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United States Air Force Aircraft Accident Investigation Board Report

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United States Air Force Aircraft Accident Investigation Board Report UNITED STATES AIR FORCE AIRCRAFT ACCIDENT INVESTIGATION BOARD REPORT T-6A, T/N 07-3890 89TH FLYING TRAINING SQUADRON 80TH FLYING TRAINING WING SHEPPARD AIR FORCE BASE (AFB), TEXAS LOCATION: 21 MILES NE OF SHEPPARD AFB, TEXAS DATE OF ACCIDENT: 1 MAY 2019 BOARD PRESIDENT: COLONEL EDWARD S. BREWER Conducted IAW Air Force Instruction 51-307 United States Air Force Accident Investigation Board Report Class A, Sheppard AFB EXECUTIVE SUMMARY UNITED STATES AIR FORCE AIRCRAFT ACCIDENT INVESTIGATION T-6A, T/N 07-3890 21 MILES NE OF SHEPPARD AIR FORCE BASE, TEXAS 1 MAY 2019 At 1313 hours local time on 1 May 2019 a T-6A Texan II, tail number 07-3890, crashed 21 miles northeast of Sheppard Air Force Base (AFB), TX. The mishap crew (MC) included a mishap instructor pilot (MIP), 97th Flying Training Squadron (FTS), who supervised the mishap pilot (MP), 89 FTS. The MP was conducting a transition sortie in the Pilot Instructor Training course from the front seat. The MC ejected and sustained minor injuries. The mishap aircraft (MA) was assigned to the 80th Flying Training Wing, Sheppard AFB, TX. While setting up a training maneuver with building cloud formations, the MIP flew the MA in an unintentional nose-high trajectory with decreasing airspeed. In an attempt to regain airspeed, the MIP tried to lower the nose of the aircraft towards the horizon and penetrated the weather. Next, the MIP attempted to roll wings level while still in a nose-high attitude with insufficient airspeed and high-power setting. As a result, the MA departed controlled flight in a power-on, inverted spin. The MC attempted to recover the MA until the MIP assessed the MA unrecoverable and commanded ejection at approximately 10,800 feet mean sea level. The MA, valued at approximately $5.7 million, impacted the ground and was destroyed. There were no casualties and no loss of civilian property. The Accident Investigation Board President, by a preponderance of evidence, determined the cause of the mishap to be pilot error. Specifically, the MIP flew the MA into an aerodynamic stall due to fixation on environmental factors. Then the MIP did not follow the prescribed memorized, critical-action checklist, inhibiting recovery. Under 10 U.S.C. § 2254(d) the opinion of the accident investigator as to the cause of, or the factors contributing to, the accident set forth in the accident investigation report, if any, may not be considered as evidence in any civil or criminal proceeding arising from the accident, nor may such information be considered an admission of liability of the United States or by any person referred to in those conclusions or statements. United States Air Force Accident Investigation Board Report Class A, Sheppard AFB SUMMARY OF FACTS AND STATEMENT OF OPINION T-6A, T/N 07-3890 1 MAY 2019 TABLE OF CONTENTS ACRONYMS AND ABBREVIATIONS ...................................................................................... iii SUMMARY OF FACTS ................................................................................................................ 2 1. AUTHORITY AND PURPOSE ...........................................................................................2 a. Authority .........................................................................................................................2 b. Purpose ............................................................................................................................2 2. ACCIDENT SUMMARY .....................................................................................................2 3. BACKGROUND ..................................................................................................................3 a. Air Education and Training Command ...........................................................................3 b. The 80th Flying Training Wing ......................................................................................3 c. The 89th Flying Training Squadron ................................................................................3 d. The T-6A Texan II ..........................................................................................................4 4. SEQUENCE OF EVENTS ...................................................................................................4 a. Mission ............................................................................................................................4 b. Planning ..........................................................................................................................4 c. Preflight ...........................................................................................................................5 d. Summary of Accident .....................................................................................................5 e. Impact ............................................................................................................................11 f. Egress and Aircrew Flight Equipment (AFE) ...............................................................12 g. Search and Rescue (SAR) .............................................................................................12 h. Recovery of Remains ....................................................................................................13 5. MAINTENANCE ...............................................................................................................13 a. Forms Documentation ...................................................................................................13 b. Inspections ....................................................................................................................14 c. Maintenance Procedures ...............................................................................................14 d. Maintenance Personnel and Supervision ......................................................................15 e. Fuel, Hydraulic, Oil, and Oxygen Inspection Analyses ................................................15 f. Unscheduled Maintenance .............................................................................................15 6. AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS ............................................16 a. Structures and Systems .................................................................................................16 (1) Flight Control Surfaces ......................................................................................... 16 (2) Landing Gear System ............................................................................................ 16 (3) Engine.................................................................................................................... 16 b. Evaluation and Analysis ...............................................................................................17 7. WEATHER .........................................................................................................................17 a. Forecast Weather ...........................................................................................................17 b. Observed Weather .........................................................................................................17 c. Space Environment .......................................................................................................18 d. Operations .....................................................................................................................18 T-6A, T/N 07-3890, 1 May 2019 i United States Air Force Accident Investigation Board Report Class A, Sheppard AFB 8. CREW QUALIFICATIONS ...............................................................................................18 a. Mishap Instructor Pilot ..................................................................................................18 b. Mishap Pilot ..................................................................................................................19 9. MEDICAL ..........................................................................................................................20 a. Qualifications ................................................................................................................20 b. Health ............................................................................................................................21 c. Pathology.......................................................................................................................21 d. Lifestyle ........................................................................................................................21 e. Crew Rest and Crew Duty Time ...................................................................................21 10. OPERATIONS AND SUPERVISION .............................................................................21 a. Operations .....................................................................................................................21 b. Supervision ...................................................................................................................22 11. HUMAN FACTORS ........................................................................................................22 a. Introduction ...................................................................................................................22 b. Fixation (PC102) ...........................................................................................................22
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