SAFETY INVESTIGATION REPORT HELLENIC AIR FORCE F-16D BLK 50S/N 93-1084 341SQ/111CW ALBACETE AFB (ESP), ALBACETE 26 JANUARY 2015 2 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report DECLARATION AccordingtoNATOSTANAG(STANDARDIZATIONAGREEMENT)3531and AFSP-1.3,theSafetyInvestigationBoard(SIB)wasestablishedon27Jan2015underthe GreekPresidency(RefertoAppendixA),delegatedbytheinvolvednations.Theinvolved nations are Spain, France, Germany, Italy, the USA and Greece. The framework of this investigation is STANAG 3531 and AFSP-1.3. InaccordancewithAFSP-1.3,theSafetyInvestigationBoard(SIB)releasesthe reportunderthestatement:Itisnotthepurposeofaircraftaccidentinvestigationto apportionblameorliability.ThesoleobjectiveoftheinvestigationandtheFinalReportis the prevention of accidents and incidents. Inthisregard,anyopinionofthemishapinvestigatorsastothecauseof,orthe factors contributingto, the accident set forthin the accident investigation report maynot be considered as evidencein any civil or criminal proceeding arisingfrom an aircraft accident, normaysuchinformationbeconsideredanadmissionofliabilitybyanystateorbyany person referred to in those conclusions or statements. The SIB also states that: Unless otherwise indicated, recommendations in this report areaddressedtotheregulatoryauthoritieshavingresponsibilityforthematterswithwhich the recommendationis concerned. It isfor those authorities to decide what action,if any,is to be taken. Theinvolvedmilitarymaterial,isbynaturesubjecttoinformationsensitivityand restrictionsappliedonderivedinformationdissemination.Involvednationsaretoclaim sensitiveinformationthatrequiresprotectionofconfidentiality,integrity,availabilityand disclosure. 3 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report SYNOPSIS TheHellenicAirForce(HAF)F-16DS/N93-1084(hereafterreferredtoasthe mishap aircraft) of the 341 squadron (SQ), was the number 2 of a 2 aircraft (A/C) formation, taking offfor aTactical Leadership Programme (TLP) FlyingCourse 2015-1missionfrom Albacete AirForce Base (Albacete AFB), Albacete, Spain on 26 January 2015. Themishap A/C crashed at 15:16 local time (14:16 UTC), approximately 7.8 sec after takeoff on runway 27 (RWY 27). The aft seat pilot initiated ejection out of the seat safe ejection envelope. The mishapresultedinthefatalinjuryofbothmishappilotsandthetotaldestructionofthe mishap A/C. The main causes of the mishap were: - Mishap A/C was not properly trimmed for takeoff as before TAXI, the yaw trim was inadvertentsettomaximumrightyawtrimming(12oright),drasticallyaffectingthe aerodynamics of the aircraft during takeoff. -PilotincommandconductedtheBeforeTakeoffchecklistactionsintheparking area (ramp E2) approximately 20 min before takeoff. AfterTake-off,pilotstickcommandsandtheresultantcontrolsurfaceoutputswere insufficient to maintain the A/C in controlled flight. Impactandthepostimpactfireledtothedestructionordamageofeight(8) additionalA/Candcausedfatalinjuriestonine(9)FrenchAirForcepersonnel,numerous injuriesandsignificantdamagestogroundequipmentandtoAlbaceteAFBandTLP infrastructure in the vicinity of Ramp E2 and in front of the TLP hangar. 4 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report TABLE OF CONTENTS DECLARATION .................................................................................................................. 2 SYNOPSIS ........................................................................................................................... 3 TABLE OF CONTENTS ...................................................................................................... 4 1FACTUAL INFORMATION ........................................................................................ 6 1.1History of the flight................................................................................................ 6 1.2Injuries to persons .................................................................................................. 6 1.3Damage to aircraft ................................................................................................. 7 1.4Other damage ........................................................................................................ 7 1.5Personnel information ............................................................................................ 7 1.6Aircraft and Maintenance information.................................................................... 8 1.6.1General Information - Documentation ................................................................ 8 1.6.2Selected systems information and analysis ......................................................... 8 1.7Meteorological information.................................................................................. 10 1.8Aids to navigation ................................................................................................ 10 1.9Communications .................................................................................................. 10 1.10Aerodrome information........................................................................................ 11 1.11Flight recorders .................................................................................................... 11 1.11.1Flight Control System Memory - Seat Data Recorder (SDR) .......................... 11 1.11.2Crash Survivable Memory Unit (CSMU) ....................................................... 12 1.11.3Signal Acquisition Unit (SAU) ....................................................................... 12 1.11.4Other Recorders ............................................................................................. 12 1.12Wreckage and impact information........................................................................ 12 1.13Medical and pathological information .................................................................. 13 1.14Fire ...................................................................................................................... 13 1.15Survival aspects ................................................................................................... 14 1.16Tests and research ................................................................................................ 14 1.17Organizational and management information ....................................................... 15 1.18Additional information ......................................................................................... 16 1.18.1Normal Procedures ......................................................................................... 16 1.18.2End of runway inspection ............................................................................... 16 1.18.3Previous Incidents .......................................................................................... 17 1.18.4Previous Flight ............................................................................................... 19 1.18.5Trim System Other A/C Types .................................................................... 19 1.18.6Flight characteristics specification .................................................................. 20 2ANALYSIS ................................................................................................................. 21 2.1Chronology of Selected Events Based on SDR and CSFDR Data ......................... 21 2.2Sequence of Events .............................................................................................. 23 2.2.1Flight Preparation ............................................................................................ 23 2.2.2Step to Taxi...................................................................................................... 24 2.2.3Take Off to WOW ........................................................................................... 25 2.2.4WOW to crash. ................................................................................................ 26 2.3Main Factors Involved with the Accident ............................................................. 30 2.3.1Aircraft and Maintenance ................................................................................. 30 2.3.2Pilots................................................................................................................ 30 2.3.3Systems (Trim panel) ....................................................................................... 32 3CONCLUSIONS ......................................................................................................... 33 3.1Findings ............................................................................................................... 33 5 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report 3.2Causes ................................................................................................................. 36 4SAFETY RECOMMENDATIONS ............................................................................. 38 APPENDICES .................................................................................................................... 39 ABREVIATIONS ............................................................................................................... 40 6 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report 1FACTUAL INFORMATION1.1History of the flight On Monday, 26 January 2015, TLP mission 4, consisting of 22 A/C was scheduled in accordance with the Tactical Leadership Programme (TLP) Syllabus. Mishap A/C (MA) was thenumber2ofa2shipelement(formation)underCallSignARROW31-32.The ARROWformationwastaskedtoprotectafriendlyA/Cpackageandtheflightwas coordinated with the Mission Commander (MC). Flight preparation andelement brief werein accordance with themissions timeline. During the brief, F-16D (two seat model) special procedures were analyzed. The Hellenic F-16s were parked at ramp E2 (Refer to Appendix B). TheMAwasloadedwithone(1)AIM-9captivemissileonStation1,one(1) WeaponPylononStation3,one(1)FuelPylonwithone(1)370GallonExternalTankon Stations 4 and 6, one (1) Fuel Pylon with 300 Gallon External Tank at Station 5 (centerline), one91)WeaponPylonwithone(1)CATM-88BcaptivemissileonStation7andone(1) ACMI Pod on Station 9. All External Fuel Tanks were full of fuel. NormalgroundprocedureswereaccomplishedinaccordancewithTechnicalOrder (TO) GR1F-16CJ-1 FLIGHT MANUAL HAF SERIES F-16C/D BLOCKS 50 and BLOCK52+AIRCRAFT(hereafterreferredtoasthe-1).TheformationconductedtheBefore Takeoff checklist in the parking area (E2). The MA then waitedon the rampfor 8 minutes, waiting taxi for takeoff. During that time a slight right roll trim was applied and the yaw trim was set to the full right position (-12). TheMAtaxiedandtook offwithrudderdeflectionto themaximumrightyawtrim position.The MA crashed shortly after takeoff close to shelter D-4 at Albacete AFB, which resulted in the fatal injury of both mishap pilots and the total destruction of the MA. Theimpactandpost-impactfireledtothedestructionordamageofeight(8) additionalA/C,causedfatalinjuriestonine(9)FrenchAirForcepersonnel,numerous injuriesandsignificantdamagestothegroundequipmentandtoAlbaceteAFBandTLP infrastructure on the vicinity of Ramp E2 and the front of the TLP hangar. 1.2Injuries to persons InjuriesMishap A/C Others Fatal2 (GRC)9 (FRA) Serious7 (FRA), 10 (ITA) Minor14 (FRA), 2 (ITA) Total242 Onalert .grOnalert.gr7 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report 1.3Damage to aircraft The Mishap A/C (MA) was destroyed by impact forces and a post-impact fire. 1.4Other damage Theimpactandpostimpactfiredestroyedordamagedeight(8)moreA/C(Referto Appendix B): -FRA M-2000D S/N 651(totally destroyed) -FRA M-2000D S/N 669 (substantially damaged) -FRA Alpha Jet S/N E047 (totally destroyed) -FRA Alpha Jet S/N E096 (substantially damaged) -FRA Rafale S/N 335 (slightly damaged) -ITA AMX S/N 7193 (totally destroyed) -ITA AMX S/N 7192 (slightly damaged) -USA F-15E S/N 202 (slightly damaged) Significant damages were also caused to ground equipment and to Albacete AFB and TLPinfrastructureinthevicinityofRampE2andinfrontTLPhangar(RefertoAppendix B). 1.5Personnel informationBoth pilots were current and qualified to fly the mission. ThepilotoccupyingtheforwardseatwasthePilotinCommand(PIC)andhewas flyingthe.Hewasa36yearsoldmale,arecentlycertifiedInstructorPilot(IP),an experienced pilot and qualified Mission Commander (MC) flight leader qualified, with a total of 1527 flight hours including 940 hours in the F-16C/D BLK50 aircraft. His flight hours for the last day, week and 2 months were 0, 4.0 and 11.7 respectively. The32yearsoldmaleoccupyingtheaftseat(aftseatpilot,ASP)wasaMedium ExperiencedPilotandqualifiedfour-shipflightleader,withatotalof1140flighthours including536hoursintheF-16C/DBLK50 aircraft. Hisflight hoursfor thelast day, week and 2 months were 0, 3.3 and 15.0 respectively. Both pilots were medically qualified to fly the mission. Theircrewrestfortheweekend,includingSunday,wasinaccordancewith regulations. Onalert.gr8 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report 1.6Aircraft and Maintenance information1.6.1General Information - Documentation F-16DBLK50S/N93-1084wasmanufacturedbyLockheedMartinAeronautics Company(LM)anddeliveredtotheHellenicAirForce(HAF)on7Jan1997.TotalA/C flyinghours(AFH)priortotheaccidentwere4,056.6(excludinganyfractionduringthe mishapsortie).TheA/CsenginewasanF110-GeneralElecric-129S/N538399.Priorto theaccident,EngineFlyingHours(EFH)were2,166.7andTotalAccumulatedCycles1 (TAC) 6,235.9. The last scheduled MA phase inspection (400 hours cycle) was completed on 16 Oct 2014,at3,984.4AFH,72.2AFHbeforethemishap.Thelastscheduled50EFHengine inspectionwascompletedon12December2014,at2,142.1EFH,24.6AFHbeforethe mishap. AnexaminationoftheMArecordshasbeenconducted.Nodeferredmaintenance defects had been recorded. All Time Compliance Technical Orders (TCTOs) were complied withorwerewithinrescissiondates.AlloftheSafetyTCTOswereaccomplished.All documented periodic/hourly inspections were complied with except Rinsing (every 15 days) of the A/C. Areviewoftheunscheduledmaintenancerecordsrevealsthatthemostrecent discrepancies included an AIFF malfunction (9 Jan 2015) and a Removal and Installation of FWD side stick grip due to broken DMS switch (21 Jan 2015). The MA flew 1 sortie (23 January15)withoutmalfunctions.Thehistoryofpartsremovedandreplacedindicatedno unusual historical data.EngineoilspectrometricandchipdetectorSEM/EDXanalysisfor30dayspriorto the mishap indicated no discrepancies. Mass and center of gravity of the MA were within the prescribed limits. Asummaryoftrainingandmedicalrecordsforallindividualswhoperformed maintenance on this A/C for the mishap mission and the unscheduled maintenance of the last 15 days revealed they were adequately trained and qualified for the work performed.In accordance with the technicians who performed the preflight, launch and End of Runway Inspections on 26 January 2015 for the MA, no abnormalities were noted. 1.6.2Selected systems information and analysis1.6.2.1Flight Control System (FLCS) Description 1 Total Accumulated Cycles: form of life measurement that major engine components are tracked against.Onalert.grOnalert.gr9 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report TheF-16usesadigitalfour-channel,fly-by-wiresystemwhichhydraulically positions control surfaces. Electrical signals are generated through a stick, rudder pedals, and a Manual Trim panel. A main component of the FLCS is the flight control computer (FLCC). Redundancyisprovidedinelectronicbranches,hydraulicsystems,powersupplies,and sensor systems (Refer to Appendix C). Command signals to the FLCC are initiated by applying force to the stick and rudder pedals. These signals are processed by the FLCC along with signals from the air data system, flightcontrolrategyros,accelerometers,andtheInertialNavigationSystem(INS).The processedsignalsaretransmittedtotheintegratedservoactuators(ISAs)ofthehorizontal tails, flaperons, and rudder which are positioned to give the commanded response. Pitchmotioniscontrolledbysymmetricalmovementofthehorizontaltails.Roll motioniscontrolledbydifferentialmovementoftheflaperonsandhorizontaltails.Yaw motioniscontrolledbytherudder.Rollcoordinationisprovidedbyanaileronrudder interconnect (ARI). The ARI function is not available whenever Main Landing Gear (MLG) wheelspeedexceeds60knotsorifAngleofAttack(AOA)exceeds35degrees.After takeoff,ARIis activated within 2 seconds after theLGhandleis raised (spin downbraking system). If the LG handle remains down, 10-20 seconds are required for the MLG wheels to spin down and activate ARI. ARI was not activated during mishap flight. F-16usesaroll-ratecommandsystem.Rolltrimandrollstickinputsareadditive.Whentheaircraftiscommandedtoroll(bythepilot),thecorrespondingcontrolsurfaces deflecttoinitiatetheroll,thentheirdeflectiondecreasesasthecommandedroll-rateis achieved. Rudderpedalforceissummedwithyawtrimtoformayawcommandsignal.Yaw commands vary linearly as function of above mentioned signal. 1.6.2.2Trim System TheF-16FLCSusespitch,rollandyawtrimto reducepilotstickandrudderpedal forces. PitchandrolltriminputsmaybeinitiatedusingeitherthetrimbuttonontheA/C control stick or using the Pitch Trim or Roll Trim wheels on the Manual Trim panel (Refer to Appendix D).Roll trim inputs also command proportional rudder deflection through the ARI functionwhichautomaticallycounterssideslip. Ruddertrimisinitiatedusingtheyawtrim knob on the Manual Trim panel only. TheManualTrimpanelislocatedon theaftsectionoftheleftconsoleintheFWD cockpit only. Yaw triminputfromfullleft to full right (12 degrees) requiresapproximately one-half knob rotation (180) (maximum yaw rudder input by pedals is 30 degrees). Three (3) CompressedO-ringsinstalledbetween the knob andpanelfacingto provide the appropriate friction tomaintaintheyaw trim knob position. There are two (2) safety guardsmounted to frontandbacksideofyawtrimknobtoprotectagainstinadvertentmovementoftheknob (Refer to Appendix D). F-16isnotequippedwithasystemwhichprovidesanadvisorytothepilotwhen mistrimming conditions exist prior to/during takeoff. Onalert.grOnalert.grOnalert.gr10 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report 1.7Meteorological information AccordingtotheMeteorologicalAerodromeReport(METAR)publishedand distributedbythemeteorologicalservicesofAlbaceteAFBonthe26January2015at 14:00UTCtheweatherwas:"LEAB261400Z31009280V340CAVOK2 11/M04Q1026 NOSIG.TheTerminalAerodromeReport(TAF)(complementtoMETARwhichreports forecastweatherratherthancurrentweather)thatwaspublishedanddistributedbythe Agencia Estatal de Meterologa (AEMET, Madrid) prediction and meteorological services at 11:00Ztimewas:''LEAB261100Z2612/262129008KTCAVOK.Weathercondition broadcastedbytheTowerofAlbaceteontheGroundfrequencyat14:03:47UTCto ARROWformation,whentheyrequestedTAXIclearance,wasthatthecurrentwindwas 310/8andtheQNHwas1026hPa(3030inchesHg).Atapproximately14:15:33UTC, Albacete Tower broadcasted that the local wind was 330/9 during the clearance for Arrow to takeoff on runway 27. Thegeographicalpositionofthesunwas32degreeselevationand194degrees bearing relative to Arrow flights takeoff position. The natural lights intensity was measured as49480LUXandcharacterizedasDirectsunlight(32000100000 lux),accordingto Photometry. 1.8Aids to navigation The Tactical Air Navigation system (TACAN) and Instrument Landing System (ILS) forRWY27,necessaryforinstrumentdepartureandapproachfromandtoRWY27were operationalandfunctionalatthetimeoftheaccident.However,duetofairweather conditions,AlbaceteAFBwasunderVisualFlightRules(VFR)/VisualMeteorological Conditions (VMC) status. The condition of the associated navigational aids was not a contributing factor to the accident. 1.9Communications Aeronauticalandfixedservicecommunicationswereeffective,functionaland operational.Moreover,therewerenoreportedproblemsordifficultiesregardingthe communications amongst aircrew, Albacete AFB and TLP. Communications were not a contributing factor to the accident. 2 Ceiling and Visibility are OK; specifically, (1) there are no clouds below 5000 feet above aerodrome level or minimumsectoraltitude(whicheverishigher)and nocumulonimbusortoweringcumulus;(2)visibilityisat least10kilometers(6statutemiles);and(3)nocurrentorforecastsignificantweathersuchasprecipitation, thunderstorms, shallow fog or low drifting snow. Onalert.gr11 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report

1.10Aerodrome information AlbaceteAFB(ICAO:LEAB),islocatedabout4miles(6kilometers)southofthe city of Albacete. The Base coordinates are: Latitude 3856'55"N, Longitude 151'49"W. The magnetic variation at LEAB is 0.47W. Thereis one runway designated 09/27 with an asphalt surfacemeasuring 2,700 ! 60 meters (8,858 feet ! 197 feet). Aerodromes elevation is 702 meters (2,302 feet) above mean sea level. There is one parallel taxiway north of the main runway. Between the north parallel taxiway andthemainrunway at the beginningofRWY 27 and RWY 09there are two leak check areas, used as ''hot brakes'' and ''hydrazine activation or leak'' areas for parking A/C in case of such an emergency situation. Thereare4additionalparkingareas(ApronsE1,E2, E3andE4)forA/Coperating from LEAB. E2 apron is used by A/C participating in TLP courses and has a capacity of 31 parking spots for fighter sized A/C. 1.11Flight recorders 1.11.1 Flight Control System Memory - Seat Data Recorder (SDR) Theseat-mountedflightcontrolsystem(FLCS)datarecorder,commonlycalledthe seat data recorder (SDR), was sent to LM Aero for retrieval andanalysis of theinformation in the presence of a Greek SIB member. TheSDRindicatednormalfunctioningoftheFLCSanddidnotrecordanyflight control system maintenance faults (MFLs). FLCS limiters are provided in all three axes to help prevent departures/spins. In cruise gains, the AOA/g limiter reduces the maximum positive G command as a function of AOA. The maximum AOA depends on the position of the STORES CONFIG switch. In CAT I, the maximumcommandedAOAis25.8degrees.InCATIII,themaximumAOAvariesfrom approximately16-20degreesasafunctionofGWandG.Intakeoffandlandinggains,the STORESCONFIGswitchhasnoeffectonlimitingorgains.MaximumpositiveGisa function of airspeed and AOA. The STORES CONFIG switch was positioned to the CAT III setting, which was the proper for the MA configuration. DuetotheshortdurationofthemishapflighttherewereonlytwolinesofFLCS memory data: The transition of weight-off-wheels (WOW) that begins the recording session, and a stall warning (Low Speed Warning Tone), which occurred 2 seconds after WOW due to AOA reaching 15 degrees with the landing gear handle down position(Refer to Appendix C) . 12 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report 1.11.2 Crash Survivable Memory Unit (CSMU) The CSMUis one of the two Crash Survivable Flight Data Recorder (CSFDR) units (theotheristheSignalAcquisitionUnit).TheCSMUdataconsistsofdiscreteeventsand analogparametersthatarebeenrecordedfortheprimarypurposeofmishapinvestigation.Recordingstartswhenthemaingeneratorcomesonlineaftergroundenginestart.The CSMU of the , damaged by fire, was sent to LM Aero. It was disassembled to remove the data directly from the memory chips in the presence of Greek and French SIB members. Heat damagetooneoftheeightmemorychipsintheCSMUresultedintheinabilityofseveral lines of data to be decompressed (Refer to Appendix C). 1.11.3 Signal Acquisition Unit (SAU) The SAU is the non-crash-hardened part of the CSFDR system that processes selected aircraft signals andsends the signals to the CSMU for recording. It contains data for service lifemonitoringandengineusagedata.TheSAUalsostoresType5data,thesameasdata stored in the CSMU (Type 1 data). The SAU was downloaded successfully by LM Aero and thedatawasdecompressed.Datafromthemishapflightandseveralpreviousflightswas availableinthisdownload,allowingdatathatwasnotabletobedecompressedduetoheat damage of CSMU was successfully recovered (Refer to Appendix C). 1.11.4 Other Recorders The aircraft containedseveral other line replaceable units (LRUs) that havememory storage devices. They include the Data Transfer Cartridge, (DTC), the Fire Control Computer (FCC),theEngineMonitoringSystem(EMS)andtheProgrammableDisplayGenerator (PDG). These LRUs were damaged by impact and /or fire and were not recovered. The only availableAirCombatManeuveringInstrumentation(ACMI)datawasthosereceivedvia datalink (the memory card was damaged and could not be recovered). This data is relatively inaccurate(notprecise)andtheyhadbeenusedonlyattheverybeginningofthe investigation, until more precise data was received (from SDR and CSFDR). 1.12Wreckage and impact information TheMAcrashednearshelterD-4closetorampE2(RefertoAppendixB),7.8 seconds (approximately) after WOW. The aircraft was destroyed byimpact forces and post-impact fire. Due to the time required for signal transmissions and processing, the CSFDR cannot store data up to the veryinstant ofimpact. Approximately one-half second of data that isin theaccumulationandprocessingphasewillnotberecorded.Asaresult,theCSFDRslast recordedvaluespriortoimpactweretrueheading329.1degrees,pitchpositionat-12.77 degrees and roll position at 87.2 degrees. Assuming these parameters, the RH wing tip should havebeenthefirstpartoftheMAtoimpacttheground.Thishasbeenconfirmedbythe shape of the initial impact point and the A/C pieces distribution (Refer to Appendix B) Onalert.gr13 Safety Investigation Board (HAF F-16D S/N 084, 26-1-2015 Albacete AFB Spain): Final Report After several checks on the runway and within its vicinity, no item relevant to the MA wasfound. Starting from the taxi and runwayarea, the canopy wasfoundfirst, followedby partoftheright-handleadingedgeflap.Forthefinallocationandthestateofthemajor components of the wreckage refer to Appendix B. All MA ejection seat firing devices that should have been activated had been checked andithasbeen confirmed that they were properly operatingin accordance with themode 1 seat operation status (KCAS 220knots