Accident Investigation Board - F-16

Transcription

,Re1-7?-P2-TSF5Cr--4plicnir FvK'ii5377/t6Y-e'd 7/,/oP,.DOC ETEDUSNRC.-AFR-110142P03 JAN) 7 PM:fUSAF AIRCRAFToF-IE 0,i,,E-EiRRULEMAKINGS STAFFANDADJUDICATIONSACCIDENTINVESTIGATIONBOARD7 FEB 94F-16 AIRCRAFTSIN 90-0764138FG125FSINVESTIGATION OF FICERRICHAIDMPEDERSEN, LT COL,. USAFS"-.i.-,."- .r'- " -" .I . ""--"" , .-U ' -" .-AU:'-,-FOR. E-,;-l57817COPY-NUMBER.'OF.ScC VY-oa,

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2. SUMMARY OF FACTS:a. Histo ofFtint:at 0914 CST(1) Two F-16CG aircraft, call signs Tulsa 11 and 12, took off from Tulsa LAPMOA (TAB V(TAB Z-1). They were to conduct a Basic Fighter Maneuver (BFM) mission in the Riverspenienced an.x,Jment1). At approximately 0945 CST while setting up for the third engage(TAB J-5,stagnationandstallexplosion and severe engine and airframe vibrations, followed by an engineFor anthrust.useableregainandV-1). Ittempted two airstarts, but was unable to start the enginebladeturbinesLagefourthaoffractureunknown reason, the engine had experienced a high cycle fatigueVS-5,S-4,J-5,(TAB(LMturbinepressurebelow the blaik platform and subsequent damage to the 1). At approximately 0948 CST,on priate proprtyminimum recommended iection altitude (TAB A-2, N-1, V-I). The aircraft crailied120 NM southapprximatelyOK.,Sope,of(NM).northused for cattle grazing 1I'2 nautical milessoutheakt of Tulsa International Airport (lAP'(TAB P-2).property ,wasiiniThulsa,.OK (TAB A 2,; P72). 'Acual diamage to privatedataPtakfftume oC09 14pli.seventS( All following tines are based on-.Tulsa lbs recordedipto-tile c.SDThe,1). ,-AB AASeal DataR.corder (SDR)aircraftoad' m- a .recorded b(,the:-,, k '' :' f.-,.,--. ,. ,:ae nSDRdetuto-rmmPact7mntatuSsystcenmmdata,dtdith, and Digital Backup Unit data Aircraftq7icýdatatermination ARAA. .(ANG). I - he Te mission was scheduled as a 2 ship BFM 3 tor-aininjission iT benflsswn'lAW-MC[betv Fly'ing Training F-16hcs rnetepnssesshptak offswith'20, second-spacinr.vzsualandmaneuvcr,-Jqneheat-t-guns cine rackk--xerqisq,ýbotbeh.- nggemen,for recoyaIAPflw.to Tulsaandae returm Tutdsa12 was.:.:. ",. ,.- ,,- ,,landmg60NA:-."heare iaaeimdeyonUVim -Range -(BVR) 'BM,"Tub I AM':.- ",, . :.:, -,,-.,:: . ,57818by

*0c. Briefing and Prefliiht:(K-4). The preflight briefing began atBoth flight members reported adequate crew rest for the missionr n Emergency divert fields were specifically briefed.07'15 CST and was briefed in detail byg regulations (TAB V-2). Both members ofThe briefing covered all applicable items required by egeneral flow of the mission, and had nothethe flight indicated they clearly understood the objectives,preflightand beganquestions about the flight briefing. Both pilots arrived at their jets IAW briefed timesuneventful (TAB V-1, V-2).inspections. Preflight, start, taxi, marshaling and arming weret:d. FlitA t-flight plan (TAB K-4). At(1) Tulsa 11 flight was filed and cleared for the Zebra 4 stereowith 20 seconds spacing between aircraftapproximately 0914 CST, they accomplished single ship takeoffsaccomplishing air-to-air systems checks(TAB V-1, Z-l). They rejoined into a 2 ship formation whileplan terminated when entering theflightenroute to the working area. The outbound portion of the stereoRiver MOA (TAB V-1,V-2).one heat-to-guns exercise and two visual(2) Tulsa 11 flight completed a G-awareness maneuver,had some minor problems withf ir-to-air radar, butBFM engagements as briefed. second engagement, Tulsa I I and 12 split upthis had no effect on the overall mission conduct. After thesetup to a visual engagement Tulsa 11with approximately 35-40 NM separation for a one-v-one BVRwent to the northeast (TAB V-1).went to the southwest part of the River MOA and Tulsa 12severefirst indications of any problems were an explosion followed ame and engine va ons. The vibrations seemedinversely, the lower the RPM, the less severe.the higher the RPM, the more severe the vibrations andof engine RPK were so severe that it wasThe vibrations continued for the rest of the flight and regardlessV-1). At approximately 31 minutes afterdifficult to read the cockpit instruments at any time (TABstagnated. The fatigue fracture of a fourthtakeoff at 0944:52 CST, the aircraft engine stalled and thenand drag on the LPT which drives the enginestage turbine blade had resulted in the ensuing damage todisrupted airflow to the engine compressorfan. This produced drag on the engine fan which limited and" was noon, 2it"pointinlet, produchig-an engine stall and stagiation:-- From thislonger capable of producing useable thrust (TAB.J-5).t0e nearestt ituation,.4*simultane( ý'-Uiltrned towardna.yzd(4) As s6utlirsduthwest ,of leemegencyaifield f c :o (TABS:-I);. Gr yon was the s iecifllybriefed g,time-Ufthe emergency (TAB V?2) The airfield haFs a 9000-FTrimaway,(rAB AA-3Gryo t-dstaii .b.t9d-Jglidigwasouuytr-i -eihriiairfPeld s soas--hkneWii.IVproid asitac overonly uedliiiL'czvihan aIyture d southwestandKatdtu. i8000to rejoraob' .Baad-z -' o- -thi,o teF-6i,irifigtheno iibwasr .l., (SVO30F, level., flinhad-ecisea,et(i)aoeMean1;O7. -5. . V-I). -. . .(TAB -J-5;. .,.Average terrain. . . . . -. .airspeed,(KCAS),.calibratedand at 364-. knotslevel.(AGL)groundaboveBased on cockpit indications,elevation nca & stion was approximately 700 IFT MSL (TAB AA-5).,: t-Tror'- ,;f f j ,.);.,-begin tosew nted tol-and-at the nars suitableAying-,f that were thaisoxum r ableengi w-bad -Iready shdnto it wasthv--Altog mH- .OKsianilitianairpotiere s" """"44)e.ngine.wul.-1). Both airldswrless 'thaw350. I,'fctiong and i* rblemnect-on hoping.thedir.uk .ic-ietheapproxiitlA. .9.

0*@I*initially interpreted the engn 'malfunction as an engine rollbc pulehe throttle beaposition at 0945:21 (TAB J-5, V-i). Despite difficulty reading the engine instruments,soon no iced that engine RPM was decreasing and fan turbine inlet temperature (FTIT) was incresing,indications of an engine stagnation. In addition to the stagnationoelt.that the problem wasgiving*much worse due to the explosion and continuing vibrations. OTfilhen accomplished the emergencychecklist procedures which called for an engine shutdown to clear the stagnation and an airstart attempt(TAB V-i).began to execute the Critical Action Procedures LCAPs) for an engine airstart(6)laedto attempt a SECparameters and cockpit indications, currentonBasdAA-6).(TABis 0aestablishedandairstartspooldownwas 'flying atwhen attempting an airstart below 10,000 FT AGL (TAB AA-6).approximately 0,300 FT AGL at the time (TAB AA-I). di id not jettisonU empty centerline fuelfelt the weight and drag of the emptyconcentration on other airstart procEdures, 0tank due to.glide nor increasýeime aloft (TAB V-I). Atcenterline fu eltank would not appreciably affl:next moved the engine control0945:20 placed the throttle to off to clear the engine stagnation.*switch fr6m the PRI to the SEC position at 0945:28, which is confirmed by the SDR. At 0946:33,inpselected START 2 on the Jet Fuel Starter (JFS) to assist with the airstart. Approximately 1EoRnsecond prior to selecting JFS START 2, the SDR shows the engine control switch was placed back in PRI(TAB J-5, V-I). While working to maintain the recommended spooldown airspeed of 275 KCAS,noticed the engine RPM had decreased below the minimum recommended 25% RPM. According toat 0945:36testimony,'Jmmediately moved the throttle to IDLE at 18-20% RPM to initiate an airstart0(TAB JFTITC698andRPM17%at(TAB J-5, V-I). The SDR shows the throttle was advanced to idlewasthrottletheassoonasbegan5). Despite the lower than recommended 25% RPM, the llyadvanced from OFF to IDLE, appearing to progress0946:00, the JFS started running (TAB O-141:ýf(TAB J-5, V-I). At some time between 0945:33 andglide (TAB V-i).KCASntinued to m'tain2n70-290(7) The SDR indicates that the engine appeared to approach normal idle power indications, thenstalled a second time at 0946:45. At some time between 0946:30 and 0946:50, the throttle was advancedrecognized the second engine stall and stagnation. Althoughýquicklyto h4IL (TAB J-5)the attempt appeared to progress normallyfel* still had the samewengine instruments sproblemsbhad prior to initiating the first airstart due to the second stagnation and continuing severevibrations (TAB V-i):the throtte to OFF a(8) At 0947:05 and an estimated 5000 FT MSLJ4300 FT AG! oew as now, rnng,JFStheSinceAA-i)2:-J-5,(TABstagnationsecond timfe to attempt to clear the secondin order lRiassisted 'planned t6-o ioa'JFSdecerate ajdmore time. * does not-remember-what airspeedsiowedtoTA&V-i).,The SDR shows airspeed decreasing during this imewith-a last reco"deifspeedtoof 243 KCAS;4p&jviimatei)' 19 sei;nIs prioito ejec tion (TAB AA-1).Th Saatemen of.Damage210 KCAS (TAB P-2).ipctatayaircraft gonropl i estimatedPrivateinS.qwI-a-'-(9) Asrm ed o zno e theengine control switch ro vhinoicditwas alreaidy in PRI ff lected to continue hairstart ini Pr'uninbailuit Aitrie orecommended constrolhedout oftimne dad approde ang -the mintimu-tn a;successf(TAB .,V-i,. A -7).M was'skepticzal abu-airs'tart si-nce.the thteoD"1-57820--57820týattempt (TABV-iztLd-otcdnRat.mpr"vemeafter the ,"5J50 TALtjinitiate th'second ai aff atept,,(rAB.- -. AA-i).estimated 420nTestimoqny indicated that he thought he was higher at an estimated 7300 feet MSL (TABV-)Ij,,'p. 'had mad a conscious decision'to eject if(10) 'At 3300 FTr MSIJ2SOO FT AGL,engine -again tried to start, but stalledTheattempt.thisonthrustusableanythe engine did not produce*--.

and stagnatedaird and final time'at 0947:54 and an estimated 2200 FT MSIJ1500 FT AGL (TAB J-5,theTAB AA-1). ibegan a zoom maneuver in preparation for ejeon. Simultaneouslygadvancget any usable thrust from the engine, but the stagnationthrottle to rail one last time to see icouldcontinued. The aircraft afeed at an unknown altitude and slowed to approximately 150 KCAS (TAB V1). At 0948:1915).40 indicat-edthatejected based on a "Canopy Open" signal recorded by the SDR (TAB 0had plenty of time to complete all post ejection procedures, watchaircraftcrash, and then prepare orarachute landing (TAB V-i).Aircraft 90-0764 crashed and was destroyed at 0948:38 CST (TAB AA-I). The aircraft impacted onA-2).private property used for cattle grazing approximately 1 1/2 NM north of Soper, OK (TAB nimal.waspropertyprivatetoActual damageteam and some by several head of cattle who were apparently spooked by the crash. A gate was alsodamaged by the cattle. Actual cost of this damage, not including soil and environmental work associatedwith the crash site itself, has not been determined because of wet conditions at the site, but is expected tobe less than S1000.00 (TAB P-2 thin P-4).f. E'ection:ejece from 4aircraft at 0948:19 CST (TAB O-15).0 stateccould not locate the 4but was not concerned. The parachute ride was very stable with noline, jettisons onchute,landed 1 to 1 1/2 NM north of the crash site (TAB V-1).oscillations.g. Personal and Survival Equipment:(1)" All personal and survival equipment inspections were current (TAB AA-8).(2) Other than the pilot's inability to locate the parachute 4-line jettisons during the parachutedecent, no personal/survival equipment difficulties were noted during ejection (TAB V-i).h- Rescue:At thisl The crash occurred at approximately 0949 CST on 7 Feba 1994 (TAB tified Fort Worth C6nterflew one low-ass ove operationi-andthe Supervisor ofFlying. -Athen returned to Tulsaunhurt.betoappearedandwavingpositiowasIAP (TAB V-2):-.--(2)- 1jiid aftelpa completingloparahutc landing fallachd.btwo civilian males in at pickup truck who wanted to know if needed any help."on" fuval radi6becuseW t it was more important to get to aopcratidIni at Tulsa LAP (TABVIPnot cota4Mephone to call squadron.isite by the two cMiviias in the pi&* Mi& 4Mcktothie4fý otI ivilan standing irio'und the burning wrekg of aircraft. Cnonerednoticed there weeýIaiwayfrm. the wYreckg for it least-abouttheii ii* 85kmd askai local sheriff to clear the pe-netlin1/2 mile.(TABV-I).nttio a localfarmdport where Wa picked UuPwas drlive by the Highway Patrol -tothe Hugo aIback totulsa.AP n member inbya fe''"-* .:-'"-".57821

i. Crash Respone:(TAB VLocal sheriff's deputies and the state highway patrol secured the crash site almost immediatelyrecoverycrashGroupFighter1). They maintained security of the crash site until the arrival of 138thteam (P-2). The wreckage was removed on 12 February 94 (P-3).j. Maintenance Documentation:(1) AFrO Form 781 and Core Automated Maintenance System (CAMS) records were reviewed.theExaminations of pilot-reported discrepancies and maintenance actions for the 90 days proceedingU-3).(TABmishapthetorelatedwhichaccident revealed no significant discrepanciesCigned the Exceptional Releasepreflighted the MA at 0800 on 7 February 1994 anprior to the mishap (TAB U-1-6).(2) Review of AFTO Form 781 and CAMS documents revealed two Time Compliance Technicaldid not affect safetyOrders (TCTOs) were not completed as of the mishap date. Neither were overdue andof flight (TAB U-4).operational(3) AFTO Forms 781 and CAMS documents reflect one overdue inspection for ichReleasecheck of the Arresting Geartheoninspectionsproperly documented and was not related to safety of flight. All other scheduledmishap aircraft (MA) were completed (TAB U-5).(4) Review of the Joint Oil Analysis Program (JOAP) documentation for the FIOO-PW-220or problems withengine (#PW-0E713391) installed in the MA did not reveal any adverse trendsU-6).measurements exceeding tolerances (TABno(5) Review of the AFrO Forms 781 and the Inspection and Time Change Forecast revealedoverdue time change requirements (TAB U-5).inspections(6) The Equipment Review Report did not reveal any discrepancies on component(TAB U-7).to(7) The mishap occurred on the second flight after the mishap aircraft (MA) had ingFighter-erGroup from the 363rdthe 138th FiwasU-i). Prior to transfer, a transf e inspection:as done by the 363 FW'and an acceptance inspectionvisualandBorescopeAFB.done by the 138th FG (TAB 3). Both inspcoions, were conducted at ShawDuring theins- etios;sof;the engiieI Weredone-during both the transer-and acceptance ispctins.-.howýver'box,9gearengine,theoil""'leak above:",notedz"'""- .o- a-simall"14--,Piew . -,--c ., ,.- - -accet,fromflig htfthBothV-9):(rAB1o cofiumton was within tolerancessubseuent uwsigation 1figt aTuýW International -Airport on3 eriy94gnradt heiusitand"ý1714YSha*TCTOs,Five ,eoh'd dismcpanciesnor si-g ct -unscheduled mdntenanc actions (TAB.U-3): io-)fngcrsaltiaffectednonewere COmplte4 WofliowIn -6rii fer of the aircafL, wit"(8). . "NoPersoeI.-,.-cc'I '' " -5a dccdntrelated."" tot.the "-3)"appearlto"'ety o " f beghpractces"'." performancee y. - "- --or--service, prlight and lauch the MA-were qualified "n tsndtoýpersonnel trainingrecords for involved mainte-.duiith.r Review ofpersonnel reflect no deficiencies indocumentation5TAB7U-s-*-o:-57822

e01. En ine, Fuel, Hydraulic, and Oil Inspection Analysis:the MA. SamplesPost mishap samples were taken from the servicing equipment last know to serviceJet A Fuel wasaddition,Intaken from servicing carts included engine oil, hydraulic fluid, liquid oxygen.AerospaceUSAFthebyanalyzedweresampled from refueler #12 and the bulk storage tank. All s Laboratory at Wright-Patterson AFB and weretolerances (TAB U-9).m. Airframe and Aircraft Systems:(SA-ALC)(1) Post-accident analysis of the engine by San Antonio Air Logistics Centerimpact.crashtheinindicated that most of the engine appeared normal except for damage incurredtop oftheatplatformitsHowever, one blade in the fourth stage low-pressure turbine was broken off belowof aindicationsrevealedsurfacethe blade/disk attachment area (TAB S-4). Examination of the fracturejustbladetheofsidepressuretheonfatigue fracture mode. The fatigue area appeared to ward of the aft face of the blade root. It eapproximately one-half inch forward along thepersonnel. Theused at the time. this area was not easily nor normally inspected inspected by maintenancethe fourth stage airseallocation of this blade was almost directly opposite the location of a heavy rub on(DOD) caused bydamageknife-edges. Further, the SA-ALC investigator determined that domestic objectengine incapabletherenderedthe fourth stage blade fatigue failure and the resultant damage to the LPTof producing usable thrust (TAB J).(2) Engine Manufacturer.Pratt and Whitney179600 Beeline Hwy.Jupiter, FL 33478-9600service on 13 May(3) All maintenance performed on the subject engine since it was placed into the mishaprelatedappearedNone1991 was done by the 363rd Fighter Wing at Shaw Air Force Base.(TAB J).n. Operations Personnel and Suvervisors:on a computer generatedThis flight was authorized b,guidancelocal flight cleitance form number 0-29 (TAB K-4) The mission was briefed LAW applicable-,,.(TAB V-1, V-2).1.," :-on .0.--M(I) Ejamiationof airerew flight records revealed thia'mmander and a 4 ship flight leadTin the F-16 t n isha flight co*military flightjoityWvas qualified and currentG, T-1, V-1).1has 2648.3 beers oftitlfyridgtimcT&AB -V-I)." 0f ta iMadhasb000 hir130.5 hours inof which is inrfighters.- At the time of the acci'the F-16, all:.it in the Block 42 F-l6CG powered by the-Pratt and.1Witney42O2.np.ie.,/60/90hadthe F-16 h4day iokals weriS.e824.5I47.6 utmrs'{rAB G-3).h arthough-r.latl "ein"earnedQualified owasxmedic6allya initialmonhecmise(TAB.A-9,-).was medically qualified at the time 40f the mishap (TAB AA-9). 't.,-. .**--6,-.-57823

q. Navaids and Facilities:All navaids and facilities were operating and functional during the mission (TAB K-6).r. Weather:Weather was VMC and not a factor (TAB K-5, K-6, V-I).s. Directives and Publications:The following publications were applicable to this mission:MCI (ANG) 11-208MCR 55-116T.O. IF-16CG-1Flying Training - F-16 Pilot Training InstructionOperations - F-16 Pilot Operational ProceduresF-16CG Flight Manual-*.*

airframe and engine va ons. The vibrations seemed related to engine revolutions per minute (RPM) the higher the RPM, the more severe the vibrations and inversely, the lower the RPM, the less severe. The vibrations continued for the rest of the flight and regardless of engine RPK were so severe that it was