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United States Air Force Aircraft Accident Investigation Board Report

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United States Air Force Aircraft Accident Investigation Board Report UNITED STATES AIR FORCE AIRCRAFT ACCIDENT INVESTIGATION BOARD REPORT F-16C, TIN 88-0433 421st FIGHTER SQUADRON 388th FIGHTER WING HILL AIR FORCE BASE, UTAH LOCATION: UTAH TEST AND TRAINING RANGE, UTAH DATE OF ACCIDENT: 4 MAY 2012 BOARD PRESIDENT: LIEUTENANT COLONEL THOMAS R. OLSEN, JR. CONDUCTED IAW AIR FORCE INSTRUCTION 51-503 DEPARTMENT OF THE AIR FORCE HEADQUARTERS AIR COMBAT COMMAND JOINT BASE LANGLEY-EUSTIS VA OFFI CE OF THE VICE COMMANDER 205 DODD BOULEVARD SUITE 203 JO INT BASE LANG LEY-EUSTIS VA 23665-2788 2 4 AUG 2012 ACTION OF THE CONVENING AUTHORITY The Report of the Accident Investigation Board, conducted under the provisions of AFI 51-503, that investigated the 4 May 2012 mishap near Hill AFB, UT, involving F-16C, TIN 88-0433, assigned to the 388 FW, Hill AFB, UT, complies with applicable regulatory and statutory guidance and on that basis is approved. Lieutenant General, USAF Vice Commander r EXECUTIVE SUMMARY AIRCRAFT ACCIDENT INVESTIGATION F-16C, TIN 88-0433 Utah Test and Training Range (Near Hill AFB, UT) 4May2012 On 4 May 2012, at approximately 08:30 hours local time (L), an F-16C, tail number 88-0433, assigned to the 421st Fighter Squadron, 388th Fighter Wing (388 FW), Hill Air Force Base (AFB), Utah, crashed in the northern portion of the Utah Test and Training Range (UTIR), approximately 50 nautical miles west of Hill AFB. No military or civilian personnel were injured in the mishap. The mishap aircraft (MA) was destroyed on impact, with no damage to private property. Mishap damage costs were $23,869,281. The mishap pilot (MP) was conducting close air support training as the second aircraft in a two­ ship formation, when he reported an engine failure. Immediately following indications of a compressor stall and engine failure, the MP maneuvered west to avoid mountainous terrain and the Great Salt Lake. He correctly applied all critical action procedures and coordinated with his mission flight lead to initiate search and rescue operations. Due to low altitude at engine failure, recovery to any runway was impossible, regardless of pilot action. After several unsuccessful attempts to restart the engine, the MP placed the MA in a stable, climbing attitude. The MP safely ejected approximately one and a half minutes after the initial compressor stall indication. UTIR emergency response crews and a local Life Flight helicopter recovered the MP. The Board President found, by clear and convincing evidence, the cause of the mishap was failure of the number 17 blade in the first stage fan section of the engine. The fan blade liberated from its supporting structure, causing catastrophic damage to the rest of the fan, compressor, and high and low pressure turbines. Because of this extensive damage, the engine could not produce thrust or be restarted. Additionally, the Board President found, by a preponderance of the evidence, a blade anomaly coupled with eight years of normal operating fatigue substantially contributed to the mishap. The anomaly at the base of blade 17 was formed during a manufacturing process. Blade 17 separated due to fatigue cracking propagating from the edge of the anomaly. The Board President also found, by a preponderance of the evidence, the failure to detect the anomaly during the installation inspection process in 2004 substantially contributed to the mishap. Under 10 U.S.C. 2254(d), any opinion of the accident investigators as to the cause of, or the factors contributing to, the accident set forth in the accident investigation report, if any, may not be considered as evidence in any civil or criminal proceeding arising from the accident, nor may such information be considered an admission of liability of the United States or by any person refe"ed to in those conclusions or statements. r SUMMARY OF FACTS AND STATEMENT OF OPINION F-16C, TIN 88-0433 4May2012 TABLE OF CONTENTS COMMONLY USED ACRONYMS AND ABBREVIATIONS ................................................. .iii SUMMARY OF FACTS ................................................................................................................. ! 1. AUTHORITY and PURPOSE .............................................................................................. 1 a. Auth.ority ......................................................................................................................... 1 b. Purpose ........................................................................................................................... 1 2. ACCIDENT SUMMARY .................................................................................................... 1 3. BACKGROUND .................................................................................................................. 1 a. Air Combat Command .................................................................................................... 1 b. Unit Information ............................................................................................................. 2 (1) Twelfth Air Force (Air Forces South.ern) ............................................................... 2 (2) 388th. Fighter Wing ................................................................................................. 2 (3) 421 st Fighter Squadron ........................................................................................... 2 c. F-16C Fighting Falcon .................................................................................................... 2 4. SEQUENCE OF EVENTS ................................................................................................... 3 a. Mission ............................................................................................................................ 3 b. Planning .......................................................................................................................... 3 c. Preflight .......................................................................................................................... 3 d. Summary of Accident ..................................................................................................... 4 e. Impact ............................................................................................................................. 6 f. Egress and Aircrew Flight Equipment (AFE) ................................................................. 6 g. Search and Rescue .......................................................................................................... 6 h. Recovery of Remains ...................................................................................................... 7 5. MAINTENANCE ................................................................................................................. 7 a Form.s Documentation ..................................................................................................... 7 b. General Scheduled Inspections and Procedures ............................................................. 8 c. Maintenance Personnel and Supervision ........................................................................ 8 d. Fuel, Hydraulic and Oil Inspection Analyses ................................................................. 8 e. The F 11 0-GE-1 00 Turbofan Engine .............................................................................. 8 ( 1) Description and Operation: ..................................................................................... 8 (2) Scheduled Hourly Engine Inspections .................................................................... 9 (3) The 4,000 Total Accumulated Cycle Inspection .................................................... I 0 f. Unscheduled Maintenance ............................................................................................ 11 6. AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS ............................................ 12 a Structures and Systems ................................................................................................. 12 b. Evaluation and Analysis ............................................................................................... 12 (1) Crash Survivable Flight Data Recorder ................................................................ 12 ·(2) Engine Analysis .................................................................................................... 12 F-16C, TIN 88-0433, 4 May 2012 1 r (3) Metallurgical Analysis .......................................................................................... 14 7. WEATHER......................................................................................................................... 15 a Forecast Weather .......................................................................................................... 15 b. Observed Weather ........................................................................................................ 15 c. Space Environment ....................................................................................................... 15 d. Operations ..................................................................................................................... 15 8. CREW QUALIFICATIONS .............................................................................................. 15 9. MEDICAL ........................................................................................................................... 16 a Qualifications - Mishap Pilot .......................................................................................
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