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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 C-17A, T/N 00-0173 3RD WING JOINT BASE ELMENDORF-RICHARDSON, ALASKA LOCATION: JOINT BASE ELMENDORF-RICHARDSON, ALASKA DATE OF ACCIDENT: 28 JULY 2010 BOARD PRESIDENT: BRIG GEN CARLTON D. EVERHART II CONDUCTED IAW AIR FORCE INSTRUCTION 51-503 EXECUTIVE SUMMARY AIRCRAFT ACCIDENT INVESTIGATION C-17A, T/N 00-0173 JOINT BASE ELMENDORF-RICHARDSON, ALASKA 28 JULY 2010 On 28 July 2010, at approximately 1822 hours local time (L), a C-17A, Tail Number 00-0173, executed a takeoff from Runway 06 to practice maneuvers for the upcoming 31 Jul 10 Arctic Thunder Airshow at Joint Base Elmendorf-Richardson. After the initial climbout and left turn, the mishap pilot executed an aggressive right turn. As the aircraft banked, the stall warning system activated to alert the crew of an impending stall. Instead of implementing stall recovery procedures, the pilot continued the turn as planned, and the aircraft entered a stall from which recovery was not possible. Although the pilot eventually attempted to recover the aircraft, he employed incorrect procedures, and there was not sufficient altitude to regain controlled flight. The aircraft impacted wooded terrain northwest of the airfield, damaged a portion of the Alaskan Railroad, and was destroyed. The mishap aircraft was assigned to the 3rd Wing based at Joint Base Elmendorf-Richardson, Alaska. The mishap crew was an integrated crew with members from both the 249th and 517th Airlift Squadrons. The mishap crew consisted of the mishap pilot, the mishap copilot, the mishap safety observer and the mishap loadmaster. All four aircrew members died instantly. The mishap aircraft was valued at $184,570,581. The impact also damaged Alaskan Railroad train tracks that transect the base. There were no civilian casualties. The board president found clear and convincing evidence that the cause of the mishap was pilot error. The mishap pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible. Furthermore, the mishap copilot and mishap safety observer did not realize the developing dangerous situation and failed to make appropriate inputs. In addition to multiple procedural errors, the board president found sufficient evidence that the crew on the flight deck ignored cautions and warnings and failed to respond to various challenge and reply items. The board also found channelized attention, overconfidence, expectancy, misplaced motivation, procedural guidance, and program oversight substantially contributed to the mishap. Under 10 U.S.C. 2254(d), any opinion of the accident investigators 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. SUMMARY OF FACTS AND STATEMENT OF OPINION C-17A, T/N 00-0173 28 JULY 2010 TABLE OF CONTENTS SUMMARY OF FACTS ................................................................................................................ 1 1. AUTHORITY and PURPOSE ..............................................................................................1 a. Authority .........................................................................................................................1 b. Purpose ............................................................................................................................1 2. ACCIDENT SUMMARY .....................................................................................................1 3. BACKGROUND ..................................................................................................................1 a. Pacific Air Forces ............................................................................................................2 b. Air National Guard .........................................................................................................2 c. Alaska Air National Guard..............................................................................................2 d. Unit Information .............................................................................................................2 (1) 11th Air Force, Joint Base Elmendorf-Richardson, Alaska ................................... 2 (2) 3rd Wing, Joint Base Elmendorf-Richardson, Alaska ........................................... 3 (3) 176th Wing, Joint Base Elmendorf-Richardson, Alaska ........................................ 3 (4) 517th Airlift Squadron ........................................................................................... 3 (5) 249th Airlift Squadron ........................................................................................... 3 e. C-17A – Globemaster III ................................................................................................4 4. SEQUENCE OF EVENTS ...................................................................................................4 a. Mission ............................................................................................................................4 (1) Aerial Demonstration Profile – Profile 3 (12-minute Profile) ............................... 4 (2) C-17 Aircrew Positions .......................................................................................... 5 (3) Airspace Considerations ......................................................................................... 6 b. Planning ..........................................................................................................................6 c. Preflight ...........................................................................................................................6 d. Summary of Accident .....................................................................................................7 (1) Weather Observation Flight ................................................................................... 7 (2) Aerial Demonstration Practice Flight (Mishap Sortie) .......................................... 7 e. Impact ..............................................................................................................................9 f. Egress and Aircrew Flight Equipment .............................................................................9 g. Search and Rescue (SAR) ...............................................................................................9 h. Recovery of Remains ......................................................................................................9 5. MAINTENANCE .................................................................................................................9 a. Forms Documentation .....................................................................................................9 b. Inspections ....................................................................................................................10 (1) Mishap Aircraft .................................................................................................... 10 (2) Mishap Engines .................................................................................................... 11 c. Maintenance Procedures ...............................................................................................11 d. Maintenance Personnel and Supervision ......................................................................11 e. Fuel, Hydraulic and Oil Inspection Analyses ...............................................................11 C-17A, T/N 00-0173, 28 July 2010 i f. Unscheduled Maintenance .............................................................................................12 6. AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS ............................................12 a. Structures and Systems .................................................................................................12 b. Evaluations and Analyses .............................................................................................12 (1) Engine Performance ............................................................................................. 12 (2) Hydraulic Systems Performance .......................................................................... 13 (3) Flight Control Systems Performance ................................................................... 13 (4) Stall Protection System: Stall Warning System and Angle of Attack Limiter System (ALS)........................................................................................................ 15 7. WEATHER .........................................................................................................................16 a. Forecast Weather ...........................................................................................................16 b. Observed Weather .........................................................................................................16 c. Space Environment .......................................................................................................16 d. Operations .....................................................................................................................16 8. CREW QUALIFICATIONS
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