I .A ,. .- m__ ".s6339 45 DOCKETED USNRC 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 AIR BASE, GERMANY VOLUME I Pr-S A UNCLASSIFIED 57328 Impaiplfe--,scc y- o F sc-c(/-O;L-SeC 9,;LEAR REGULATORY COMMvl-'-,,Si0N r,4 OMR.-T.:1 D-M.No. ILO tý,jV,-j -M In the I > a! IDENTFiED App -a t RIE-CEIVED InIcrVenor PEJECTED o""'C"s WFFHDRNNN Witness . * AIRCRAFT ACCIDENT INVESTIGATION REEPORT F-16C, SN-1451 RAMSTEIN AIR BASE, GERMANY WILLIAM F. RAKE, Lt Colonel, 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 Spangdahlem Air Base, Colonel William F. Rake, 52nd Fighter Wing, 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, Turkey. Captain September 1992, while flying from Incirlik 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 Spangdahlem Air Base, 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, Ramstein Air Base, (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 Incirlik Air Base, 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 Iraq. The 86th Wing rotation on which tasking between its squadrons. During the squadron (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.