put at approximately 1400 lbs of useable fuel.0908 {45) Z/1308 (45) L. [Encls (3), {11) and {27))109. The SR i n s t r ~ t e d VICTORY 206 to switch the flaps switch to half and theninstructed him to rotate [the landing gear] handle and pull i t to detent atwhich point the gear should blow down with the APU accumulator. He thenconcluded by stating, "let us know when you're 3 down and locked. . Time oftransmissions took place between 0909Z/1309L and 0910Z/1310L; [Ehcl (3))110. The emergency landing gear extension is mechanically controlled by theLDG GEAR handle in the front cockpit and uses hydraulic pressure provided bythe APU accumulator. Emergency extension i s mechanically activated by rotatingthe LDG GEAR handle 9 degrees clockwise and pulling to detent (approximately1.5 inches) . Emergency landing gear extension opens the hydraulic ar ming valveand directs APU accumulator pressure to the emergency selector valves. APUaccumulator pressure is used to unlock the doors , releasing the landing gearuplocks and is applied to the drag brace locking actuator and sidebracesdownlock actuator. The nose landing gear then extends by freefall aided byairloads and the drag brace locking actuators while the main landing gearextends by freefal l aided by the sidebrace downlock actuator. (Encl (33)]111. The mishap pi lo t informed the SR that he did not get any indication of thegear down af ter he rotated and pulled the LOG GEAR switch. VICTORY 206'sposition was approximately lONM from IKE. 0912Z/1312L . [Encls 3 ) , {10), (16 )and (19)]

112 . The SR then told 206 to crank the r ight motor to spin the HYDs to getthe gear down.'' This effor t fai led with the right engine RPM not coming backup. 0912Z/1312L-0912Z/1312L . [Encls {3) , (10) and (27)]113 . . The SR then instructed VICTORY 206 to recycle the circui t breakers bypull1ng them out and replacing them. This likewise fa i led with the landinggear remaining in the up position. 0913Z/1:313L-0913Z/1313L. [Encls (3), (10),11) and 27))

16 000020


23/30

Subj: COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA

114. VICTORY 206 was then instructed to emergency extend the IFR probe byswitching i t from no rmal to emergency extend to see i f that would tr igger th eva l ve. 0914(26)Z/1314(26)L. [Encl s 3) 1 10) 1 11), (15), 19) and (21))115. I t is at th i s time that VICTORY 206 f i r s t informs IKE that the probe wass t i l l extended with the refueling basket lodged upon i t . The mishap pilotattempted to cycle probe anyway. [Encls (10), (15), 19) 27) and 29) J116. At 0915Z/1215L, VICTORY 206 reported i t s fuel s ta te as 700 lbs . Airspeedwas 143 KCAS. [Encls 3) and 22))117. VICTORY 206 was then instructed to attempt a crossb l eed res tar t of theright engine for the purpose of energ i zing HYD 2 to get the gear down. He wasinstructed to bring the lef t engine up to 90 , and then to MIL. The crossbleedattempt yielded 0 RPM with the ENG CRANK switch again returning to the OFFposition. This occurred at 0915Z/1315L. [Encls 3) (15), (20), (21), 27) and 34)]118. VICTORY 206 accelerated to 260 KCAS but the r ight engine did notres tar t . RPM indications remained a t 0 with approximately 1000 PSI in HYD 2.HYD 1 was reported as normal . 0916Z/1316L. [Encls 3) and 27) )119. The SR then directed VICTORY 206 to again push the LDG GEAR handle in andpull i t to up, check the circui t breakers, and then attempt to drop the geardown. This resulted in the nose gear coming down, but the mairi landing gearremained in the up position. 0916Z/1316L. [Encls 3) and (27))120. VICTORY 206 was then instructed to accelerate to 350 knots in an attempt to rotate/windmill the r ight motor for the purpose of energizing HYD 2, whichwould in turn, enable them to get the main landing gear down. 0917Z/1317L.[E ncls (3) , 10 ) , (11) , (15), 19) , (20), 21) and (27))121. At 0917Z/1317L, VICTORY 206 reported 3 down and locked a t which pointthe y were instructed to land. VICTORY 206 was approximately NM from IKE withan airspeed between 250-300 knots. [Encls 3), 10) 11 ) , (16), 19) 1 (21),22) and (27)]122. At 0918Z/1218L, VICTORY 206 was at 2 miles behind IKE at 2500 feet, le f tof course and above glideslope. The LSO ~ ~ d e a ~ p d d l e s contact ca l l followedby you're high and l ined up le f t . [Encls 3), (10), 11) , (15), 16 ) , (19),20), 21) and (27))

Fuel Starvation and Ejection123. As V I ~ O R Y 206 was executing the las t portion of his S-turn t owards IKE,the l e ~ t e n g ~ n e flamed out, and al l electrical power was lost . Estimatede l evabon was 1200 feet . The time was 0919Z/1219L. [Encls 3) 6 ) 10) 11)and 2 0 )J124. The mishap pi lo t . fel t the j e t ro l l sl ightly to the r ight . He respondedwith a lef t la tera l stlck and fu l l l e f t rudder, which momentarily stopped therol l . The aircraf t then made an uncommanded pitch over to about 30-40 degreesnose low and rolled r ight . [Encls (10), 11) and (16)]125. At approximately 0919Z/1219L, with VICTORY 206 descending below 11 000feet a t approximately 1.5 NM behind IKE, and with the aircra f t in a steep a ng l e

17 000 021


24/30

Subj: COMMAND INVESTIGATION INTO THE FACTS ~ CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAof bank (estimated 45 degrees with 20-degree nose low), the mishap pi lotreleased the controls and pulled the ejection handle. The mishap pilotestimated the aircraf t was at 60 degree nose down and a 20 degree r ight wingdown when he in i t ia ted eject ion. The mishap pilot made no ejection cal l . Twogood chutes were immediately observed. [Encls 3), (6), (10), 11), (15), (16),(19) (20) (21) I 22) I (25) I (26) I (27) I (29) and (37)]126. The to ta l duration of VICTORY 206 s las t f l ight was approximately 5 hoursand19minutes. [Encls (3), (7) and (9)]127. At the time of the ejection, the mishap WSO was unaware that the mishappi lo t had los t control of the aircraf t and assumed he was moving the aircraf taway from the carr ier for ejection. The mishap WSO was not in proper bodyposition as he was leaning forward to view the clearance away from the ship.[Encl (11)128. The aircraf t continued a slow ro l l to port while diving towards the wakeof the ship. I t impacted the water port side of the wake l e f t wing down andnose low . [Encls (15), (16) and (20))129. Review of the Deployable Flight Incident Recorder Set (DFIRS) indicatedthat there was a to ta l of 1,983 lbs of fuel in the MA a t the moment ejectionwas in i t ia ted . Each tank indicated the following amount: Tank 1, 20 lbs ; Tank2, empty; Tank 3, 320 lbs ; Tank - 11 lbs ; l e f t wing i nternal tank - 902 lbs;r ight wing internal t ank - 606. [Encl (28)]130. The mishap pilot blacked out momentarily upon ejection, but regainedconsc iousness as he was f l oating under his parachute. He had about 5-10seconds under the canopy before hi t t ing the water. During th is time, he sawthe mi shap WSO slumped in his harness about 50-70 yards away and the spot whereVICTORY 206 had entered the water. [Encls (6) and (10)]131. The mishap pilot with his mask s t i l l on, did not complete IROKprocedures whi l e in the ai r . Upon impacting the water, the SEAWARS systemau tomatically detached him from his parachute. He sank approximately, 10 feetbefore his LPU automatically i nflated. As his mask was s t i l l on, he was ableto breathe while submerged. The mishap pi lot surfaced under his parachute,re qui ring him to use the hand-over-hand method to get out from under i t . Hethen used his shroud cutter to cut 5-6 shroud l ines to disentangle himself.The mishap pi lo t then removed his mask and, with diff icul ty due to the injur iessustained to his hands, was able to remove his lap belt that released his seatpan. [Encls (6) and (10)]132. The mishap WSO l ikewise blacked out momentarily, but regained

s n e s s while under his canopy, which he was under longer than the mishapp l l o t ~ enabling him to check his canopy and then release one si e of his. mask.The m 1 ~ h a p ~ S O waited until his feet impacted the water before manual lyreleasl.ng h1s parachute harness. His LPU inf lated automatically. (Encls 6 )and 11)]be3h3: dTihKeEmishfap pilot and mishap WSO landed in the water approximately 1.5 NMl.n a ew seconds af ter ejecting. (Encls (3), (16), (37)]134. The m ~ s h ~ p . p i l o t s hands and knuckles were swollen, and both handssustained Sl.gnl .f t 1 l.Can acerat1ons, and were bleeding profusely. [Encl (10)]

18 000022


25/30


13 5 . The mishap pi lot and mishap wso, who landed approximately 100 yards fromeach other, swam to within 10 - 30 y r d ~ of ~ c h other before the helicopter wasoverhead. [Encls (6) and (10))Helicopter Rescue

136. CANVAS 611 was the recovery plane guard helicopter stationed in portdelta when VICTORY 206 s a i rcrew ejected. [Encls (3) , (6), (16), (37) and(39)]137. CANVAS 611 was conducting a ferry mi s sion from FGS H MBURG (F220) to IKEwhile tasked with plane guard duties . At the time of ejection, CANVAS 611 wascar ry ingthreepassengers . [Encls (3) , (37) and (39))138. At 0919/13191, CANVAS 611 was directed to the downed aircrew with the LSOproviding an in i t ia l vector to thei r location . [Encls (3), (16), (37) and (39)]139. CANVAS 611 requested to drop the three passengers off on IKE beforeexecuting the SAR to ensure room was available i f a l i t t e r recovery wasrequired. This request was denied with -CANVAS 611 being directed toimmediately proceed to the survivors and begin SAR operations. [Encls (3) ,(37) and (39)140. CANVAS 611 arrived on-scene at approximately 0921Z/1321L, and lowered therescue swimmer. rEncls (3) (6) (16) (37) (39) l141. The mishap wso was recovered by a rescue swimmer via a hoist recovery at0934Z/1334L. [Encls (4), (5) , (6 ) , (15), (16) 1 (22), (37) and (39))142. The mishap pi lot was recovered by rescue swimmer via hoist recovery at0945Z/1345L. [Encl (4), (5), (6), (15) , (16) , (22), (37) and (39)1143. CANVAS 611 landed on IKE at approximately 0948Z/1348L. [Encls (4), (5),(16) , (22 and (39 ]144. The aircrew of CANVAS 611 had no complications during the recovery off i rs t survivor, the mishap WSO. During recovery of the second survivor, themishap pi lot , his parachute drifted between CANVAS 611 and the second survivordue to current and winds . [Encls (6), (37) and (39)]145. Weather conditions a t time76 deg F, air temperature 81 degvertical vis ibi l i ty of 6,000 f t .caps. (Encl (6 and (37)]

of recovery were as .follows: water temperatureF, wind 185 at 5 kts, 3 NM visibi l i ty , and aThe s ea state was 5 f t swells with no white

146. CANVAS 611 s crew chief stated having three passengers inside of thehelicopter made i t di f f i cu l t for the aircrew to prepare the cabin for survivorpickup and would have made a l i t t e r pickup very diff icul t . Had the la t te r beenrequired, ai rcraf t seats and racks would have been required to be discarded inorder to make room for the l i t t e rs . [Encls (6), (37) and (3 9))

Post-mishap status of aircrew147. The m i s h a p p i l o ~ had al l of his proper f l ight gear and safety equipmentbut was not wear1ng hls gloves at the time he in i t ia ted ejection. Speci f icgear worn and used can be found in enclosure (6). [Encls (6), (10) and (38) )

19 000023


26/30


~ h P mishao oilot sustained a (b)(6)

b {6

1 10 miAhno oi lo t ' s l i f e st ressors b 6)b) 6)

150. The mishap pilot had no indicators of alcohol use or intoxication at thetime of the mishap. Post -mishap test ing did not indicate an i l legal drug use.(Encl (13) J1 1 'T'h ' mi Ah;m oilot was ; b) 6)

b) 6)152. The mishap pilot tested posi t ive or morphine which was prescribed andgiven to him after t he ejection. [Encl (13)]153 . The mishap WSO had a l l his proper f l ight gear and safety equipment and was properly wearing his f l ight gear when ejection was in i t ia ted . Specificgear worn and used can be found in encl osure (6). (Encls (6), (11) and (38))

b) 6)b ) 6)

{ 13} )155 . The mishap WSO stated during recovery operations, the horse col i ar (LPU-36) was very t ight around his neck and caused extreme discomfort. [Encl {11)]156. The mis hap WSO indicated no l i fe st ressors a t the time of the mishap.[Encl (13))157 . Post-mishap test ing indicated no alcohol use or intoxication or i l l i c i tdrug use by the mishap WSO [Encl {13)]

Closing notes158. The total cost of the F/A- lBF Super Hornet aircraf t BUNO # 166616 andequipment, not including the refueling drogue , lost in the mishap is59,732,379.93. The ai rcraf t cost 41,250,457.00 USD and the additionalequipment totaled 18,459,437.02. [Encl (8}]159. During the entire evo ution and radio exchanges, IKE co was only told andheard expected fuel on deck a t the diverts and then at IKE. At no point while

20 000024


27/30

subj: COMM ND INVESTIGATION INTO THE FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATI ON MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA

monitoring the radios and preparing IKE to receive the mishap aircraf t was afuel s ta te passed to the Captain . [Encl (26))OP N ONS

1 . A l ikely unavoidable separation of an a i r refueling drogue, leaving thebasket attached to V;I:CTORY 206's probe, was the beginning of th is mishap chainof events. The direct cause of the loss of VICTORY 206 was extended operationswith a damaged r ight engine (due to fuel ingestion) that eventually failed, andthe subsequent flameout of the l e f t engine due to fuel starvation. However ,inadequate crew resource management CRM) at nearly every level of the chain ofcommand contributed to the outcome of th is mishap. [FOFs (30), (31), (32),34), 35), 36), (37), 39), (40), 41), (50), 54), (55), (60), (64) , (86),

(92), (93), (99 ) , (100 ) , (101 ) , (116), (123) and (129))2. The f i r s t significant l ink in the causal chain of th is mishap (e . g . ,contributing factor) was the aircrew s fai lure to accurately assess the s ta tusof the a i rcraf t ' s r ight engine immediately following the refueling incident.Having jus t torn the refueling basket from SHELL 73 and the sudden appearanceof a PERF 90 caution, the aircrew fa i led to r e c o g n i ~ e the possibi l i ty t h ~ ther ight engine had sustained serious damage from the ingestion of foreign objectdebris (FOD). While bel ieving that the ingestion of fuel may have impactedengine operabili ty, the aircrew did not consider the possibi l i ty that they weredealing with a compound emergency or see the need to take a more cautiousapproach regarding the operation of the r ight engine. This in i t i al failure to

~ w h t i f the engine signif icantly increased the r isk of a mishap, leading to adecision to execute the long t rans i t from IKE on a dual engine P.rofile .Ultimately, th is engine flamed out af ter i t was determined VICTORY 206 suseable fuel s ta tus was signif icantly lower than in i t ia l ly calculated and uponattempting to execute the bingo profi le specified for an F/A-18 E/F with bothengines online . [FOFs (34), (35), (36), (37), (38), (39), (40), (50), (51),(52 ), (53), (54), (55), (56), (59), (64) , (68), (76 ) , (78) and (86))3. The aircrew's and wingman's collective decision to have VICTORY 206 returnto IKE based on the guidance that a PERF 90 is a Land as Soon as Practicalemergency is part icular ly troublesome. Understanding that a PERF 90 caution sl i s ted as such in NATOPS (and the PCL), i t is not a s ubst i tu te for exercisingsound judgment, considering a l l the other available information and taking in toaccount the ir col lect ive experience to determine the appropriate course ofaction. Although NATOPS does not cover compound emergencies, even Land asSoon as Practical emergencies caution against extended f l ight . With a damagedr ight engine and inabi l i ty to airborne refuel , the crew of VICTORY 206 shouldhave realized the severity of the situation and the cascading effects thatcould compound th is emergency. Despite the lack of ai r wing maintenance

d e ~ a c h ~ e n t , a suitable ai r f ield wa s available in Afghanistan to safely landt h1s a1rcraft . While not responsible for this mishap, BEARCAT 22 should havebeen.more assertive in assessing th is potential compound emergency as weli asthe 1n-country divert decision process. {FOFs (35) , (36), (37), (38), (39),

40), 41), (46 ) and (47) J4 T h ~ ~ i r c r e w s fai lures to accurately assess the ir a i rc raf t ' s condition andsu1tab1l1ty for extended f l ight was f u r t h e ~ compounded by the ir in terpretat ionof C V W ~ 7 Commander s vague divert guidance for aircraf t operation over

A f g h a n 1 ~ t a n , which neither covered compound emergencies nor was intended to bea subst l tu te for sound aircrew judgment. Nonetheless, i t s clear from aircrewstatements that th is guidance contributed to a mindset where, having

21 000025


28/30

Subj;

-- - -- - -COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES S U R R O U N I ~ G THEAVIATION l-1ISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEA

categorized an aircraf t emergency as Land as Soon as Practical while on an_OEF mission, aircrew were expected to get the ir a i rcraf t back to IKE . An AirWing Commander s guidance must be cr i t i ca l ly and routinely reviewed with CVWaircrew to ensure in tent is clear, suff icient coverage of the ~ g r a y areas thatwill inevitably come up i s provided, and aircrew are confident of theircr i t ica l role in the decision-making process. [FOFs (39), (40), (41), (42),(44) and (45)]5. The col lect ive fai lure by the mishap .pi lo t , mishap WSO, and wingman torecognize the impact an extended refueling probe would have on centerline ahdinternal wing tank t ransfer is significant . VICTORY 206's decision to returnto IKE was based upon an assumption that a l l the fuel from the ir centerline andinternal wing tanks would be available. Indeed, VICTORY 206 estimated i t soverheard available fuel state when i t reached IKE would be at least 4,500 lbsini t ia l ly set at 6,500 lbs) , enough fuel to attempt to land on the carrier ands t i l l divert to Masirah, i f necessary. t was only af ter they had committed toreturning to IKE that they realized that wing fueL t ransfer was very slOW andthat approximately 3,000 lbs of wing tank fuel may be unavailable (gravity feedonly, but with aircraf t maneuvering required). Proper recognition of theimpact that the extended IFR probe would have on the ir useable fuel may havecaused VICTORY 206 to real ize the precarious nature ~ thei t fuel state(overhead fuel s ta te would have ranged from 3,500 to 1,500 lbs ) , and made i tclear that the idea of returning to IKE was not the best of course of action.(FOFs 9) , (10), 11), (12), (13), (34), (39), (40), 4 i ) , (50), (53), (56),(57), (66), (67), (68) and (98))6. The lack of NATOPS guidance on the t ransfer rate for gravity feeding whenmotive flow capabili ty is los t also contributed to th is mishap. Uponrecognizing that motive flow of fuel from the wing tanks was lost , the pilotattempted to ai d the gravity feeding by slipping and cross controlling ascalled upon by NATOPS for approximately 15 minutes. Subsequent to th is mishapi t was determined that he needed another 25 minutes to t ransfer all of theuseable fuel from the wing tanks in .a best-case scenario and would haveinvolved flying the aircraf t for 4 minutes continuously a t an angle of bankgreater than 5 degrees and i n a slideslip. Although the aircrew and IKEpersonnel eventually based divert decisions solely upon useable fuel (e.g. ,f uel inside the fuselage), knowledge of th is slow t ransfer rate would havegreatly enhanced decision-making, saving valuabt e time and fu e l in the process.[FOFs 9) , 13} , (57) and (58)]7. A lack of adherence to the fundamentals of CRM, specif ical ly effectivecommunications among al l decision-makers to fully understand the extent ofVICTORY 206's emergency, also contributed to this mishap. VICTORY 206'sin i t i a l request of the CRC in Afghanistan to pass the ir a i rcraf t status andintentions back to the ship did not get communicated accurately (no awarenessat the ship of the basket s t i l l attached to the probe). Once VICTORY 206 wasback within communications range of the CVN, the aircrew could have done a muchbet te r job painting the ful l picture of the ir emergency, aircraf t system'sstatus and useable fuel states for the CVW representative (not in CATCC , thesquadron representat ive (in CATCC and al l those l istening intently on therep frequency. That said, CRM i s a two-way process and the in i t ia lquestioning . of VICTORY 206 by ei ther the CVW representative or squadronrepresentatlve should have been more assertive and direct ive. The fact that noone on the ship was aware that the IFR probe was extended with the basket s t i l lattached unti l minutes before eject ion clear ly reinforces the inadequacy of the

22 000026


29/30

Subj: COMM ND INVESTIGATION INTO THE FACTS ND CIRCUMSTANCES SURROUNDING THEAVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIANSEAin i t ia l dialogue to determine the status of VICTORY 206 s fuel system for al ldecision-makers . {FOFs (50), (51), (59), (60), 64 ) , (66), (68) and (115))8 . As the emergency progressed in the vicinity of the ship, the mishap pi lo t scommunications to his WSO and squadron representative were unsatisfactory .Even more cr i t ical to the outcome of this m i s h a ~ he never discussed h i ~intention to restart the r ight engine usin-g the APU before moving any switches.Had that conversation taken place, i t wou l d l ikely have generated concerns fromthe mishap WSO and squadron representative (and any others familiar with thebasic hydraulic/APU systems on an F-18F) that an APU restart attempt wouldresult in the depletion of hydraulic pressure needed to emergency extend thelanding gear. Loss of emergency g ~ r functionality subsequently required eightminutes of additional f l ight time to rectify (e.g. , get the gear down andlocked) during which the majority of VICTORY 206is remaining fuel was expendedwhile attempting to windmill the r ight engine to regain HYD 2 pressure in alas t - ditch effort to get the landing gear down and locked. In taking theseactions without referencing the PCL, communicating with his WSO or consultingwith the SR aboard IKE, the mishap pi lot violated the most basic tenants. ofCRM, and the APU res tar t attempt led to the self-induced, compound emergenciesthat would ult i mately dim any prospects of a successful recovery aboard theCVN. {FOFs (15), (16), (99), (101), (102), (103), (104); (1{)5 ) , (106), (109 ) ,(110), (111), (112), (113), (114) 1 (116), (117), (118), (119), (120) and (121))9. The CSG Commander s decision to direct VICTORY 206 to Masirah was thecorrect one based upon the available information (3.7 useable fuel and noinformation passed at th is time by VICTORY 206 that i t had a degraded r ightengine). As recognized by the CSG Commander himself, his decision to intervene(and bypassing the IKE CO in the process) was not one in which he made l ight lyand should be the exception. CSG Commanders, especially one who is airborne asa pi lo t in command, must exercise res t ra int in such circumstances and to theextent P,Ossiblel rely on thei r subordinates to make the correct calls . [FOFs(64), (68), (71), (72 ) , (73) and (74))10. The changes to VICTORY 2061s destination from IKE to Masirah, Masirah toMuscat, Muscat back to Masirah1 and f inal ly back to IKE did not signif icantlycontribute to this mishap. While recognizing that fuel was expended inexecuting these course changes , all were made at al t i tude and with theexception of the final 180-degree turn back to IKE, a l l were less than 60degrees. [FOFs (71), (76) (79) (83), (96) and (98) J11. Although weather conditions was the reason that VICTORY 206 did not divertto Muscat, there i s widespread perception that although i t is l i sted as one oftwo p r i ~ a r y d i v e r t f ields for carriers operating in the North Arabian Sea, theperceptlon lS t hat i t is not a viable option due for dip l omatic reas ons. [FOFs(77) and (83)]12. The mishap pi lo t s injur ies were sustained in the l ine of duty and not dueto misconduct. (FOFs (125), (131) , (134) and (148)]13. The mishap WS0 1s injur ies were sustained in the l ine of duty and not dueto mi sconduct. [FOFs 1 ~ 5 ) , (127) and (154)]

OHHEND riONS

1. In l ight of the fact i t is impossible to cover every possible contingencythat may arise, cognizant commanders need to arm aircrew with the tools to ma ke

23 000027


30/30

super hornet crash - north arabian sea

Documents