Super Hornet Crash - North Arabian Sea

DEPARTMENT OF THE NAVY
COMMANDER NAVAL AIR FORCE ATLANTIC

1279 FRANKLIN ST.
NORFOLK, VIRGINIA 23511-2494
Mr . Daniel G. Lamothe
National Security Foreign
Policy Magazine
11 Dupont Circle NW, Ste 600
Washington DC 20036
Dear Mr . Lamothe:
5720
Ser N01L/ 284
Dec 12, 2013
This letter responds to your Freedom of Information Act
(FOIA) email request of November 1 , 2013 seeking a copy the
JAGMAN Investigation into the Apri l 8 , 2013 crash of the Class A
mishap involving an F- 18F jet that was lost in the Arabian Sea.
Your request was received by this office on November 18 , 2013 and
assigned case number CNAL2014F000007 . Subsequent clarification
of your request indicated that you will accept the basic
investigatory materials at this time with the opportunity to
obtain copies of the enclosures if desired at a later date .
The investigation has been paginated at the bottom right hand
corner for easier reference .
The enclosed pages have been reviewed under applicable
portions of the FOIA statute (5 U. S.C . 552) and Secretary of the
Navy Instruction 5720 . 42F . This review indicated a requirement
to delete the names , ranks and email addresses of military
members under 5 U. S . C. 552(b) (6). Release of this information
would result in a clearly unwarranted invasion of personal
privacy . Deletions have been indicated by placing an exemption
code in place of the redacted material .
By withholding parts of the investigation, your request has
been partially denied . Because your request has been partially
denied, you are advised of your right to appeal this
determination in writing to the Judge Advocate General , General
Litigation (Code 14) , 1322 Patterson Avenue , Suite 3000 ,
Washington Navy Yard , DC 20374 - 5066 . I am the official
responsible for the partial denial of your request.
An appeal must be postmarked no later than 60 calendar days
after the date of this letter to be considered. A copy of this
letter should be enclosed along with a statement explaining why
you believe your appeal should be granted . It is recommended
that both the letter of appeal and its envelope bear the
notation , " Freedom of Information Act Appeal ."
5720
Ser NOl L/ 28 4
J?. ec 12, 2013
There are no fees associated with the processing of your
request .
n e w ~
J . WELSH
ptai n , JAGC , U.S. Navy
y direction of
the Commander
Enclosure : 1 . Repor t of I nvestigation w/o encl
2
COMMANDER NAVAL AIR FORCE ATLANTIC
1279 FRANKLIN ST.
NORFOLK, VIRGINIA 23511-2494
5830
Ser N01L/247
7 Nov 13
From:
To:
Subj:
Commander, Naval Air ForceAtlantic
File
ACTION OF THE FINAL REVIEWING AUTHORITY REGARDING THE
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES
SURROUNDING THE AVIATION MISHAP THAT OCCURRED ON
08 APRIL 2013 IN THE NORTH ARABIAN SEA
Ref: (a) (b)(6) ltr 5800 of 23 Apr 13
(b) JAG Manual, Chapter II
1. Reference (a) has been reviewed in accordance with reference
(b). Further endorsement is considered unnecessary; therefore,
the investigation is final and will be retained at this command
for a period of two years from the date of this action. Any
further correspondence. regarding this matter should be forwarded
accordingly.
2. Summary. On 8 April 2013, while VFA 103 F/A-18F aircraft
206 (BUNO 166616) was conducting inflight refueling with a US
Air Force KC-135 over Afghanistan, the tanker's refueling drogue
separated from its hose and the basket ' remained lodged on 206Js
extended refueling probe. Fuel from the refueling drogue was
ingested in 206's right engine, causing damage. During the
transit back to USS DWIGHT D. EISENHOWER (CVN 69) in the North
Arabian Sea, the right engine experienced compressor stalls.
The loss of motive flow transfer capability (due to the extended
probe) significantly reduced the amount of fuel available in the
aircraft's wing tanks. Once in the vicinity of EISENHOWER, a
decision was made to divert 206 to Oman. During the divert, the
right engine failed, and 206 did not have sufficient fuel to
continue the divert on a single engine. Upon return to the ship
for landing, 206's left engine also flamed out due to fuel
starvation, requiring the aircrew to eject approximately 1.5 NM
behind t he carrier.
3. The reference (a) report of investigation has been
substantially re-written. The final investigatiqn is included
as an appendix. The findings of fact, opinions, and
recommendations, as contained in this report of investigation,
are approved.
000001

Subj : ACTION OF THE FINAL REVIEWING AUTHORITY REGARDING THE
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES
SURROUNDING THE AVIATION MISHAP THAT OCCURRED ON
08 APRIL 2013 IN THE NORTH ARABIAN SEA
4. In accordance with section 0223(b ) of reference (b), a
complete copy of t he investigation is. forwarded to Commander,
Naval Safety Center.
5. Point of contact for this matter i s
(b )(6)
Copy t o:
COl'iNAVSAFECEN
COMUSNAVCENT/COMUSFIFTHFLT
CS FWL
VFA 122
COMCARSTRKGRU 8
CVW 7
VFA 103
USS DWIGHT D. EISENHOWER (CVN 69)
(b )(6)
2
(b)(6)
(b )(6)
000002
. - ------
Commander, Cerrler Strtke Group EIGHT
Unk60104
FPO AE
SECOND ENDORSEMENT on (b)(6) , USN, 1 tr 5800 of 23 Apr 13
From: Commander, Carrier Strike Group EIGHT
To: Commander, Naval Air Force Atlantic
5830 .
Ser N02/ 064
21 May 13
Subj: COMMAND INVESTIGATION INTO CLASS "N' MISHAP OF VFA-103.
F/A-18F BUNO 166616 THAT 1320 ON 8 APRIL 2013
1. I concur with the findings of fact, .opinions and recommendations
of the investigating officer.
2. Summary. On 08 April 2013, VFA-.103 F/A-18F .Aircraft 206 (BUNO
166616), was involv.ed in an aircraft mishap w.hile returning to USS
DWIGHT D. (CVN 69)-', located in the Nortp Arabian Sea, from
a scheduled daytime mission in support of Operation ENDURING FREEDOM
(OEF). During airborne refueling in Afghanistan, caused
the u.s. Air Force KC-135 refueling basket to detach from its .hose .and
remain affixed to the extended probe of A/C 206. During the transit
back to. the carrier, A/C 206 experienced right engine stalls, degraded
engine operation, and ultimately flameout of both the right and left
engines. Both aircrew safely ejected wi-th no major injuries, (l.nd were
recovered at sea. The total cost of equipment iost in the mishap.
(including the aircraft) is $59,732t379.93.
3. The primary cause of the mishap is attributed to d.eficiencies in
Crew Resource Management by the pilot, comprised of (1) failure to
communi cate timely and prqper1y with the Weapons Syetem Operator (WSO)
or the squadron representatives (SR), who could have assisted with the
emergency; and (2) failure .to use established NATOPS emergency
procedures and checklists.
Copy to.:
COMNAVSAFECEN
CVW-7
' . . .
VFA-103
(b )(6)
(b )(6)
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. DEPARTMENt OF NAVY
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FPC AE 6950M4os.
5800
Ser: NOQ/113 .
30 Apr 13 :
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FIRST ENDORSEMENT ON .
(b)(6.)
,_ usN 1tr ssqo .of 23. Apr 13
From: Commander, Carri er Air Wing SEVEij:
To: Commander, Naval Air Force, Atlantic
Via: Commander, Carrier St-rikeGroup E:iGHT
Subj: COMMAND. . INVESTIGATION INTO CLASS "A" MISiiAP OF VFA..:.H)3 F/l6F
BONO n 66616 THAT OCC)JRRED AT 1320 :oN. a AI?E\!.I. ' 2.013 . .
1. and forwarded. ,
2. On 9 April 2013 l (b)(6) _ to. con'cluct a
investigation inquidng int'o the tact and ciicumstai:lces of YFA-103's Class
.. ''A" .Mishap of .a April 2013. (b)(6) reviewed all , relevant evidence, .. .
. , i !'l tervi ewed numero1,1_s wi tnessesJ and coo,rdl nated with (b_)(6) for
legal advice and inves'tigative. support ' durihg the c6urse o.f the
'i nvestigation. The. results of the were wi.thin the sctJpe and
measure of my request and the: final product submitted: to me today . is well.
recei -ved. I have no disagreement with his finqings of Fact, Opini_ons or
Recommendations as 'stated in enclosure (l).
As stated i n the results, (b)(6) . concluded. that.. th.e cause of the ...
. rnisl)ap was. the inability .to in-fl,i.ght refuel (-IFR) a.nd fuel dt1e. te
trapped fuel. Significant .factors included a failure of the aircraft
commander. to -properly asse.ss aircraft. Qamage _lmpa_cting the -IFR
compounded by of a large amount of fuel t:h;rough the engine intake
.. and f ailing to associate the PERF 90 caution with a damaged engine. .., :
. .
Recotmlendations incl uded. CVW-7 emphasis and r.evj,.&w pQ];,icy . regarding a,ircraft ' . .
" l <:!. nd as soon as . possible;, when compounding :emergenCies .could .
_r esult i n' inj.ury or loss of Hfe. upqate Nfl.7'0Ps/SO!?s t .o
. grea ter detail i n the 'fue). .transfer and. fuel . feed . .
4. I concur with recommendations that no . p'uni tive , ot - adl\\inistrative action
t;ake-o ag'!inst the crew of .VictQry 206 and tl:\at . the injt1i:es suffe.red.- by (b)(6) : .
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. (b)(6) and . (b)(6). to be. in th'e ;line of duty not . due to . . . ... .
misconquct .
Copy to:
CNO . (N09G)
COMNAVAIRLANT
Naval Safety
CO, VFA-103
(b)(6)
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5800
From: (b)(6) , USN
To: Commander, Carrier Air Wing SEVEN
Subj: COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THE
AVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN 'THE NORTHERN ARABIAN
SEA .
Ref: (a) Chapter II, JAGMAN (2012 ed.)
Encl: ( 1)
(2)
(3)
( 4)
( 5)
(6)
(7)
( B l
(9)
(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 ltr 5830 Ser N00/078 of 9 Apr 13
Letter from (b)(6) , USN, dtd 14 Apr 13
Mishap transcript from CATTC/ILART of 8 Apr 13
Xray Papa Watch log of 8 Apr 13
USS DWIGHT D EISENHOWER (CVN 69) Tactical Action Officer (TAO) log
of 8 Apr 13
(b)(6) , USN, ltr of 17 Apr 13
VFA- 103 Flight Schedule of 8 Apr 13
Costs associated with lost aircraft and equipment
USS DWIGHT D EISENHOWER (CVN 69) Air plan for 8 Apr 13
Statement of (b)(6) , USN, dtd 13 Apr 13
Statement of (b)(6) , USN, and notes from interview dtd
12 Apr 13
(b )(6)
Statement of
, USN,
Aircrew summary dtd 11 Apr 13
(b)(6)
Statement of
(b)(6)
, USN,
. USN, Fl i ght Surgeon dtd 20 Apr 13
Aircrew summary dtd 12 Apr 13
Statement of
(b)(6)
(b)(6)
Weather forecast for 8 Apr 13
USN, dtd 13 Apr 13
, USN, dtd 13 Apr 13
Statement of _(b)(6) . USN, and e-mail dtd 13 Apr 13
Statement of
statement of
15 Apr 13 and
Statement of
(b)(6) , USN, dtd 10 Apr 13
(b)(6) , USN, and summary of interview dtd
email dtd 22 Apr 13
(b)(6) _, USN, dtd 14 Apr 13
(b)(6) , USN, dtd 12 Apr 13, and email dtd
Statement of
22 Apr 13
Summary of interview with (b)(6) , USN, dtd 15 Apr 13
Summary of Miser and Pyramid communications fr om 8 Apr 13
Statement of (b)(6) USN, dtd 15 Apr 13
Compact Disc (CD) containing a copy of Aircraft 206 Deployable
Flight Incident Recorder Set . (DFIRS) data from 8 Apr 13
Email from (b)(6) 1 USN, dtd 12 Apr 13
NATOPS excerpt V-ib-1
NATOPS excerpt V-15-1
NATOPS excerpt I-2-47
Emails from (b)(6)
NATOPS excerpt I-2-14
and
(b)(6) dtd 16-17 Apr 13
Statement of (b)(6) , USN, undated
VFA-103 Aircrew list of 8 Apr 13
Statement of (b)(6)
NATOPS excerpts (miscellaneous)
1 USN, dtd 18 Apr 13
(b)(6) Memorandum for the Record of 15 Oct 13
000005
AVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIAN
SEA
PRELIMINARY STATEMENT
1. Pursuant to enclosure (1) and in accordance with reference (a), a Command
Investigation was conducted to inquire into the facts and circumstances of a:
Class A aviation mishap involving the loss of an F/A-18F Super Hornet that
occurred on 08 April 2013 while conducting routine operations in the Northern
Arabian Sea. Both the mishap pilot, {b)(6) , USN, and the mishap
WSO, {b)(6) , USN, were recovered at sea after a successful
ejection from the aircraft. Each sustained minor injuries.
2. I am qualified 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 Safety
Command Course.
3. I have met each of the Convening Authority' s directives. I have
investigated the cause of the accident and provided my opinions as to any
fault, neglect or responsibility. I have also provided recommendations to
mitigate the possibility of this type of mishap happening in the future.
4. USS DWIGHT o. EISENHOWER (CVN 69) was on. the 46th day of deployment when
the mishap occurred. The ship was conducting routine operations in the
Northern Arabian Sea while on her 2013 deployment in support of Operation
Enduring Freedom (OEF) .
5. All relevant information was collected. The original USS DWIGHT D.
EISENHOWER (CVN 69) Air Department and Operations Department records are
retained by the Air Department and Operations Department onboard. All records
regarding Mishap Aircraft and Mishap Aircrew, to include the Maintenance log,
are retai ned by Strike Fighter Squadron 103 (VFA-103), homeported at NAS
Oceana, Virginia. All documentary evidence enclosed is either the original or
a true representation of the original document.
6.
. (b)(6)
, USN, assisted me in this investigation.
7. There were no extensions of time requested.
8. All times given are listed in both Zulu (Z) and Local (L) time. This was
done to synchronize the differences in time listed in the substantiating
enclosures or provided by witnesses in their statements.
9. References to the mishap aircraft varied according to the witnesses. It
was alternatively identified as VFA-103 Aircraft 206, BEARCAT 21, and VICTORY
206. For consistency arid clarity purposes, it is referred to as VICTORY 206
throughout this report
10. Witness recollections varied significantly as to the timing and sequence
of events following VICTORY 206's refueling . This was particularly true in the
last 30 minutes leading up to the aircrew's ejection; witness recollections as
to fuel states, projected overhead or divert fuel state, communications and
other events differed significantly. For obvious reasons enclosure (3) the
t I I
ranscr1pt of CATCC/ILART recordings of radio transmissions on 8 April 2013 was
used as a a?ainst which other witness statements, often captured days
after the av1at1on m1shap occurred, were reconciled. Moreover , it is
that . not all of the radio transmissions were captured or reflected
Accordingly, the findings of fact contained in this
1nvest1gat1on required the Investigating Officer to reconcile the differences
2
000006
- --------------------- -
SEA
in testimony to reconstruct the mishap sequence of events. In any event, the
exact sequencing of events did not preclude the Investigating Officer from
determining the underlying cause of this mishap.
11. Findings of fact in italics contain background information that is
necessary for a complete understanding of this mishap. This includes
information regarding operation of the F/A-18E/F as well as information
influencing decisi6ns made on 8 April 2013.
FINDINGS OF FACT
I. INTRODUCTION
1. Aircraft side number 206, BUNO 166616, was lost at sea at approximately
0920Z/1320L on 8 April 2013 in the North Arabian Sea (NAS), approximately 1.5
NM aft of the DWIGHT D. EISENHOWER (CVN 69) (hereinafter referred to as "IKE").
[Encls (2), (3), (4), (5), (6), (10), (il), (15), (i6), (19), (20), (21), (22),
(26), (27), (29) and (37)]
II . BACKGROUND
Aircraft 206 , BUNO 166616 (Lot 27)
2. The aircraft involved in the mishap was F/A-.18F Super Hornet, side number
206, assigned to Strike Fighter Squadron ONE ZERO THREE (VFA-103). [Encls (2) ,
(7), (10 ) , (11) and (21)]
3. VFA-103 was in compliance with all required and pertinent maintenance
directives for Aircraft 206. [Encl (2))
4. Aircraft 206 had flown 38 hours since the last phase inspection and had
3,371.5 total hours on the airframe. The flight hour threshold for aircraft
rework had not been reached . [Encl (2 ) )
5. There were no recent codes noted during preflight and servlclng for both
engines was well within limits. Likewise, there were no outstanding gripes on
the engine . The right engine had 3, 322.4 hours and the left engine had
4, 119. 4 . [Encl ( 2) ]
6. There were no outstanding maintenance actions or issues related to the fuel
system, engines, or hydraulic systems for aircraft BUNO 166616 when it was
accepted for flight on 8 April 2013. [Encl (2))
The F/A- 18E/F Sys tems
7. The F-18 is fitted with four internal fuselage tanks (Tanks 1 through 4),
two internal wing tanks (left and right. Tanks 2 and 3 are ehgine feed tanks
while Tanks 1, 4, and the wing tanks are transfer tanks. The plane's fuel
capacity can be increased by adding up to four 480 gallon external fuel tanks
on the centerline, inboard or midboard pylons. (Enol (40)]
8. The F-18's fuel system is composed of the following subsystems: engine
feed, motive flow, fuel transfer , tank pressurization and vent , therma l
management, refueling, fuel dump, fuel quantity indicating, and fuel low
indicating. [Encl (40)]
3
000007
SEA
9. Fuel is transferred from the wing tanks to Tank 4 by two motive flow
powered ejector pumps, one in each tank. When Tank 4 is less than full, the
Signal Data Computer opens both wing motive flow control valves, which direct
motive flow to the ejector pumps and transfer fuel from the wing tanks to Tank
4. When Tank 4 is full, the motive flow control valves are closed and normal
wing transfer is inhibited. If motive flow is lost on one side (single engine
shutdown), the cross-motive shutoff valve opens so that one motive flow system
can power the ejector pumps in both wing tanks. If both motive flow systems
are lost, the wing tanks gravity transfer to Tank 4. Barik angle changes . or a
steady sideslip may be required to gravity transfer all available wing fuel .
[Encl (35))
10. External fuel, including from the centerline tank, is transferred by
regulated engine bleed air pressure applied to all installed external tanks
with weight off wheels. External tank pressurization is terminated for
inflight refueling (PROBE -switch in EXTEND). [Encl (40)]
11. The EXT TANKS transfer switches are for the pylon tanks and the centerline
tanks. With the external tanks pressurized, fuel transfers when the FUEL LO
caution is displayed regardless of the position of the EXT TANKS transfer
switches. When in the ORIDE position, pressurization is applied and is
transferred from all external tanks for which the switches are not in STOP . In
the NORM position, normal transfer and refueling of controlled external tank(s)
is permitted. In the STOP position, transfer and refueling of controlled
external tank (s) is prevented except with a FUEL LO caution. [Encl (40))
12. During refueling, the soc opens all refuel valves, allowing fuel to
transfer into all internal tanks. External tank pressurization is terminated
when the probe is extended, allowing the refuel/defuel line to fill all
installed external tanks (EXT TANKS switch(es) not in STOP). With the PROBE
switch in EXTEND or EMERG EXTD, normal internal wing transfer is not available.
Gravity transfer is still available. [Encl (40))
13. Motive flow transfer from the wings is disabled with the IFR probe
extended. Transfer will happen only through the gravity check valves when the
pilot rolls the wings at least five (5) degrees. The transfer rate then
depends on the amount of fuel in the wings and the amount of roll induced in
the aircraft for gravity feed. The NATOPS specifically states: (a) with the
PROBE switch in EXTEND position, normal internal wing transfer is not
available, but gravity transfer is still available; (b) wing tanks will gravity
transfer to Tank 4 when motive flow systems are lost; and (c) bank angle
changes or a steady slideslip may be required to gravity transfer all available
wing fuel. NATOPS does not contain any information regarding the rate fuel
will transfer from the wings via gravity feeding. [Encls (34) and (40))
14. The APU is a small gas turbine engine used to generate a source of air to
power the Air Turbine Starter (ATS) for normal engine start. A hydraulic motor
powered by the APU accumulator is used to start the APU. The APU receives fuel
the left engine feed line upstream of the left engine feed shutoff val ve,
Dur1n? operation, the APU shaft turns a separate compressor which
suppl1es a1r for main engine start. (Encl (40))
15. The . hydraulic.power supply system is a dual pressure system (3,000 and
5,000 ps1), The a1rcraft uses hydraulic power to actuate primary flight
surfaces and to run several utility hydraulic functipns, such as the landing
gear and the refueling probe. Two hydraulic accumulators provide emergency
4
000008
Subj : COMl1AND INVESTIGATION INTO THE FACTS AND .CIRCUMSTANCES SURROUNDING THE
SEA
hydraulic power for critical utility functions. The hydraulic power supply
system incorporates two independent hydraulic systems, HYD 1 (powered by the
left engine) and HYD 2 (powered by the right engine). Each system is divided
into two branches providing four independent hydraulic circuits. HYD 1
circuits are dedicated solely to flight controls. HYD 2A powers both flight
controls and most utility hydraulic functions. HYD 2B powers the flight
controls and arresting hook and pressurizes both the APU and emergency brake
accumulators. [Encl (40)]
16. Two hydraulic accumulators are provided in the HYD 2B circuit: the APU
accumulator and the brake accumulator. The APU accumulator provides hydraulic
pressure to start the APU (last alternative to restart an engine airborne).
With a HYD 2 failure (inoperable righ engine), pressure from the APU
accumulator can also be used to emergency extend the landing gear or the
refueling probe inflight. [Encl (40))
Aircrew
17. The Aircraft Commander {pilot): (b)(6) (1310)
(hereinafter referred to as "the mishap pilot") was commissi-oned through the
USNA and designated a Naval Aviator on 27 AUG 2004. (b)(6) completed
FRS training at Strike Fighter Squadron ONE TW9 FIVE (VFA-125) and has deployed
multiple times to the Middle East in support of Operation ENDURING FREEDOM
(OEF). He has 1959.7 total flight hours, 649.6 hours in F/A-18 E/F and 980.7
hours in F/A-18 C/D and has flown 55 flights in Afghanistan in support of OEF.
[Encls (6), (10), (12) and (41))
18. At the time of the mishap, the mishap pilot had a current Medical Up Chit,
was current and NATOPS Qualified in the F/A-18F, had a current and valid
Instrument Check, and was a qualified Mission Commander. [Encl (12))
19. The mishap pilot stated that he had approximately 8 hours of sleep the
night prior to the mishap. (Encl (41)]
20. The Weapons Systems Officer (WSO): b ) ~ )
(1320) (hereinafter referred to as "the mishap WSO") was commissioned through
the USNA and designated a Naval Flight officer on 31 July 2008 . (b)(6)
completed FRS training at Strike Squadron ONE ZERO SIX (VFA-106) in July of
2009 and is on his second deployment to the Middle East in support of OEF. He
has 1262.3 total flight hours, 1077.7 hours in the F/A-lBF and 13.1 hours in
the F/A-l8B/D and flown 43 flights in Afghanistan in support of OEF. IEncls
(14) 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 valid
Instrument Check and was a qualified Mission Commander. [Encl (14))
22. The mishap WSO stated he had an "ample 5 hours" of sleep the night pr ior
to the mishap and that he averages 5-7 hours of sleep a day. [Encl (11))
III. 8 APRIL 2013
Preflight to Refueling Incident
23. The Mishap Sortie was scheduled and approved for flight by Commandi ng
Officer, VFA 103. The flight was scheduled for a 0400Z/0800L launch and a
5
000009
SEA
lOOOZ/14001 recovery in support of an OPERATION ENDURING FREEDOM Close Air
Support (CAS) mission over Afghanistan. [Encls (6), (7), (8), (9), (2-1) and
(24)]
24. The Mishap Sortie was scheduled in support of IKE' s 8 April 2013 Air
[Encl (9)]
25. The weather brief for the morning mission was as follows: The weather
forecast at launch was Visual Meterological Conditions (VMC). At launch, few
to scattered clouds at 3,000-5,000 feet and scattered clouds at 8,000 feet.
Visibility was forecasted as 4-6 nautical miles (NM)/2-4 NM in dust. Winds
were west-northwest at 10 knots gusting to 15. Thunderstorms up to 45,000 feet
were forecast for the Boulevard (the transit corridor from the North Arabian
Sea to Afghanistan) and southern areas of Afghanistan. Moderate turbulence
between 28,000-32,000 feet was forecast for the Boulevard and Iran/Pakistan
border. No turbulence was forecast in the area of Afghanistan that BEARCAT 21
and 22 would be conducted airborne refueling . [Encl (17))
26. The mishap pilot and mishap WSO stated they received a good, standard OEF
mission brief from CVIC with weather being the main focus of the brief. The
mishap pilot recalled thunderstorms briefed from the through
central/eastern Afghanistan. The mishap WSO stated the expectations were for
layers and thunderstorms on the northern half of the Boulevard info Afghanistan
and multiple layers in the south and east Afghanistan.. Divert weather was
briefed, but not discussed. [Encls (10) and (11))
27. VICTORY 206 launched at 0800, completed standard checks and reported ready
for mission. VICTORY 206 was assigned the OEF mission callsign of BEARCAT 21.
The original lead jet experienced a left generator failure and to IKE,
resulting in the launch of the spare, VFA-143 Aircraft 112, callsign BEARCAT
22, flown by (b)(6) , VFA-143 (b)(6) (hereinafter referred
to as "BEARCAT 22"). [Encls (4), (6), (10), (11) and (18)]
28. The mishap pilot and mishap WSO reported the weather on the Boulevard was
not an issue. Enroute to their first tanker, during the transit through
Pakistan and into the southern port.ion of Afghanistan, they encountered
thunderstorms up to 31,000 feet and spots of rain up to 45,000 feet. Once the
controlling agency gave clearance above the weather, a Climb to 33,000 ft , the
weather was workable and below the aircraft. The aircraft were able to descend
to below 30,000 for their first refueling. Light turbulence was encountered
during the first tanking evolution but it did not affect the refueling.
However, BEARCAT 22 stated he could see storms developing in the area and to
the west. [Encls (10), (11), (18) and (41))
29. For their mid-cycle tanking evolution, the aircraft used the same tanker
track as they used for their initial refueling. With cloud layers at
approximately 23,000 feet, no turbulence and clear weather at tanking altitude,
206 joined up and connected with SHELL 73, US Air Force KC-135 , without
1nc1dent. [Encls (10), (11) and (18))
30. The first.s minutes of this refueling evolution, during which Victory 206
took on 14,800 pounds of gas , likewise was without incident.
SHELL 73 and VICTORY 206 hit a section of clear air turbulence upon
enter1ng southern part of the track, significantly jarring both the basket
and refuel.lng boom. [Encls (10), (11) and (18))
000010
6
Subj:
COM1'1AND INVESTIGJ\TION INTO THE FJ\CTS 1\ND CIRCUMSTJ\N.CES SURROUNDING THE
SEA
31. 1\fter approximately 2 minutes of tanking in significant turbulence and
reaching 15,300 pounds of gas, the boom unexpectedly moved below the nose of
VICTORY 206 and then back up, resulting in the hose becoming wrapped around the
basket. (Encls (10) and (11)]
32. The mishap pilot brought the throttles to idle to back out of the basket;
when simultaneously, the boom returned back above the nose and the hose
detached from the basket. [Encls (10) and (11))
33. BEARCAT 22, flying port observation at the time of the drogue separation,
did not notice any significant deviations between VICTORY 206 and SHELL 73 or
observe the boom movement or the basket separate from the boom. [Encl (18))
Land as Soon as Practical vs. Possible: The Initial Divert Decision
34. After backing away from SHELL 73 , the VICTORY 206 aircrew recognized that
the tanker's refueling basket was still attached to VICTORY 206's inflight
refueling(IFR) probe and fuel was pouring out of the hose in the direction of
the right intake. They surmised that a significant amount of fuel from the
now-separated refueling hose had entered the right engine intake of the mishap
aircraft. [Encls (10) and (11))
35. The aircrew then received a R ENG caution with aural tone, a Full
Authority Digital Engine Control (FADEC) advisory, channels A and B on the
right engine lined out and PERF 90 in red on the engine page. [Encls (10) and
(11))
36. The FADEC, mounted on each engine casing, controls engine operation. Each
FADEC computer has two central processor units, channel A and channel B, and is
integrated with the mission computers, flight control computers and throttles.
Normally, both FADEC channels monitor engine and control system operation with
one channel in control and the other in standby.
a. Engine status is reported by the FADEC and appears on the ENG STAUTS
line of the ENG display. These include NORM, PERF90, AB FAIL, THRUST, IDLE and
SHUTDOWN.
b. FADEC/engine degrades fall into two categories: minor failures which do
not affect engine operability and significant failures that do affect engine
operability.
(1) Due to a high level of redundancy, most minor control system
failures do not cause any degradation in engine performance (ENG STATUS remains
NORM) Inflight cockpit indications for these types of failures include: FADEC
and BIT advisories.
(2) Significant failures which do cause degradation in engine
performance (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; DEGD
lndlcatlon for the affected engine channel on the BIT/HYDRO MECH display; and
both CH A and CH B lined out on the ENG display.
[Encl (40)]
000011
7
Subj:
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THE
SEA
37. A PERF 90 indicates that the engine will produce at least 90 thrust, and
may exhibit slow transients. Afterburner is not inhibited. A PERF 90 is a
"Land as Soon as Practical" emergency. [Encls (18) and ( 4 0))
38. "Land as soon as practical" means extended flight is not recommended. The
landing site and duration of flight . is at the discretion of the pilot in
command. [Encl (40))
39. BEARCAT 22 conducted a visual inspection of the aircraft (VICTORY 206) and
then discussed the situation with VICTORY 206 ' s aircrew. VICTORY 206 passed
that they had 15,500 lbs of fuel and showed a PERF 90 advisory on the right
engine. VICTORY 206' s aircre.w stated that they believed the PERF 90 was caused
by the large amount of fuel that was ingested by the right engine immediately
following the refueling incident. This made sense to BEARCAT 22 because of the
amount of fuel that spewed from the severed hose after the drogue separation
and before the tanker crew was able to secure the flow. No other information
(e.g., regarding engines, etc . ) was discussed'. [Encls (10), (11) and (18))
40. VICTORY 206 elected to return to IKE because a PERF 90 is a "Land as Soon
as Practical" emergency, they had sufficient fuel to attempt a shipboard
arrestment and divert if necessary, theY perceived there were no other engine
issues, and CAG's direction was that aircraft with "Land as Soon as Practicaln
emergencies should return to IKE. The pilot assessed at this point that
they would have 6,500 lbs of fuel when overhead IKE, enough for 6 landing
attempts at IKE or 4 landing attempts and enough fuel to divert. [Encls (10),
(11) and (18))
41. BEARCAT 22 concurred. In his oplnlon, based upon the information relayed
to him, VICTORY 206 only had a slightly degraded engine that would not go into
afterburner, and in keeping with CVW-7 policy to return to the ship with a
"land as soon as practicaln emergency, it made sense that VICTORY 206 would
elect to return to IKE. BEARCAT 22 felt confident that VICTORY 206 would not
have any issues recovering on IKE . If other, more serious engine issues had
been reported, such as compressor stalls, poor throttle response or other
abnormalitieB, BEARCAT 22 stated he would have recommended VICTORY 206 divert
to Kandahar, an operational coalition airfield in Afghanistan. [Encl (18) )
42. CVW-7 aircrew conducting OEF Missions were under CVW-7 instruction to l and
at the nearest suitable airfield for "Land as Soon as Possible" emergencies and
recover aboard IKE for "Land as Soon as Practital" emergencies. This guidance
was not delineated in a written instruction,. but was more of a "Commander ' s
intent'' initially put out by the previous Air Wing commander and inherited by
the current Commander. As it was not formalized, it did not address compound
emergencies and was never intended to substitute for aircrew judgment. it was
more of a strong preference that CVW 7 aircraft be brought back to the carrier
if the aircrew did not have to land as soon as possible. [Encls (11 ), (18),
(23) and (41))
43. ''Land as soon as Possiblen means to land at the first site which a safe
landing can be made. [Encl (40)
44. CAG's guidance, as understood by the mishap pilot, is that for Land as
Soon.as Practical emergencies, the crew should bring the aircraft back to the
carrler; for Land as Soon as Possible emergencies, the crew should land at the
suitable field in Afghanistan. Following the mishap, the mishap pilot
Oplned that this guidance could lead some aircrews to attempt to return to the
000012
8
- -- . - ---- - -
SEA
ship when the more prudent decision might be divert in Afghanistan.
pilot believed the decision should be left to the pilot in command.
(10))
The mishap
[Encl
45. The mishap WSO observed that there was a less stringent interpretation of
"Land as Soon as Practical" when he flew OEF missions with VFA-32 with
{leadership) "not as hard over on getting [the aircraft) back to the boat."
[Encl (11))
46. CVW-7 did not maintain a maintenance detachment in Kandahar as other air
wings had done. This decision was based upon an assessment by the former
Commander, and as continued by the current air wing commander that the costs of
maintaining such a detachment outweighed its benefits. Specifically, that
there would be a significant amount of unused manpower at the detachment while
any aircraft diverted to Kandahar would likely require additional tools,
personnel and equipment that could be flown in to repair an aircraft that had
diverted. [Encls (23))
47. The CVW-7 Operations Officer acknowledged that CVW-7's decision not to
maintain a maintenance detachment at Kandahar could be interpreted as a signal
not to land there, but stated that this was not the reason for the divert
mindset of the Air Wing Commander. [Encl (23))
48. BEARCAT 22 opined that it is generally accepted by pilots flying OEF
missions in Afghanistan that any diverts are going to be long diverts back to
the ship. Although diverts to shore landing fields are available when
necessary, the logistical challenges associated with getting a detachment into
Afghanistan following an in-country divert, coupled with the operational
impacts associated with the loss of a jet and aircrew for several days means
that pilots may not take a conservative approach when it comes to divert
decisions. While not willing to say whether this puts undue pressure to bring
an aircraft back to the ship, BEARCAT 22 did not believe the mishap pilot's
decision was "overly aggressiveH at the time based upon the information on
hand. [Encl ( 18) )
49. The weather forecast for the diverts in Afghanistan was briefed as poor
with Instrument Meteorological Conditions prevailing. [Encls (10) and (21))
VICTORY 206's Return Flight to IKE
50. Having made the decision to RTB to IKE, both VICTORY 206 and BEARCAT 22
communicated VICTORY 206's status and intentions to air traffic controllers
(PYRAMID and MISER) for relay back to IKE via the CAOC.
a. VICTORY 206 passed their estimated overhead fuel state of 6500 lbs t o
the Control and Reporting Center for Afghanistan to relay via the CAOC to IKE.
BEARCAT 22 took the lead in coordinating VICTORY 206's return back to IKE. The
mishap WSO stated they al.so requested PYRAMID inform IKE that the tanker basket
was attached to the refueling probe.
b. BEARCAT 22 passed that VICTORY 206 took the drogue off
SHELL BEARCAT 22 from refueling from SHELL 73, and asked PYRAMID
to coordlnate through the CAOC to let IKE know that VICTORY 206 was returning
to IKE the next cycle. BEARCAT 22 subsequently communicated to PYRAMID
to conf1rm that the drogue was still on VICTORY 206's probe and VICTORY 206
000013
9
\
'
Subj: INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THE
SEA
anticipated to be overhead IKE at OBOOZ/12001 . The time of BEARCAT 22's
communications 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 it
sustained probe damage while refueling and was unable to refuel and that it
would be overhead at approximately 0800Z/1200L, and then corrected the overhead
time to 0845Z/1245L after an update from VICTORY 206. Overhead fuel state was
anticipated to be 4500 lbs. This information was passed approximately 30
minutes prior to the corrected overhead time (45 minutes later) and was wiqely
disseminated to appropriate persons. It was not passed that the refueling
basket was still on VICTORY 206' s IFR probe. [Encls (11), (15), (16), (20),
( 2 2 ) , ( 2 4 ) , ( 2 5 ) and ( 2 6 ) )
52. A bingo profile of 4700 lbs to Masirah was originally calculated. When
told that VICTORY 206 would be close to BINGO when they reached IKE, the IKE co
directed IKE Air Ops Officer that VICTORY 206 was to divert immediately to
Masirah if they could not arrive with a minimum of 4700 lbs. Time of this
conversation t ook place prior to 0830Z/1230L. There is no indication that this
was passed to VICTORY 206. [Encls (15), (20), (22), (25) and (26)]
Centerline Tank not Transferring
53. Approximately halfway down the Boulevard, the mishap pilot and mishap WSO
noticed that the centerline fuel tank was not transferring. The mishap pilot
placed the EXT TANK switch into the ORIDE position, and the centerline fuel
tank began transferring normally. [Encls (10) and (11))
54. The right engine then experienced a momentary compressor stall which
stopped after the mishap pilot retarded the right throttle. [Encls (10) and
{11)) .
55. Around this time, the mishap WSO also noted and informed the mishap pilot
that the right engine inlet temperature was high. [Encl (11)]
Wing transfer issues
56. The mishap pilot and mishap WSO also noticed that fuel from the wing tanks
was transferring slower than normal. The mishap pilot recalled that each wing
tank had approximately 1,500 lbs of fuel. They stated they noticed this
approximately 200 NM from IKE or two-thirds of the way down t he Boulevard and
about the time they established solid communications with XP (Air Wing
representative in CVIC, a separate space on the ship from CATCC, where squadron
representatives are located). [Ehcls (10), (11)]
57. The mishap pilot assumed the fuel in the wings was gravity feeding, and
attempted to aid the gravity feed by slipping and cross controlling for
approximately 15 minutes. [Encl (10)]
58. NAVAIR F-18 engineers subsequently calculated that the transfer rate for
?ravity feeding fuel in wing tanks is about 10 pounds a minute. In this case,
have up to 40 minutes to transfer all of the useable fuel from
t he w1ng tanks in a best-case scenario, and would have involved flying
the for 15 minutes continuously at an angle of bank greater than 5
degrees and in a sideslip. This would have to be done for each wing and would
000014
10
Subj: COMMAND INVESTIGATION INTO THE 'FACTS AND CIRCUMSTANCES SURROUNDING THE
SEA
have transferred all but 150 pounds of fuel out of the wing tanks. [Encls (34)
and ( 41) 1
VICTORY 206 Communications with XP
59. VICTORY 206 informed XP they would be overhead IKE with 4,500-5,000 lbs . of
fuel with expectation of being able to attempt one Case III approach and then
execute a divert to Masirah. The mishap aircrew also asked XP to assist with
the BINGO profile numbers to Masirah, which they expected would be around 4,500
lbs of fuel. The mishap aircrew stated that they had discussed with XP the
slow transfer of fuel out of the wing tanks, 10-20 lbs per minute, and asked
for any techniques to increase wing transfer . (Note: The mishap WSO recalled
informing XP they would be at 4 800 lbs of fuel on the ball.) [Encls ( 10) ,
(11) 1 (15) 1 (21) 1 (22) 1 (25))
60. (b)(6) , airborne as the WSO in VICTORY 210 being flown by
(b)(6) . (hereinafter "CSG Commander"), recalled
hearing VICTORY 206 provide the update to XP along with the PERF 90 indication.
(b)(6) came up on MIDS A (a separate communications frequency) and
asked VICTORY 206 to confirm the damage to the refueling probe was the reason
they would be unable to conduct an airborne refueling. VICTORY 206 replied
that there was damage to the probe, but did not specify the nature of the
damage or that the refueling basket was stuck on the probe. [Encls (21))
61. Aboard IKE, the bingo profile 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 profile, the decision was made to give VICTORY 206 one pass
at IKE before diverting to Masirah. [Encls (16) and (22)]
63. VICTORY 206 was then instructed by XP to contact the CATCC squadron
representative (SR) on Button 18 . [Encls (10) and (27)]
VICTORY 206 Communications with SR
. 64. VICTORY 206 provided the SR with an overview of the situation. The mishap
pilot informed him that they were approximately 130 NM from IKE with 6,200 lbs
of fuel and estimated they would be overhead IKE with "probably about 4,600 or
4,700 lbs." The mishap pilot also briefed the right engine issues (FADEC
advisory, PERF 90 condition possibly due to fuel ingestion, and engine surgi ng
slightly) and that they had incurred probe damage and thus would not be able to
refuel while airborne. No indication was given that the drogue was still on
VICTORY 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 it would get one pass at IKE and would divert
t o Masirah if the landing attempt was unsuccessful . VICTORY 206 was also
briefed that the bingo to Masirah was 4.5 with a 70- knot headwind. Normal
bring profile, when flown correctly, has the aircraft on deck with a fuel state
of 2.0 . 0836Z/1236L. [Encls (3), (15), (16), (19), (20), (22), (27 ) )
66. pilot then passed that there was approximately 1,100 lbs of
1n the 1nternal wing fuel tanks , tanks 1 and q were empty, and Tanks 2 and
3 under 2000 lbs. He also stated the assumed the tanks were gravity
feed1ng, going down about 10-20 lbs every minute. [Note: transcript has 10 lbs
000015
11
Subj:
SEA
every 20 seconds, but other witness statements put it 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 (used
to isolate the wing tanks) switch in the NORM position (normal transfer from
and refueling of internal wing tanks permitted), and not the INHIBIT position
(normal transfer from and refueling of the wing tanks is prevented) . [Encls
(3), (11) and (40)]
68. Twenty seconds later, the mishap pilot was asked "what would you call your
'usable' fuel"? The mishap pilot replied, "3,700 lbs, if no additional fuel
transferred from the wings." At this point, the mishap pilot -stated he
understood he had to change his assumptions regarding fuel status. From this
point forward, he began only refe-rring to the fuel in tanks 2 and 3, excluding
the fuel in the wing tanks. The mishap pilot later reflected that this was
when he first realized that VICTORY 206 . was in any in-extremis situation.
0836Z/1236L. [Encls (3) and (10))
69. VICTORY 206 was then directed to monitor their wings for about 5 minutes,
at which point they would decide whether they needed to divert to Masirah while
they would begin reviewing the NATOPS to investigate the wing transfer rate
issues. [Encls (3), (21) and (27)]
70. VICTORY 206 was not displaying a FUEL XFER caution light at this time.
[Encl (3)]
The CSG Commander Intervenes
71. A few seconds later, the CSG Commander, still airborne and monitoring the
dialogue between VICTORY 206 and the SR, came up on Button 18 and said, "I want
you to send 206 to Masirah now. " The time was 0838Z/1238Z. [Encls (3),
(10), (11), (15), (19), (20), (21), (22), (25), (26) and (27) J
72. The IKE CO heard the CSG Commander's order, but did not know why he had
ordered VICTORY 206 to divert. The CO stated he had been waiting to see if
VICTORY 206 was going to be able to arrive on final approach at or above the
bingo amount. [Encl (26))
73. The CSG Commander, (b)(6)
(b)(6) and was exper1encea 1n maKing divert decisions, explained
that two courses of action (COA) came to mind as .he monitored the conversation
between VICTORY 206 and the SR: COA #1 would be for VICTORY 206 to attempt an
approach to IKE and if unsuccessful, divert to Masirah; and COA #2 was to make
the decision to divert while VICTORY 206 was still at altitude, thereby not
expending the fuel on an approach. The CSG -Commander directed COA #2 for the
following reasons: the stated fuel on deck at Masirah was 1.3, which, while
than the amount specified by the NATOPS, was still enough to sustain
eng1ne thrust; the unknown status of the wing fuel quantity and transfer; less
than two miles of visibility at IKE; the BINGO profile needed to be executed
perfectly in light of the distance and the headwinds; and finally, the "Hail
Mary" of the ship approach in that if the mishap pilot was unsuccessful
the aircrew was now committed to the aircraft remaining
1n the v1c1n1ty of the ship with no possibility of diverting or refuel ing .
(b)(6) viewed this option as a plan Of last resort with very high risk in
that lt would be a potential landing or controlled ejection
[Encl (19) J
000016
12
'
'
Subj:
AVIATION MISHAP THAT OCCURRED ON 08 APRIL 2013 IN. THE NORTHERN ARABIAN
SEA
74. The CSG Commander stated having decided upon COA i2 based upon the
information available at the time, he acknowledged his role as the CSG
Commander and associated risk with his decisions, but wanted to preclude any
indecisiveness by the representatives in AIROPS; therefore, he directed what he
thought was the safest COA, a divert to Masirah. This was his only radio
transmission during the entire evolution. He pointed out that no one rebutted
his decision on the radio or did VICTORY 206's mishap pilot state that he did
not have enough fuel to make the divert. [Encl (19))
75. The SR acknowledged the CSG Commander's order and immediately ordered
VICTORY 206 to divert to Masirah. The time was 0838Z/ 1238L. [Encls (3), (10)
and (27)]
Changes to the Divert Field
76. VICTORY 206 acknowledged the order to divert to Masirah, approximately 250
NM away, and commenced climbing to 42,000 feet, the altitude specified for the
BINGO profile. (b)(6) believed they were within 10NM of IKE's position
at this time. [Encls (:j), (10) and (ll)]
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 not
the "diplomatically preferred" divert. CAG OPS stated that, per .the Defense
the US Embassy in are significant sensitivities
regarding diverting US military aircraft, even unarmed, into Muscat. Tactical
aircraft diverts are almost always sent to Masirah, which is about twice as far
away as Muscat, even though Muscat is briefed as an option. Thus, when it was
thought that VICTORY 206 was "just a normal divert" and could make it to
Masirah with at least 2,000 lbs of fuel, Muscat was not considered as an
option. 0840Z/1240L. [Encls (3), (10), (11), (18), (20), (22) and (41)]
78. As VICTORY 206 passed 39,000 feet, the mishap pilot informed the SR that
they were unable to maintain the BINGO profile airspeed of 200 KCAS. He
reported the wing fuel continued to transfer very slowly, and that they were
down to about 2,600 lbs of usable fuel. The mishap pilot stated they
calculated they would reach Masirah with 1,200 to 1,300 lbs of fuel, compared
to 2, 000 lbs if they diverted to Muscat. 0851Z/1251L. [Encls (3), (10), (11),
(15) I (19) I {20) 1 (21) I (22) I (26) and (27)]
79. VICTORY 206 requested to diver to Muscat, and at 0853Z/1253L, was directed
to proceed to Muscat. He was also directed to jettison his ordnance, but to
keep his centerline fuel tank. The IKE CO stated VICTORY 206 was overhead the
carrier at this time . [Encls (3), (10), (11)
1
(15), (19), (2 0) , {21), (22),
{26), (27) and (29)]
80. In order to jettison its ordnance, VICTORY 206 was told that it would need
clear the sea space below them "to the best of their ability" either
or by using their surface search radar or FLIR. [Encls (3)
1
(11),
(15) 1 (20), (21) and (22)]
81. 206 replied that it did not have the ability or the fuel to get
down from current altitude of 38,000 feet to a reasonable altitude to
SEL the ordnance. CO, IKE then informed them that the airspace and sea
space vicinity were clear based upon radar and other ship's naviaation
and systems (SSDS and GCCS-M). At this point, VICTORY 206 was'
13
000017
SEA
approximately 25 NM north of IKE. 0853Z/1253L-0856Z/1256L. [Encls (3) 1 (11) 1
(21); (22), !26) and (27))
82. The SR then discussed Selective Jettison (SEL JET) procedures with the
aircrew. [Encls (3), (11), (19), (21) and 27)]
83 . In the process of discussing SEL JET .procedures with VICTORY 206, the SR
received word that Muscat had fallen below weather minimums (below 1 mile
visibility with a ceiling of less than 100 feet), and re-directed VICTORY 206's
divert to Masirah. Victory 206 executed 1 50 to 60 degree left heading change
back 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, and
showed the following conditions: Masirah - winds 250 at 13 knots and 2 miles
visibility from dust (0600Z/1000L observation). Muscat- winds of 030 at 11
knots and 1 statute mile of visibility due to dust (0850Z/1250L observation)
(Note: The updated weather conditions for these diverts did not list
information on ceilings.) [Encl (17)).
85. At 0858Z/1258L, VICTORY 206 reported that it had jettisoned its air-to-
ground 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 Engine
86. At 0901Z/1301L
1
VICTORY 206 reported R STALL, R ENG and R ENG FLAMEOUT
cautions with the right engine RPM stuck at 67 . A few seconds later, VICTORY
206 reported the flameout went away, but they were getting intermittent stalls
with the throttle at about 70. [Encls (3), (10), (11), (15), (19), (20),
( 2 6)
1
( 2 7) and ( 2 9) )
87. VICTORY 206 also stated it would be unable to make it to Masirah [Encls
(3), (10), (11) and (22)]
88. VICTORY 206 was instructed to jettison centerline tank and move the
throttle to idle. 0902(13)Z/ 1302(13)L. [Encls {3)
1
(11), (15) and (20))
89. VICTORY 206 reported the jettison of the centerline fuel tank 39 seconds
later. [Encl (3), {11), (15) and (22))
90. At 0903Z/1303L, the SR began walking VICTORY 206 through the Single Engine
Flameout procedure. The first part of this procedure called for to attempt an
auto restart of the engine. [Encls (3), (10), (21) and (27)]
91. The optimum restart envelope is below 25,000 feet. [Encl (31)]
92. At 0904Z/1204L, the mishap pilot reported the engine had failed to
restart. Engine was at 67 with exhaust gas temperature around 850-900
Celcius. The SR then informed VICTORY 206 that it would now be a single engine
bingo and that IKE would recalculate the bingo requirements. [Encl (3)]
93. VICTORY 206 reported its usable fuel as 1400 lbs with 900 lbs in each wing
tank that was still transferring slowly. 0904Z/1304L. [Encl (3))
000018
Subj:
INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES SURROUNDING THE
SEA
Return to IKE
94. Aboard IKE, it was determined that VICTORY 206 would only have 800 lbs of
fuel on deck Masirah, well below the single-engine bingo minimum of 1800
pounds, and Muscat weather precluded a divert to that airfield. At this point,
it was determined to have VICTORY 206 RTB to IKE. [Encls (10), (11), (15),
(16), (20), (22), (25), (26), (29))
95. It was calculated that VICTORY 206's fuel rema1n1ng, if successfully
landing on IKE on first pass, would be 1400 lbs. [Encl (26))
96. VICTORY 206 was estimated to be approximately 40 NM from IKE and iSO NM
from Masirah and at a very high altitude (most likely still around 39,00D
feet). (Encls (15), (20) and (22))
97. At 0905Z/1205L, VICTORY 206 was directed to turn back toward IKE and was
informed that IKE was going to take them for an approach. Although this
reversal of course was the fourth destination change for VICTORY 206, the
previous adjustments to diverts had all been done with the aircraft at altitude
and with relatively small heading changes required (e.g, less than 60).
(Encls (3), (10), (11), (22) and (27)]
98. Having turned towards IKE, the mishap pilot continued maneuvering the
aircraft with wing slices and wing dips in an effort to expedite graviiy feed
of the fuel from the wing tanks. [Encl (11)]
99. Additionally, having begun his descent, the mishap pilot then attempted to
restart the right engine by crossbleeding. There is no indication that he
discussed his intention to do this with the mishap WSO or the SR. The
attempted crossbleed yielded 0 RPM with the crank switch returning to the OFF
position. (Encls (3), (10), (11), (27) and (34)).
100. The mishap pilot recalled his fuel state at this point as 900 lbs of
usable fuel with 1000 lbs in each wing tank. [Encl (10)]
101. When the attempted crossbleed proved unsuccessful, the mishap pilot then
attempted an Auxiliary Power Unit (APU) engine restart via the APU switch. He
did not discuss this with the mishap WSO or the SR who was backing them up on
NATOPS procedures. [Encls (3), (10), (11) and (27)]
102. An APU restart is the last alternative for restarting an engine and
uti l izes the APU accumulator to start the APU, The prescribed APU restart
envelope is below 10,000 ft and below 250 KCAS. Finally, start i ng the APU
while airborne may result in a Bleed Air Leak Detection (BALD) shutdown due to
ingestion of exhaust gasses into the APU ducting. The BALD system is designed
to protect the aircraft from damage resulting from a bleed air leak. [Encls
( 31 ) and ( 4 0) ]
103. Normal landing gear extension requires an operable right engine to
hydraulic pressure to lower the gear. Emergency landing gear extension
lS a back to normal gear extension and also uses the APU accumulator. Without
an operabl e right engine, once the APU accumulator is depleted in an attempt to
a failed engine airborne, it is not available for emergency gear
[Encl (40))
15
000019
Subj:
SEA
104. The mishap pilot held the APU switch in place for approximately 20
seconds, and then shut it off without bringing the APU online. VICTORY 206 was
descending through approximately 30, 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 sys tem. [Encls (10) and
(11) J
106. Both aircrew pulled their green rings to provide emergency oxygen.
[Encls (10) and (11)]
Final Approach
107. At 0908Z/1308L, the SR talked VICTORY 206 through the Single Engine
Approach and Landing and Emergency Extension of Landing Gear procedures. The
SR briefed that it was "going to be a half- flap. approach" and that they wer e
going to "have to blow your gear down" (e.g., extend gear via
using 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 VICTORY 206 to switch the flaps switch to half and then
instructed him to "rotate [the landing gear] handle" and "pull it to detent" at
which point "the gear should blow down with the APU accumulator." He then
concluded by stating, "let us know when you're 3 down and locked." . Time of
transmissions took place between 0909Z/1309L and 0910Z/1310L; [Ehcl (3))
110. The emergency landing gear extension is mechanically controlled by the
LDG GEAR handle in the front cockpit and uses hydraulic pressure provided by
the APU accumulator. Emergency extension is mechanically activated by rotating
the LDG GEAR handle 90 degrees clockwise and pulling to detent (approximately
1.5 inches) . Emergency landing gear extension opens the hydraulic ar ming valve
and directs APU accumulator pressure to the emergency selector valves. APU
accumulator pressure is used to unlock the doors , releasing the landing gear
uplocks and is applied to the drag brace locking actuator and sidebraces
downlock actuator. The nose landing gear then extends by freefall aided by
airloads and the drag brace locking actuators while the main landing gear
extends by freefall aided by the sidebrace downlock actuator. (Encl (33)]
111. The mishap pilot informed the SR that he did not get any indication of the
gear down after he rotated and pulled the LOG GEAR switch. VICTORY 206's
position was approximately lONM from IKE. 0912Z/1312L. [Encls (3 ), {10), (16 )
and (19)]
112 . The SR then told 206 to "crank the right motor to spin the HYDs to get
the gear down.'' This effort failed with the right engine RPM not coming back
up. 0912Z/1312L-0912Z/1312L. [Encls {3), (10) and (27)]
113 .. The SR then instructed VICTORY 206 to recycle the circuit breakers by
pull1ng them out and replacing them. This likewise failed with the landing
gear remaining in the up position. 0913Z/1:313L-0913Z/1313L. [Encls (3), (10),
(11) and (27))
16
000020
Subj:
SEA
114. VICTORY 206 was then instructed to emergency extend the IFR probe by
switching it from normal to emergency extend to see if that would trigger the
val ve. 0914(26)Z/1314(26)L. [Encl s (3)
1
(10)
1
(11), (15), (19) and (21))
115. It is at this time that VICTORY 206 first informs IKE that the probe was
still extended with the refueling basket lodged upon it. The mishap pilot
attempted to cycle probe anyway. [Encls (10), (15), (19) 1 (27) and (29) J
116. At 0915Z/1215L, VICTORY 206 reported its fuel state as 700 lbs . Airspeed
was 143 KCAS. [Encls (3) and (22))
117. VICTORY 206 was then instructed to attempt a crossbl eed restart of the
right engine for the purpose of energi zing HYD 2 to get the gear down. He was
instructed to bring the left engine up to 90 , and then to MIL. The crossbleed
attempt yielded 0 RPM with the ENG CRANK switch again returning to the OFF
position. This occurred at 0915Z/1315L. [Encls (3)
1
(15), (20), (21), (27)
and (34)]
118. VICTORY 206 accelerated to 260 KCAS, but the right engine did not
restart. RPM indications remained at 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 and
pull it to up, check the circuit breakers, and then attempt to drop the gear
down. This resulted in the nose gear coming down, but the mairi landing gear
remained 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 right motor for the purpose of energizing HYD 2, which
would in turn, enable them to get the main landing gear down. 0917Z/1317L.
[Encls (3), (10 ) , (11), (15), (19) , (20), (21) and (27))
121. At 0917Z/1317L, VICTORY 206 reported "3 down and locked" at which point
they were instructed to land. VICTORY 206 was approximately 4NM from IKE with
an airspeed between 250-300 knots. [Encls (3), (10)
1
(11 ) , (16), (19)
1
(21),
(22) and (27)]
122. At 0918Z/1218L, VICTORY 206 was at 2 miles behind IKE at 2500 feet, left
of course and above glideslope. The LSO a contact" cal l followed
by "you're high and lined up left." [Encls (3), (10), (11), (15), (16) , (19),
(20), (21) and (27))
Fuel Starvation and Ejection
123. As 206 was executing the last portion of his S-turn t owards IKE,
the flamed out, and all electrical power was lost . Estimated
el evabon was 1200 feet. The time was 0919Z/1219L. [Encls (3) (6 ) (10) (11)
and ( 2 0 ) J ' ' '
124. The mishap pilot . felt the jet roll slightly to the right. He responded
with a left lateral stlck and full left rudder, which momentarily stopped the
roll. The aircraft then made an uncommanded pitch over to about 30-40 degrees
nose low and rolled right. [Encls (10), (11) and (16)]
1
25. At approximately 0919Z/1219L, with VICTORY 206 descending below 1
1
000
feet at approximately 1.5 NM behind IKE, and with the aircraf t in a steep a ngl e
17
000021
Subj:
COMMAND INVESTIGATION INTO THE FACTS CIRCUMSTANCES SURROUNDING THE
SEA
of bank (estimated 45 degrees with 20-degree nose low), the mishap pilot
released the controls and pulled the ejection handle. The mishap pilot
' estimated the aircraft was at 60 degree nose down and a 20 degree right wing
down when he initiated ejection. The mishap pilot made no ejection call. Two
good chutes were immediately observed. [Encls (3), (6), (10), (11), (15), (16),
(19) 1 (20) 1 (21) I (22) I (25) I (26) I (27) I (29) and (37)]
126. The total duration of VICTORY 206's last flight was approximately 5 hours
and19minutes. [Encls (3), (7) and (9)]
127. At the time of the ejection, the mishap WSO was unaware that the mishap
pilot had lost control of the aircraft and assumed he was moving the aircraft
away from the carrier for ejection. The mishap WSO was not in proper body
position as he was leaning forward to view the clearance away from the ship.
[Encl (11) l
128. The aircraft continued a slow roll to port while diving towards the wake
of the ship. It impacted the water port side of the wake left wing down and
nose low. [Encls (15), (16) and (20))
129. Review of the Deployable Flight Incident Recorder Set (DFIRS) indicated
that there was a total of 1,983 lbs of fuel in the MA at the moment ejection
was initiated. Each tank indicated the following amount: Tank 1, 20 lbs; Tank
2, empty; Tank 3, 320 lbs; Tank 4 - 11 lbs; left wing i nternal tank - 902 lbs;
right wing internal tank- 606. [Encl (28)]
130. The mishap pilot blacked out momentarily upon ejection, but regained
consciousness as he was f l oating under his parachute. He had about 5-10
seconds under the canopy before hitting the water. During this time, he saw
the mi shap WSO slumped in his harness about 50-70 yards away and the spot where
VICTORY 206 had entered the water. [Encls (6) and (10)]
131. The mishap pilot, with his mask still on, did not complete IROK
procedures whi l e in the air. Upon impacting the water, the SEAWARS system
automatically detached him from his parachute. He sank approximately, 10 feet
before his LPU automatically i nflated. As his mask was still on, he was able
to breathe while submerged. The mishap pilot surfaced under his parachute,
requi ring him to use the hand-over-hand method to get out from under it. He
then used his shroud cutter to cut 5-6 shroud lines to disentangle himself.
The mishap pilot then removed his mask and, with difficulty due to the injuries
sustained to his hands, was able to remove his lap belt that released his seat
pan. [Encls (6) and (10)]
132. The mishap WSO likewise blacked out momentarily, but regained
while under his canopy, which he was under longer than the mishap
enabling him to check his canopy and then release one side of his'. mask.
The waited until his feet impacted the water before manually
releasl.ng h1s parachute harness. His LPU inflated automatically. (Encls (6 )
and (11)]
b
1e3h3: dTihKeEmishfap pilot and mishap WSO landed in the water approximately 1.5 NM
l.n a ew seconds after ejecting. (Encls (3), (16), (37)]
13
4. The hands and knuckles were swollen, and both hands
sustained Sl.gnl.f t 1
l.Can acerat1ons, and were bleeding profusely. [Encl (10)]
18
000022
Subj:
SEA
135 . The mishap pilot and mishap wso, who landed approximately 100 yards from
each other, swam to within 10- 30 of other before the helicopter was
overhead. [Encls (6) and (10))
Helicopter Rescue
136. CANVAS 611 was the recovery plane guard helicopter stationed in port
delta 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 HAMBURG (F220) to IKE
while tasked with plane guard duties . At the time of ejection, CANVAS 611 was
carryingthreepassengers. [Encls (3) , (37) and (39))
138. At 0919/13191, CANVAS 611 was directed to the downed aircrew with the LSO
providing an initial vector to their location . [Encls (3), (16), (37) and (39)]
139. CANVAS 611 requested to drop the three passengers off on IKE before
executing the SAR to ensure room was available if a litter recovery was
required. This request was denied with -CANVAS 611 being directed to
immediately proceed to the survivors and begin SAR operations. [Encls (3) ,
(37) and (39) J
140. CANVAS 611 arrived on-scene at approximately 0921Z/1321L, and lowered the
rescue swimmer. rEncls (3) I (6)' (16)' (37)' (39) l
141. The mishap wso was recovered by a rescue swimmer via a hoist recovery at
0934Z/1334L. [Encls (4), (5), (6) , (15), (16)
1
(22), (37) and (39))
142. The mishap pilot was recovered by rescue swimmer via hoist recovery at
0945Z/1345L. [Encl (4), (5), (6), (15), (16) , (22), (37) and (39)1
143. CANVAS 611 landed on IKE at approximately 0948Z/1348L. [Encls (4), (5),
( 16) , ( 2 2) and ( 3 9) ]
144. The aircrew of CANVAS 611 had no complications during the recovery of
first survivor, the mishap WSO. During recovery of the second survivor, the
mishap pilot, his parachute drifted between CANVAS 611 and the second survivor
due to current and winds . [Encls (6), (37) and (39)]
145. Weather conditions at time
76 deg F, air temperature 81 deg
vertical visibility of 6,000 ft.
caps. (Encl ( 6) and ( 37)]
of recovery were as .follows: water temperature
F, wind 185 at 5 kts, 3 NM visibility, and a
The s ea state was 5 ft swells with no white
146. CANVAS 611 ' s crew chief stated having three passengers inside of the
helicopter made it difficult for the aircrew to prepare the cabin for survivor
pickup and would have made a litter pickup very difficult. Had the latter been
required, aircraft seats and racks would have been required to be discarded in
order to make room for the litters. [Encls (6), (37) and (39))
Post-mishap status of aircrew
147. The had all of his proper flight gear and safety equipment
but was not wear1ng hls gloves at the time he initiated ejection. Specific
gear worn and used can be found in enclosure (6). [Encls (6), (10) and (38) )
19
000023
SEA
} ~ A ~ h P mishao oilot sustained a
(b)(6)
(b ){6)
1 .10
~ h P miAhno oilot's life stressors
(b )(6)
(b)(6)
150. The mishap pilot had no indicators of alcohol use or intoxication at the
time of the mishap. Post - mishap testing did not indicate an illegal drug use.
(Encl (13) J
1 "1 'T'h"' mi Ah;m oilot was ;
(b)(6)
(b)(6)
152. The mishap pilot tested positive or morphine which was prescribed and
given to him after t he ejection. [Encl (13)]
153 . The mishap WSO had all his proper flight gear and safety equipment and
was properly wearing his flight gear when ejection was initiated. Specific
gear worn and used can be found in encl osure (6). (Encls (6), (11) and (38))
(b)(6)
(b )(6)
{ 1 3} )
155 . The mishap WSO stated during recovery operations, the horse coli ar (LPU-
36) was very tight around his neck and caused extreme discomfort. [Encl {11)]
156. The mis hap WSO indicated no life stressors at the time of the mishap.
[Encl ( 13))
157 . Post-mishap testing indicated no alcohol use or intoxication or i l licit
drug use by the mishap WSO. [Encl {13)]
Closing notes
158. The total cost of the F/A- lBF Super Hornet aircraft BUNO # 166616 and
equipment, not including the refueling drogue , lost in the mishap is
$59,732,379.93. The aircraft cost $41,250,457.00 USD and the additional
equipment totaled $18,459,437.02. [Encl (8}]
159. During the entire evo ution and radio exchanges, IKE co was only told and
heard expected fuel on deck at the diverts and then at IKE. At no point while
20
000024
subj:
AVIATI ON MISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIAN
SEA
monitoring the radios and preparing IKE to receive the mishap aircraft was a
fuel state passed to the Captain. [Encl (26))
OPINIONS
1 . A likely unavoidable separation of an air refueling drogue, leaving the
basket attached to V;I:CTORY 206's probe, was the beginning of this mishap chain
of events. The direct cause of the loss of VICTORY 206 was extended operations
with a damaged right engine (due to fuel ingestion) that eventually failed, and
the subsequent flameout of the left engine due to fuel starvation. However ,
inadequate crew resource management (CRM) at nearly every level of the chain of
command contributed to the outcome of this 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 first significant link in the causal chain of this mishap (e . g .,
contributing factor) was the aircrew' s failure to accurately assess the status
of the aircraft's right engine immediately following the refueling incident.
Having just torn the refueling basket from SHELL 73 and the sudden appearance
of a PERF 90 caution, the aircrew failed to the possibility the
right engine had sustained serious damage from the ingestion of foreign object
debris (FOD). While believing that the ingestion of fuel may have impacted
engine operability, the aircrew did not consider the possibility that they were
dealing with a compound emergency or see the need to take a more cautious
approach regarding the operation of the right engine. This init i al failure to
if" the engine significantly increased the risk of a mishap, leading to a
decision to execute the long transit from IKE on a dual engine P.rofile .
Ultimately, this engine flamed out after it was determined VICTORY 206 ' s
useable fuel status was significantly lower than initially calculated and upon
attempting to execute the bingo profile specified for an F/A-18 E/F with both
engines 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 return
to IKE based on the guidance that a PERF 90 is a "Land as Soon as Practical"
emergency is particularly troublesome. Understanding that a PERF 90 caution is
listed as such in NATOPS (and the PCL), it is not a s ubstitute for exercising
sound judgment, considering all the other available information and taking into
account their collective experience to determine the appropriate course of
action. Although NATOPS does not cover compound emergencies, even "Land as
Soon as Practical" emergencies caution against extended flight. With a damaged
right engine and inability to airborne refuel, the crew of VICTORY 206 should
have realized the severity of the situation and the cascading effects that
could compound this emergency. Despite the lack of air wing maintenance
a suitable airfield wa s available in A,fghanistan to safely land
t h1s a1rcraft. While not responsible for this mishap, BEARCAT 22 should have
been.more assertive in assessing this potential compound emergency as weli as
the 1n-country divert decision process. {FOFs (35) , (36), (37), (38), (39),
(40), (41), (46 ) and (47) J
4 . failures to accurately assess their aircraft's condition and
su1tab1l1ty for extended flight was compounded by their interpretation
of Commander ' s vague divert guidance for aircraft operation over
which neither covered compound emergencies nor was intended to be
a s ubstltute for sound aircrew judgment. Nonetheless, it is clear from aircrew
statements that this guidance contributed to a mindset where, having
21
000025
'.
Subj;
-- -- - - ------ - - -- - -- --------------
COMMAND INVESTIGATION INTO THE FACTS AND CIRCUMSTANCES THE
AVIATION l-1ISHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIAN
SEA
categorized an aircraft emergency as "Land as Soon as Practical" while on an_
OEF mission, aircrew were expected to get their aircraft back to IKE . An Air
Wing Commander's guidance must be critically and routinely reviewed with CVW
aircrew to ensure intent is clear, sufficient coverage of the areas" that
will inevitably come up is provided, and aircrew are confident of their
critical role in the decision-making process. [FOFs (39), (40), (41), (42),
(44) and (45)]
5. The col lective failure by the mishap . pilot, mishap WSO, and wingman to
recognize the impact an extended refueling probe would have on centerline ahd
internal wing tank transfer is significant . VICTORY 206's decision to return
to IKE was based upon an assumption that all the fuel from their centerline and
internal wing tanks would be available. Indeed, VICTORY 206 estimated its
overheard available fuel state when it reached IKE would be at least 4,500 lbs
(initially set at 6,500 lbs), enough fuel to attempt to land on the carrier and
still divert to Masirah, if necessary. It was only after they had committed to
returning to IKE that they realized that wing fueL transfer was very slOW) and
that approximately 3,000 lbs of wing tank fuel may be unavailable (gravity feed
only, but with aircraft maneuvering required). Proper recognition of the
impact that the extended IFR probe would have on their useable fuel may have
caused VICTORY 206 to realize the precarious nature theit fuel state
(overhead fuel state would have ranged from 3,500 to 1,500 lbs ) , and made it
clear that the idea of returning to IKE was not the best of course of action.
(FOFs (9), (10), (11), (12), (13), (34), (39), (40), (4i), (50), (53), (56),
(57), (66), (67), (68) and (98))
6. The lack of NATOPS guidance on the transfer rate for gravity feeding when
motive flow capability is lost also contributed to this mishap. Upon
recognizing that motive flow of fuel from the wing tanks was lost, the pilot
attempted to ai d the gravity feeding by slipping and cross controlling as
called upon by NATOPS for approximately 15 minutes. Subsequent to this mishap
it was determined that he needed another 25 minutes to transfer all of the
useable fuel from the wing tanks in .a best-case scenario and would have
involved flying the aircraft for 40 minutes continuously at an angle of bank
greater than 5 degrees and i n a slideslip. Although the aircrew and IKE
personnel eventually based divert decisions solely upon useable fuel (e.g.,
f uel inside the fuselage), knowledge of this slow transfer rate would have
greatly enhanced decision-making, saving valuabt"e time and fuel in the process.
[FOFs (9), (13}, (57) and (58)]
7. A lack of adherence to the fundamentals of CRM, specifi cal ly effective
communications among all decision-makers to fully understand the extent of
VICTORY 206's emergency, also contributed to this mishap. VICTORY 206's
initial request of the CRC in Afghanistan to pass their aircraft status and
intentions back to the ship did not get communicated accurately (no awareness
at the ship of the basket still attached to the probe). Once VICTORY 206 was
back within communications range of the CVN, the aircrew could have done a much
better job painting the full picture of their emergency, aircraft system's
status and useable fuel states for the CVW representative (not in CATCC), the
squadron representative (in CATCC) and all those listening intently on the
"rep" frequency. That said, CRM is a two-way process and the initial
questioning . of VICTORY 206 by either the CVW representative or squadron
representatlve should have been more assertive and directive. The fact that no
one on the ship was aware that the IFR probe was extended with the basket still
attached unti l minutes before ejection clearly reinforces the inadequacy of the
22
000026
SEA
initial dialogue to determine the status of VICTORY 206's fuel system for all
decision-makers . {FOFs (50), (51), (59), (60), (64 ) , (66), (68) and (115))
8 . As the emergency progressed in the vicinity of the ship, the mishap pilot's
communications to his WSO and squadron representative were unsatisfactory.
Even more critical to the outcome of this he never discussed
intention to restart the right engine usin-g the APU before moving any switches.
Had that conversation taken place, it woul d likely have generated concerns from
the mishap WSO and squadron representative (and any others familiar with the
basic hydraulic/APU systems on an F-18F) that an APU restart attempt would
result in the depletion of hydraulic pressure needed to emergency extend the
landing gear. Loss of emergency functionality subsequently required eight
minutes of additional flight time to rectify (e.g., get the gear down and
locked) during which the majority of VICTORY 206is remaining fuel was expended
while attempting to windmill the right engine to regain HYD 2 pressure in a
last- ditch effort to get the landing gear down and locked. In taking these
actions without referencing the PCL, communicating with his WSO or consulting
with the SR aboard IKE, the mishap pilot violated the most basic tenants. of
CRM, and the APU restart attempt led to the self-induced, compound emergencies
that would ult i mately dim any prospects of a successful recovery aboard the
CVN. {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 the
correct one based upon the available information (3.7 useable fuel and no
information passed at this time by VICTORY 206 that i t had a degraded right
engine). 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 lightly
and should be the exception. CSG Commanders, especially one who is airborne as
a pilot in command, must exercise restraint in such circumstances and to the
extent P,Ossiblel rely on their subordinates to make the correct calls. [FOFs
(64), (68), (71), (72 ) , (73) and (74))
10. The changes to VICTORY 206
1
s destination from IKE to Masirah, Masirah to
Muscat, Muscat back to Masirah1 and finally back to IKE did not significantly
contribute to this mishap. While recognizing that fuel was expended in
executing these course changes , all were made at altitude and with the
exception of the final 180-degree turn back to IKE, all were less than 60
degrees. [FOFs (71), (76)
1
(79)
1
(83), (96) and (98) J
11. Although weather conditions was the reason that VICTORY 206 did not divert
to Muscat, there is widespread perception that although i t is l i sted as one of
two fields for carriers operating in the North Arabian Sea, the
perceptlon lS t hat it is not a viable option due for dipl omatic reas ons. [FOFs
(77) and (83)]
12. The mishap pilot's injuries were sustained in the line of duty and not due
to misconduct. (FOFs (125), (131) , (134) and (148)]
1
3. The mishap WS0
1
s injuries were sustained in the line of duty and not due
to mi sconduct. [FOFs (127) and (154)]
RECOHHENDA'riONS
1. In light of the fact it is impossible to cover every possible contingency
that may arise, cognizant commanders need to arm aircrew with the tools to ma ke
23
000027
Subj: COMMAND I NVESTIGATION INTO THE FACTS AND CI RCUMSTANCES SURROUNDING THE
AVIATI ON MI SHAP THAT OCCURRED ON 08 APRIL 2013 IN THE NORTHERN ARABIAN
SEA
s ound decisions in t he cockpit. As a community, we must remain vigilant
against a mindset i n which a diver t is viewed upon as a sign of weakness or
inferior airmanship. Aircrew must have confidence that wel l -reasoned di vert
decisi ons will be supported by the chain of command. [Opinions ( 1)- ( 4) )
2. The f acts of this mishap and the safety investigation report should be
bri efed t o all Hornet, Super ~ o r n e t and Growler squadrons to raise their
s i tuational awareness on t he decisi ons made in the cockpit and the l essons
learned regardi ng the operation of the F/A-18 c-G. {Opinions (1) -(8))
3. A copy of thi s investigati on be forwarded to commanding Officer, VFA-122,
the F/ A- 18E/F Model Manager, with a recommendati on that the NATOPs be updated
to provide guidance on the gravity feed fuel transfer rate . [Opinion (6)]
4. A copy of thi s investigation be forwarded to commander, U.S. Navy Central
Command (NAVCENT ) , wi th a request that his staff review the continued
identificat ion of Muscat, oman, as a viable di vert opt i on. If necessary,
provi de CSGs and CVWs guidance regarding the type of emergencies/ aircraft
confi gurati ons that would be acceptable to land at Muscat International
Airport. [Opi ni on (11))
5. No disciplinary be taken against the VIcTORY 206 aircrew. [Opinions (1)-
(13 ))
(b )(6)
24
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Super Hornet Crash - North Arabian Sea

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Super Hornet Crash - North Arabian Sea

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DEPARTMENT OF THE NAVY

COMMANDER NAVAL AIR FORCE ATLANTIC

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