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8TH FIGHTER WING (PACAF),.3 KUNSAN-AIR BASE, REPUBLIC OF-KOREA 7J1 27 JULY1 993

CONDUCTED INACCORDANCE WITH AFR 110-14 APPOINTING AUTHORITY: SUBMITTED BY: ROBERT-L. RUTHERFORD THOMAS A. ORAM GENERAL, USAF LIEUTENANT COLONEL, USAF COMMANDER, PACAF DEPUTY COMMANDER HICKAM AFB, HI 96853-5420 354TH OPERATIONS GROUP EIELSON AFB, AK 99702-1805

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1) DEPARTMENT OF THE AIR FORCE PACIFIC AIR FORCES

126NOV 1993 FROM: PACAF/CC 25 E Street, Ste G214 Hickam AFB, HI 96853-5420 SUBJ: AFR 110-14 Report of Investigation, F-16C, SN 86-0275 and SN 87-0335 TO: 7 AF/CC The subject report of investigation is approved except for the Investigating Officer's opinions that the pilot of Slap 02 violated the approach procedures contained in Air Force Regulation 60-16 and that the control tower watch supervisor failed to maintain situational awareness since these opnýsu•pported by clear and convincing evidence.

RORD, General, USAF Commander

57755 AIRCRAFT ACCIDENT INVESTIGATION CONDUCTED IN ACCORDANCE WITH AFR 110-14

F-16C S/N 86-0275 AND F-16C S/N 87-0335 8TH FIGHTER WING KUNSAN AIR BASE, REPUBLIC OF KOREA

INVESTIGATING OFFICER LIEUTENANT COLONEL THOMAS A. ORAM

1. STATEMENT OF AUTHORITY AND PURPOSE appointed Lieutenant Colonel Thomas A. Oram was a. Pacific Air Investigating Officer by General Robert L. Rutherford, on 18 Aug 93 under the authority of Air Force Forces Commander and 110-14, Investigations of Aircraft, Missile, Regulation (AFR) of Space Accidents, dated 15 Dec 89, for investigation Nuclear and on the accident that occurred on Tuesday, 27 Jul 93, an aircraft Republic of end of Runway 36 at Kunsan Air Base (AB), approach 86-0275 and F-16C, Korea (ROK), involving F-16C, Serial Number Five technical advisors were also appointed Serial Number 87-0335. 8 OG/QA, the investigation: Major Douglas W. Freeman, to assist in Flight Advisor; Major Jay A. Clemens, 31 SOS/SGP, Maintenance 80 FS/SELO, and Medical Advisor; Captain Douglas J. Fogle, Surgeon Legal Advisor; Advisor; Captain Deborah L. Collins, 51 WG/JA, Pilot Air Traffic Control and Captain Ricky L. Smith, 3 OSS/DOFC, Advisor. officer and b. The documents appointing the investigating investigation officially technical advisors are at Tab Y. The began 30 Aug 93. according to c. The purpose of this accident investigation, all available evidence for AFR 110-14, is to obtain and preserve litigation, disciplinary action, adverse use in -claims, deemed proceedings, and for all other purposes administrative is not by competent authority. This accident report appropriate with AFR 110-14, privileged and is releasable in accordance paragraph 12. investigation are d. The times addressed in this report of Korean local times unless otherwise stated. is provided at Tab e. A glossary of acronyms and abbreviations FF.

57756 2. SUMMARY OF FACTS

a. HISTORY OF FLIGHT Air Force F (1) On 27 Jul 93 at 3:31 PM, a United States call sign "Slap 02," collided 16C, Block 30, Serial Number 86-0275, Block 30, Serial Number 87 with a United States Air Force F-16C, at 35 degrees 53 minutes 30 seconds 0335, call sign "Stingray 01," on 37 minutes 5 seconds east longitude north latitude, 126 degrees the 36, Kunsan AB, ROK, fatally injuring the approach end of Runway a. Lieutenant Colonel Ralph E. Gardner, pilot of Stingray 01. 8th assigned as the Chief of Safety, United States Air Force pilot Slap was the pilot of Stingray 01. Fighter Wing, Kunsan AB, ROK, D. LeBlanc, a United States Air 02 was flown by Captain Richard 35th Fighter Squadron, 8th Operations Force pilot assigned to the 2) AB, ROK. (Tabs A-i, C-i, and Group, 8th Fighter Wing, Kunsan second flight of the day, a training Slap 02 was returning from his AB at 2:34 PM. Stingray 01 was mission that originated at Kunsan for his second flight of the day, just beginning the takeoff roll V when the mishap occurred. (Tabs a single-shlp training mission, 1, 2, 3, and EE-26) was an intended route of flight (2) Stingray 01's Visual departure to the northeast to Instrument Flight Rules (IFR) for then direct to Osan AB, ROK, Meteorological Conditions (VMC), followed by an instrument recovery practice instrument approaches and AA-2). back at Kunsan AB (Tabs V-7, 74, flight on the mishap sortie (3) The route flown by Slap 01 southeast of the base, Kunsan AB to approximately 50 miles was from (MOA) 15 and MOA 16. to Military Operating Area then direct Julop, the Initial the operating areas was direct to Recovery from Launch And Recovery Fix (IAF), for the Aircraft Surge Approach for Runway 36, the active Instrument Landing System (ILS) (ASLAR), was the pilot of the number runway at Kunsan AB. Captain LeBlanc 0 a formation of two F-16s. (Tabs two aircraft in Slap 01 flight, 14, 37, 38, V-i, 2, AA-I, and EE-26) with one 300 gallon and two (4) Stingray 01 was configured AIM-9 air-to-air training gallon external fuel tanks, a captive 370 pod, two TER-9/A triple an acgeleration monitor assembly missile, and 387 rounds of 20 bomb racks, 30 RR-170 chaff bundles, ejector Gross weight at takeoff was millimeter target practice ammunition. 34,439 pounds. (Tab L-1) engine start and taxi for (5) Ground operations to include receiving takeoff clearance from Stingray 01 were normal. After onto Runway 36, accomplished the control tower, Stingray 01 taxied afterburner, and began his takeoff an engine run-up check, selected

2

57757 02 while after brake release on takeoff roll, Slap roll. Shortly injuring the to land, collided with Stingray 01, fatally attempting 47, X, BB-3, and EE-37) pilot of Stingray 01. (Tabs A-i, V-4, 46, with one 300 gallon external (6) Slap 02 was configured an AIM-9 air-to-air training missile, fuel tank, a captive air-to-air monitor assembly pod, two empty LAU-129 acceleration air-to-ground training missile launchers, two CATM-88/A captive chaff bundles, and 511 rounds missiles, 30 M-206 flares, 30 RR-170 ammunition. Gross weight at of 20 millimeter target practice takeoff was 30,760 pounds. (Tab L-2) were uneventful for (7) Engine start, taxi, and takeoff Kunsan AB and proceeded at Slap 01 flight. The flight departed High-speed Anti-Radiation Missile medium altitude to practice site tactics against a surface-to-air missile (HARM) employment Kunsan AB. Weather approximately 50 miles southeast of located were not suitable for the conditions in the briefed training area 01 coordinated with Airedale, the military primary mission. Slap approved for MOAs 15 and 16 to accomplish an radar control agency, at medium mission. Slap 01 flight proceeded alternate training the airspace, to their assigned MOAs. Upon entering altitude between Slap 01 and Slap 02 multiple intercepts were accomplished roles as the target aircraft and the with both aircraft exchanging Slap 01 aircraft. Departing the training airspace, interceptor Slap 02, who led the the flight lead responsibilities to passed ASLAR ILS approach and back through Julop, the IAF, for an flight portion of the approach, landing at Kunsan AB. During the landing Following the collision, the Slap 02 collided with Stingray 01. from his aircraft. (Tabs A-l, pilot of Slap 02 successfully ejected V-i, 2, 64, and 0-30) following the Both aircraft skidded down the runway (8) apart. Stingray and came to rest approximately 1600 feet collision off the runway surface to was totally engulfed in flames just 01 the runway with a small west while Slap 02 was just east of the R-1, S-i, V-36, and 37) fire at the tail of the aircraft. (Tabs data following the collision, the flight (9) Immediately crash net, in the control tower activated the primary controller fire, and rescue personnel initiating the response of base crash, (Tab V-4). / collision were (10) Weather conditions at the time of the scattered deck of clouds at 500 poor. Forecast weather indicated a ceiling and 1 1/2 miles above the ground with a 1500 foot feet taken by base weather visibility with rain showers. An observation mishap generally confirm the personnel within five minutes of the

3

57758 (Tab 0-25) with a slightly higher ceiling of 1800 feet. forecast estimated the ceiling Statements by personnel witnessing the mishap mile (Tabs V-i, 3, 4, 10, at 300 to 500 feet and visibility at 1 and 46). end of Runway (11) The collision occurred on the approach land utilized by United 36 at Kunsan AB, which is Korean government to an agreement between the States Air Force personnel pursuant Korea. Both aircraft were United States and the Republic of (35 FS), 8th Operations Group assigned to the 35th Fighter Squadron Air Force (7 AF), Pacific Air (8 OG), 8th Fighter Wing (8 FW), 7th Forces (PACAF). (Tab A-l) Wing Public Affairs Office at Kunsan (12) The 8th Fighter crash mishap at 3:35 PM, via the secondary AB was notified of the at 4:00 notified 7th Air Force Public Affairs net. They, in turn, directed all PM, United States Forces Korea (USFK) PM. At 4:24 A total of four news be handled through 7th Air Force. inquiries third release, dated 28 were made by 7th Air Force. The releases Gardner as a fatality in the Jul 93, identified Lieutenant Colonel mishap. (Tab EE-39)

b. MISSION flight lead of a two (1) Stingray 01 was scheduled as the The purpose of Stingray 01's ship formation of F-16 aircraft. in train and maintain pilot proficiency scheduled mission was to prior to Support (CAS). (Tab K-4) However, performing Close Air 02's weather weather deteriorated below Stingray taxiing, the Now a single F-16, causing his sortie to be cancelled. minimums planned alternate instrument Stingray 01's mission changed to his and V-74). Stingray 01's alternate proficiency sortie (Tabs 0-30 flying maintain proficiency in instrument mission was to train and procedures, enroute, arrival, and approach to include departure, in accordance with accomplish flying training requirements and to (Tabs 0-30, V-74, and EE-18) Multi-Command Regulation (MCR) 51-50. formation of F Slap 02 was the wingman of a two-ship (2) to train and maintain purpose of Slap 02's mission was 16s. The of Enemy Air Defenses pilot proficiency in performing Suppression 01 flight was to accomplish this (SEAD). (Tabs K-4 and EE-29) Slap tactics against a surface-to-air by practicing HARM employment of the of Kunsan AB. Weather in the area missile site southeast reverted the planned training and the flight missile site prevented mission's intercept mission. The alternate to its alternate missile defensive was to accomplish radar and infrared purpose with local directives. tactics and was accomplished in accordance (Tabs 0-30, V-i, and 2)

4

57759 c. BRIEFING AND PREFLIGHT in the days (1) Lieutenant Colonel Gardner's activities with no disruptions to his prior to the mishap were uneventful the day prior to the mishap, normal work-rest cycle. On 26 Jul 93, 7:00 AM and had a typical he reported for duty at approximately accomplished at 4:00 PM, when workday with his last official duty Following the staff meeting he he attended a wing staff meeting. Officers Club where he consumed attended an awards ceremony at the at 7:00 PM. On the day of one beer with friends and then departed reported to the squadron at the mishap, Lieutenant Colonel Gardner missions that day. (Tabs V-9 and 7:30 AM in preparation for his two 74) were typical of his Captain LeBlanc's activities (2) work-rest with no disruptions to his regular normal lifestyle at mishap he departed the squadron cycle. On the day prior to the at the Officers Club a short time approximately 5:30 PM, arriving Officers Club at 9:30 PM, Captain later. Prior to departing the dinner. On the day of the mishap, LeBlanc consumed two beers with the 35th Fighter Squadron LeBlanc reported for duty at Captain final preparation assist his flight leader with around 7:15 AM to V-l, scheduled to fly together. (Tabs for the two sorties they were 2, and 13) a large force employment (3) The morning of the mishap, that would include not only Lieutenant (LFE) exercise was scheduled flights but all of the Gardner's and Captain LeBlanc's Colonel that morning. The sorties in the 35th Fighter Squadron scheduled to train in a squadron pilots the opportunity LFE would afford multiple practice coordination between large force scenario, HARMs. such as F-16s configured with formations, and employ assets (Tabs V-i, 7, 14, 15, and 16) all participants mass briefing was attended by (4) The LFE prior a little more that three hours and began on time, at 8:00 AM, scheduled takeoffs. The briefing to Stingray 11's and Slap 22's mission commander briefing combined the 35th Fighter Squadron's guide. Included items were ground slides and a personal briefing taxi timing, takeoff ,include engine start and operations to Rules of NOTAMs (Notices to Airmen), times/flow, weather, and interest items, abnormal procedures, Engagement (ROE), special no the target area. There were coordination of attacks in of the mass briefing and the questions at the conclusion conduct their individual flight participants were released to 15, and EE-27) briefings. (Tabs K-3, V-l, 2, 14,

5

57760 included trail The mission profile for the exercise (5) track where the proceeding to the "Wedding" refueling departures, with a KC-135R conduct individual air refueling flights would refueling, the of the Boeing 707). Following (military version 80 miles southwest reform in an area approximately flights were to of aircraft as a package (a large group of Kunsan AB and depart or timing within the group by visual, radar, maintaining position to head north target area. The package was references) for the complex Chik-Do Range, an island bombing from the rejoin area to and of Kunsan AB. (Tabs V-1, 2, 14, approximately 25 miles due west 15) the flight Lieutenant Colonel Gardner was (6) In the LFE, 11. The of four F-16s, call sign Stingray lead of a formation filled) MK-82 configured with inert (cement flight's aircraft were pilots to configuration allowed the 500 pound bombs. This load of the F-16 with a realistic combat experience the performance live restrictions associated with while reducing the training EE-27) munitions. (Tabs V-14, 74, and Gardner conducted the individual (7) Lieutenant Colonel guide. 11 flight using a squadron briefing briefing for Stingray Nothing approximately 30 to 35 minutes. The briefing lasted His briefing about his briefing or mannerisms. unusual was noted in MCR 55 all required items as defined was thorough and included Gardner the briefing, Lieutenant Colonel 116. At the conclusion of life donned their required flying and and the other flight members V-14 to the aircraft on time. (Tabs support equipment and stepped and 74) as well as engine start, taxi, (8) Preflight inspection 11 and without incident for Stingray and takeoff were all normal later AM as planned, fifteen minutes flight. Takeoff was at 11:20 27) (Tabs K-4, V-74, EE-26, and than the printed schedule. the were as briefed. Due to timing, Departure and package rejoin not accomplished. As the package planned inflight refueling was the mission commander determined proceeded north to Chik-Do Range, and was not sufficient to that the- weather had deteriorated were planned mission. The flights accomplish the remainder of the to Kunsan AB by the mission subsequently gleared to return Colonel Gardner in the lead, Stingray commander. With Lieutenant out of as a four-ship formation landing 11 returned to Kunsan AB and 1:12 PM. Lieutenant Colonel Gardner straight-in approaches at of attend the mass debrief, because his wingman were unable to the and planned to debrief with limited time between sorties, second mission. (Tabs K-4, V-14, mission commander following their 15, 74, and EE-26)

6

57761 to fly as Colonel Gardner was scheduled (9) Lieutenant This sortie was a second sortie of the day. stingray 01 on his a CAS mission. His of two F-16s that would accomplish formation again fly with him on the from the morning mission would wingman to be flown in P-518, training sortie. It was scheduled This second of the Republic of Korea. in the northern part flew with airspace Lieutenant Colonel Gardner was identical to one briefed in mission prior. The mission was this same wingman the day utilizing by Lieutenant Colonel Gardner accordance with MCR 55-116 all required guide and adequately addressed a squadron briefing at the conclusion of the The wingman had no questions on subjects. the squadron for the aircraft briefing and the flight departed time. (Tabs K-4 and V-74) since their first sortie The weather had deteriorated (10) while accomplishing ground day and after engine start, that the supervisor of flying determined operations prior to taxiing, V-7, 34, and pilots would not fly (Tabs that "C" weather category Lieutenant wingman was now weather cancelled, EE-33). Since his to fly his prebriefed obtained squadron approval Colonel Gardner V-7). The remainder of his mission of instruments (Tab alternate and in accordance with local operations and taxi were normal ground crew chiefs nor the end of runway Neither the aircraft with directives. any difficulties or deficiencies crew members noted Stingray inspection 60, and 74) At 3:30+12 PM, the aircraft. (Tabs V-46, 47, for takeoff (Tab EE-37). 01 was cleared on the runway was flying as the In the LFE, Captain LeBlanc (11) of two F-16s configured call sign Slap 22, in a flight wingman, on station five; two CATM-88A, a 300 gallon external fuel tank and with missiles on stations three captive air-to-ground training missiles on AIM-120, air-to-air training seven; two captive air-to-air training and eight; and a captive AIM-9, stations two assembly pod on stations and an AMA, acceleration monitor missile missiles were inert and contained one and nine. All of these the MK-82s nor explosive charge. As with neither a rocket motor training missiles flight was carrying, these that Stingray and affect the performance the weight of actual missiles and replicate combat load. (Tabs V-1, 2, of the F-16, simulating a realistic EE-27) the flight lead, Slap 21, conducted (12) gaptain LeBlanc's Since using a personal briefing guide. individual flight briefing missions and to fly two back-to-back SEAD the flight was scheduled flights, both return to the squadron between not scheduled to The briefing lasted briefed at this time. sorties were required briefing items. 40 minutes and included all approximately of the briefing with the were no questions at the conclusion There on time. (Tabs V-I and 2) flight stepping to the aircraft

7

57762 inspection, engine start, taxi, (13) Slap 22's preflight Airborne normal with no difficulties noted. and takeoff were all air refueling Slap 21 flight proceeded to the on time at 11:14 AM, enroute to the incident. Following air refueling, area without by their squadron to Slap 21 flight was directed rejoin area, configuration on their return to Kunsan AB due to an unauthorized to a and EE-19) Slap 21 flight proceeded aircraft. (Tabs V-2, 7, to landing. Kunsan AB to burn down fuel prior point just east of AB and landed at the flight returned to Kunsan Once accomplished, the same approach later PM out of an ASLAR ILS approach, 12:48 K-4, V-i, 2, and EE-26) flown on the mishap sortie. (Tabs to refuel immediately (14) Slap 21 flight was scheduled the first sortie with the aircraft's following their landing from to the refuel) and then taxi back engine running (i.e. hot pit the second sortie. Because of runway for takeoff on their back to aircraft refueled, then taxied configuration problem, the personnel to have squadron maintenance their parking locations with technical order configure the aircraft in accordance properly LeBlanc, unsure of the impact At this time Captain to directives. have on his second sortie, went reconfiguring the aircraft would which debriefing section to confirm the squadron's maintenance While there, he fly on the second sortie. aircraft he would his flask before of cookies and drank water from consumed a package aircraft 86-0275, aircraft. Arriving back at returning to the and called squadron noted the deteriorating weather Captain LeBlanc of his second sortie. twice to confirm their approval operations by 3:30 PM. During the was given with directions to land Approval and his flight lead only between sorties, Captain LeBlanc period did not conduct any debriefing each other for a short time and saw briefing of their second sortie. of their first mission or further (Tabs V-i, 2, and 64) LeBlanc's his first sortie that day, Captain (15) As with difficulties or start, and taxi were without preflight, engine launched Slap 02 Testimony by the crew chief who abnormalities. his aircraft prior to end of runway crew who inspected and the of the ordinary. (Tabs V-1, noted nothing unusual or out takeoff was cleared for takeoff and was 46, 64, and 66) Slap 01 flight airborne at 14:38 PM (Tab EE-26). d. FLIGHT.,ACTIVITY takeoffs with a (1) Slap 01 flight executed single-ship This type of departure requires radar assisted trail departure. setting and fly a prebriefed engine power all flight members to and use on same navigation reference points, airspeed, turn at the aircraft. Once radar to monitor all preceding board air-to-air to a heading of 180 airborne, the flight turned right safely to route formation (aircraft degrees and subsequently rejoined 8

57763 laterally spaced 75-500 feet apart). The weather on departure consisted of a 500 foot ceiling with layers of clouds extending upwards to approximately 19,000 feet above Mean Sea Level (MSL). (Tabs V-l, 2, and AA-l)

(2) As the flight continued to the south, it became apparent to Slap 01 that the primary mission of practicing HARM the employment tactics would not be possible due to the weather in for planned training area. Slap 01 coordinated with Airedale alternate training airspace in MOAs 15 and 16, just east of Kunsan the briefed alternate mission of intercepts. AB, to accomplish in During this process Slap 01 flight turned north and proceeded direction of the requested MOAs. After receiving the general and from Airedale, Slap 01 flight entered the airspace approval V-l, maneuvered to begin their prebriefed intercept mission. (Tabs 2, and AA-I)

(3) The objective of Slap 01 flight's intercept training to practice defensive maneuvering as a single F-16 against was air another aircraft which was employing radar and infrared guided to-air missiles at medium to high altitudes (15,000 to 30,000 feet To accomplish this, Slap 01 split-up the flight and sent MSL). 01 Slap 02 to the western portion of the airspace as Slap of the maneuvered to the east. Prior to the intercept, one (the aircraft would be designated by the flight lead as the fighter the aircraft simulating the employment of air-to-air missiles) and other would be the target (the aircraft defending against air-to the air missiles). When both aircraft were ready to start intercept training, they would turn towards each other and use the aircraft's air-to-air radar and other on-board systems to locate the opposing aircraft and maneuver to simulate employing air-to-air missiles or maneuver defensively against the attack. The flight 02 accomplished several intercepts with Slap 01 and Slap alternating roles between fighter and target aircraft. (Tabs V-1 and 2)

(4) After Slap 01 reconfirmed, via radio, the requirement to land by 3:30 PM, Slap 02 rejoined with his flight leader, Slap 01, for the return to Kunsan AB. Once rejoined, a battle damage check (a visual inspection of each aircraft in a flight normally accomplished at the completion of tactical maneuvering) was accomplished. .During this check, Slap 01 passed the lead of the formation to Slap 02 who maintained it for the remainder of the flight. (Tabs V-1 and 2)

(5) Slap 02, now in the lead of the flight, began a descent in anticipation of an instrument recovery back to Kunsan AB. During the recovery, the flight accomplished a descent check and entered the weather. The flight continuing its descent, proceeded towards Julop, the IAF for the ASLAR ILS approach to

9

57764 radio contact with 36 at Kunsan AB. Slap 02 established Runway and requested the ASLAR ILS approach control at 3:22+30 PM Kunsan V-1, 2, and EE-37). to Runway 36 at Kunsan AB. (Tabs Slap 01 flight was established (6) Radar contact with Kunsan to the east of Kunsan AB by approximately fifteen miles approach at 3:22+42 PM. On initial contact, approach control weather, altimeter Slap 01 flight of the current control advised at Kunsan AB. The active runway, and runway conditions setting, to 5000 feet MSL and proceed flight was then cleared to descend from 02 acknowledged the radio call direct to Julop. Once Slap Kunsan 01 flight was cleared to contact approach control, Slap flight to the frequency. Slap 02 directed the arrival on another advising them of and checked in with Kunsan arrival new frequency arrival cleared Slap 01 request for the ASLAR ILS. Kunsan his 36 at 3:24+38 PM. At 3:26+45 flight for the ASLAR ILS to Runway was advised Kunsan arrival that he PM, Slap 02 reported Julop and Slap Continuing inbound on the approach, inbound for the approach. PM who Kunsan radar final control at 3:28+54 02 was contacted by this point that gear check radio call. It was at made an advisory 02 was out in the controlling agency that "Slap Slap 02 advised all radio calls as Prior to this time, Slap 02 answered front." tower local controller advised 01. At 3:29+35 PM, the control 02, Slap was in radio contact with Slap the radar final controller, who then to land. The radar final controller that he was cleared PM. As Slap 02 clearance to Slap 02 at 3:29+40 passed the landing the control tower the final portions of his approach, continued Stingray 01 for takeoff. controller, at 3:30+12 PM, cleared local of the clouds on final and 330 feet MSL, Slap 02 broke out At of the cloud bases on his VHF radioed Slap 01 with the altitude 3:31+00 PM, Slap 02 collided with radio. Shortly thereafter, at of the runway. Moments after the Stingray 01 on the approach end his 02 successfully ejected from collision, the pilot of Slap and EE-37) aircraft. (Tabs A-i, V-l, 2, 3, plan with ground Stingray 01 coordinated a flight (7) to Visual Meteorological to include an instrument departure control to Osan AB, ROK, to practice Conditions (VMC) and then direct for V-74 and AA-2). He was cleared instrument approaches (Tabs the EE-37). Stingray 01 taxied onto takeoff at 3:30+12 PM (Tab brake his engine run-up checks prior to runway and accomplished afterburner released brakes, Stingray 01 selected release. As he release, Slap 02 his takeoff roll. Shortly after brake and began 800 feet down the runway. collided with Stingray 01 approximately (Tabs A-i, V-3, 46, 47, and BB-3) for a ceiling forecast weather for 3:31 PM called (8) The 0-25). A flight of and visibility of 1 1/2 miles (Tab of 1500 feet two to three minutes F-16s that had departed Kunsan approximately weather as being worse to the prior to the mishap described the

10 Witnesses in the area and improving to the north (Tab V-10). south of the mishap to be a 300-500 described the weather at the time 1 mile visibility. (Tabs V-i, 10, foot ceiling with approximately and 18) Flight Data Recorder Data from the Crash Survivable (9) a fairly constant 11 Slap 02's aircraft indicates (CSFDR) from until impact. The last Angle of Attack (AOA) approach degree airspeed of 160.0 knots, one show an AOA of 10.72 degrees, readings 0 degrees of bank, and an altitude "G" flight, 8 degrees nose up, of 0 feet. (Tab BB-2) 01's aircraft CSFDR data taken from Stingray (10) The rolling down the the aircraft to be in full afterburner, shows occurred. (Tab BB-3) runway at 88 kts, when the collision who observed Slap In testimony given by individuals (11) and who observed the approach prior to impact, 02 on final though Slap 02 did not stated that it appeared as collision, 01. (Tabs V-i, 3, 46, and 48) attempt to maneuver to avoid Stingray of communications The following is a transcript (12) Control (RAPCON), Stingray Slap 01 flight, Radar Approach between transcript are derived from Kunsan Tower. Times in this 27 01, and and times are inclusive of, RAPCON time announcer. Dates the 1531.40 (3:31+40 PM). (Tab EE-37) Jul 93, 1522.20 (3:22+20 PM) thru CALL SIGN AGENCY FLIGHT OF TWO KUNSAN F-16s -SLAP 01 AIRCRAFT 86-0275 SLAP 02 MISHAP APPROACH CONTROL (RAPCON) APPROACH KUNSAN CONTROLLER (RAPCON) APP CONTROLLER (APP) APPROACH CONTROLLER (RAPCON) ARR CONTROLLER (ARR) ARRIVAL FINAL CONTROLLER (RAPCON) RFC CONTROLLER (RFC) RADAR TOWER LOCAL CONTROLLER LCL CONTROLLER,(LCL) KUNSAN OF TWO KUNSAN F-16s VEGAS 21 FLIGHT OF TWO KUNSAN F-16s VENOM 31 FLIGHT 31's WINGMAN VENOM 32 VENOM AIRCRAFT 87-0335 STINGRAY 01 MISHAP 11

57766 SOURCE TIME TRANSMISSION

SLAP 02 1522.20 SLAP check

SLAP 01 1522.21 Two one uh with you enroute to SLAP 02 1522.22 Approach, SLAP zero Julop for the ASLAR for an IFR pickup Kunsan approach, Ident APP 1522.30 SLAP zero one, miles zero one, radar contact one five APP 1522.42 SLAP Juliet east of Kunsan, verify information uh negative ATIS SLAP 02 1522.50 SLAP zero one, one roger, runway three six in use, APP 1522.51 SLAP zero one and wind two niner zero at five, visibility sky conditions one half miles, rain showers, scattered, one thousand eight five hundred thousand broken, ceiling measured one hundred thousand eight hundred, overcast three approach altimeter two niner six five, one thousand eight hundred, visibility ceiling is wet one mile, and runway condition six five zero one copies all, two niner SLAP 02 1523.15 SLAP full stop enroute Julop, like ASLAR drag, five one roger, descend and maintain APP 1523.21 SLAP zero thousand, proceed direct Julop Julop descent to five thousand direct SLAP 02 1523.26 SLAP in a local one, contact Kunsan arrival APP 1524.06 SLAP zero channel one one push button one one SLAP 02 1524.09 SLAP flight

SLAP 02 1524.27 Check

SLAP 01 1524.28 Two zero one with you entering Julop, SLAP 01 1524.29 Arrival SLAP ASLAR drag cleared ASLAR SLAP zero one, Kunsan arrival, uh ARR 1524.38 Julop inbound ILS runway three six, report

12

57767 SLAP 02 1524.44 SLAP zero one, cleared the ILS, Wilco of two ASLAR ILS full ARR 1524.45 SLAP zero one, flight stop One, Julop inbound SLAP 02 1526.45 SLAP right zero three zero, taxi into LCL 1526.45 VEGAS two one, position and hold one's on the hold VEGAS 21 1526.47 Two

ARR 1526.48 SLAP zero one, roger white LCL 1526.48 Say again on the of two ASLAR ILS full ARR 1526.58 SLAP zero one, flight stop departure, wind three 1527.17 VEGAS two one, change to LCL takeoff three zero at eight, cleared for for takeoff, push four VEGAS 21 1527.19 Two one cleared

VENOM 31 1527.35 VENOM check

VENOM 32 1527.36 Two takeoff, yoking right VENOM 31 1527.43 Tower, VENOM ready for zero three zero

hold short of runway, number LCL 1527.46 VENOM three one, two for departure

VENOM 31 1527.51 VENOM to departure wind two LCL 1528.12 VENOM three one, change zero at eight, cleared for takeoff, niner final with traffic flight of two, nine miles GCA, correction RAPCON

VENOM 31 1528.25 VENOM three one ready, single-ship STINGRAY 1528.27 Tower, STINGRAY zero one hold short of runway LCL 1528.31 STINGRAY zero one, Kunsan, STINGRAY 1528.34 Zero one holding

13

57768 final controller, how do RFC 1528.54 SLAP zero one, Kunsan you hear me SLAP zero one gets you loud SLAP 02 1528.57 Kunsan controller, and clear

also RFC 1528.59 Loud and clear wheels should be down RFC 1529.09 SLAP zero one,

SLAP 02 1529.13 Standby for gear zero two is out front and SLAP SLAP 02 1529.19 Approach, SLAP zero two is gear down, full stop roger SLAP 02 1529.21 SLAP zero two

RFC 1529.32 Full stop

LCL 1529.35 Cleared to land two seven zero at eight, RFC 1529.40 SLAP zero two, wind cleared to land cleared to land SLAP 02 1529.42 SLAP zero two, mile final, Zero one, flight of two F-16s five LCL 1530.12 one zero change to departure, wind three at four, cleared for takeoff down SLAP 01 1530.17 Zero one's gear roger RFC 1530.18 SLAP zero one, one cleared for takeoff STINGRAY 1530.18 STINGRAY zero active, single-ship LCL 1530.27 STINGRAY one around, go around, go around LCL 1530.58 Go around, go tower clearance canceled, climb RFC 1531 .00 SLAP zero one one thousand until departure end, and maintain fly then climb and maintain two thousand, runway heading

Back- 1531.06 ELT ground

14

57769 LCL 1531.09 Second guy go around, go around

RFC 1531.10 SLAP zero two, SLAP zero one, tower clearance canceled, climb and maintain one thousand until departure end, then climb and maintain two thousand five hundred, correction seven hundred, fly runway heading right, go around LCL 1531.13 Second guy go around, exit

SLAP 01 1531.18 SLAP zero one's low approach SLAP zero one low RFC 1531.23 Zero one low approach, approach copy climbout RFC 1531.29 SLAP zero two, you SLAP zero one's level SLAP 01 1531.40 Approach, SLAP zero two, at two thousand

e. IMPACT 35 degrees 53 (1) Slap 02 collided with Stingray 01 at 37 minutes 5 seconds minutes 50 seconds north latitude, 126 degrees from the approach end of east longitude approximately 800 feet A-1, C-i, and 2). Runway 36, Kunsan AB, ROK, at 3:31 PM (Tabs occurred on, and was confined to Kunsan (2) The accident 01 was is on Korean government property. Stingray AB, which fire (Tab M-1). destroyed by the collision and resulting totally (FOD) to its engine, sustained major foreign object damage Slap 02 landing gear, and substantial structural damage to the intake, and of the collision and underside of the aircraft as a result (Tabs J-1 thru 7, and M-5). uncontrolled departure from the runway 356 degrees (3) Both aircraft were heading approximately Stingray 01 was on the time of impact (Tabs C-i, 2, and BB-2). at at 11 degrees AOA, 8 takeoff roll at 88 kts with Slap 02 flying 160 kts at impact (Tabs degrees nose high, 0 degrees of bank, and the collision, both aircraft skidded down BB-2 and 3). Following came to departed the prepared surface. The aircraft the runway and 01 just west of approximately 1600 feet apart with Stingray rest surface to the east. the runway and Slap 02 just off the prepared (Tabs R-1 and AA-3) injured in the The pilot of Stingray 01 was fatally (4) and was uninjured and the pilot of Slap 02 safely ejected mishap did not observe any A-I and X). Witnesses to the mishap (Tabs and 50). Both pilots ejection attempt by Stingray 01 (Tabs V-46 15

57770 no evidence of any correctly attired/restrained and there was were (Tabs H-i, 4, EE-38, equipment failure or maintenance discrepancies 40, 41, and 42).

f. EJECTION SEATS Advance mishap aircraft was equipped with one (1) Each seat of Seat (ACES II) (Tab EE-30). The ejection Concept Ejection which were (Slap 02) was used, the components of aircraft 86-0275 seat from aircraft from the mishap site. The ejection recovered found totally fragmented 87-0335 (Stingray 01) was not used and was wreckage. (Tabs EE-38 and 40) and burned in the cockpit area of the seat from aircraft (2) Post crash analysis of the ejection rendered the escape indicated that the initial impact 87-0335 components had been inoperative and that none of the system analysis indicated Lieutenant initiated (Tab EE-38). Post-mortem consistent with an attempted Colonel Gardner's injuries were not ejection (Tab EE-8). from aircraft 86-0275 (3) Analysis of system components ejection, the low altitude and shows the pilot initiated a Mode-i seat. (Tabs EE-30 and 38) low airspeed mode of the ACES II g. PERSONAL AND SURVIVAL EQUIPMENT inspections on Lieutenant Colonel (1) All required harness, LeBlanc's helmet, oxygen mask, torso Gardner's and Captain the day of the and survival vest were current on two anti-G suits, Lieutenant Colonel Survival equipment recovered from mishap. damage due to the impact and Gardner's aircraft- indicated severe 41) subsequent fire. (Tabs EE-40 and Captain extremely short time between (2) Due to the survival and rescue, very little of his personal LeBlanc's ejection fully opened shortly was used. His parachute canopy equipment limited time of descent, ground impact, however due to the before jettison modification of his did not accomplish the four-line he life raft did not inflate parachute. Additionally, Slap 02's Analysis indicates the inflation during the ejection sequence. the interrupted by ground impact due to sequencing for the raft was from the ejection and the limited time low altitude achieved during Locator (Tabs EE-38 and 40) The Emergency kit deployment. transmitting a beacon on Transmitter (ELT) functioned normally, successful seat-man separation. guard frequency (243.0 MHz) upon (Tab EE-37) were of the parachutes in both aircraft (3) Inspections kits, including The inspections of both seat survival current. (Tab EE-42) life rafts and medical kits were current. 16

57771 h. RESCUE the impact, the tower flight (1) Immediately following base primary crash phone alerting data controller activated the (Tab V-4). The response by Kunsan crash, fire, and rescue forces rescue Rescue-9 (a fully equipped AB fire protection flight's V-36 and was almost immediate (Tabs vehicle with three personnel) net was the base's secondary crash 37). Shortly thereafter, a flight fully equipped ambulance with activated and at 3:35 PM, a Group technicians from the 8th Medical surgeon and three medical The ambulance the mishap site (Tab EE-4). Clinic was dispatched to established Point (ECP) which had been arrived at the Entry Control at 3:39 PM front of the control tower on the parallel taxiway in (Tab EE-4). were at base 38th Rescue Squadron, who (2) Members of the onto the the collision and ran out operations at the time, heard and ran LeBlanc, who had just ejected, airfield. They saw Captain Squadron, and 82). The 35th Fighter assist him (Tabs V-81 of the to mishap site, was notified a short distance from the at located A flight surgeon, who was by the supervisor of flying. accident immediately proceeded to the squadron, along with two pilots, the All parties arrived almost scene in a military vehicle. 38, 78, Captain LeBlanc. (Tabs V-17, simultaneously and assisted and 82) aircraft just east of the Rescue-9 located Slap 02's (3) seat were missing and noted the canopy and ejection runway and Also arriving on the pilot had ejected (Tab V-37). assumed the Captain LeBlanc with the fire training chief who saw scene was the the members of the two squadron pilots, and flight surgeon, the pulled up to the As the fire training chief 38th Rescue Squadron. "I have the the flight surgeon to say flight surgeon he understood along with the fire." This statement pilots, you take care of rescue flight suits initially led the seeing several personnel in and 37) had been located. (Tabs V-36 forces to believe both pilots for, Rescue both pilots were believed accounted (4) Since efforts. Rescue assist with the fire fighting 9 was detailed to and secured the entered Slap 02's cockpit 9's crew chief then off, and turned shut the still running engine emergency power unit, 3:39 PM, it was off (Tabs V-36 and 37). At the battery switch to been located of the pilots had in fact determined that only one to locate Rescue-9 again resumed efforts (Tab EE-I). At 3:41 PM, which had at Stingray 01's aircraft, the missing pilot. Arriving the crew since the initial impact, been fully engulfed in flames area approach the aircraft's cockpit of Rescue-9 attempted to EE-1) chief heat. (Tabs V-36, 37, and but was driven back by the intense

17

57772 for the second (5) Additional forces joined in the search V-35, 37, and EE-l). Sweeps of the airfield pilot at 3:41 PM (Tabs Group were accomplished. The Disaster Control and its perimeter assistance 3:39 PM and coordinated security police (DCG) formed at helicopter from search. (Tabs V-43, 76, and EE-1) A UH-60 with the which was at Kunsan Rescue Squadron based at Osan AB, ROK, the 38th efforts. Launching at temporary duty, also joined rescue AB on portions of the Yellow 4:05 PM, the helicopter initially searched two sides and then assisted in Sea that surrounds the airfield on (Tabs V-37, 38, 81, 82, 84, 86, the search of the airfield itself. and 87) location at second ambulance arrived on (6) A and three medical 3:45 PM with another flight surgeon approximately who at this time (Tabs V-38 and 79). Captain LeBlanc, technicians and was found to have no been evaluated in the first ambulance had to the second ambulance and significant injuries, was transferred further examination. (Tabs V-38, transported to the base clinic for 39, 40, and 79). the intense heat from (7) Search efforts continued while aircraft prevented rescue fire that engulfed Stingray 01's the aircraft. At 3:59 PM, 20 forces from getting close to the exploding in Stingray 01's aircraft millimeter ammunition began a safe fighting personnel to evacuate to forcing rescue and fire efforts minutes later at 4:29 PM, fire fighting distance. Thirty 01's aircraft was by 4:52 PM, the fire on Stingray resumed, and in the wreckage. and potential remains were located extinguished PM and officially surgeon identified the remains at 4:54 The flight The remains were later determined that the pilot did not survive. Group Clinic for positive transported to the 8th Medical 41, 79, and EE-1) identification. (Tabs V-36, 38, 40, the mishap scene was (8) Continuous medical support of until the evening of 28 Jul provided with one ambulance remaining 93 (Tab V-79).

i. CRASH RESPONSE Kunsan's by the primary crash net at 3:31 PM, (1) Alerted crash, fire, flight responded with all available fire protection a carry-all vehicle forces. Chief-2 was dispatched in and rescue P20 command and control fire training chief utilized a and the Crash-3, 4, 5, and 6 in (Tabs V-36 and 37). In addition, vehicle a foam cart proceeded to Rescue-9 in a P10, a P18 tanker, and Pl9s, within minutes of the initial the south end of Runway 36, arriving Chief-l established the ECP on notification (Tabs V-36 and EE-1). the tower at 3:39 PM (Tab EE-1). the parallel taxiway in front of

18

57773 to the transient ramp fire engine and the hose cart proceeded A P24 efforts. (Tabs V-35, 36, area to lay hose and prepare for resupply 37, and EE-1) in the mishap were (2) Since the two aircraft involved 1600 feet, the responding units were separated by approximately (Tabs R-l, to maximize their fire fighting capabilities apportioned chief established command V-35, 37, and AA-3). The fire training fighting efforts on Stingray 01's aircraft and control of the fire (Tabs runway and totally engulfed in flames which was west of the vehicles, He directed three P19 fire fighting V-35, 36, and EE-1). (Tabs V-35 the foam cart in fighting the fire the P18 tanker, and of the fire established command and control and 36). Chief-2 one P19 fire on Slap 02's aircraft. He directed fighting efforts at the right rear vehicle to combat the small fire located fighting The fire was extinguished and of the aircraft. (Tabs V-35 and 36) when fire fighters arrived, was the engine, which was still running shut off by 3:41 PM (Tab EE-1). the P19 fire out on Slap 02's aircraft, (3) With the the fire on that effort now joined forces fighting supporting EE-l). The fire was 01's aircraft (Tabs V-36 and Stingray to fight. The 20 millimeter extremely intense and difficult of at 3:59 PM forcing the withdrawal ammunition began detonating Stingray and equipment from the area around fire fighting personnel training chief (Tabs V-36 and EE-1). The fire 01's aircraft ramp and discussed how to regrouped his forces on the transient safe to return (Tabs V-35, 36, and best fight the fire when it was a was noted that one fireman had suffered EE-1). At this time it and EE-1). broken a thumb (Tabs V-36, 38, 39, cut hand and one had one at 4:13 two on-base fire responses were required, Additionally, vehicles responded to other at 4:25 PM. Fire fighting PM and the fighting efforts. At no compromise to the ongoing fire both with to Stingray 01's aircraft the fire training chief returned 4:29 PM, and continued to battle four Pl9s, a P18, and the foam cart with at 4:52 PM (Tabs V-36 and the fire which was finally extinguished EE-1). inspected Ordnance Disposal (EOD) personnel (4) Explosive be safe (EE at 4:22 PM, and determined it to Slap 02's aircraft, of Stingray also conducted an initial survey 5). EOD personnel explosive devices, 5:05 PM, swept the area for any 01's aircraft at (Tabs EE-I and 5). the area to be safe at 6:16 PM and determined to depressurize the PM, the hydrazine response team arrived At 5:30 and was completed by 5:59 systems and tanks on both mishap aircraft PM. (Tab EE-1) to Slap 02's aircraft Fire fighting personnel returned (5) cockpit area of the PM, when smoke was noted in the at 6:58 and the smoking ceased. At aircraft. A chemical agent was applied 19

57774 one of the wings. An time fuel was noted leaking from this in three places and had to be internal wing fuel tank had ruptured was defueled and the leaking had defueled. By 11:27 PM, the tank stopped. (Tab EE-l) on location, one by (6) Fire fighting vehicles remained on the taxiway near Slap 02's Stingray 01's aircraft and one aircraft for the next 36 hours.

j. MAINTENANCE DOCUMENTATION A() AIRCRAFT 86-0275 Coded (CC) Serial Number 86-0275, a Combat (a) F-16C Air Force on 18 was accepted by the United States fighter aircraft, Fort Worth Division, Fort Nov 87 at General Dynamics Corporation, At the Kunsan AB, ROK, on 14 Dec 87. Worth, TX, and delivered to airframe it had accrued a total of 1824.6 time of the accident, aircraft's Air Force (Tab U-l). A review of the flight hours identify any maintenance Order (AFTO) Form 781 did not Technical to the mishap. discrepancies that would relate Compliance Technical Orders due (b) All required Time The prior to 27 Jul 93 were accomplished. to be accomplished for the replacement was overdue a Time Change Requirement aircraft battery, and the aircraft was the Inertial Navigation Unit of inspection of the engine midspan overdue a 150 hour ultrasonic shroud. (Tab U-2) annotated in (c) There was one delayed discrepancy write-ups in the active AFTO Form the AFTO Form 781K and two open 78lAs (Tabs U-3 and 4). hour #4 phase inspection was accomplished (d) A 1800 Including actual aircraft time of 1789.8 hours. on 9 Jul 93 with of 27 sorties and sortie, the aircraft had flown a total the mishap Seventeen sorties were Code hours since the phase inspection. 34.8 Code 3. (Tab U-5) 1, seven were Code 2, and three were (2) AIRCRAFT 87-0335 Coded (CC) Number 87-0335, a Combat (a) F-16C Serial Air Force on 6 accepted by the United States fighter aircraft, was Division, Fort Dynamics Corporation, Fort Worth Apr 89 at General on 12 Apr 89. The delivered to MacDill AFB, FL, Worth, TX, and on 30 Jan 91. At the was transferred to Kunsan AB, ROK, aircraft a total of 1389.9 airframe of the mishap, it had accumulated time of the aircraft's AFTO Form 781 hours (Tab D-1). A review to flight discrepancies that would relate did not identify any maintenance the mishap.

20

57775 Orders and (b) All required Time Compliance Technical prior to 27 Jul 93 inspections due to be accomplished scheduled the time of the mishap, was accomplished. The aircraft, at were for the replacement of the overdue a Time Change Requirement (Tab U-6) Inertial Navigation Unit battery. annotated (c) There were three delayed discrepancies write-up in the active AFTO Form in the AFTO Form 781K and one open 781A. (Tabs U-7 and 8) was accomplished (d) A 1350 hour #1 phase inspection of 1345.6 hours. Prior to 15 Jun 93 with actual aircraft time on a total of 30 sorties and 44.3 the mishap, the aircraft had flown Twenty sorties were Code 1, six hours since the phase inspection. 3. (Tab U-9) were Code 2, and four were Code

k. MAINTENANCE PERSONNEL AND SUPERVISION of individuals involved in the maintenance Supervision and training preflight 86-0275 and aircraft 87-0335 from performed on aircraft the mishap 93 through the EOR inspection for inspection on 26 Jul qualified for no deficiencies. Individuals were flight revealed in their AF Forms 623, the work they accomplished as reflected On-the-Job Training (OJT) record. OIL INSPECTION 1. ENGINE, FUEL, HYDRAULIC, OXYGEN, AND ANALYSIS

(1) AIRCRAFT 86-0275 Electric F110-GE100 turbofan engine, (a) General All was installed in aircraft 86-0275. Serial Number E509778, Compliance Time Change Requirements, and Time required inspections, Jul 93 were due to be completed prior to 27 Technical Orders for engine Serial (Tab U-10). The Oil Analysis Record accomplished between 5 May 93 and the E509778 shows 30 samples analyzed Number parameters were within normal mishap. Testing indicates all limits. (Tab U-11) the aircraft was (b) Prior to the mishap flight, taken from Hydrant the hot pits. Fuel samples were refueled in #2, Hydrant Tank #2 Separator #1, Hydrant Filter Separator Filter system). All parameters were (bulk storage), and Loop #1 (delivery within normal limits. (Tab U-12) oil samples taken (c) There were no hydraulic following the mishap.

21

57776 all 8th Fighter (d) From 15 Jul 93 until the mishap, carts filled from Bulk aircraft were serviced by liquid oxygen Wing taken from Bulk Tank #12. #12. A liquid oxygen sample was Tank within normal limits. (Tab Test results indicated all parameters U-13) from oil carts OC (e) Engine oil samples were taken results showed all parameters 4, OC-6, OC-8, and OC-17. Test within normal limits. (Tab U-14) (2) AIRCRAFT 87-0335 engine, Electric FII0-GEI00 turbofan (a) General All was installed in aircraft 87-0335. Serial Number E509403, Compliance Time Change Requirements, and Time required inspections, 27 Jul 93 were due to be completed prior to Technical Orders for engine Serial (Tab U-15). The Oil Analysis Record accomplished between 14 May 93 and the E509403 shows 30 samples analyzed Number parameters were within normal mishap. Testing indicates all limits. (Tab U-16) from Fuel 26 Jul 93 the aircraft was refueled (b) On fuel tank was On 27 Jul 93, a 300 gallon external Truck 81L-357. refueled from Fuel Truck on the aircraft and it was also hung Truck 81L-357 was taken. The 81L-357. A fuel sample from Fuel within normal limits. (Tab U-17) results showed all parameters were oil samples taken (c) There were no hydraulic following the mishap. all 8th Fighter (d) From 15 Jul 93 until the mishap, carts filled from Bulk aircraft were serviced by liquid oxygen Wing taken from Bulk Tank #12. #12. A liquid oxygen sample was Tank within normal limits. (Tab Test results indicated all parameters U-13) from oil carts OC (e) Engine oil samples were taken results showed all parameters 4, OC-6, 0C-8, and OC-17. Test within limits. (Tab U-14)

m. AIRFRAME AND AIRCRAFT SYSTEMS (1) AIRCRAFT 86-0275 and end of assistant crew chief, expediter, The launch crew chief, encountered testified that there were no problems runway supervisor inspection prior the aircraft's launch and end of runway throughout (Tabs V-46, 47, 64, 65, it taxiing on to the runway for takeoff to are no indications of any 66, and 68). Additionally, there 22

57777 to the malfunctions during the mishap sortie prior aircraft indicated that the collision (Tabs V-I and 2). However, testimony was not functioning during the aircraft lower left wingtip light by V-64 and 66). Operational testing was accomplished launch (Tabs UHF Radio, the Fighter Wing personnel on the ARC-164 8th panel, the landing anti-collision light, exterior lighting control lights from the right light switch, the top and bottom wingtip Up Display (HUD) unit. All systems/components wing, and the Heads memory normally. Downloads of the crash survivable functioned data recorder were the signal acquisition unit, and the seat unit, Fort Worth, TX. The accomplished by Lockheed Fort Worth Company, landing until the collision data indicated a normal approach for with aircraft 87-0335. (Tab BB-2) (2) AIRCRAFT 87-0335 end of chief, assistant crew chief, expediter, The launch crew that there were supervisor, and end of runway crew testified runway aircraft's launch and end of no problems encountered throughout the on to the runway for takeoff runway inspection prior to it taxiing 60, and 68). Testimony also (Tabs V-47, 48, 50, 54, 57, 58, exterior aircraft lights were functioning indicated that all to extensive V-45, 48, 54, 58, and 60). Due normally (Tabs or accessory there were no pertinent component aircraft damage, was accomplished. which operational testing or tear down systems on and the seat data of the crash survivable memory unit Downloads Worth Company, Fort were accomplished by Lockheed Fort recorder takeoff until approximately Worth, TX. The data indicated a normal which time the collision with 88 Knots Calibrated Air Speed, at aircraft 86-0275 occurred. (Tab BB-3)

n. OPERATIONS PERSONNEL AND SUPERVISION Fighter Squadron is tasked by Headquarters, (1) The 35th Operational Forces (HQ PACAF) to maintain a Designed Pacific Air close air support, (DOC) of interdiction, counter air, Capability Gardner was authorized to air superiority. Lieutenant Colonel and by the squadron operations fly a CAS mission on the mishap flight officer had also authorized Captain officer. The operations The mission on the mishap flight. LeBlanc to fly a SEAD Form 35, was documented on a local computer generated authorization on 27 Jul 93. (Tabs K Local Flight Clearance/Flight Authorization 5, 6, EE-27, and 31) flown by Slap 01 (2) The alternate intercept mission mission planned by Stingray 01 flight and the alternate instrument PACAFR 55-116/8 FW Chapter 8 were authorized in accordance with (Tab 0-30).

23

57778 flights both attended the squadron's (3) Slap and Stingray was on the day of the mishap. The briefing morning mass briefing that both commander for the LFE exercise conducted by the mission of the in that morning. A combination flights participated and a personal mission commander briefing slides squadron's the briefing, which addressed briefing guide were used to conduct and Air Force Director of Operations all required items. The 7th in the Operations Officer, participated the 35th Fighter Squadron the mass briefing and attended the briefing. Following exercise accomplished. (Tabs V-I, 2, 14, individual flight briefings were 15, and 74) 11 flight flight briefing for Stingray (4) The individual using a standard by Lieutenant Colonel Gardner was accomplished by flight members indicates no briefing guide. Testimony of squadron The 7th Air Force Director deficiencies in the briefing. Fighter Squadron Assistant Operations Operations, and the 35th A separate members and attended the briefing. Officer were flight Colonel Gardner prior briefing was conducted by Lieutenant flight squadron guide. The 7th Air mishap sortie using the same to the the briefing as a member of Force Director of Operations attended briefing to be thorough and complete. the flight and indicated the (Tabs V-14 and 74) Slap 21 flight Patterson, the flight lead for (5) Captain sortie) conducted the sortie) and Slap 01 flight (second (first a personal briefing guide. individual flight briefing utilizing to to hot pit refuel and not return Since the flight was scheduled at this sorties, both sorties were briefed the squadron between thorough and indicates that the briefing was time. Testimony Slap flight's No supervisory personnel attended adequate. V-i and 2) individual flight briefing. (Tabs o. AIRCREW QUALIFICATIONS rating Colonel Gardner held an aeronautical (1) Lieutenant 92 (Tab T-1). His with an effective date of 8 Dec of Command Pilot including the 1.8 flying time was 3182.9 hours, total military G-5). He had flown on the morning of the mishap (Tab hours flown hours in the F-16A/B hours-in the F-16 including 1,225.6 1,818.6 model. Graduating from the model and 593.0 hours in the F-16C/D in 1976, Lieutenant Colonel Gardner United States Air Force Academy Vance Pilot Training on 8 Dec 77 at then completed Undergraduate Kadena training and an 18 month tour at AFB, OK. Following upgrade F-4 pilot, accumulated 383.7 hours as an AB, Japan, where he at Vance AFB, Gardner transitioned to the T-37 Lieutenant Colonel instructor pilot he flying 737.9 hours as a T-37 OK. After at Hill AFB, UT, Kunsan transitioned to the F-16 with assignments 24

57779 to AFB, VA, where he upgraded MacDill AFB, FL, and Langley a total AB, ROK, pilot, and eventually logged flight examiner and instructor Following a short in all models of the F-16. of 1,732.3 hours MacDill AFB, FL, Lieutenant course in the F-16C/D at AB, conversion the 8th Fighter Wing, Kunsan Gardner was assigned to on 23 Colonel Ready (MR) status as a wingman where he achieved Mission ROK, 10, and 17) Apr 93. (Tabs G-4, T-4, was entered Lieutenant Colonel Gardner (2) On 28 Apr 93, T-9). A review lead upgrade program (Tab into the four-ship flight completed all required folder indicated he had not as a of his training the squadron commander he been certified by training nor had addressed in any of his lead. Although not was four-ship flight lead certification sortie program, a two-ship flight assistant upgrade Captain Davis, a squadron flown on 20 May 93 with Gardner still had not but Lieutenant Colonel operations officer, flight lead. (Tabs squadron commander as a been certified by the T-9 and 16) in was instrument qualified Lieutenant Colonel Gardner (IRC) (3) Instrument Refresher Course He completed the with a grade the F-16C/D. instrument examination passed the pilots written Checkride and Initial Qualification/Instrument of 98 on 3 Dec 92. His 31 May 94 (Tab T-4). and was valid through was flown on 10 Dec 92 a "B" weather category squadron commander as He was approved by the and EE-33) on 3 May 93. (Tabs T-8 the mishap flight was F-16C sortie prior to (4) His last where he logged 1.8 day in aircraft 86-0290, earlier that same Weapons Delivery Surface the flight lead of a four-ship Lieutenant hours as (Tabs T-20 and EE-27). Tactics (WDSAT) mission (Tabs G-1 and 6 Attack currency was as follows: Colonel Gardner's F-16 thru 8)

Ti F-16C/D Sorties Flight 18 25.6 Last 30 Days 26 36.0 Last 60 Days 50 68.3 Last 90 Days

Emergency Egress Colonel Gardner's (5) Lieutenant Survival Training, Annual Harness Training, Water Training, Hanging Training were all current. Training, and Physiological 31 May Life Support Training had expired on Emergency Procedures (AFSC) was His Situational Air Force Specialty Code (Tab T-18) His duty Aviation Service 93. Date was 10 Jan 77, and X1455N, Aviation Service 25

57780 was 2A on Aeronautical Order 0020, dated 11 Feb 93. The F-16C Code G-3, T-1, was Lieutenant Colonel Gardner's primary aircraft. (Tabs and EE-23) Pilot (6) Captain LeBlanc held an aeronautical rating of flying time was effective 9 Jun 89 (Tab T-21). His total military the morning of the 1229.1 hours, including the 1.7 hours flown on flown on the mishap sortie (Tabs G-12 and mishap and the .9 hour on his commission through Officer Training School 14). He received at Reese graduated from Undergraduate Pilot Training 5 May 88 and in Dec 89, on 9 Jun 89. After completing upgrade training AFB, TX, A-10 squadron at LeBlanc was assigned to an operational Captain hours as a pilot Beach AFB, SC, where he accumulated 789.2 Myrtle from F-16C/D conversion in the A-10. Graduating with distinction assigned to Kunsan AB, training at Luke AFB, AZ, in Nov 92, he was 35th Fighter Squadron at ROK, reporting in Dec 92. Assigned to the Ready (MR) status as a Kunsan AB, Captain LeBlanc achieved Mission 206.0 hours in the F wingman on 7 Jan 93 and had logged a total of T-26, and 27) 16C/D prior to the mishap. (Tabs G-11, 12, Training (7) On 7 Jan 93, following Mission Qualification as MR, Captain LeBlanc's previous ASLAR (MQT) and certification commander from Luke AFB was accepted by the squadron qualification Reconnaissance T-26). He was certified Peacetime Aerial (Tab was entered in the Program (PARPRO) qualified on 8 Mar 93. He Low Altitude Step-Down Dissimilar Air Combat Training (DACBT) and programs and was fully Training (LASDT) for Air-to-Air (A/A) Mar 93 and 12 Apr 93 respectively. He was Infrared qualified on 8 Warfare qualified on 28 Apr 93, completed Chemical (IR) Maverick HARM pilot on 14 Training on 2 Jun 93, and qualified as a Defense was not entered Jul 93. On the day of the mishap Captain LeBlanc (Tabs T-27, 35 thru 41, in or participating in any upgrade program. V-7, and EE-23) was LeBlanc's instrument rating in the F-16C (8) Captain obtained 28 Feb 94. He had completed IRC on 12 Aug 92, valid until examination, and grade of 100 on the pilots written instrument a Checkride on 3 Sep accomplished an Initial Qualification/Instrument on 23 Jun 93. (Tabs 92. He was upgraded to an "A" weather category T-24, 28,-and EE-33). LeBlanc prior (9) The last F-16C sortie flown by Captain 86-0275, where to the mishap was on that same morning in aircraft of 1.7 hours. Examination of his flight records he logged a total those discrepancy of 4 sorties and 5.9 hours from revealed a G-1. Two by the safety mishap investigation board at Tab reported on the day of the of the sorties and 2.7 hours were those flown flown in an F-16D mishap with the remaining 2 sorties and 3.2 hours

26

57781 currency follows: on 15 Jun 93. Captain LeBlanc's adjusted F-16 (Tabs G-1, 13 thru 15, T-47, and EE-27)

F-16C/D Sorties Flight Time 13.3 Last 30 Days 10 35.6 Last 60 Days 24 60.3 Last 90 Days 43

Hanging (10) Captain LeBlanc's Emergency Egress Training, Annual Life Support Harness Training, Water Survival Training, Training were all current. His Training, and Physiological 93 Procedures Training had expired on 31 May Situational Emergency was 1115Q, duty Air Force Specialty Code (AFSC) (Tab T-44). His Service Code was Service Date was 8 Jun 88, and Aviation Aviation 21 Feb 90. The F-16C was 1A on Aeronautical Order 0036, dated (Tabs G-10, T-21, and EE-23) Captain LeBlanc's primary aircraft. p. MEDICAL review of Lieutenant Colonel Gardner's (1) A thorough flying duty indicate he was medically qualified for medical records II physical the mishap. His ,last Flying Class on the day of through 31 performed on 6 Oct 92 and was current examination was on 24 Sep 92 His physiological training was accomplished Dec 93. centrifuge training was valid until 30 Sep 95. He accomplished and Dental records showed 19 Jan 90, at Holloman AFB, NM. on, Class I (fully qualified Lieutenant Colonel Gardner to be Dental 3) for duty) on 29 Oct 92. (Tabs T-2 and were identified (2) Lieutenant Colonel Gardner's remains Group Clinic, Kunsan AB, ROK. Positive at the 8th Medical and the was accomplished utilizing dental records identification dental officers. Post concurrence of three 8th Medical Group Commander Kilbane, Medical mortem examination was accomplished by on 31 Jul 93 at the 121st Corps, United States Naval Reserve, of death was multiple blunt Evacuation Hospital, Seoul, ROK. Cause to F-16 aircraft accident--death was force trauma secondary by the Toxicology tests performed on the remains instantaneous. D.C. revealed no Armed Forces Institute of Pathology, Washington Alcohol was found to be present in evidence of drugs present. 28 of 96 milligrams percent and a level of blood samples at a level be vitreous fluid. This was thought to milligrams percent in no in performing the autopsy and of caused by the delay and X Further post-mortem evaluation of photographs significance. Forces Institute of ray examinations completed by the Armed

27

57782 with an ejection Pathology did not reveal any injuries consistent attempt. (Tabs X, EE-6, 7, 8, and 10) was LeBlanc's medical records indicate he (3) Captain mishap. for flying duties on the day of the medically qualified was dated 12 Flying Class II physical examination His most recent and was valid It did not reveal any disqualifying defects Nov 92. centrifuge training on 31 Dec 93. Captain LeBlanc completed until training on 10 Jun 92 11 Sep 89 and accomplished physiological A review of dental records which was'current until 30 Jun 95. Class I (fully qualified for showed Captain LeBlanc to be Dental 23) duty) as of 8 Jun 93. (Tabs T-22 and evaluation was completed on Captain (4) A thorough medical no mishap even though he had indicated LeBlanc following the entire A radiographic examination of his physical difficulties. complete and was without abnormality. A spine was accomplished sustained. revealed no external injuries were physical examination samples showed performed on both urine and blood Toxicology tests, complete visual alcohol or drugs present. A no evidence of sensitivity, was by an optometrist, to include contrast examination Group Hospital, Osan on 4 Aug 93 at the 51st Medical accomplished abnormalities. (Tabs DD-2 and AB, ROK, and revealed no significant EE-9) chemistry, complete blood count, (5) Toxicology, routine His conducted on the pilot of Slap 01. and urinalysis testing was level no detectable ethanol, but an ethanol blood specimen revealed The urine ethanol percent was found in his urine. of 25 milligrams Pathology and was with the Armed Forces Institute of was discussed activity and to be of no felt to be secondary to microbiological DD were within normal limits. (Tabs significance. All other tests levels screens on urine and blood ethanol 3 and EE-6) Toxicology traffic control on the supervisor of flying, air were also obtained with aircraft 86 and maintenance personnel associated personnel, were negative. (Tabs DD-5 0275 and aircraft 87-0335. All results and 6)

q. NAVAIDS AND FACILITIES NAVAIDS or facilities is no evidence regarding malfunctioning There EE-35). (Tabs 0-1 thru 5, V-3, 4, 24, 26, and r. WEATHER 93, weather cells the early afternoon of 27 Jul (1) In intensity rain the west coast of Korea, bringing moderate skirted afternoon. Kunsan AB carried showers to Kunsan AB throughout the for four and one half hours moderate and heavy rain showers 28

57783 4

of rain fell. at 1:55 PM. During this time, 1.75 inches starting the hour of the mishap The heaviest precipitation occurred during when .72 inches accumulated. (Tab 0-21) at 0609Z (2) The latest 12-hour forecast (disseminated PM] thru 27/1800Z PM], valid from 27/0600Z [27 Jul 93/3:00 [3:09 of 27 Jul 93 was; wind: 300 [28 Jul 93/3:00 AM]) for the afternoon 1 1/2 miles; sky conditions: 500 degrees at 10 knots; visibility: feet feet broken, ceiling 1500 feet, 3000 feet scattered, 1500 overcast, to 1500 feet scattered, 3000 feet overcast, improving latest hourly by 0900Z(6:00 PM) (Tab 0-25). The ceiling 3000 feet, at 0555Z (2:55 to the accident was disseminated observation prior at 05 knots; follows; wind: 290 degrees PM) and read as sky condition: 1 1/2 miles with moderate rain showers; visibility: ceiling measured 1800 feet, 500 feet scattered, 1800 feet broken, 23 degrees celsius; dew point: 21 3000 feet overcast; temperature: setting: 29.65 inches; remarks: approach degrees celsius; altimeter 1 1/2 miles 1800 feet and approach visibility ceiling estimated following the accident, with a wet runway (Tab 0-24). Immediately (3:35 PM) which read; wind: 280 an observation was taken at 0635Z 1 1/2 miles with moderate rain degrees at 04 knots; visibility: 500 feet scattered, 1800 feet overcast, showers; sky conditions: celsius; dew 1800 feet; temperature: 22 degrees ceiling measured 29.65 inches; degrees celsius; altimeter setting: point: 21 feet and approach approach ceiling estimated 1800 remarks: (Tab 0-25). visibility 1 1/2 miles with a wet runway disparity in forecasted weather and (3) There was no great AB by official weather observers at Kunsan that actually observed identifies Weather as described by witnesses (Tabs 0-24 and 25). reported of the mishap to be lower than that conditions at the time by the reports. The conditions described by official base weather 500 feet, approximated ceiling between 300 and witnesses were an All witnesses varying between 3/4 and 1 1/2 miles. with visibility the mishap with moderate to heavy rain showers during described as the rain showers passed intermittent breaks in the precipitation 18, 46, 47, 60, 64, 65, and 86) through the area. (Tabs V-1, 3, 10, weather were made Three Pilot Reports (PIREPs) of the (4) PIREPs reported prior to the mishap. Two departure in the hour aircraft reported the clouds at 500 feet while one arrival entering approach visibility of 1 1/2 arrival ceiling of 1800 feet with an of the departure PIREPs were miles. The arrival PIREP and one by control tower personnel. (Tab passed to the base weather station 0-21)

29

57784 s. DIRECTIVES AND PUBLICATIONS directives (1) The following applicable publications and Numbered Air Force, and were reviewed. In all cases Major Command, supplements were reviewed: 8th Fighter Wing volumes, chapters, and (FAAH) (a) Federal Aviation Administration Handbook 93 7110.65G, Air Traffic Control, 27 May Information (b) Department of Defense Flight Handbook, 19 Aug 93 Publication (Enroute), Flight Information Information (c) Department of Defense Flight Pacific, Australasia and Publication (Enroute), Supplement Antarctica, 27 May 93 Information (d) Department of Defense Flight Altitude Pacific, Australasia Publication (Terminal), High and Low and Antarctica, 24 Jun 93 Supervisor of (e) Air Force Regulation (AFR) 60-4, Flying (SOF) Program, 10 May 93 Air Traffic (f) Air Force Regulation (AFR) 60-5, Control, 28 Feb 92 General Flight (g) Air Force Regulation (AFR) 60-16, Rules, 27 Jan 92 Investigations (h) Air Force Regulation (AFR) 110-14, Space Accidents, 15 Dec 89 of Aircraft, Missile, and Nuclear and Investigating (i) Air Force Regulation (AFR) 127-4, Jan 90, Change 1, 13 May 91 and Reporting US Air Force Mishaps, 3 Medical (j) Air Force Regulation (AFR) 160-43, Examinations and Standards, 16 Feb 93 Operational (k) Air Force Manual (AFM) 2-1, Aerospace Air, Close Air Support, Doctrine Tactical Air Operations-Counter and Air Interdiction, 2 May 69 Flying, (1) Air Force Manual (AFM) 51-37, Instrument 15 Jul 86, Change 4, 1 Apr 92 Volume I, (m) Air Force Manual (AFM) 66-279, 93 Attachment 1, Introduction to CAMS, 1 Jul I, Pilots' (n) Air Force Pamphlet (AFP) 60-19, Volume Guide, 10 Sep 91 Instrument Refresher Course (IRC) Instructor 30

57785 (o) Multi-Command Regulation (MCR) 51-50, Tactical Aircrew Training, 30 Oct 85 (p) Multi-Command Regulation (MCR) 55-116, F-16 Pilot Operational Procedures, 7 May 93 55-65, (q) Pacific Air Forces Regulation (PACAFR) Procedures Aircraft Surge Launch and Recovery Implementation (ASLAR), 22 Feb 91 Manual (r) Technical Order (T.O.) 1F-16C-I, Flight 30, and 32, 17 Oct 88, USAF Series Aircraft F-16C/D Blocks 25, Change 8, 10 May 93 2 (s) Technical Order (T.O.) lF-16C-I- , Supplemental Blocks 25, 30, and 32, Flight Manual USAF Series Aircraft F-16C/D 1 Oct 92 1 , (t) Technical Order (T.O.) 1F-16C-2-27FI-00- F-16C and F-16D Manual Flight Control System USAF Series Technical Change 8, 22 Apr 93 Aircraft Blocks 25, 30, and 32, 8 Aug 90, 1 , (u) Technical Order (T.O.) lF-16C-2-31GS-00- System USAF Manual Crash Survivable Flight Data Recorder Technical 25, 30, and 32, 4 Nov 87, Series F-16C and F-16D Aircraft Blocks Change 4, 27 Aug 90 1 , (v) Technical Order (T.O.) lF-16C-2-33GS-00- Series F-16C and F-16D Technical Manual Liqhting System USAF 83, Change 11, 19 Feb 91 Aircraft Blocks 25, 30, and 32, 13 Aug Technical (w) Technical Order (T.O.) IF-16C-6-1I, Requirements USAF Scheduled Inspection and Maintenance Manual Engine Block 30, Series F-16C and F-16D Aircraft Using FLl0-GE-l00 10 Apr 91, Change 7, 12 Apr 93 Avionics (x) Technical Order (T.O.) IF-16C-34-I-l, Manual USAF Series Aircraft and Nonnuclear Weapons Delivery Flight F-16C/D Blocks 25, 30 and 32, 18 Mar 92 Force (y) Technical Order (T.O.) IF-16C-38, Series F-16C and F-16D Management Data Collection Procedures USAF 50, 52, 28 Jan 91, Change Aircraft Blocks 25, 30, 32, 40, 42, and 3, 13 Apr 93 Order (T.O.) 5F5-4-28-2, Technical (z) Technical Data Instructions Intermediate Central Air Manual Maintenance 17 Aug 81, Computer Part No. 4025116-905 and Part No. 4025116-907, Change 7, 7 Sep 90

31 Wolfpack (aa) Wing Standards, 8th Fighter Wing Standards, Mar 93 Wing Wing (bb) Wing Training Plan, 8th Fighter Training Plan, 1 Jan 93 Tower/Radar (cc) Operations Letter, Kunsan Control Procedures, 16 Jul 93 Approach Control (RAPCON) Coordination (01) 60-1, Facility (dd) DOFR Operating Instruction Memorandums, 1 May 93 (01) 60-1, Facility (ee) DOFCT Operating Instruction Memorandums, 17 Jul 93 violations of (2) The following are known or suspected regulations and/or directives: Handbook (a) Federal Aviation Administration Departure and Arrival, states: "Except 7110.65G, paragraph 5-114, from 5-115, separate a departing aircraft as provided in paragraph miles if on final approach by a minimum of 2 an arriving aircraft (5 miles when 40 will increase *to a minimum of 3 miles separation 1 minute after takeoff." miles or more from the antenna) within 1 states: "This procedure Additionally, paragraph 5-114 note to be released so long as an arriving permits a departing aircraft time. than 2 miles from the runway at the aircraft is no closer aircraft is determined at the time the departing This separation with Departures takeoff roll." (Paragraph 5-115 deals commences Diverging Runways and and Arrivals on Parallel or Nonintersecting is not applicable.) (Tab 0-13) failed to ensure The control tower local controller RATIONALE: thus allowing separation compliance with the established standard, by the mishap (Tabs A-i, 3, to decrease below 2 miles as evidenced 4, 47, 48, and 68). Handbook (b) Federal Aviation Administration note, states: "A paragraph 3-124 Landing Clearance, 7110.65G, separation on the landing clearance to land means that appropriate runway will be ensured." (Tab EE-1l) controller failed to ensure RATIONALE: The control tower local runway as evidenced by the adequate separation existed on the mishap (Tabs A-i, V-3, 4, 47, 48, and 68).

32

57787 2-1, (c) Air Force Regulation 60-5, paragraph Qualifications, and Responsibilities, Personnel Titles, states: Watch Supervisor (WS) Responsibilities, subparagraph g(2), during their for the overall operation of the facility "Responsible awareness of air traffic." shift and maintains general situational (Tab EE-12) failed to maintain The control tower watch supervisor RATIONALE: allowed the control awareness of air traffic in that he situational in violation of Federal tower local controller to direct aircraft 7110.65G (Tabs A-1, V-3, and 4). Aviation Administration Handbook 3-1, ATC Force Regulation 60-5, paragraph (d) Air Facility AF Form 3616, Daily Record of Forms, subparagraph b, duties "Each WS or SC who performs supervisory Operation, states: Form 3616 when portion of a shift signs the AF for all or any the entries are their shift. Their signature certifies completing required entries." (Tab EE-12) correct and the form contains all 90 course of the investigation approximately RATIONALE: During the twenty-five 3616s were examined. Approximately days worth AF Form watch supervisor forms failed to have the required percent of the review by both the controllers signatures. Documented or senior Control Operations failed to Chief Controller and Chief Air Traffic identify the deficiency. 3-5, Local Force Regulation 60-5, paragraph (e) Air "CCTLRs issue Procedures, subparagraph k, states: Operating and standardize administrative operating instructions to regulate CATCOs issue operating instructions practices within a facility. of more than standardize administrative practices to regulate and Number operating one facility under their jurisdiction. subject series." (Tab EE-12) instructions according to their established one Each facility chief controller has RATIONALE: serves as a directory for Operating Instruction (01), which of establishing OIs for each Facility Memorandums, instead operation or function. 1, 60-5, PACAF SUPPLEMENT (f) Air Force Regulation paragraph 2-1C(2), states: "CCTLRs Air Traffic Control Management, maintain a program to ensure controllers shall establish in, except as noted in all positions they are certified proficiency The program must include in paras 2-lb(l)(d) and 2-ld(l)(c). requirements, a means of tracking minimum monthly/quarterly a controller fails and actions that will be taken when proficiency, observation procedures/time to meet requirements. Proficiency facility operating instruction." frame should be contained in a (Tab EE-13) 33

57788 a addresses its proficiency program in RATIONALE: Each facility radar vice an operating instruction. The facility memorandum Although the program fails to set or track standards. facility their program lacks a tower has set standards for proficiency, standards. system to track and document those paragraph 8-14, (g) Air Force Regulation 60-16, states: "No person Landing Minimums, subparagraph d, Approach and MDA or continue an an aircraft below the prescribed may operate is in a position to below the DH unless: (1) The aircraft approach intended landing; and (2) normal approach to the runway of make a threshold of the runway, pilot clearly sees the approach The identifiable with the approach approach lights, or other markings end of that runway." (Tab EE-14) that he initially saw the RATIONALE: Despite Slap 02's testimony and VASIs; his testimony to the lighted T, runway marker lights, the painted runway markings and didn't contrary that he did not see and clearly because of rain and poor visibility expect to see them runway, clearly that he never saw Stingray 01 on the his testimony above regulation. Slap 02's non-compliance with the establishes that Slap 02 was unaware of Further supporting this, was evidence the runway until advised of that his collision with an aircraft on the mishap. (Tabs V-l, 13, 17, fact approximately one hour after and 78). Regulation 60-16, paragraph 8-14, (h) Air Force "If on Minimums, subparagraph e, states: Approach and Landing at any time missed approach point or DH (or arrival at the d above are not any of the requirements in paragraph thereafter) the appropriate missed met, the pilot must immediately execute 8-14d is quoted in paragraph [g] approach procedure." (Paragraph above.) (Tab EE-14) was made to execute Testimony indicates that no attempt RATIONALE: go-around at any time missed approach, climb-out or a either a landing (Tabs V-l, 48, during the mishap approach and/or attempted and BB-2). Volume 8, Multi-Command Regulation 51-50, S(i) e, states: "The Flight Lead Upgrade, subparagraph paragraph 6-6, who have not yet of this section do not prohibit pilots provisions from leading limited portions entered FLUG and are not FL-qualified of an IP or FL-qualified SQ of a mission under the supervision supervisor." (Tab EE-15) verify and transcripts of radio transmissions RATIONALE: Testimony the latter portion the leader of Slap 01 flight during Slap 02 as At the time of the mishap sortie (Tabs V-l, 2, and EE-37). of the supervisor or instructor mishap Slap 01 was neither a squadron 34

57789 also indicated that pilot (Tabs V-2, 7, and EE-24). Testimony Gardner had led a four-ship mission on the Lieutenant Colonel of his the mishap. (Tabs V-14, 74, and EE-27). A review morning of upgrade to folder indicated all required training to training had the squadron flight lead had not been accomplished nor (Tabs T-9 and 16) commander certified him as a flight lead. Fighter (j) Pacific Air Forces Regulation 55-116, 8th paragraph 8-6, Command Wing Chapter 8, section B, General Policy, Supervision, subparagraph d, states: "Prebriefed and Control/Flight wingman on the of the flight may be tactically led by a portions pilot." (Tab 0-30) wing of a squadron supervisor or instructor RATIONALE: See (i) above. Aircraft Air Force Regulation 127-4, Chapter 5, (k) Related, and Reporting, paragraph 5-4, Flight, Flight Flight Mishap g(7), Other Events FOD Mishap Reporting Requirements, subparagraph identifies "Flight control Reportable as Class C Flight Mishaps, flight control, stability malfunction (including helicopter resulting in an unexpected, augmenter, autopilot, and trim systems) altitude, or heading." as a hazardous change of flight attitude, reportable Class C Mishap. (Tab EE-16) LeBlanc experienced a RATIONALE: Testimony indicates Captain Jul 93. It further confirms departure from controlled flight on 9 accomplished even though that a Class C Mishap Report was not the aircraft. (Tab V-l, 12, extensive maintenance was performed on and EE-36) 6, Life (1) Air Force Regulation 60-16, Chapter Table 6-1, Oxygen Requirements For Pressurized Support Systems, of an aircraft identifies the requirement for the pilot Aircraft, a pressure suit. (Tab EE operating above Flight Level 500 to wear 17) Assembly of aircraft RATIONALE: Data from the Electronic Component pressure suit operations, 86-0286 which is not equipped to support on 9 Jul 93, was examined for a piloted by Captain LeBlanc the controlled flight. This data confirms departure from (Tab EE-2) operation above Flight Level 500. aircraft's AFR 60-16/PACAF Sup 1 Additionally, testimony confirms that paragraph 6-2g was not applicable (Tab V-l). Volume 8, Chapter (m) Multi-Command Regulation 51-50, 4-2, Ground Training, 4, Continuation Training, paragraph Situational Emergency Procedures Training subparagraph d(2)(a), calendar "This training will be accomplished each (SEPT), states: month will result Failure to accomplish by the end of the month. (Tab EE-18) in grounding until subsequently completed." 35

57790 A review of the individual currency summary printout RATIONALE: shows both both Lieutenant Colonel Gardner and Captain LeBlanc for emergency procedures pilots were overdue the required situational and 44). training on the day of the mishap (Tabs T-18 Order IF-16C-6-11, section 1, part H, (n) Technical the Requirements, page 1-H-038, identifies Phased Inspections FII0 engine to perform an ultrasonic inspection of the requirement EE-43). midspan shroud every 150 flight hours (Tab for aircraft 86 RATIONALE: A review of inspection requirements midspan shroud inspection 0275 indicated the 150 hour ultrasonic corrected time) at the time was overdue by 26.4 hours (25.5 hours of the mishap. (Tabs U-I and 2) 2 Order 1F-16C-1- , Figure 5-10, Sheet (o) Technical 30 aircraft authorized configurations for F-16 Block 99, identifies training missiles. when loaded with CATM-88/A captive air-to-ground (Tab EE-19) configuration Testimony confirms that an unauthorized RATIONALE: flight during their first flown by both aircraft in Slap 01 was V-1, and 2). sortie on the day of the mishap (Tabs 8th Fighter Pacific Air Forces Regulation 55-116, (p) Control/Flight 8, paragraph 8-6, Command and Wing Chapter senior flight subparagraph b, states: "The most Supervision, the 8 OG/CC on a case by case commander may be approved as TOP-3 by basis." (Tab 0-30) Squadron The flying schedule for the 35th Fighter RATIONALE: as the squadron's Captain Norris, "C" Flight Commander, indicates indicates he had not at the time of the mishap. Testimony TOP-3 commander as a TOP-3. (Tabs been approved by the operations group V-84 and EE-27)

3. STATEMENT OF OPINION any opinion of the accident investigator Under 10 U.S.C. 2254(D), accident or the factors contributing to, the as to the cause of, not be accident investigation report may set forth in the arising evidence in any civil or criminal proceeding considered as be considered an aircraft accident, nor may such information from States or by any person an admission of liability by the United referred to in those conclusions or statements.

36

57791 a. FACTORS CAUSING THIS ACCIDENT of my investigation, certain information (1) In the course convincing in my opinion, provided clear and was discovered, which Stingray 01 and the cause of the mishap involving evidence as to the control tower local The main factors involve (1) did Slap 02. separation in accordance with controller maintain proper aircraft watch (2) was the control tower all appropriate regulations? by Air Force of the situation as required supervisor aware the mishap? and (3) and should/could he have prevented regulations without clearly defined visual Slap 02 continue his approach Force did environment contrary to Air references of the runway regulations? tower local controller Specifically, the control (2) Administration Handbook comply with Federal Aviation failed to 0-13) and 3-124 (Tab EE-1I). 7110.65G, paragraphs 5-114 (Tab (FAAH) with separation of aircraft specific paragraphs deal These and clearing an aircraft for a runway for landing he approaching 01 for takeoff at the exact time takeoff. In clearing Stingray ensure the local controller failed to did, the control tower simultaneously of two miles between aircraft minimum separation flight rules conditions as and departing under instrument by arriving cited above. Additionally, required by the FAAH paragraphs tower local 01 onto the runway, the control clearing Stingray environment was free failed to ensure that the runway controller after he cleared Slap 02 to and remained free of any obstructions above complied with either of the land. (Tab EE-37). Had he been opinion, Slap 02 would not have referenced regulations, in my Stingray 01. (Tab A-l) in a position to collide with established that the control (3) The facts also clearly to maintain general situational tower watch supervisor failed of the in the control tower at the time awareness of operations paragraph 2 with Air Force Regulation 60-5, mishap in accordance the control tower During the course of events, lg(2) (Tab EE-12). wasn't right", yet he supervisor admits to feeling "something watch actions to verify any traffic failed to take any positive If the any corrective action (Tab V-3). conflicts, nor did he take requisite supervisor had exercised the control tower watch of the control awareness as to the actions/inactions situational 01 flight, ample opportunity local controller regarding Slap tower corrective action. Thus, his have been available to take up to would the course of events leading lack of action contributed to the mishap. indicate that the pilot of Slap (4) The facts also clearly 60 in violation of Air Force Regulation 02 operated his aircraft to execute the 8-14(d) and (e), when he failed 16, paragraphs and continued his approach appropriate missed approach procedure, 37

57792 approach at below the decision height for the ASLAR ILS Runway 36 clearly defined visual references to the runway Kunsan AB, without this (Tab EE-14). In thoroughly examining the facts of environment impact the investigation analyzed several areas which could mishap, with the above Slap 02's ability to fly the approach in compliance regulation. and (a) Examination of the official weather forecast the mishap shows the observation at Kunsan AB at the time of the 200 foot ceiling and 3/4 mile visibility weather well above W-l). to fly the approach (Tabs 0-14, 21, and minimums required confirm the by Slap 02 and witnesses to the mishap Testimony a 300 foot ceiling and weather at the approach end of Runway 36 at mile above the minimum 1 mile visibility; i.e. 100 feet and 1/4 moderate to heavy rain requirements. Testimony also confirms runway at the time of the showers at the approach end of the mishap. (Tabs 0-14, V-l, 3, 10, 18, and 47) ceiling at 330 (b) Slap 02 stated he broke out of the and the minimum ceiling feet MSL, 101 feet above decision height 0-14 and V-l). Witnesses stated they for the approach (Tabs of come out of the clouds over the beginning observed the aircraft the which are approximately 3700 feet from the approach lights V-47, AA of interception for the approach (Tabs 0-14, runway point path Slap 02 This position on final, for the glide 3, and EE-20). that Slap 02 flew, would be consistent with the altitude stated he to the decision that he broke out of the clouds and close testified would have been at of 229 feet MSL (Tabs 0-14 and V-l). It height Slap 02 would have to this point (i.e. decision height) that thereafter, if he did not execute a missed approach, or any time clearly have the runway environment in sight. with continue the approach in accordance (c) To a normal Slap 02 had to be in a position to make regulations, approach threshold of approach to the runway and clearly see the lights, or other markings identifiable with the runway, approach the end of the runway (Tab EE-14). In my opinion, the approach a normal that Slap 02 was in a position to make evidence shows a normal the runway. Witnesses to the mishap indicated approach to recorder is and data captured by the flight data glidepath (Tabs BB-2, V-l, 46, consistent with a normal approach to landing 47, and 48). to clearly see the runway (d) The requirement His where Slap 02 deviated from the regulation. environment is and the that he saw the lighted T, runway marker lights, testimony he broke out of approach slope indicator (VASI) lights when visual environment (Tab clouds indicates he saw portions of the runway the he did not see the V-i). His testimony to the contrary that runway markings, and threshold, touchdown zone, and centerline

38

57793 of the rain and the expect to see them very clearly because didn't he could see some approach visibility confirms that although poor the requirement to clearly see lighting it was insufficient to meet the runway environment. (Tab V-I) investigation was (e) To insure that a thorough that may have unknowingly limited accomplished, additional factors examined. Rain collecting on the Slap 02's forward visibility were known problem and is addressed in canopy in front of the HUD is a it however, testimony by Slap 02 confirmed the F-16 flight manual, as a factor V-i and EE-32). Also excluded was not a factor (Tabs visibility. for HUD symbology to obscure forward was the potential was flown in the F-16 ILS to Runway 36 at Kunsan AB An ASLAR and weather conditions Slap simulator with the same HUD symbology Tab Z, the mishap. The photos, at 02 experienced on the day of Slap 02 symbology would not have prevented clearly show that HUD approach end of the runway environment or the from clearly seeing Z-1 thru 5). Slap 02 the collision occurred (Tabs the runway where hamper his forward that the HUD symbology did not also testified Captain LeBlanc was not Testimony also indicated that visibility. or to have any known problems known to suffer from HUD fixation EE-34) (Tabs V-1, 2, 9, 11, 13, and with situational awareness. establishes Slap 02's The primary evidence that (f) 60-16 is his own testimony that violation of Air Force Regulation impact, when 01, even at the moment of he never saw Stingray wide aircraft, with entire 49 foot long and 33 foot Stingray 01's a minute) anti-collision flashing (approximately 50 times a white than ten feet in front of operating on its tail, was less light see Stingray 01 on the runway The only way Slap 02 could not if him. vision was totally blocked or at some time would be if his final 02's field of view during the Stingray 01 was not in Slap EE-44, attempted landing. (Tabs V-1, portions of the approach and and 45) 02, was below minimums, and Slap (g) If visibility in violation reason elected to continue the approach for whatever to use on-board navigation regulations, it is quite possible to of he described in his testimony aides and the limited visual cues by V-i). This can be accomplished fly the F-16 to a landing (Tab canopy, acquiring visual references looking out either side of the the aircraft, which in low visibility from below and to the side of to the than forward visibility due situations are much better the aircraft Using this technique to land shorter slant ranges. approach in limited the pilot to fly a "normal" would allow flown, the pilot would If this type of approach is visibility. from the cockpit until just looking out the side and low continue then transition to looking forward the runway where he would When above moments prior to touchdown. began to flare the aircraft an as he it would be impossible to see flying an approach in this manner, 39

57794 aircraft on the runway until the pilot looked forward. If this is not done until the flare, a pilot could collide with another aircraft on the runway and never see it, as Slap 02 did. (h) Irrespective of how he flew the approach, Slap 02 and failed to execute a missed approach as required by regulations continued his approach without clearly defined visual references. Had he complied with the regulations described above, this mishap would not have occurred.

b. CONTRIBUTING FACTORS

(1) In addition to those factors that caused the mishap may have there were other elements which, in my opinion, to the sequence of events leading to the mishap. These contributed evidence contributing factors are not based on clear and convincing but on my personal experience as a pilot and commander. Testimony indicated Captain LeBlanc's scheduled (2) no on mid-tour leavesthe morning after the mishap, had departure V-i, 2, on his decision making process that afternoon (Tabs impact diverting and 13). However, I find it difficult to believe that 7, been of afternoon prior to his mid-tour leave would not have the This, as any consequence to his decision to continue the approach. PM may have well as the squadron's direction to land by 3:30 the approach contributed to Captain LeBlanc's decision to continue (Tabs V-i and 2). flight (3) Captain LeBlanc's demonstrated lack of mishap. His discipline was also a contributing factor in this 500 and, on actions, on 9 Jul 93, when he flew above Flight Level the mishap, when he led Slap 01 flight, indicate Captain the day of of propensity to disregard regulations and his lack LeBlanc's LeBlanc flight discipline (Tabs V-l, 2, and EE-2). Had Captain executed the been a more disciplined pilot, he would have with Air Force appropriate missed approach procedure in accordance regulations and thus prevented the mishap. 4. SUMMARY: factual This report is submitted as a complete document of all available to the Investigating Officer, in accordance information F-16C with AFR 110-14, regarding the aircraft accident involving Jul 93. Serial Number 86-0275 and F-16C Serial Number 87-0335 on 27

THOMAS A. ORAM, Lt Col, USAF Investigating Officer

40

57795 In some instances a copy or other facsimile has been substituted for the original. I certify that all such facsimiles contained herein are true and accurate copies of the originals.

THOMAS A. ORAM, Lt Col, USAF Investigating Officer

If