F-15C Fatal Mishap in the North Sea (June 2020) AIB Report Review

on june 15 2020 just one day after his 27th birthday first lieutenant kenneth cage allen was tragically killed flying an f-15c in a training sorority over the north sea serving with the 493rd fighter squadron out of raf lakenheath cage was born at edwards air force base in california he grew up in a military family at wright-patterson air force base albuquerque new mexico and perry utah during high school he achieved the rank of eagle scout served as box elder high student body president earned his private pilot license participated in jazz band cross country and soccer and was selected as most outstanding senior boy in 2011. he attended the united states air force academy where he majored in aeronautical engineering served in cadet leadership and was on the prestigious flying following his dual year at the academy he served a two-year mission for the church of jesus christ of latter-day saints from 2012 to 2014. after college cage excelled in pilot training and was chosen to fly the f-15c air superiority fighter he and his wife hannah were married february 20th 2020 just before he reported to raf lakenheath in england today we're going to take a look at the accident investigation board official report talk about what happened on the morning of june 15 2020 that tragically took the life of first lieutenant cage allen as with the previous aib reviews we've done we'll try to stick to the facts and what the aib has found and not speculate or talk about anything else also i will break this up in the chapter so if you want to skip around the chapters should match the actual aib report and how it's laid out so i know it's probably going to be a bit of a long video but at least it's got chapters so let's take a look here's the executive summary at 0 8 27 zulu time which was 0 9 27 local on 15 june 2020 an f-15c from the 493rd fighter squadron royal air force lakenheath united kingdom crashed in the north sea 124 nautical miles northeast of raf lincoln heath during a local combat training flight the mishap aircraft was completely destroyed the mishap pilot assigned to the 493rd fighter squadron was fatally injured the weather in the airspace was reported to have multiple cloud layers up to 25 000 feet and thus the mishap sortie was conducted using instrument meteorological conditions rules during the engagement if imc would be encountered during an air-to-air training engagement the mishap pilot was flying east at 20 300 feet and was directed by his mishap element lead mel to execute a hard right turn back toward the west and look for an exercise adversary aircraft at a lower altitude the mishap pilot made a descending right turn toward the west using his on-board radar to lock onto the adversary aircraft which was headed eastbound at 5000 feet less than 20 miles away and executed a simulated missile shot the mishap pilot stabilized on approximately a westbound heading and continued his descent to 12 000 feet at 507 knots true airspeed mishap pilot made a radio transmission of a simulated missile kill of the adversary aircraft the miss app pilot received a pk miss which is a probability of kill miss radio transmission from the blue air range training officer rt01 so the mishap pilot continued maneuvering to engage the adversary which was then 5.5 nautical miles north or southwest of the mishap pilot's position the mishap pilot entered a descending left turn through imc toward the south lowering the mishap aircraft pitch attitude to 42 degrees nose low and varying from 21 to 107 degrees of left bank angle mishap pilot sustained 0.3 to 3.8 g's throughout the maneuver and accelerated to 570 knots true with a maximum vertical velocity of thirty eight thousand eight hundred feet per minute descent rate the mishap pilot breached the brief training floor of four thousand feet and at approximately one thousand feet the mishap pilot maneuvered the mishap aircraft to nearly wings level and pulled 8.2 g's in an apparent attempt to recover the mishap aircraft above the water the mishap aircraft impacted the water at 10 degrees pitched low 4 degrees of left bank and 566 knots true mishap pilot did not eject the accident investigation board president found by preponderance of the evidence the cause of the mishap was the mishap pilot's fixation on his intercept of the adversary and failure to execute cockpit instrument visual scans when the mishap pilot encountered imc reduced visibility and lack of discernible horizon for the mishap pilot resulted in spatial disorientation the inability of the mishap pilot to accurately sense the pitch attitude of the mishap aircraft due to spatial disorientation substantially contributed to the mishap aircraft's undesirable low pitch attitude rapidly descending altitude and the resulting mishap alright so it talks about who the players are what the eagle is training rules so i've talked about training rules before there are set up rules and procedures for air-to-air training operations and designed to promote safe and effective mission accomplishment the tr's are the foundation for coordination execution among all training participants to include command authorities controlling agencies and airborne weapons systems we call that it's afi 11214 it's our training rule document and that lays out everything that we can and cannot do when we go out and either do air-to-air or air to surface imc describes a condition in which any of the criteria for visual media or logical conditions are not met operations occurring within the scope of the trs vmc is 2000 feet vertical one mile horizontal cloud clearance and with five miles visibility discernible horizon so if it's less than that um it's imc which means you're in the clouds during the weather imc rules are provisions which allow air-to-air training to occur while the aircraft are in imc so you're in the weather it imposes a pitch limitation of 15 degrees and a bank limitation of 60 degrees if operating in these conditions so you can operate in the clouds but you can't exceed more than 60 degrees of bank and 15 degrees pitch up or down range training officers use air combat maneuvering instrumentation the individual combat aircrew display system icads and acmi to monitor the airspace during the training missions and are in radio contact with the participants their responsibilities are to monitor the flight mission for flight safety facilitate training provide real-time simulated kill removal and assist flight leads in mission reconstruction during debrief so essentially it's another pilot who's sitting in a room and there's displays just like top gun and they're talking to the blue there's a blue rto and a red rto and they're telling them uh so if you call a shot that's when they'll say nope it's a pk miss which means your missile did not guide and fuse or copy kill and he'll pass the kill to the red player so he's kind of got the god's eye view and he's also helping to make sure there's no mid errors and just general safety so that is another pilot all right so the sequence of events the mishap sortie was scheduled and authorized by the operations supervisor which is the top three as a four ship flight lead upgrade certification sortie for the mishap formation flight lead so what this was was an upgrade for it was an upgrade ride for number one who was getting checked out to be a flight lead so he was had gone through the syllabus and now he was proving that he could lead four aircraft to defend this point mishap pilot was assigned to the number four position of the mishap formation mishaps already involved nine f-15c and one f-15d four of which were planned as blue air and that's conducting dca operations and the six were planned as adversary training aids also known as red air additionally a contractor operated the salt falcon 20 supplemented red air as a electronic attack platform while her majesty's ship hms queen elizabeth was simulated defended asset and performed command and control for the blue air forces so they were actually defending a real thing a ship they were simulating that they were defending the hms queen elizabeth it was executed over the north sea in egd 323 managed danger area airspace approximately 75 miles north of raf lakenheath for the planning during the preceding week and day before the mishap flight lead completing mission planning and coordination with the rto it's his upgrade ride that's what he's supposed to do on the morning of the mishap sortie a pilot scheduled to fly in the blue air flight notified the top three of an illness so he called in sick at 5 45 in the morning the top three replaced the ill pilot with the mishap pilot so cage was actually supposed to be red four and that morning due to the illness they rolled him into uh blue four so what he planned to do was return to base refuel in the mishap aircraft so they were going to do what's called hot pit where you roll into the pits and they fuel you without shutting down refuel the mishap aircraft and then fly a second sortie i think it was bfm basic fighter maneuvers prior to 6 30 the mishap flight lead in adversary pilot 1 completed operational risk management worksheets which are standardized checklists identifying common risk factors for a sortie as cumulative risk increase the level of the authority required to approve the mission profile also increases both flight leads calculated a low risk for the sorting so they did the orm worksheet and they said nope this is a lower authority we don't need any higher approval to go do what we're doing at 6 30 the mishap flightly conducted a coordination brief attended by all of the pilots including red air and blue air squadron commander was the instructor pilot for the mishap flight lead and flew as number two he so he was the one doing the cert ride he was checking out number one as the instructor pilot of record flying is the number two position so he could monitor uh number one who was on an upgrade right blue rto red rto did not attend the cord brief but we're briefed by the mishap flight lead prior to the court brief which is standard you don't really rto doesn't always have to go coordination brief covered everything that they're supposed to cover they talked about imc rules during the training rule portion of the brief following the court brief then they went did their uh element brief where they talk tactics and stuff like that and that's just blue air that's the four ship only afterwards the ip briefed the mishap pilot on topics covering the basic fighter maneuvers flight schedule following the rtb so yeah they were going to do bfm after they did the hot pit and how he briefed him on hey there's how we're going to do our bfm sorority and here's how you hot pit they taxi took off at 8 47 departed the airspace encountered an overcast layer of clouds from 500 feet to 1500 feet when established in the training airspace the mishap flight performed a g-awareness exercise a maneuver designed to heighten pilot awareness of g-forces test-related system we talked i've talked about this on the channel so first turn checks your system make sure your g-suit's inflating second turn checks your body if there's any problems on either of those you would sing up and say hey i'm not feeling great i'm going to be low g today or i'm just going home so that's what the purpose of the g awareness so they could be full up and pull g's mishap flightly directed the ip to perform a weather check and obtained a weather observation from red air flight lead due to clouds throughout the airspace the mishap flight lead declared over the blue radio that they were unlimited clear of clouds imc rules 29 or 88 which established that they were so unlimited versus limited if we do unlimited we can just maneuver until you run out of gas i mean 360 degrees of turn 720 whatever it takes when you start fighting with somebody limited maneuvering limits you 180 degrees a turn so once one person and it's established that there's a role somebody's offensive defensive or whatever 180 degrees a turn you terminate the engagement red air goes away blue air goes back to where they were not necessarily a kill removal but 180 degrees of turn that's called limited maneuvering so they were full up unlimited maneuvering but with the caveat that they would use imc rules when an imc so they're basically saying if you were visual and out of the clouds because it's kind of scattered and milky and there's some parts where it's clear and some parts where it's not if you're not in the clouds you're full up and if you're in the clouds adhere to imc rules which is 60 degrees of bank 15 degrees pitch up 15 degrees pitch down tactical execution the mission began at 9 15 local at 9 25 the mishap flight and red air flight converge within 10 miles of each other requiring a transition to more restrictive maneuvering for aircraft operating in imc in accordance with the training rules separation between the mishap flight and red air flight remain less than 10 miles through the mishap sequence so there you go so you see here uh here's the four ship and this is where everybody is they're inside of ten miles to uh the four aircraft this guy looks like he's killer moving so they at least kill one but they've got four left they had to deal with at 9 26 the mishap element lead directed the mishap pilot to execute a hard right turn back to the west to look for an adversary aircraft at a lower altitude at 9 26 20 the mishap pilot was at 20 300 feet heading southeast 125 degrees as the mishap pilot initiated a right turn to engage the adversary aircraft located 18.5 nautical miles to the west at 5 000 feet the mishap pilot descended below 20 000 feet midterm and stabilized on a westbound heading at 17 100 feet and 560 knots true airspeed so at this point he's 17 000 feet he's 560 knots true he's at a tactical air speed they're looking for a low striker essentially typically the 5 000 foot guy is the guy trying to go and bomb the point they're defending so his flight lead told him hey snap to this heading target the guy at 5000 feet because that's the biggest priority because he's going to go bomb their the ship that they're defending at 9 26 the mishap pilot fired a simulated air-to-air missile against the adversary aircraft and made a call to inform the rto and other pilots in the mishap flight so he made his call and that's his engagement after he turned he made the right turn he's at 17 000 feet there's his the low guy right there he simulated the missile launch he turned further right to a northwest heading and then continued descending mishap turned missed that pilot turned further right to a northwest heading and then continued descending so he's following up descending down to get lower with the striker if he has to mishap aircraft reached a maximum bank angle of 94 degrees maximum pitch of 17 degrees nose-down descent rate of 16 000 feet per minute at 530 knots passing 14 000 feet the minnesota pilot initiated a left turn to the west and reduced the descent rate to 7200 feet per minute so this is his maneuver here so i'm assuming i don't know whether he is in vmc or imc but i think at this point he is in visual meteorological conditions because remember it's scattered so may or may not be a visual outside and we'll talk about why that's important later mishap pilot made a radio transmission informing rt01 of the kill so on his display he believed that the missile had guided and fused and it was a valid kill the rto responded that it was a pk miss probability of kill miss which means the missile didn't kill so that's a trainingism to allow more training to give them opportunity to make sure it's not just laser missiles where you shoot the missile and then it automatically works every time it's a trainingism to go okay i gotta make sure that the guy actually blows up and the rto gives you feedback of yes or no and in this case the rto as a training aide said no didn't blow up you have to follow on so at this point he is kind of offset here because he was watching to make sure you know he was giving himself some time in case the missile didn't fuse and so now that striker is going way um that striker is going past him and the missile didn't work so he's got to do something about it he's got to go target this guy so he began a roll to the left in the direction of the adversary aircraft which was five and a half miles to the southwest he was heading west at twelve thousand feet so he had to descend it all the way down to twelve thousand feet 107 degrees of bank 17 degrees nose down pitch attitude descending at 15 800 feet per minute other aircraft had pilot programmable altitude warnings set for ten thousand and twelve thousand five hundred we don't know if he did or not so as he's going this way that's what his aircraft look like so at 927 he stopped the turn reduced the bank angle to 21 degrees and decrease g-forces from 0.3 to 0.8 during this time the pitch attitude lowered to 25 degrees nose-down descent rate increased to 22 800 feet a minute and his air speed increased to 520 knots he was descending through 10 000 feet they called this a g unload maneuver so he might have been trying to get his air speed back because now he's potentially ended up in a tail chase with this guy or he could have ended up in the weather they don't really know from that 10 to 20 thousand feet what part he was in the weather or visual he increased g-forces resumed the turn in the direction of the adversary aircraft the bank angle was initially increased to 107 degrees and slowly reduced pitch attitude lowered to 42 degrees nose down and his air his air speed and descent rate increased he sustained between 1.1 and 3.8 g's from this period he crossed the transition altitude of 5000 feet transistor altitude was the minimum altitude by the training rules for unlimited maneuvering and vmc coincided with the minimum altitude for operating imc for the mishap sortie so so at this point he's through the transition altitude and now he's um in the minimum altitude for operating imc or if he's vmc now they transition unlimited maneuvering at 9 27 40 he breached the 4 000 foot training floor so the way it typically works is um there's different floors that you have to adhere to 5 000 feet being the transition altitude now everything below that as low altitude rules apply so limited maneuvering and then a no kidding floor at a thousand feet is what we use but in this case they were using a 4000 foot floor so nothing below 4000 feet the training floor was a minimum altitude established in the spins that's the special instructions coordinating brief for tactical execution at the training floor he was heading southwest 566 knots with 52 degrees of left bank 41 degrees in nose down pitch and descending at 38 800 feet per minute that's a depiction of his aircraft passing a thousand feet the mishap pilot abruptly reduced bank and pitch angles and rapidly increased g-forces to 8.2 the mishap aircraft was heading south 579 knots 40 degrees of left bank 31 degrees down pitch and descending at 33 300 feet per minute and that's what it looked like parametric data indicated a sudden increase in g-forces during the last 0.7 seconds of the flight which was inconsistent with other parameters this decrease in g-forces with the pitch and bank attitude of the mishap aircraft at this moment should have coincided with a succession of pitch angle reduction airspeed stabilizing or increasing descent rate stabilizing or increasing rather during this time period pitch angle was reduced from 19 to 10 degrees down bank angle was decreased by 10 air speed decreased 9 knots and the descent rate decreased by at least 4 000 feet a minute all of which are indicative of positive control inputs by the mishap pilot up until the moment of input and this is the impact he impacted at 566 knots 4 degrees left bank 10 degrees nose down pitch distance rate of 17 000 feet a minute and this is where his final position was so you can see here that's a good depiction so he turns he he turns back around he goes to shoot he offsets pk miss and now he's going to get the guy and he ends up in the weather and then that's where he ends up with his impact into the water search and rescue crashed at 9 27 47 multiple members of the mishap flight attempted to contact the mishap pilot on several radio frequencies at 29 2915 they initiated the knock it off call to signify that the end of tactical engagements uh they tried to use c2 on-board and off-board sensors to search for his aircraft initially they thought he had an electrical problem or something else so they thought he was just flying around nordo which is calm out and couldn't talk to anybody they contacted the soft to initiate the search and rescue operation multiple forces were launched including the royal navy strike eagles kc-135s and e3d so the royal navy stepped up to help find him adverse except over the subsequent hours the royal navy surface vessels recovered items from a stationary debris field that included his survival kit and unopened parachute from maintenance they reviewed all the records for the mishap aircraft as they are known to do although not an inspection it should be noted that the mishap aircraft was in a cannibalization program from 18 february to 1 may meaning that it was non-flying and they were using parts off of it to keep other jets flying and then they put it back together after that so during the 45 days of flight operations after that there were no maintenance actions performed on any component that was replaced no evidence indicates that that contributed to the mishap unscheduled maintenance it flew 16 sorties over 45 days after its rebuild time 15 sororities with zero or minor aircraft discrepancies no discrepancies associated with aircraft flight controls or cockpit instrumentation during this time everything seemed to be noted except on the last flight the pilot of the mishap aircraft reported a major discrepancy and mission essential equipment the left bleed air light illuminated in the airspace that discrepancy was troubleshot and corrected and passed required tests no evidence to suggest maintenance was a factor in this mishap so for the weather so let's talk about that raf lakenheath was forecast at 830 was winds northeast at nine knots nine kilometers visibility was missed overcast at 500 feet above ground level forecast in the airspace was winds 290 at nine unrestricted visibility broken from seven to twenty five thousand scattered from twenty five to twenty eight thousand so not great weather the observed weather so what actually was uh overcast 500 to 1500 then clear of clouds above until they got to the airspace at 909 local so it's just kind of a low broken deck from five to fifteen hundred prior to tactical maneuvering the ip performed a check and the airspace 20 south of the crash site the iep reported a little bit of haze 10 mile visibility not the best horizon from five to between 10 and 14 000 so right in that area where we talked about where he started maneuvering to to chase that low striker broken overcast layers starting between 10 and 14 continuing up to 20 000 a thick layer of clouds from 20 to 25 000 clear clouds above 25 000. at 9 27 at the time of the mishap the adversary pilot was five miles south of the crash site at 5500 reported low-level clouds below as well as clouds above the aircraft precipitation greater than five miles vis no discernible horizon to the north or east adversary pilot one reported that the weather to the northeast and east appeared to be progressively worst additionally he descended down to two thousand feet was unable to make visual contact with the surface so he's basically saying he was full up imc rules socked in just looking at his instruments at 934 local during the search and rescue operations the mishap elementally descended westbound from 20 000 to 1000 following the approximate path of the aircraft he reported overcast clouds from less than a thousand to between four and five thousand clear of clouds with a difficult to discern horizon between four and five thousand up to between eight and nine thousand overcast from eight and nine up to fourteen thousand and clear clouds from 14 to 20 000. he was not able to make visual contact with the surface so basically what he's saying is at the where the mishap happened so where cage was in that 10 000 there's not much of a horizon and he's kind of in the soupy in and out of clouds so more than likely from the time he was at 12 000 descending to turn to go find the striker is how he ended up inadvertently in instrument meteorological conditions and was not vmc but above that when he first took the shot descending down out of 20 000 he was in vmc all right crew qualifications this is a big one the mishap pilot was an inexperienced f-15c pilot that had a total of 270.7 military flying hours as of the date of the mishap he had 64.3 hours in the f-15 charlie delta and 151.7 simulator hours his recent flying hours are reflected below on the table we'll take a look at he had a current instrument qualification for mate and a flying evaluation completed on 16 august 2019 also had a current mission qualification form eight flying evaluation which was done um barely not even a month prior on 20 may 2020. mishap pilot regional recently graduated from the f-15 schoolhouse qualify as f-15c wingman on 20 may after completing mqt he received high marks for performance in the ftu and had slightly above average grade sheets in mqt so in the f-15 he was a rising star he was doing well he he had done well in the uh the b course at kalamath and he was doing well here he was not a weak swimmer at all he was a good pilot in the squadron he had a reputation as a hard worker who exerted a significant effort studying and preparing for missions so he was always on top of things the mishap pilot received training in the ft regarding execution using imc rules the mishap pilot completed at least one sortie in which imc rules were used in executing execution and actual imc occurred on that sortie during the mqt he received specific training regarding tactical intercepts in imc here's his look back in the last 30 days he had flown eight times so he'd flown i mean not terrible eight is a pretty good number uh the last 60 days though he'd only flown 15 hours so that's only six more so he hasn't flown much remember this is the covet time and then the last 90 days he'd only flown two more sorties but also to note a lot of this heavy flying was because he was in the mqt so they were trying to get him through the syllabus and before this he 90 days prior i mean three months prior is march that's the start of the covet restrictions and also he's just showing up at the squadron because remember he just got married in february right before he showed up so he's not i mean that's not a horrible look back he had just shown up at the squadron so he hadn't had a whole lot of time to get acclimated and start flying medically qualified with no issues they did consider g-lock g-induced loss of consciousness momentarily attained at 8.2 but a comprehensive study on healthy individuals demonstrated that a minimum of five seconds from rapid acceleration to nine g's are needed to lose consciousness so they ruled out g-lock so operations supervision let's talk about that because there's some covet stuff to mitigate the risk of exposure to covid squadron operated as two teams every week the teams alternated between flying and simulator operations the pilot perception regarding readiness was that the increased simulator time honed tactical skills though the compressed flying schedule slightly atrophied certain muscle memory actions such as ground operations to communicating with atc consensus amongst those interviewed was that coven 19 split operations produced a level of readiness on par better than operations prior to covet 19. no evidence that ops tempo contributed to the mishap supervision i was led by a two-ship flight lead executing his floor flag cert the ip was the squadron commander who was also a weapons officer no evidence that operation supervision contributed to the mishap all right statement of the opinion the opinion summary just rehashes what we've already talked about the cause he finds by the preponderance of the evidence that the cause of the mishap was his fixation on his intercept of the adversary aircraft and failure to execute cockpit instrument visual scans when he encountered imc throughout the mishap sequence based on the testimony from other pilots in the vicinity cloud layers were prevalent from nine to fourteen thousand addition to one thousand to four thousand with multiple layers of clouds and the air space around the mishap area testimony indicates the horizon was difficult if not impossible to discern below nine thousand feet after the mishap pilot received the pkms transmission from the rto the mishap pilot was approximately seven thousand feet above and five and a half miles to the north northeast of the adversary aircraft at twelve thousand feet the mishap pilot immediately maneuvered towards the adversary aircraft with an aggressive left bank of 107 degrees increase the pitch of the mishap aircraft to 25 degrees nose low and then suddenly decrease the bang angle 20 21 degrees left bank decrease g forces to 0.3 however remain 25 degrees pitch low this maneuver strongly indicates mishap pilot entered imc conditions and decreased his bank complying with the imc rules bank limitation at 60 degrees but neglected to adjust his low pitch attitude it is evident the mishap pilot exited the clouds at 10 000 feet when he continued to intercept the engagement of the adversary aircraft by aggressively entering a left bank of 107 degrees and increasing the 3.8 g forces while his pitch lowered to 42. as the mishap pilot approached the brief training floor of 4000 feet with a left bank angle of 60 degrees the mishap aircraft accelerated above 560 and 38 800 feet a minute descent his lack of awareness of accelerating downward through the brief training floor of 4000 feet clearly indicates the mishap pilot fixated on acquiring the adversary aircraft either visually or with his radar and did not monitor his aircraft altitude airspeed and attitude cockpit instruments as the mishap pilot exited the low cloud layer at approximately a thousand feet with a visible horizon and ground rush of the rapidly approaching ocean mishap pilot immediately since his low pitch attitude and position and initiate a recovery attempt in mishap aircraft but was unable to complete the recovery based upon the low altitude and speed of his descent it is my opinion based on the weight of the evidence he did not attempt to eject parametric data indicates a sudden decrease in g-forces during the last 0.7 seconds of flight inconsistent with those parameters this decrease in g-forces should have coincided with a cessation of pitch angle reduction air speed stabilizing or increasing and descent rate stabilizing or increasing however during the same period the pitch angle was reduced from 19 to 10 degrees down bank angle was decreased by 10 degrees airspeed decreased by 9 and the descent rate decreased by at least 4 000 feet a minute all of which indicate positive control inputs by the mishap pilot until impact i considered and analyzed the possibility that he lost consciousness or an aircraft failure was the cause of the mishap however technical data clearly indicated the mishap aircraft was responding to deliberate flight control inputs consistent with the intent to intercept and shoot the adversary aircraft until his recovery attempt during the recovery attempt the mishap aircraft responded predictably to the mishap pilot flight control inputs of roll and pitch changes thus indicating the mishap pilot was conscious and there was no aircraft malfunction additionally there were no discrepancies or malfunctions with the cockpit instrumentation and previous maintenance inspections and flights preceding the mishap sortie thus providing no evidence to indicate managements were not functioning normally during the sorting substantially contributing factors based on the testimony of the weather conditions from other pilots in the vicinity i believe that he exited the clouds at 10 000 feet during his intercept but the reduced visibility below the cloud layer and lack of discernible horizon resulted in spatial disorientation spatial disorientation occurs when an individual fails to correctly sense a position motion or attitude of the aircraft or oneself without a discernible horizon asap pilot could not accurately sense the low pitch attitude of the mishap aircraft and subsequent altitude loss spatial disorientation was unrecognized by the mishap pilot due to his failure to execute cockpit instrument visual scans during the mishap sequence by aggressively maneuvering the aircraft with lack of exterior visual references of the horizon sky or ocean the only way for the mishap pile to recognize a spatial disorientation would have been for him to reference his cockpit instruments for pitch attitude and altitude indication inability of the mishap pile to correctly sense the pitch attitude due to spatial disorientation significantly contributed to his undesirable low pitch rapidly descending altitude and resulting mishap i find the cause was the fixation on his intercept and failure to execute cockpit instrument visual scans when he encountered imc also fined by proponents of the evidence airspace environmental conditions reduced visibility lack of discernible horizon for the mishap pilot resulting in spatial d the inability of the missile pilot to accurately sense pitch attitude and mishap aircraft to spatial disorientation substantially contributed to mishap aircraft's undesirable low pitch rapidly descending altitude and resulting mishap i developed my opinion by analyzing the data directives etc everything from this point on is my opinion it does not represent the air force the air force reserve reserve dod anything this is just my opinion um as a fighter pilot so um this is a tough one to read and i i think it has saddened me even more than measures and measures was a tough one because we let him down a lot in that mishap i mean there were a lot of uh holes in the swiss cheese model but this is a situation where i think you have an inexperienced wingman who is a hard charger who is very good at what he does up at this point and he gets put into a situation that he doesn't have the experience yet to deal with he only had 64 hours in the jet which is i mean it's amazing to me that you leave the b course with 64 hours i can't believe the syllabus is live i know it said he had 150 something hours of simulator time i don't count that i mean it's there's nothing that replaces sitting in the jet and feeling the g-forces and feeling what happens when you maneuver the aircraft um spatial disorientation is probably the one of the most dangerous things out there and it's just like when you close your eyes and start spinning around you know what your eyes are telling you doesn't match what your inner ear is telling you and you can get disoriented and the same thing is true in aircraft and why it's so dangerous in the weather i've i've seen this in the t-38 because the cockpit is not laid out that great we have a very old aircraft and it's not very user friendly and you can get to a point where your scan breaks down and you feel like you're in a left bank turn but actually you're you're sitting straight and level and that's called spatial disorientation and there's various levels whether it's recognized unrecognized and they always say once you you know recognize that you're spatially disoriented confirm that you are using your instruments and then you know execute a recovery maneuver so usafe which is our european command has a little bit different rules of weather in the u.s with a 500-foot ceiling he probably wouldn't have gone flying in the first place i think usafe's got different minimums but 500 feet for an inexperienced wingman is minimums and you're not going to take off when the weather is at minimum so that right there probably would have canceled the sortie from the beginning he switched from red to blue we've talked about that before that's a little bit of a shift but for a good hard charging studying wingman not a big deal that's not really a fact the weather call so upgrade rides are typically more complicated because we put all these assets in place you know they had um the the falcon that was out there they had the uh british ship so they had a lot of external assets and they get all these jets together because they want to get this one cert ride done so there's a little bit of a pressure to to get the mission done because you know we never know especially when they're alternating operations and stuff this person's got to get their upgrade ride done so we're kind of a lean forward let's get it done the problem is cage had 64 hours so he takes off and the weather's 500 feet which is i i mean that's pushing it a 500 foot ceiling and a fighter is it's not it's not an easy day just right off the bat they go to the airspace and the weather is layered and broken and they make a weather call and they knew the weather was kind of skosh prior to even taking off so they make the weather call and what imc rules did not exist when i was first in the air force the first time i was in the air force reserve flying f-16s we didn't have imc rules we could either do what's called a high war where we fought above the weather a low war where we fought below the weather or a split war where some guys were above it some guys were below it and we never crossed paths we didn't have that imc rules came about to allow more training in the weather and they gave us restrictions they said you can only go 60 degrees of bank and 15 degrees up or down most of the time i've done it in the navy most of the time when you do it it's auto pilot on if you have an autopilot i mean that's usually the best time to do it and that way at the very least you can look at the radar because your head's down we call it the jewel cup because your head's down looking at your displays and your sensors because you're trying to get a radar lock and stuff but when your heads down your inner ear is now telling you one thing and what the instruments are telling another so you have to have a cross check going back and forth between the radar and your displays now i don't know if you've seen the f-15c cockpit it's not the greatest as far as instrument layout you know it's not user-friendly it's not not very great you know it's not laid out it's a 1970s or 60s design it's a very old design it's not exactly high-tech and new where everything is right where you think it should be because they've added stuff over the years so the the danger when you're in the weather is that you end up in the drool cup looking at the radar and this stuff falls out of your cross check and so you can if you're not on autopilot which obviously is not you can start maneuvering the aircraft and it is very easy to get spatially disoriented when you're not paying attention to it it has happened to me i mean i'm not the best pilot by any stretch of the imagination and this happened one of my first combat sorties i took off out of balad and it was one of the it was funny because air force rules being what they are i wasn't allowed to be a night guy so i couldn't be nighttime but i was a daytime guy but because i was a daytime guy we took off and it was still dark so i took off and what happens is especially with the bubble canopy of the f-16 you need the ground rush you lose the lights behind you because the runway is the only thing that's lit because nothing outside of balad was lit and we take off and then you're just in this dark abyss and i remember locking up my flight lead because we were doing a radar trail departure and getting heads down and then looking outside and i could not see anything like everything was black and i looked at the hud and the hud didn't make sense and i was almost inverted and i completely got spatial deed and the flight lead that i was flying with that time great man that i highly respect was somebody who very experienced at night doing red air perfectly clear night got himself spatial deed and actually ejected from an f-16 so we talked about it in depth after that but my point to that is i had about i mean probably 80 or 90 hours in the f-16 at this point maybe less it's about like cage that could have been me i mean when you're young and inexperienced you don't have that mission cross-check time to go from you know okay i've looked at the radar for uh 10 seconds i need to go back and make sure i'm still upright i've looked at the radar i need i need to have this cross check because he doesn't have time to develop it and there's just you just don't get that in 64 hours you need experience so going into the sortie i don't think he was set up to succeed i think this was a little bit too much of a even though he was a great fighter pilot he was doing well and you know he he had proven to everyone that he was going to be an awesome outstanding fighter pilot i don't think he had the experience to do what they were doing and so when he found himself in a situation where he just he ran out of experience and me personally either there are a couple ways that this could have been approached it could have been okay we know where imc rules the weather is crappy um we still need to get this ride done but we're gonna break it down we're not gonna do a full up defensive counter air we're not going to defend the point everybody is at a hard altitude and we're going to be non-maneuvering a limited maneuvering and stay in your block autopilot on just to do intercepts you could have easily gotten their four ship certification done that way not a big deal they could have sent him home they could have said well you mean this is this doesn't work the problem in this situation and you can't blame the flight lead or the ip because what they did was legal it's it's just not something that we think about and the fact that the orm was low i mean it just kind of shows you we kind of pay lip service to this orm worksheet because honestly weather in the airspace imc rules a wingman when it's only got 64 hours and we've just been doing alternating sim flight sim flight that should have been a really high risk mission i mean it really was because there's a lot it's an upgrade ride there's a lot of stuff going on um you know it just it's one of those things that we just don't think about it because i'm sure any other day he would have done well i mean he just had a bad day and the problem with having a bad day and a fighter is that sometimes you can't recover and that's what happened i firmly believe that exactly what the board said is he shoots the missile it doesn't work pk miss so he's like oh i've got to do i've got to kill this guy i've got to kill the striker i can't be the one that lets the striker bomb our target he goes after him he ends up in the weather he realizes oh crap i'm upside down i've been looking at the the radar here now what do i you know what i do and then as he kind of gets his senses back the ground rush he's pulling eight g's and then he doesn't he probably got another beeper and didn't want to over g but this is a tough one to go through because i think it's a it's a it's one of those things where you know heinz sign is 20 20 and you can't you can't lay the blame on anybody there because you know what they know then was that yeah he's a full-up wingman and he can do anything that is legal and we're able to do but in looking back when you look at that we always talk about there's always a swiss cheese model and the model lined up he just didn't have the experience and recency to do what what they were asking him to do and i think that uh ultimately led to this mishap and that's that's very tragic because it's very avoidable and um you know we lost a really good young fighter pilot so uh nickel on the grass for you cage um you know the world's a lesser place now

Channel: C.W. Lemoine

Views: 80,048

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Id: iOb5BzdKbPo

Length: 43min 25sec (2605 seconds)

Published: Fri Dec 04 2020