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2003 JAN 15 PI' 3: 33 UNCLASSIFIED iJFFICL Of i; ,L SECRETARY RULEtIAIINGS AND ADJUDICATIONS STAFF AIRCRAFT ACCIDENT INVESTIGATION REPORT

8 SEP 92

F-16C (SN85-1451) 86TH WING RAMSTEIN ,

VOLUME I Pr-S A UNCLASSIFIED

57328

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AIRCRAFT ACCIDENT INVESTIGATION REEPORT F-16C, SN-1451

RAMSTEIN AIR BASE, GERMANY

WILLIAM F. RAKE, Lt , USAF Investigation Officer

KEVIN P. KOEHLER, Captain, USAF Legal Advisor

ROBERT A. REVIS, TSgt, USAF Technical Advisor

WILLIE G. TRAMMELL, JR. Technical Advisor

57329 STATEMENT OF AUTHORITY AND PURPOSE

Air Force, Lieutenant By order of the Commander, Headquarters Seventeenth Air Base, Colonel William F. Rake, , 19 October 1992, to conduct an Germany, was appointed by orders, dated aircraft which occurred on 8 investigation into the crash of an F-16C Air Base, . Captain September 1992, while flying from the Staff Judge Advocate, Ramstein Kevin P. Koehler, 86th Wing, office of same orders as the Legal Advisor Air Base, Germany, was detailed by the the course of the investigation. to accompany Lt Colonel Rake throughout , Germany, TSgt Robert A. Revis, 52nd Fighter Wing, by special order, effective 27 was detailed as the Technical Advisor, October 1992. (Tabs Yl and Y2)

MATTER INVESTIGATED

A aircraft accident involving F-16C This was an investigation of a Class the 86th Wing, , (Serial Number 85-1451) assigned to hours, local Turkish time, into a Germany. The aircraft crashed at 0920 farm area, near the village of barren hillside in a sparsely populated of , Cakiruyuk, 120 nautical miles east-northeast and survived. The objective of Turkey. The pilot successfully ejected all available relevant facts the investigation was to obtain and preserve and to investigate the and evidence pertaining to the accident, for use in claims adjudication and circumstances leading to the accident action, adverse administrative evaluation, litigation, disciplinary deemed appropriate by competent proceedings, or other purposes conducted the investigation under the authority. Lieutenant Colonel Rake guided by the general procedures authority of AFR 110-14, and was outlined in AFR 120-3.

used in this Aircraft Accident NOTE: A glossary of abbreviations of Facts. (See page 16) Investigation Report follows the Summary

1 57330 SUMMARY OF FACTS

I. History of Flight

with F-16C 1. The 86th Wing, Ramstein Air Base, Germany, equipped COMFORT flying from aircraft, was tasked to support Operation PROVIDE was to provide flight Incirlik Air Base (AB), Turkey (TU). Unit tasking (CTF) missions in the operations in support of Combined Task Force extends down to the 36th Turkish Area of Responsibility (TAOR) which routinely cycled this degree of latitude in northern . The 86th Wing rotation on which tasking between its squadrons. During the (FS) had deployed to this mishap occurred, the 526th Fighter Squadron COMFORT support sorties Incirlik AB, TU and had flown Operation PROVIDE since 6 Aug 92.

two F-16Cs, took off from 2. On 8 Sep 92, Lucky 01 and 02, a flight of mission (Tabs A-i, K-i, Incirlik AB, TU on an Operation PROVIDE COMFORT the mishap F-16 pilot, V-1.4, V-2.3, and FF-l). Enroute to the TAOR, relieve himself into a callsign Lucky 01, unfastened his lap belt to soft plastic container piddle-pack (a dehydrated sponge in a disposable, In the process, used by pilots in cockpits without other provisions). (stick) and the the lap belt slid down between the side-stick controller raised his seat (Tab V-l. ejection seat and became wedged when the pilot roll to the right 12). The aircraft entered a nose low uncontrollable ejection (Tab A, B, C, N, (clockwise). The pilot successfully initiated and the aircraft, F-16C SN V-1.15 to V-I.16, V-2.9, DD-i, EE-l, and EE-2) N, and V-2.9). Crash site 85-1451 was destroyed upon impact (Tabs A, C, of south-central Turkey (Tabs was an isolated and sparsely populated area damage was minimal. (Tabs P A, S, V-1.17, V-2.10, and EE). Property and GG)

information concerning the 3. At the time of this mishap, general "F-16C/D Flight Manual" (Tab hazards of stick interference existed in the States Air Forces in Europe FF-3). Additionally, Headquarters, United and Life Support offices had (Hq USAFE), Standardization and Evaluation which directly addressed the issued supplementary data on the subject in conjunction with the use of possibility of stick interference problems FF-IO) piddle-packs. (Tabs CC-5.1, CC-6, CC-7, and

"F-16 C/D Flight Manual" a. Stick interference was discussed in the "Cockpit Interior Check", and under "F-16D Aircraft" (two seat model), (Tab FF-3). With the again in Section III, "Emergency Procedures" flight manual did not address exception of Section III, references in the to F-16D or ground operation inflight operations and were confined address interference while using discussions. The flight manual did not a piddle-pack.

Standardization and b. Hq USAFE Deputy Commander for Operatiops, to an ongoing Class-A Safety Evaluation Branch (DOV), in response mishap, disseminated Investigation Board and a previous Class-C addressed stick interference information on 20 Dec 90 which specifically use inflight (Tab FF- with an unfastened lap belt during a piddle-pack 2 57331 File 10). This information was in the form of a Flight Crew Information FCIF (FCIF) message to all USAFE F-16 units and was to remain an active it item for 90 days, at which time it was to be rescinded. By making prior part of the FCIF, the item was required reading for all F-16 pilots to their next flight.

(1) It could not be ascertained if this item was entered into was no the 86th Wing's FCIF because the item had been rescinded and current or longer on file. The item did not appear on 86th Wing rescinded FCIF indexes. (Tab FF-12)

(2) Lt Col Snelgrove arrived at the 86th Wing in Sep 91 (Tabs item, but was T-2.1, V-l.1, and BB-3.8) and had not seen the FCIF published. (Tab familiar with the accidents which prompted the FCIF to be V-i.1)

c. Hq USAFE Deputy Commander for Operations, Current Operations information Branch (DOOT), Life Support Section, had also published usage. In a specifically addressing stick interference and piddle-pack to all USAFE 4 May 92 "Life Support Current Interest Letter" distributed to include wing and squadron life support sections, units were authorized training plans instruction on the use of piddle-packs into unit-created life support and (Tabs V-6, CC-4, and CC-5.1). Similarly, a joint these same safety working group held 2-4 Jun 92 at Hq USAFE emphasized meeting, unit problem areas (Tabs CC-6 and CC-7.2). At this to USAFER 55-44 representatives were informed of an impending change hazards of piddle which would direct the inclusion of training on the were encouraged pack use into their lesson plans. Unit representatives the regulation to include this training prior to actually receiving change

of (1) The term "unit" in the AFR 55-44 discussion defined as a "Wing" responsibility to maintain current lesson plans was CC-3) not a "Squadron." (Tabs V-2.14, V-5.3, V-6.3, and time of the (2) Unit lesson plans were under revision at the topics. (Tabs V mishap and did not include piddle-pack interference and CC-IO) 2.15, V-5.3, to V-5.4, V-6.3 to V-6.4, CC-8, CC-9,

letter but was (3) The 526 FS had received the 4 May 92 Jun 92 Working Group. unaware of the information discussed at the 2-4 (Tabs V-2.16 and V-6.5)

training (4) Lt Col Snelgrove accomplished semi-annual egress (Tab CC-I) 27 Apr 92, and was current the day of the mishap.

accident was light. 4. News media interest and coverage of the the Air Force Times, Newspaper articles appeared in Stars and Stripes, and EE-5). Queries and four Turkish daily papers (Tabs EE-1, EE-3, EE-4, the British Broadcasting were received from the Associated Press and were directed to Company, both in Ankara, TU (Tab EE-2). Media inquiries Incirlik AB, TU. the 39th Tactical Group (TACG) Public Affairs offices,

3 57332 II. Mission

PROVIDE 1. The mission of Lucky 01 and 02 was to perform Operation roles along with COMFORT presence, air superiority, and reconnaissance down to 36 degrees of other coalition aircraft in the TAOR which extends The majority of north latitude in northern Iraq (Tabs K-i and FF-l). three hours long and Operation PROVIDE COMFORT sorties were approximately cruise, air-to-air included takeoff from Incirlik AB, TU high altitude via high altitude. refueling, air patrol of TAOR airspace, and return refueling and air some missions were tasked for a second air-to-air flying time to about patrol period prior to returning which increased longer mission. (Tab K, four hours. Lucky 01 and 02 were tasked for the V-1.5, V-2.4, and FF-1)

flight lead duties for the 2. Specifically, Lucky 01 was to perform V-1.4, V-2.2, and FF-2) mission and Lucky 02 as the wingman. (Tabs K,

III. Briefing and Preflight

experience flying 1. Lt Col Snelgrove, the mishap pilot, had previous deployed to Incirlik AB, Operation PROVIDE COMFORT missions. He had been five Operation PROVIDE TU since 19 Aug 92 and in that time, had flown (Tab V-1.3) COMFORT sorties prior to the mishap sortie.

Lt Col Snelgrove was mentally 2. On 8 Sep 92, the morning of the mishap, He had pilot rest required and physically prepared to lead the sortie. departing his quarters (Tab by AFR 60-1, and had eaten breakfast prior to wingman in sufficient time V-1.4). He arrived at the squadron with his all pre-mission briefing prior to their scheduled briefing time to gather (NOTAMs), intelligence information, i.e., weather, Notices to Airmen No mass pilot briefing was update briefings, and flight planning data. routing to the TAOR given. The flight was filed for along prescribed not signing off two Safety (Tabs V-1.9 and V-2.7). With the exception of Message Change (IMC) to the Information File (SIF) items and one Interim was prepared to fly (Tabs T "F-16C/D Flight Manual", Lt Col Snelgrove to V-2.4, AA-1, AA-2, 1.1, V-1.3 to V-1.4, V-1.6 to V-1.7, V-I. , V-2.3 not "Go/No-Go" or safety of AA-3, BB, and FF-1l). The missed items were flight items.

by Lt Col Snelgrove with 3. The flight briefing was accomplished and personal notes. It reference to USAFER 55-116 briefing guides items and special subjects, started on time and covered all applicable emphasis items. The as well as current Operation PROVIDE COMFORT at the conclusion of the wingman, Capt Carlisle, had no questions attendant dehydration briefing. Due to high outside air temperatures, the tasked sortie, Lt Col problems, and the anticipated length of the briefing. Both pilots Snelgrove drank a container of water during prepare to go to their had ample time to don flight gear and otherwise aircraft. (Tabs V-1.7 and V-2.3)

concrete apron in front of a 4. The mishap aircraft was located on the for flight in a timely protective shelter and was properly prepared 4 57333 manner. Lt Col Snelgrove departed the squadron, arrived at the aircraft, and performed a preflight inspection in daylight conditions at the scheduled times. Aircraft configuration was as directed by the CTF and as expected by the pilot: AIM-9 missiles on wingtip stations number 1 and 9, wingtanks on underwing stations number 3 and 6, empty MAU-12 pylons on underwing stations 4 and 6, ALQ-131 Electronic Counter-Measure (ECM) pod on centerline station number 5, as well as 510 rounds of 20 millimeter (mm) cannon shells, 30 chaff bundles, and 15 flares carried internally. Start, taxi, and end of checks were normal and performed IAW applicable directives. (Tabs V-1.8 and V-2.7)

IV. Flight Activity

1. Lt Col Snelgrove and his wingman took off at 0903 Incirlik Local Time (ILT), three minutes later than planned (Tab K and FF-l) but well within the time allowed by Turkish air traffic controllers and Operation PROVIDE COMFORT directives. Because of prevailing good weather at Incirlik AB, TU and forecast good weather along the entire route, Lt Col Snelgrove elected to accomplish a visual flight rules (VFR) departure instead of the SID which was filed (Tabs V-1.9, V-2.7, and W). The entire mission, up to the time of the mishap, complied with Turkish, Operation PROVIDE COMFORT, and local Incirlik AB, TU directives. Both aircraft climbed to 33,000 feet mean sea level (MSL) and proceeded on course as cleared by Incirlik departure radar monitoring service. Leaving Incirlik's airspace, Lucky 01 and 02 contacted the Airborne Warning and Control System (AWACS) aircraft, callsign "Cougar", for flight following service and advisories. (Tabs V-1.10 and V-2.8)

2. The flight plan at this point was for approximately 30 minutes of virtually straight-line routing to the northwest corner of Iraq for air to to-air refueling. During this phase of flight the pilot decided relieve himself into a piddle-pack. This decision was based on the from length of time spent flying in straight and level flight well away use the ground and the fact that these conditions lend themselves to the of the auto-pilot. Additionally, if not accomplished enroute to the air would to-air refueling rendezvous point, work load and flight conditions the not normally permit the pilot to use a piddle-pack for approximately next three hours. (Tab V-l.ll)

no 3. Use of a piddle-pack in the F-16 was difficult and there were other provisions in the aircraft which allow a pilot to relieve himself. The F-16 was a single seat aircraft with a small cockpit which restricted 30 pilot movement laterally as well as forward and aft. The rearward of the degree incline of the ejection seat and the close proximity ejection seat to other instruments and controls further complicated of successful use of the piddle-pack in the cockpit. The greatest range the motion for the pilot was vertically in the ejection seat which took of the pilot out of optimum position to control the aircraft. The use pilot to aircraft auto-pilot was generally required to enable the to maintain controlled flight conditions for the length of time required use the piddle-pack.

piddle-pack. He 4. The pilot prepared the cockpit prior to using the 5 57 734 the lap disarmed the ejection seat, turned on the auto-pilot, unfastened his thighs, and belt, draped each half of the lap belt over the inside of glove to the cockpit was removing his flight gloves when he dropped one his right hand and floor. The pilot reached forward and down with knocked the right retrieved his glove. While pulling his arm back, he to rest between the lap belt off his thigh and the metal buckle came ejection seat and the stick controller. (Tab V-1.12)

seat height adjustment 5. The pilot then moved his right hand to the the ejection seat to switch on the right wall of the cockpit and raised panel located create more room between the seat and the instrument wedged between the upward between the pilot's knees. The lap belt became to the instrument moving ejection seat and the stick which was attached V-1.12) console on the right side of the cockpit. (Tab

transducers in both a. The stick was a force-sensing unit containing one quarter inch in both pitch and roll axes and moved approximately axes. (Tab FF-6)

controlled upward and b. The ejection seat height adjustment switch spring-loaded to a center downward movement of the ejection seat and was was perceived to stop "off" position (Tab FF-5). Upward seat movement (Tab V-1.14) coincident with the pilot releasing the switch. the auto-pilot and 6. The resultant stick movement to the right overrode righthand (clockwise) roll commanded the aircraft into a nose low, rapid (Tabs 0-1.2 and V of approximately two to three seconds per revolution. 1.12, and V-2.8)

apparent to the mishap 7. The cause of the aircraft roll was immediately began its right hand pilot who saw the wedged lap belt as the aircraft attempts to regain roll (Tab V-1.12). He made multiple unsuccessful control of the aircraft. (Tab V-1.12 to V-1.15)

with full force to the a. He unsuccessfully tried moving the stick left. (Tab V-1.12)

by reversing the the b. He attempted to lower the ejection seat would not lower and the ejection seat height adjustment switch. The seat lap belt remained wedged. (Tab V-1.12 to V-1.14) by a (1) The seat actuator motor (seat actuator) was protected power if overheated. (Tab FF thermal relay which interrupted electrical 5) a circuit breaker (2) The seat actuator was protected by sensed more amperage than designed to pop (open) if the circuit breaker the seat actuator. The it was designed to allow (Tab FF-8) and disable from the aircraft wreckage seat actuator circuit breaker was recovered (Tab J-l.3). This may have and found to be in the popped (open) position result of running the seat occurred at impact or could have been the J-l.3 and FF-8) actuator while the seat was not movable. (Tabs

6 57335 left hand while c. He attempted to pull the lap belt free with his trying to fly the aircraft with his right. (Tab V-1.13) switch d. He tried to interrupt the auto-pilot, using the "paddle" on the stick. (Tabs V-1.13 and FF-7)

aircraft dropped to 8. During the rapid rolls, the flight path of the aircraft rapidly lost approximately 30 degrees below the horizon and the an estimated 10,000 altitude (Tabs V-1.12 to V-1.13, and V-2.8). At he may be able feet Above Ground Level (AGL), the mishap pilot perceived AGL, he was able to to control the aircraft and, passing about 4000 feet full force to the stop the roll momentarily by holding the stick with and at approximately left. The aircraft continued in a nose low descent roll as he pulled 2000 feet AGL, the aircraft again entered a righthand to V-1.15) back on the stick to recover from the dive. (Tab V-1.14

ejection despite 9. The pilot re-armed his ejection seat and initiated his lap belt fastened concern he would not survive the ejection without his left hand while to hold him in the seat. He initiated ejection with his right. (Tab V attempting to counter the roll by stick inputs with 1.15)

mishap aircraft, 10. Lucky 02, initially attempted to follow the some unknown reason. thinking he was executing an avoidance maneuver for After Lucky 01 started No radio transmissions were made by Lucky 01. that Lucky 01 had into a second roll, it became apparent to the wingman, recorder (VTR) and his a problem. Lucky 02 turned on his video tape the mishap pilot to intercom to record what transpired. He instructed aircraft departure from perform the Critical Action Procedures (CAPs) for above the ground. He controlled flight and informed him of his altitude feet AGL. (Tab N and V-2.9) directed him to eject at approximately 10,000 were noticed by 11. At the time of the ejection, no aircraft malfunctions flight data recorder (Tabs the pilot or detected by the mishap aircraft analysis results were J, 0-1, and V-1.9). Flight data recorder by the pilot (Tabs J consistent with the aircraft flightpath described instruments 1.1, 0-1, and V-1.12). Additionally, analysis of recovered The engine seemed to revealed no instrument or instrumentation failures. hydraulic gauges was be operating normally. Only one of the two normal pressure range and recovered, but it was found to indicate in the systems were under the flight data recorder indicated that both hydraulic No electrical power sufficient pressure to operate the flight controls. 0-1) supply or interruption problems were evident. (Tab

V. Impact

in an isolated, sparsely 1. The aircraft crashed on 8 Sep 92 at 0920 ILT .5 nm southwest of a small populated area of south-central Turkey, approx the crash site was the farm community called cakiruyuk. specifically, wheat field located 070 base of a barren, rocky hillside near a harvested S and Z). Coordinates degrees and 120 nm from Incirlik Air Base TU (Tabs and east 37 degrees, 49.55 were north 37 degrees, 33.8 minutes latitude 7 57336 minutes longitude (Tabs A and N). F-16C SN 85-1451 was destroyed on impact. (Tab M)

2. Flight conditions at the time of impact were: an easternly heading low, (heading indicator destroyed), 290 knots airspeed, 22 degrees nose and 47 degrees left wing down with a right (clockwise) rolling motion. (Tab J-l.1)

29.81 3. Analysis of the altimeter revealed an altimeter setting of J-1.l). inches of mercury (in. Hg) was entered at the time of impact (Tab time the This was the local altimeter setting at Incirlik AB, TU at the a standard mishap aircraft took off (Tab W-2). AFM 51-37 directs through setting of 29.92 in. Hg be entered flying at or climbing 110 foot specified transition altitude (Tab FF-13). The resultant have had no indicated altitude error while at cruising altitude should affect on this mishap.

VI. Ejection Seat

modes of The Advanced Concept Ejection System (ACES) II seat has three parachute operation which determine the speed with which the pilot's main seat's deploys. Ejection was initiated and occurred within the ejection was designed operating envelope Mode-2 (Tab FF-4). The ejection without a successful despite the fact the pilot was forced to eject sequence fastened lap belt. All components involved in the ejection appeared to have functioned properly. (Tabs V-1.16, and V-2.9)

VII. Personnel and Survival Equipment

1. The pilot landed on a rocky hillside which was predominately in the covered with boulders. The pilot encountered no difficulties equipment used operation or use of survival equipment. The only survival in the was the PRC-112 radio which was used to talk to aircraft involved rescue operation. (Tab V-1.18 to V-l.19)

VIII. Rescue

radio contact 1. At the time of the mishap, both Lucky 01 and 02 were in the Incirlik with the AWACS who maintained continual radio contact with the AWACS Command Post. Therefore, at 0920 ILT, when Lucky 02 informed able to notify that Lucky 01 had ejected, AWACS was immediately efforts (Tabs N Incirlik's Command Post to initiate rescue and recovery Because Operation 1.2, V-2.9 to V-2.10, DD-2, DD-3.1, DD-4, and DD5.1). Turkey and PROVIDE COMFORT involves a coalition of countries including the Turkish because of Status of Forces Agreement (SOFA) provisions, military was also soon notified of the crash.

passed coordinates 2. Lucky 02 established an orbit over the crash site, ascertained that the to AWACs, contacted the mishap pilot via radio and for helicopter pilot was not injured (Tabs V-2.9 to 2.10). While waiting was provided by response to the crash site for pilot pickup, air coverage two A-lOs, callsign the mishap pilot's wingman, Lucky 02, a flight of three more flights Vulture, a flight of two F-111's, callsign Ratch, and B 57337 DD-1.2) of two'A-10s each, callsigns Condor, Puma, and Sawtuth. (Tab

Cakiruyuk 3. A number of inhabitants from the nearby village of friendly and responded to the crash site within five minutes. They were able to willing to help but could not speak English. The pilot was the crash communicate using German and instructed them to stay away from where the site. They recovered a number of personal items located near pilot landed and delivered them to him. (Tab V-1.18 to V-1.19)

and were 4. Turkish military personnel responded from a local garrison the first to cordon the crash site. (Tab Vl.19)

delayed by 5. CTF, helicopter rescue and crash recovery responses were problems bi-lateral (US-TU) coordination and treaty interpretation centered predominately around jurisdictional issues.

west of the a. HH-53 helicopters located at Incirlik AB, TU 120nm PROVIDE COMFORT crash site were primarily responsible for Operation to be notified. search and rescue (SAR) operations and were the first and take off However, due to problems coordinating engine start HH-53, callsign clearances, their launch was delayed. At 1220 ILT, an ground party to Pave 11, launched from Incirlik AB, TU to deliver a small pilot pickup was secure and begin clearing the crash site. By this time, AB, TU. The HH already in progress by UH-60 helicopters from Diyarbakir at 2019 ILT. (Tab 53 arrived at 1317 ILT and returned to Incirlik AB, TU DD-1.2)

the HH-53 b. At 0950 ILT, because of delays in launching AB, TU 114 nm east helicopters, UH-60 helicopters located at Diyarbakir recalled and aircraft of the crash site were alerted. Flight crews were 13, launched. made ready. At 1124 ILT, UH-60 helicopters, callsign Eagle at 1225 ILT and They arrived at the crash site for pilot pickup was taken to a transported the pilot to Incirlik AB, TU where the pilot AA-4, and DD flight surgeon. Arrival time was 1329 ILT. (Tabs V-1.21, 4)

two Turkish c. Prior to the arrival of Eagle 13 for pilot pickup, been operating in the helicopters arrived on scene. The first one had him to a local vicinity, located the pilot, and offered to transport to the crash site hospital. The second Turkish helicopter was dispatched pilot and transport from Diyarbakir AB and was directed to pick up the him back to Diyarbakir AB, TU. (Tab V-1.20 to V-1.21)

not seem injured d. Both offers were declined by the pilot who did had contact with the and desired to return to Incirlik AB, TU. AWACS as intermittent radio aircraft orbiting overhead the crash site as well intentions to the CTF contact with the pilot. They relayed the pilot's which agreed to the decision. (Tabs V-l.21, DD-l.2)

notification at e. Crash response was also delayed. After initial travel via helicopter 0945 ILT, an initial response team was prepared to Force (DRF) was to the crash site and a follow-on Disaster Response The initial response preparing to depart via military vehicle convoy. 9 57_-38 Pave 11, at 1120 (1130 in team departed on an HH-53 helicopter, callsign follow-on DRF convoy was Explosive Ordinance Disposal report). The until 1730 ILT due to scheduled to depart at 1300 ILT, but was delayed escort. The DRF convoy the requirement to have a Turkish military Sep 92. (Tabs 0-2.2, DD-3.1) arrived at the crash site at 0130 ILT on 9

accomplished by US military 6. EOD and bioenvironmental operations were the wreckage was performed with personnel following which, a search of duties were completed on 14 the assistance of the local populous. DRF TU on 15 Sep 92. (Tabs 0-2.4 Sep 92 and the DFR returned to Incirlik AB, and DD-5)

IX. Maintenance Documentation

Order (AFTO) Forms 781A as 1. The current aircraft Air Force Technical 92 to 8 Sept 92 were reviewed. well as previous 781A forms dated 30 Apr were found. (Tabs U Only minor non-related documentation discrepancies 1, U-3, and U-4)

Orders (TCTO) revealed no 2. A review of Time Compliance Technical overdue TCTOs. (Tabs U-6, U-10, and U-11)

satisfactorily completed. No 3. Aircraft scheduled inspections were U-5) discrepancies were found. (Tabs U-i and

found to be within limits. 4. Oil analysis records were reviewed and (Tab U-13)

revealed time change 5. A review of automated history products (Tab U-1) requirements were complete with no discrepancies. on the aircraft after the 6. No unscheduled maintenance was performed on 8 Sep 92. The mishap postflight/preflight and walk-around inspections (Tabs U-3 and U-4) sortie was the first flight of the day.

and testimony revealed no 7. A review of maintenance documents appear related to the mishap. maintenance procedures or practices that (Tabs U-I, U-4, V-3, and V-4)

X. Maintenance Personnel and Supervision performed duties IAW 1. All maintenance personnel and supervisors technical data. (Tabs U-i, V-3, and V-4)

inspections were completed with 2. Preflight/Postf light and walk-around U-4, V-3.3, and V-4.4) no discrepancies noted. (Tabs U-2, U-3,

Forms 623) were reviewed. All 3. On-the-job training records (AF satisfactorily. (Tab U-i) training and certifications were completed

10 573-3q XI. Engine Oil. Fuel and Hydraulic Inspection Analysis

Due to the All engine oil records were within standards (Tab U-13). V), fuel and nature of this mishap and the testimonies given (Tab not completed. hydraulic analysis were deemed unnecessary and therefore

XII. Airframe and Aircraft Systems

J, 0-1, 1. All aircraft systems appeared to be operating normally. (Tabs and Vl.9)

nothing that 2. The technical analysis of recovered instruments revealed or at the time indicated the aircraft was operating abnormally prior to of impact. (Tab J)

XIII. Operations Personnel and Supervision

(Tab FF-I) The mishap sortie was tasked by CTF Operation PROVIDE COMFORT Flight and properly authorized on USAFE Form 406, Consolidated FS, Assistant Deputy Authorization/Approval (Tab K). Capt Peterson, 526 Snelgrove was the Commander for Operations approved the flight. Lt Col the aircraft. All only pilot onboard and was the pilot in command of capable of the supervisory personnel were considered qualified and launch, and flight required decisions and duties related to the tasking, of the mishap aircraft and pilot.

XIV. Pilot qualifications

with an 1. Lt Col Snelgrove was highly qualified and experienced He was previously an extensive background in tactical fighter aircraft. Weapons Instructor instructor pilot and a graduate of the USAF Fighter the FWIC in the Course (FWIC) in the F-4. He was also an instructor in BB-2.9 to 2.14, and BB F-4 and the F-16A/B aircraft (Tabs G, T-2, V-1.1, abilities, he was 2.17 to 2.36). Due to his experience and demonstrated at Ramstein Air given an abbreviated upgrade to instructor pilot while for Operations of Base, Germany (Tab BB-3.54). He was Deputy Commander the 526 FS at the time of the mishap. (Tab V-1.1)

over 15 years, was a 2. At the time of the mishap he had been rated for time, and had command pilot with a grand total of 2,298.5 hours of flying He had a total of 2,092.9 total hours as first pilot or instructor. instructor. The sum of 552.7 hours in the F-16 of which 316.6 were as an were 14 sorties and 27.1 his flying experience in the last 30/60/90 days and 63.8 hours hours, 20 sorties and 40.0 hours, and 36 sorties respectively. (Tabs G, T-2.2 to 2.3, and BB-l.3)

training and flight 3. A complete review of Lt Col Snelgrove's or performance evaluation records revealed no significant training in all required problems (Tabs BB-2 and BB-3). He was current and FF-Il). With the recurring training (Tabs BB-I, BB-5, CC-l, an IMC to the flight exception of not signing off two SIF items and Lt Col Snelgrove was manual, neither of which were critical flight items, Ii 5 7 3240 V-1.7, V-2.3 to V prepared to fly (Tabs C-1.1, V-1.3 to V-1.4, V-1.6 to information was 2.4, AA-I, AA-2, AA-3, and FF-11). No unfavorable contained in his personnel records.

XV. Medical

flight on 1. Lt Col Snelgrove was medically qualified for the mishap not on Duty-not-to 8 Sep 92. He had a current flight physical and was AA-3) Include-Flying (DNIF) status. (Tabs AA-l, AA-2, and

AB, TU, Lt Col 2. After the helicopter delivered him to Incirlik Medicine Clinic Snelgrove was immediately taken to the 39 TACG Flight have minor bruises where an examination was performed. He was found to as one in the lower on the right and left sides of his neck as well He also complained of portion of his spine above the tail bone. AA-6) tenderness in the middle of his back. (Tab

exam and toxicology 3. The findings of the post mishap flight surgeon affected his report revealed nothing that would have adversely performance as a pilot. (Tabs AA-4 and AA-5)

until 20 Oct 92 due to 4. The pilot was subsequently put on DNIF status physical therapy. muscular stiffness in the neck and chest which required (Tab AA-6)

XVI. Navaids and Facilities

reviewed and would not The status of Incirlik facilities and NOTAMS were appear to affect this mishap. (Tab FF-9)

XVII. Weather

Base, TU for the time The forecast weather condition at Incirlik Air takeoff was three eights period in which the mishap aircraft was to visibility outside of cumulus cloud cover at 3,000 feet AGL, unrestricted knots. Enroute weather was clouds and winds out of the northeast at 5 three eights cumulus cloud forecast to be only slightly different with cloud cover at 10,000 feet cover at 4,000 AGL four eights alto-cumulus visibility outside of AGL, which constituted a ceiling, unrestricted knots (Tabs W-1 and W-3). clouds and winds out of the southwest at 12 time the mishap aircraft took Actual observed weather condition at the at 3,000 feet AGL and off was one eight cumulus cloud coverage Airfield operations under unrestricted visibility outside of clouds. Enroute weather was better visual flight rules (VFR) were permitted. (Tab W-2) than forecast with no ceiling observed.

XVIII. Directives and Publications

and technical orders were The following directives, publications and the maintenance performed applicable to the operation of the mission on the mishap aircraft.

12 57341 1. Regulations and Manuals:

a. AFR 60-1, Flight Management Program b. AFR 60-2, Aircrew Standardization/Evaluation C. AFR 60-16, General Flight Rules Flying d. AFM 51-37, Flying Training Instrument e. USAFER 51-1, Aircrew Ground Training Fighter and F-16 Aircrew f. USAFEM 51-50, Vols I and VIII, Tactical Training g. USAFER 55-44, Life Support Program Systems Program h. USAFER 55-27, Air Force Life Support Procedures; Ramstein AB i. USAFER 55-116, F-16 Pilot Operational Chapter 8 to USAFER 55-116 Organization j. USAFER 66-5, Combat Oriented Maintenance General Planning k. DoD Flight Information Publication, Planning, Special Use 1. DoD Flight Information Publication, Area Airspace, Europe-Africa-Middle East M. 86 TFW In-flight Guide Guide n. Operation PROVIDE COMFORT In-flight

2. Technical Orders (T.O.):

a. IF-16C-1, F-16C/D Flight Manual b. 1F-16C-lCL-l, F-16C/D Checklist Launch, Recovery, C. IF-16C-6WC--11, Basic Postflight/Preflight, and End of Runway Inspection Guide d. IF-16C-2-1OJG-O0-1, Aircraft Ground Safety Guide e. IF-16C-12JG-O0-1, Aircraft Ground Servicing Weapons Delivery Flight f. IF-16C-34-1-I, Avionics and Non-nuclear

Non-nuclear Weapons g. 1F-16C-34-1-1CL-1, Checklist Avionics and Delivery Flight Crew Procedures h. IF-16C-70FI-O011, Power Fault Isolation Maintenance Requirements. i. 1F-16C-6, Scheduled Inspections and

WILLIAM F. RAKE, Lt Col, USAF Accident Investigating officer

13 57342 CERTIFICATION

aircraft accident As the investigation officer appointed to conduct this investigation investigation, I certify that I have conducted a complete of the facts of this accident under AFR 110-14.

the accident investigation The following originals were not included in report.

to the Accident 1. The originals of Tabs A through S were not forwarded sent to Hq AFSA/SER Investigation officer. Instead they were reportedly provided to the Accident Norton Air Force Base, . Copies were Investigation Officer.

be obtained by contacting 2. Lt Colonel Snelgrove's Flight Records may the following offices: Wing, Flight Records a. Flight Data Records and History - 86th Management Office, Ramstein Air Base, Germany Squadron, b. Flight Evaluation Folder - 526th Fighter Air Base, Standardization and Evaluation Section, Ramstein Germany Squadron, c. Flying Training Records - 526th Fighter Training Office, Ramstein Air Base, Germany records can be located at 3. Lt Colonel Snelgrove's medical and dental and Dental Clinics respectively, the 86th Medical Group, Flight Medicine Ramstein Air Base, Germany.

(F-16C, SN 85-1451) not 4. All maintenance documents of aircraft report, all photo negatives included in the original copy of this all other photocopied original provided to the investigating officer, and the Staff Judge Advocate, 86th documents can be located at the office of Wing Ramstein Air Base Germany.

WILLIAM L. RAKE, Lt Col, USAF Accident Investigating Officer

and certify that the I have reviewed the above referenced originals copies of the originals. copies contained herein are true and correct

KVIN P•. KOEHL RAF Legal Advisor

14 57343 LEGAL SUFFICIENCY REVIEW

investigation and find I have observed and reviewed all aspects of this in accordance with AFR it was conducted in a legally sufficient manner Any information from 110-14, AFR 120-4, and other applicable directives. not be appropriate for the documents included in this report which would Act has been deleted. release under the provisions of the Privacy

KEVIN P. KOEHLER, Captain, USAF Legal Advisor

15 57344 GLOSSARY OF TERMS

AB Air Base System ACES Advanced Concept Ejection Officer ADO Assistant Operations Manual AFM AFSC Air Force Order AFTO Air Force Technical Level AGL Above Ground AOR (Turkish) Area of responsibility Carrier APC Armored Personnel Control System AWACS Airborne Warning and to eject Bail Out The command Transmitter (ELT) Beacon Emergency Locator fuel from a tanker to BOOM Device used to transfer another aircraft (Inspection) BPO Basic Postflight version of the F-16 C-Model Single seat System CAMS Core Automated Maintenance Air Patrol CAP Combat Procedures CAPS Critical Action Capt Captain to lower altitude Combat Descent A rapid descent Trainer CPT Cockpit Procedural Force CTF Combined Task to Include Flying DNIF Duty Not (Operations Officer) DO Deputy Commander Operations, Life Support DOOT Deputy Commander for Branch Standardization DOOV Deputy Commander for Operations and Evaluation Branch Force DRF Disaster Response Cartridge DTC Data Transfer Ordnance Disposal EOD Explosive Power Unit EPU Emergency of Runway EOR End File FCIF Flight Crew Information order FRAG Fragmentary Squadron FS Fighter Inlet Temperature FTIT Fan Turbine frequency Guard Universal distress Parachute harness trainer Hanging Harness Shelter HAS Hardened Aircraft Refuel Hit A Tanker Incendiary HEI High Explosive Up Display HUD Heads Hq Headquarters With IAW In Accordance Flight Rules IFR Instrument Local Time ILT Incirlik Message Change IMC Interim of mercury In.Hg Inches 16 57345 IP Instructor Pilot JFS Jet Fuel Starter JINK A small turn Knots Nautical miles per hour routing K-Town Turn point on standard PROVIDE COMFORT Lt Col Lieutenant Colonel system to Marked the Position Command to the inertial navigation remember a current position MQT Mission Qualification Training MR Mission Ready MS Mission Support Charge NCOIC Noncommissioned Officer in NM Nautical Miles NOTAM Notice to Airmen to the face of a O'Clock Position expressed in relation clock OJT On the Job Training OPS Operations PAS Protective Aircraft Shelter PAR Precision Approach Radar after a Phase Aircraft inspections accomplished certain amount of flying time Down to the Area A sortie into the TAOR to repair an aircra ft Red Ball Rapid maintenance response RAPCON Radar Approach Control RECCE Reconnaissance RTB Return to base Unit RTU Replacement Training SA Situational Awareness SAR Search and Rescue SIF Safety Information File SN Serial Number SOF Supervision of Flying SOFA Status of Forces Agreement squadron to fly STEP A time set to depart the STICK Side-stick controller TACG Tactical Group TAOR Turkish Area of Responsibility Order TCTO Time Compliance Technical slow motion Temporal Distortion Recollection as if in TU Turkey Twenty-eight Twenty-eight Frequency 282.8 Training UPT Undergraduate Pilot Forces in Europe USAFE Air in Europe Regulation USAFER United States Air Forces Forces in Europe Manual USAFEM United States Air VFR Visual Flight Rules Conditions VMC Visual Meteorological VTR Video Tape Recorder VUL Time Vulnerability time of aircraft condition Walk Around Inspection A cursory check WG Wing 17 573a F 271 Flight management specialists 451 Aircraft Serial Number 85-1451 ZULU A time referencing Greenich Meridian Time (GMT)

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