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United States Air Force Abbreviated Aircraft Accident Investigation Board Report

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United States Air Force Abbreviated Aircraft Accident Investigation Board Report UNITED STATES AIR FORCE ABBREVIATED AIRCRAFT ACCIDENT INVESTIGATION BOARD REPORT MQ-9A T/N 12-4174 42D ATTACK SQUADRON 432D WING INSTALLATION WITHHELD LOCATION: UNITED STATES CENTRAL COMMAND AREA OF RESPONSIBILITY DATE OF ACCIDENT: 27 October 2018 BOARD PRESIDENT: COLONEL BARTON D. KENERSON Abbreviated Accident Investigation conducted pursuant to Chapter 12 of Air Force Instruction 51-307 EXECUTIVE SUMMARY UNITED STATES AIR FORCE ABBREVIATED AIRCRAFT ACCIDENT INVESTIGATION MQ-9A, T/N 12-4174 UNITED STATES CENTRAL COMMAND AREA OF RESPONSIBILITY 27 October 2018 On 27 October 2018, at approximately 1300 local time (L), the mishap aircraft (MA), an MQ-9A, tail number (T/N) 12-4174, crashed approximately 142 nautical miles from the airfield in an undisclosed location within the United States Central Command area of responsibility. At the time of the mishap, the 42d Attack Squadron mission control element was in control of the MA. Loss of Government property is valued at $13,788,693. There were no reported fatalities, injuries, or damage to civilian property. The mishap crew consisted of the Mishap Pilot (MP1) and Mishap Sensor Operator (MSO). Prior to MP1 taking over the MA, the mid-shift Mishap Pilot observed several issues in the MA: the MA’s exhaust gas temperature (EGT) fluctuated more than normal, the flight control station was not properly displaying any maps, and the MA was not visible on the tracker display. Ground control station (GCS) maintenance personnel determined that the solution was to reset the MA’s rack (the console where the pilot controls the aircraft). MP1 agreed with the proposed plan and entered the GCS. At approximately 0830L, MP1 performed the standard gaining checklists in order to gain control of the MA, along with the rack configuration and presets checklists to ensure the rack and parameters for the MA were set up correctly. MP1 successfully re-established link with the MA and the MA appeared to be functioning normally. However, a “[Digital Electronic Engine Control (DEEC)] – sensor fault” caution message appeared on the heads-down display (HDD). This caution is normally associated with a “DEEC in Backup Mode” warning, which would flash on the HDD in red. That second indicator did not appear on the MA screen. MP1 ran the appropriate checklist and, based on indicators he observed in the MA, believed that the DEEC mode was active. MP1 determined this caution was an anomaly and elected to stay on course. From approximately 0900L to 1230L, the flight was uneventful. At approximately 1230L, the MSO came on shift and MP1 set the MA in orbit to fly itself while he began documenting the DEEC sensor fault discrepancy in Skynet. MP1 noticed the EGT fluctuating rapidly. Torque and propeller speed began to decrease, resulting in an uncommanded descent. MP1 attempted several automatic and manual engine restarts but was unsuccessful. MP1 was forced to make an emergency landing in a relatively clear area. The destroyed MA was not available for inspection. The Abbreviated Accident Investigation Board President found, by a preponderance of the evidence, the mishap was caused by: (1) the decoupling of the propeller from the engine, and (2) MP1’s failure to adequately follow the DEEC sensor fault checklist. There was insufficient evidence indicating any substantially contributing factors. Under 10 U.S.C. § 2254(d) the opinion of the accident investigator as to the cause of, or the factors contributing to, the accident set forth in the accident investigation report, if any, may not be considered as evidence in any civil or criminal proceeding arising from the accident, nor may such information be considered an admission of liability of the United States or by any person referred to in those conclusions or statements. SUMMARY OF FACTS AND STATEMENT OF OPINION MQ-9A, T/N 12-4174 27 October 2018 TABLE OF CONTENTS ACRONYMS AND ABBREVIATIONS......................................................................................iii SUMMARY OF FACTS ................................................................................................................ 2 1. AUTHORITY AND PURPOSE...........................................................................................2 a. Authority .........................................................................................................................2 b. Purpose............................................................................................................................2 2. ACCIDENT SUMMARY.....................................................................................................2 3. BACKGROUND ..................................................................................................................3 a. Air Combat Command (ACC) ........................................................................................3 b. Twelfth Air Force (12 AF)..............................................................................................3 c. 432d Wing (432 WG)......................................................................................................3 d. 42d Attack Squadron (42 ATKS) ...................................................................................4 e. MQ-9A Reaper................................................................................................................4 4. SEQUENCE OF EVENTS ...................................................................................................4 a. Mission............................................................................................................................4 b. Planning ..........................................................................................................................4 c. Preflight...........................................................................................................................5 d. Summary of Accident .....................................................................................................5 e. Impact..............................................................................................................................6 f. Egress and Aircrew Flight Equipment.............................................................................7 g. Search and Rescue (SAR)...............................................................................................7 h. Recovery of Remains......................................................................................................7 5. MAINTENANCE .................................................................................................................7 a. Forms Documentation.....................................................................................................7 b. Inspections ......................................................................................................................7 c. Maintenance Procedures .................................................................................................7 d. Maintenance Personnel and Supervision ........................................................................7 e. Fuel, Hydraulic, and Oil Inspection Analyses ................................................................8 f. Unscheduled Maintenance...............................................................................................8 6. AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS ..............................................8 a. Structures and Systems ...................................................................................................8 b. Evaluation and Analysis..................................................................................................8 7. WEATHER...........................................................................................................................9 a. Forecast Weather.............................................................................................................9 b. Observed Weather...........................................................................................................9 c. Space Environment .........................................................................................................9 d. Operations.......................................................................................................................9 8. CREW QUALIFICATIONS.................................................................................................9 a. Mishap Pilot (MP1).........................................................................................................9 b. Mid-Shift Mishap Pilot (MP2)........................................................................................9 MQ-9A, T/N 12-4174, 27 October 2018 i c. Mishap Sensor Operator (MSO1) .................................................................................10 d. Mid-Shift Mishap Sensor Operator (MSO2) ................................................................10 9. MEDICAL ..........................................................................................................................10 a. Qualifications ................................................................................................................10 b. Health............................................................................................................................10 c. Pathology.......................................................................................................................10 d. Lifestyle
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