F-35A Crash at Eglin AFB (5-19-20) Accident Investigation Board Report Review and Analysis

f-35a assigned to eglin air force base was destroyed during a landing mishap the pilot made it out okay but there's some lessons learned we can get from that today we're going to take a look at the full accident investigation board report that was recently released uh keep in mind that the pilot involved um is still flying today and i'm not going to use this to cast judgment on the pilot involved because it can happen to anybody this is the kind of stuff that is aviation aviation's a dangerous business we make mistakes and hopefully from this video we can learn from it and extract some of the lessons learned that came from it three two one [Music] all right so let's take a look at the report uh 58th fighter squad and 33rd fighter wing at eglin air force base uh in florida uh it was on 19 may 2020 and colonel brian callahan is who is giving his uh official uh opinion in this as before what we'll do is we'll go through it uh the summary and the details and everything i've divided this video up in the chapter so if you want to skip around or whatever it should be easier to do we'll try to match the format of the report in the chapters so the executive summary on the night of 19 may 2020 at 2126 local 926 the mishap aircraft which was an f-35 alpha with the tail number zero zero five zero five three crashed on runway 3-0 at eglin air force base in florida the aircraft was operated out of eglin for the 58th fighter squadron and 33rd fighter wing he ejected safely but sustained non-life-threatening injuries which we're going to talk about some of his injuries because that's important to this the mishap aircraft valued at 175 million dollars rolled caught fire and was completely destroyed the mishap pilot set and held 202 knots calibrated air speed throughout the approach and landing the aircraft touched down approximately 50 knots fast and was approximately 8 degrees more shallow than desired for landing at a 5.2 degree angle of attack the aircraft landing lasted approximately five seconds before he ejected the nose of the aircraft drove down at a high rate of speed the nose gear contacted the runway immediately after the main landing gear so hit the just slammed it down with the nose gear next the mishap aircraft experienced a significant no high bounce and after the initial bounce the mishap pilot made stick inputs consistent with an attempt to recover and set a landing attitude however the messhap pilot's stick inputs quickly fell out of sync with the aircraft pitch oscillation so he's getting into this what's called pilot induced oscillation pio an aircraft control cycle two seconds after touchdown the mishap pilot set and held afstic which is what you're supposed to do which would normally bring the nose of the aircraft up approximately one second after commanding afsic the pilot also commanded full afterburner on his throttle presumably to go around both of those actions are consistent with an attempt to establish an attitude that would have allowed the aircraft to take off and go around for another landing attempt the horizontal stabilizer remained in full deflection down which would tend to keep the nose of the aircraft down despite the pilot holding av stick for three seconds so the aircraft didn't do what he asked it to do at this point after being unsuccessful in the attempt to go around after multiple and progressively worsening bounces the mishap pilot released the stick to eject the aib president found by a preponderance of the evidence that the mishap was caused first by touching down at 202 knots second by flight control services namely the tail of the aircraft conflicting with the inputs upon landing resulting in the pilot's inability to recover from the oscillation the ib president also found by proponents of the evidence that four additional factors substantially contributed the mishap they are he landed with speed hold engaged and using an alternate crosscheck method which we will talk about in detail the helmet mounted display misalignment distracted the mishap pilot during a critical phase of flight experienced cognitive degradation due to fatigue and he lacked the system's knowledge on how the flight controls work so that is the summary as we've done before we're going to go through it uh step by step and how and break this down in more detail in case you didn't know f35a lightning ii i like to call it fat amy a beast amelia if you will kind of a name for it i think they're trying to call it the panther now but this is uh what it is it does talk about the f-35a airframe is inherently unstable this instability provides excellent maneuverability and performance but requires artificial stabilization augmentation by the flight control system known as a fly-by-wire system f-16 f-18 are the exact same way so this is not really that new the control system maps the desired aircraft response and a movement of the most optimal control surfaces to meet the pilot's request aircraft control is provided by execution of a defined set of control laws which is essentially computer programming that determines how the combination of all aircraft inputs will be translated into changes in the flight control surfaces based on the particular flight mode of the aircraft the modes include power approach for takeoff and up and away when the gear is up power approach provides precise control of glideslope lineup and angle of attack during approaching landing below x degrees a08 is pure pitch command which is good for aircraft turn performance and changing the flight path if a pile touched down at less than x degrees aoa and attempts to use the stick to set landing out to the pitch rates will be significant volatile and difficult to control above y degrees the aircraft is in an aoa system which is optimal for finer fly patch changes prioritizing stable out attitudes during a round out and flare that's a lot of geek speak for basically uh the aircraft basically tries to adapt to what phase of flight you're in so if you're at high angle of attack on landing it gives you a more refined control system if you're faster speeds it gives you a different control logic law that way because it's not designed for you to touch down to 202 knots it's designed for you to be at that 150 knots at that stable angle of attack so there's different control laws based on what phase of flight you're in how fast you're going what angle of attack you are because the jet is trying to compensate because it's an inherently unstable aircraft the f-16 does the exact same thing and so does the f-18 on ground weight on wheels mode activates when the aircraft sensors indicate weight on wheels duh ground handling claws provide tax capabilities using high and low gain nose wheel steering commands through the pedals pitch damping is provided through feedback that activates when wheel speed exceeds the knot's ground speed threshold the claws are especially tailored to provide excellent aerobraking capabilities using wheel speed and weight on wheels indication to provide good control of pitch attitude so in the air force when we land f-16 was the same way when you land you'd pitch back and establish an aerobrake and what that does is you've got forward relative motion to the air and it uses the entire aircraft as a giant speed brake to help you slow down so you're not using the wheel brakes you're not burning up the brakes possibly popping a tire or whatever it gives you a better uh landing roll out uh and shorter landing distance so air brakes are important we're using the t-38 f-15s use it f-16s use it the f-18 does not but that's because of the way the gear is actually designed so it's not actually designed to do an aerobrake per se there are multiple transitional claws including a bounce mode that is enabled momentarily during wheel spin up these transitional modes and logic are typically transparent to the pilot during a touch and go the plane enters weight on wheels mode and the aoa reference is reset at touchdown from approach aoa to just below y degrees the flight control system rapidly and continually captures new data in the state of the aircraft the current mode the pilot inputs in order to determine any errors between pilot inputs and the desired movement of the flight control surfaces for stability in situations where there is a large divergence between inputs and anticipate inputs the flight control system resets in such a way that inputs may have a minimal effect on flight control systems for a significant period of time and the reason it does that is because it could be a flawed input you know it basically is it's it's a computer that's getting all these inputs and if if it's wildly different than what it expects in that phase of flight it may go well that probably isn't a valid input and i'm just going to ignore it and give it what i think it wants so in that case it's a control law or the computer's trying to be smarter than the pilot which in this case didn't work out so well so in the sequence of event he was scheduled and authorized as a two-ship formation conducting knight tactical intercepts with another two ship was flown uh following the guidance for a knight ti with a combined wingman syllabus so it was an upgrade ride for the wingman mishap pilot was originally scheduled to fly as red air in direct support of the student formation meaning he would have been acting as a simulated adversary for the student formation instead of acting as the instructor for a specific student at 1400 local the msap pilot was informed he was rescheduled to be the instructor for the mishap wingman via text message due to the original instructor pilot of record falling out as a precaution for coronavirus flying as an ip for a ti is known as blue air he arrived at 1600 mishap flight members accomplished all required mission planning for the sortie checked the nodems et cetera and signed off at the appropriate risk level where we talked about the risk level for the f-16 they were rated at medium risk and that was due to the human factors uh mishap pilot reached out to the ground control intercept uh training unit because they were going to be controlled uh dog house or whoever's controlling uh but did not reach anyone successfully left a message at 1800 local the missile pilot conducted the flight instructor briefing into the mishap wingman covered all items so starting out and this might go to the fatigue thing for professional red air like what i do red air is the mission that's what we focus on it's it it is it is what we do all the time when you are blue air so when i was flying f-16s or when you are in an operational squadron red air is an alternate mission so if you look at the schedule and you're like i'm red air today that is an easy day you are not expecting to have to do a lot it's basically show up here's the card i'll make a quick plan they're usually pre-planned sets especially for tactical intercepts where they have specific uh learning objectives so they tell you hey at this range do this with your jet so that we can see it with our sensors and everything so in that respect the mishap pilot that day fully expected well this is gonna be an easy night sortie i'm not gonna have to do anything and once it switched so once there was fallout now he went from uh i'm just gonna be the red air or red one or red two where it was going to be an easy night now he is the instructor so he has to put together the plan he has to put together the products he has to put together his brief and his briefing boards and how he's going to instruct this student and now he's going to have to stay longer and it's going to be a longer debrief and a longer brief so that that's kind of starts the well he expected one thing and now he's coming in that's not to say that's an excuse because any instructor should be able to walk in pick up and go yep i'm going to do this no problem but it is different from what he expected you know waking up that day summary of the accident they departed on runway 1-2 in a two-mile trail they went to the south went to 151 alpha charlie echo conducted their syllabus events and then they did a they had to at the completion of their tactical training and delay for a minor physiological event with the mishap wingmen so the mishap wingman had something going on the mishap flight lead began their return to base via radar vectors the instrument landing system approached to runway 3-0 at eglin as planned so not sure what was going on with the wingman but they did have some kind of physiological something was going on with the wingmen uh that they had to kind of pause and go hey you okay what's going on so at 2125 he reached the final approach fix on the glide slope so realize at night and i talked about this in the last video at night we fly precision approaches we don't do overheads in the air force we fly uh an ils you have to have precision approach guidance or papi's or something to back yourself up that's typically doctrinally what we do so he reached the final approach fix glass of intercept with the gear down and locked auto throttle enabled would speed hold set to 202 knots calibrated air speed in accordance with standard procedures and normal habit patterns remember he's in a radar trail so he's trying to set spacing for the wingman behind him so if he slows down the wingman's not going to be able to get that two miles behind him so he has to keep a speed up so that the wingmen can maintain or contin can get back there to that two miles and then uh call saddled and then he's in the right position so he's just trying to keep his speed up for the wingman in other words he reached the point in his landing approach where he takes his final alignment of his aircraft for his descent to the runway therefore the speed displayed would have shown command 202 shortly after the final approach fix which is the last part of the landing the mishap pilot noticed a discrepancy in the alignment of his helmet-mounted display after setting his command marker aimpoint to the threshold of runway the mishap pilot expected to see it go below glide slope or see the ils glide slip indicator rise instead he observed the opposite cueing him to the fact his hmd might may be misaligned in relation to the horizon the mishap pilot confirmed this by cross-checking his virtual head-up display and the ils data continuing to show mishap aircraft getting higher in relation to glides up again opposite of what a pilot would expect to see after these inputs so the ils data wasn't matching what he thought he should be seeing so perception versus reality just it wasn't matching up based on what his helmet was telling him um and you can see in figure one the side by side representation of an aligned hmd of what that looks like versus the misaligned hmd with a crosswind hand of god phenomenon green glow so it was off completely what he expected he visually corrected his aim point and glides up towards the threshold of runway for the remainder of the approach and touchdown approximately 103 seconds the ils glideslope data showed the aircraft high on glide path forcing an aggressive nose low flight path correction so he's high he's got to dump the nose which is increasing his speed and lowering his aoa angle of attack trying to correct for this error placed the hmd misaligned symbology further and uncomfortably short of the runway mishap pilot described having to point into black abyss referring to how the area in front of the runway appeared at night there's no lights out there especially runway 3-0 which points uh which goes north it's i mean it's the bay it's water there's nothing there's no land mass or anything like that it's just the bay the discomfort for the mishap pilot was aggravated by the lack of visual cues at night particularly because of the low illumination so it wasn't a moon there wasn't anything illuminating uh out there and there's not a lot of cultural lighting on the end of that runway mishap pilot never cross-checked his airspeed or angle of attack during the approach and touchdown meaning he did not look at the aoa and airspeed indicators to verify they were appropriate for landing so he is so fixated on the green symbology that he is letting some of the more basic stuff like angle of attack which is what we usually fly and his air speed fall out of his cross check additionally through the descent the hmd projector brightness or green glow that projects over the field of regard was increasingly distracting throughout the descent despite the mishap pilot manually adjusting brightness levels on final approach so it was really bright he was getting like this haze and this glow around it and he kept trying to turn it down and it didn't seem to work the hmd misalignment was undetectable during the sortie until this point however once the mishap pilot pushed the nose of the aircraft down to set his aim point on the runway one degree nose low attitude could be clearly seen against the backdrop of the runway all this occurred during the final moments of flight and coincided with the point in the approach when the mishap pilot normally engages apc and set speed this is the first time the mishap pilot had experienced an hmd misalignment at night mishap pilot had also not experienced an hmd misalignment a simulator before the mishap pilot used the revised control performance scan method in accordance with their 3-3 which is the document that kind of tells you how to fly the aircraft do basic stuff the revised method emphasizes maximum use of auto throttles for airspeed control throughout the range of operation for this aircraft as a means of decreasing the cross-check burden between performance indication and de-emphasizes traditional cross-check techniques such as known pitch and power settings according to 3-3 f-35 once the apc is engaged the pilot can concentrate on situational environmental factors instead of performance instruments so set it and forget it is what they're basically saying it instructs the pilot to gauge apc and then shift cross-check to the aimpoint glideslope with altitude as a secondary item to track emphasizes aoa and airspeed as apc will be managing those aspects of the approach so if he had engaged apc the jet would have taken over managing his speed in aoa so he's assuming he's he's in apc based on habit patterns he just never engaged it so he thinks yeah jet's doing it i don't need to look at airspeed and altitude i got to figure out why the symbology is wrong and focus on the aimpoint but he thought he'd engaged and he never did he was still in speed hold from earlier because he had been at 202 knots he touched down in speed hold a prohibited maneuver in accordance with the joint service technical data this is approximately 50 knots faster and eight degrees aoa shallower than the on speed parameter parameters for the gross weight at the time of landing so he's really fast he should be about 150 knots or so and his aoa should be much higher the speed forced the mishap pilot to input slight forward stick to enable touchdown because it doesn't want to land and he touched down in a three-point attitude meaning all three gear touched the same time as designed upon initial weight on wheels the at disengaged speed hole so the auto throttle kicked off and the throttle back drive selected ground idle engine thrust request this three-point attitude an immediate nose gear bounce caused the nose of the aircraft to rise rapidly and excessively which the mishap pilot attempted to stop with foreign stick input so he bounced it and the nose came right back up this began a series of multiple increasingly violent pitch oscillations so nose comes up he pushes down nose comes up he pitches down so he's it's starting to oscillate as he's trying to figure this out main gear then nose gear then all three he attempted to stop these oscillations pitch right with forward and after inputs during the first two seconds attempting to set a landing go around attitude approximately 10 degrees nose high so he fought it for a little bit and he's like oh i need to set this at slightly half pitch attitude and then i'm probably gonna have to just go around so he tried to do a go-around he attempted to set a landing attitude a manner consisted with common aviation habit patterns for post-bounce recovery which is correct so it's easy to stick slightly after of neutral and then just go around mishap pilot's control inputs were quickly out of sync with the commands from the flight control systems and combined with the nose gear bounce resulted in the flight control system becoming over saturated over saturation this contact means the fcs was effectively overwhelmed because multiple conflicting inputs were competing for limited processing power oversaturation can result in latent or ignored flight control inputs so i mean it was either he was either getting a lot of lag because the computer couldn't keep up or just was gone yeah he's he's nothing nothing he's doing is right so i'm just not gonna give him anything so basically hal took over at this point over saturation cued fcs logic direct the horizontal stabilizers to default to remain in the trailing edge down position and cause the nose of the aircraft to go down so it can it commanded the nose down and he's going to stick slightly aft the mishap pilot then pulled full aft stick for approximately three seconds selected maximum afterburner and an unsuccessful attempt to go around before ejecting it crash on the infield it touched down at 202 knots at 5.2 aoa so he should be closer to that 13 degrees aoa 2000 feet down the runway at eglin so he's long because he's really fast he's eating up a lot of ground he ejected 4 600 feet down the runway slightly left the center line main body the airframe to part of the runway approximately 6000 feet and came to a stop 6 500 feet near taxiway hotel mishap pilot elected to eject and was able to use his right hand to release aft stick and pull the ejection handle while his left hand was still on the throttle so he ejected at 202 knots close to ground level heading 3-0 with a wind speed of six to nine knots an air force life cycle management center evaluation of the ejection sequence showed the event was successful with only minor issues identified specifically the left arm restraint did not uh provide restraint against flailing injury because his hand was not you're supposed to be in a good body position here his arm was over here he's i mean that's not a good body because it retracted him in but not enough minor issues did not affect the ejection sequence and no other abnormal indications report in regards to the condition of the applicable equipment post mishap analysis i'm going to talk about that in a second because he did get some injuries that are a little weird out of this so they went to the maintenance and the maintenance uh the modification of a helmet mounted display system deferred to next scheduled depot input this modification would enable the pilot to perform fine alignment of the hmds with gen 3 helmets um it was given a rescission date of 2029 although parts were available tctd posted alice completed required depot level assistance additionally the only lrip 6 aircraft assigned to eglin air force base this specific tctd applied only to the mishap aircraft miss that pilot mentioned during his interview that he had experienced hnb misalignments previously and they reported these descriptions and that he reported these discrepancies to afe personnel for repair that's life support they have the helmets they noted that they checked missed that pilot's helmet on their alignment tester and there were no discrepancies noted however without the appropriate hardware installed with the h-mod the pilot could not accomplish any fine alignment in the aircraft additionally as noted in the interviews with test pilots hmds are known to migrate out of alignment over time or known issue in the f-35 community so if he had had the mod he might have been able to realign it in flight but this jet didn't have it all right control law during mess app lockheed martin's report indicated the pilot inputs combined with the fcs control law and landing gear characteristics upon a three-point landing at 202 knots led to the aircraft oscillation large pitch rates the toggling between different control modes due to weight on the wheels large pilot inputs and high-speed aircraft stress the control system's ability to respond to the pilot input and stabilize the aircraft so basically we were in unknown territory at this point the the jet control law could not keep up with what he was asking to do in particular the rate at which the horizontal tail could change was maximized and the flight controls were saturated the saturation flight control then defaulted to a nose down position preventing immediate response to his final attempt to abort the landing by pulling af stick and max a b as a result the pilot was unable to command nose up horizontal tail deflection despite holding full f stick for three seconds when questioned neither the mishap pilot aib pilot member or f-35a test pilots were familiar with some of the details of this logic in reference to some of the specific functions that came into play during the oscillation this app could not be found in the f-35 manuals to's or jtd some of the control functions are reset when the aircraft exits pa mode and goes into pa bounce mode the claw is trying to remove steady-state error between the pilot flight controls commands and the actual status of the flight control surfaces to stabilize the aircraft so nobody knew that it would do this sounds a lot like mcas so here's something interesting his flight suit they looked at his flight suit and was consistent with high-speed egress to include embedded fragments of the transparent portion of the canopy and exposure to propellants used in the ejection sequence it was determined that all right pilot flight equipment functioned as designed provided physiological protection of the pilot during the full flight duration and through the emergency escape realize on the f-35 um it's not like a traditional canopy the canopy goes and then the seat goes this is the canopy fractures and the seat goes through the canopy so he had fragments in his flight suit which i believe they'll talk about here in a second ended up in his skin so i don't think that's a good thing but at least the seat worked and he made it out safely weather a few clouds of 2000 not a factor crew qualification he was an instructor pilot in the f-35 he had 137 hours uh in the f-35 total he um initially initially qualified a year ago and he was previously qualified in the strike eagle with uh 1200 hours and 410 combat hours uh the last 30 days he'd only flown four sorties the last 60 days uh cumulative he had flown eight sorties in the 90 days uh 19 sorties so 1970's in 90 days he hadn't been flying very much and that's probably also due to covet because remember this is in that may time frame uh it talks about medical nothing really was a factor he had a waiver for a medical diagnosis but they said he was in good health and it's not relevant to this he was evaluated at eglin in the hours following he sustained injuries during the process of ejection there were numerous small foreign bodies in the skin especially in his forearms which was covered by the flight suit or at least there was at least one foreign body in his eye lastly he appears to have suffered a vertebral body compression fracture he reportedly was able to walk immediately afterwards feeling wonderful to be alive so um those kind of compression fractures happen ejecting so he's just happy to be alive but the foreign bodies in the skin that's a big deal i mean that's that's not good so crew rest they talk about that 12 hours duty-free eight hours of uninterrupted sleep opportunity um there's flight duty period tables and all that stuff the flight duty period for single-seat aircraft was 12 hours based on a 72-hour history he met the rest requirements he reported at work at sixteen hundred takeoff was at eight o'clock so he hadn't been at work very long the day prior he was scheduled to fly but that flight was canceled due to weather and he arrived home at 1700 uh that the day prior uh and the two days prior to that it was a weekend so no duty on those days ops tempo was normal slightly degraded due to covid uh precautions and minimum were essential uh manning mask word social distinct lack of personal pilot meetings and phase briefs had been six weeks since the squadrons last night week and he last flew at night 42 days prior on 7 april he hadn't been flying much at night his most recent flight part of the mishap was 11 days earlier so a little over a week almost two weeks human factors so um talks about all the human factor stuff and that's always especially when it's not a mechanical issue that's usually where we go so the first one is procedure not following uh not followed correctly he did not follow guidance when he failed to achieve final airport approach airspeed announce airspeed change and did not follow guidance when he failed to slow to on speed so he never engaged the approach power compensator apc didn't go into the right mode stayed and speed hold was 202 knots so that's not the procedure that's not what he did over control under control the aircraft that is his oscillations so he under controlled the aircraft when he didn't switch out a speed hold so he didn't do what he needed to do to get into the right aircraft mode uh and then to stop the pitch in subsequent oscillations uh he was ineffective so he wasn't he ended up in this oscillation where nose is up he's pushing down nose is down he could not get in sync with the aircraft and then at some point the aircraft just ignored him preconditions latent failures or conditions instrument factors such as design reliability lighting location symbology etc he experienced an instrumentation system issue when it had the hmd misalignment so remember it doesn't have a hud it's got a virtual hud it's the helmet that's doing everything's in his helmet there's no physical hud like on an s16 or an f-18 he was experiencing the green glow from the projector in his hmd couldn't turn it down so when that glow is high and it's bright you can't see past it you know it's just creating this blob of green everywhere um worse than normal due to humidity he had to adjust settings to try to mitigate the glow within a few hundred feet of the ground and within several seconds of landing so he's in the landing approach phase messing with his helmet trying to get it turned down so he can land when he should have been you know going off of speed hold into that approach coupled mode fatigue so this is where he talks about fatigue is indicated on his report orm he did not he got for sleep with some frequency additionally he noted that he usually feels more fatigue in the process of flying this aircraft than previous aircraft the f-15 so the jet itself was making him fatigued it is known amongst the f-35 flying community the oxygen delivery system is very different than legacy oxygen delivery systems such as the one using the f-15e and i don't know if the f-15e uses locks liquid oxygen like some versions of the f or older versions of the f-16 and the older versions of the hornet or it uses an on-board oxygen generation system which is what's common in just about everything new now f35 t6 f22 it is known different than legacy oxygen generation systems it is a closed feedback driven system such as the initiation of inhalation exhalation actuate the liver air flow in the pilot with a slight change in pressure you will often experience it imperceptibly a delivered pressure of 0.01 to 0.03 pounds per square inch even when trying to exhale this means the pile is breathing out against the pressure gradient additionally feedback is initiated by the sense change and pressure of the pile to the system each breath in and out is since then augmented by the feedback system however this augmentation is not instantaneous such that the pilots subjected to slight delays in the pressure change delivery to the system with each breath these features inherent to the f-35 closed feedback system caused many pilots to report feeling more fatigued than normal because it's a little bit harder it's not a lot harder to breathe just a little bit harder it's just that little bit of getting that oxygen and you know it just takes a little bit more effort to breathe and over time it starts to wear you down the insidious increase in physical demand can translate into a degree of cognitive degradation on the night of the mishap he reported feeling 50 percent more degrade more drained than a similar prior sorority with a score on a cognitive degradation scale a six out of ten versus a baseline of four out of ten in the routine sorority the next thing they talked about is fixation uh that's when he's focused on one thing and not what he should be focused on which is all the sum of everything uh he was fixated on the faulty symbology during that critical phase of flight uh task saturation uh heating aggregate of degrading factors to his mental processes leading up to the mishap uh he's just over saturated with with his level of awareness and fatigue everything that was going on at that time it was just too much first he was a contact of a contact of an individual that tested positive the first order contacted the positive case had a pending case and if that individual tested positive then the mishap would be quarantined at home pinning his own taste which would cause operational logistical disruption second he found out he was switching from a less intensive so i guess that first thing was on his mind like hey am i going to be code positive i just i might be this might not be good second he found out he was switching from red to blue which i told you less less intensive to more intensive and he only had four hours to get everything ready and stuff third gci was late uh addition to the mission which changed the mission plan yeah last minute changes that can kind of get you off your game because you're like oh well that's an ad i really don't think that should be a real big excuse it happens like all the time you know you'd always have to have a primary and a backup game plan fourth the nighttime ils contributed to the oversaturation according to mishap pilot and other witnesses landing in f35 at nighttime is not a mundane task it's more difficult than nighttime ils landing in some of the legacy fire aircraft i believe that yeah a lot more symbology a lot more systems to manage yeah absolutely the critical confounding item that ultimately resulted in oversaturation was the misalignment at this moment the mishap pilot who was already fully taxed now had to identify and navigate the hmd misalignment correction of this error involves setting a flight path into the abyss because it's water i mean there's nothing out there uncomfortable place to aim essentially because the archives pointed dirt prior to the runways such as the illusion given the lack of visual daytime cues as opposed by the hand of god phenomenon which is mental resistance so he's trying to push his mind knows where it's supposed to go but he's like i don't want to do that a negative habit transfer is a factor when the injury visual reverts to a highly learned behavior to previous air system he was a very experienced strike eagle pilot and as a prior strikeout pilot he was not accustomed using the e bracket to assess aoa because it did not have an aoa sample so it's the e bracket tells you what your aoa is and you put your flight path marker around that i did not know that the aoa the f-15e did not have an aoa stamp staple but in the f-16 that's what we use same thing in the hornet further he had a negative habit transfer when he assessed his ground track based on his f-15e experience he thought the ground rush effect mean the rate at which the ground was rising toward him during his landing descent was within the realm of normal he did not interpret that as indicating that he was fast it was also dark at night you're just watching lights come up at you he had landed the simulator at approximately the same speed he was traveling during the mishap that's interesting simulator did not replicate the oscillation he experienced in addition two members of the aib team were able to successfully land at the speed and altitude at the speed and attitude the lockheed martin mishap technical reports say the pitch rate sensitivity evident in the flight was not observed in the pilot simulation or initial attempts to match the maneuver with offline simulation so there they couldn't get replicated in the sim in addition simulation did not reflect the divergence could result in from flight control saturation efforts to recreate the mishap the next one is confusion he had confusion after the first two seconds of landing his attempts to raise the nose initiated go around were flu so he's confused he's like i've got full astic on burner why is this thing not climbing away it's got the power to do it why is it not climbing why is it going full nose down so it was just ignoring what he had what he he had commanded it to do so he's like i'm out interference and interruption um so that is his normal habits were interrupted by the misalignment of the hmd and that's basically at the final approach fix or when the glideslope reaches two and a half degrees begin to sense capture the design glideslope for the ils then engage a pc or slow down speed no later and decision height so you've got between the final approach fix and decision height to engage apc for that final portion of landing and that is where all this stuff happened with hmd alignments and being too bright and stuff so it was interference and interrupted his normal habit patterns that you know he forgot about it because he was worried about his helmet so he forgot about going in the speed hole he he said he typically engages and verifies apc set and aoa on final after setting the aircraft glide path and aimpoint after failing to set the apc that did not verify her crosstalk speed or aoa for the remainder approach is generally de-emphasizing the revised cross-check method and normal habit patterns evidence command and control resources are deficient as a factor when installation procedures are inadequate the mishap occurs during covet 19 pandemic significant measurable impacts on infrastructure logistics planning and execution we saw that with the shaw mishap week on week off split operations has uh negative effects on unit cohe cohesion flying operation an example it makes proper pilot meetings such as phase breeze prior to the start of night flying impossible in conventional sense it relies on passive disconcerted methods by which to pass critical information individuals with elderly ill or otherwise susceptible family members in the house such as newly pregnant wife maintain a constant degree of vigilance and skepticism at work threat mitigation of the coronavirus is a constant mental exercise and when the mp was deciding when he would show up for work the impact of this epidemic on flying operations which is impossible to quantify cannot be overstated all right now the opinion summary from uh the board president he finds that was caused by touching down to 200 knots um the four factor speed hold hmd alignment fatigue and a lack of knowledge of that logic and it wasn't just him no one really knew about it uh so the cause 202 knots it's 50 knots fast shallow caused the balance the second one is uh conflicted inputs upon landing resulted in the his inability to recover the aircraft he can attempted to re-establish a landing attitude after touchdown the aircraft landing lasted five seconds before he ejected upon touchdown he initially attempted to dampen the rise rapid rise of the nose produced by the first bounce his initial reaction was consistent with attempting to recover from a bounce instead of landing attitude however his inputs quickly fell out of sync with the aircraft oscillations this resulted multiple conflicting inputs and at that point the claw just started ignoring him who's in charge here [Music] the claws are master claw chooses who will go and who will stay ludicrous at the two second mark he set afstic tried to re-establish laning attitude uh was unable to overcome the nose-down bias and had to execute a go-around he was confused helpless and ignored three seconds of input was not enough to overcome the saturation caused by the two second prior inputs it failed to orient the aircraft to appropriate attitude to go around thus catastrophic loss these are those are the main reasons so contributing landing would speed hold and gauge wasn't supposed to do that we talked about that says the mishap pilot was distracted at his normal auto throttle configuration point misalignment contributing factor the mp's preferred technique of landing in the apc mode would not include amend to being in speed hold either as neither mode requires pilot interaction with the throttle once set landing with speed hole engage produces no audible warnings for dangerous configuration flew the remainder of the final approach with auto throttle engage continue the approach unaware of the aircraft's incorrect configuration as there was no need for throttle interactions no airspeed cross-check and queuing he's in the wrong throttle mode the hmd alignment distracted him we talked about that cognitive degradation um mentally drained he was preparing for red air ended up going to blue gci i mean he couldn't coordinate and that just happened at the last minute he had interrupted sleep uh and he was notified the day prior of exposure to cover 19 was waiting a colleague's test results to determine if he was susceptible um i remember he had some underlying health conditions so he might have been worried about covet uh the hmd projector brightness was bright at 300 agl uh he was having to squint through the green glow to even find the runway because it was just overwhelming him um and he reported constant mental fatigue flying the f-35 work of breathing and we talked about why which is how the obox system is uh designed so it was more challenging than normal and then lack of knowledge on the claw logic there are so many different modes and there's minimal discussion of any in the manual the 3-3 it's complex there's too many sub-modes to describe in the aforementioned forums nonetheless there existed efficiency and depth of claw logic and flight control system knowledge in the f-35a baseline manuals in academics so what his fault he didn't know it's just people just don't know conclusion um yep he speed hold misalignment and then lack of sleep post cognitive postmission cognitive degradation um lack of system knowledge and negative training from similar experience prevented him from responding to high speed landing i mean what can we learn from this we see this a lot it reminds me a lot of the boeing mcas thing where you have a system that nobody really knows how it is not to say that this what lockheed did was you know a workaround or anything like that eventually it does come out and it is uh known it's just the knowledge wasn't sufficient in this case but at the end of the day our over reliance on automation while technology is a good thing and you know they call them children of the magenta having all that stuff automation auto throttles and all that stuff is great but at the end of the day you have to fly the airplane so you know and if you get to the point where you know you can't see the runway go arounds are free you know unless you're about to flame out and you know this is your only attempt at landing you can go around and go around try again get everything squared away on downwind and then come back and land the weather was good he wasn't facing a divert or anything so he could have gone around to see if he could fix that but again his cognitive function maybe he you know just wasn't thinking that but even when you have automation even though you know as an f35 pilot if you say well you know we don't really look at that you still should as basic pilot skills be looking at your aoa and your airspeed just as a cross check because it's always trust but verify you know and i'm not saying that that makes him a bad pilot or that i'm any better or would do any better than he did i mean i always talk about you know the any given sunday this could happen to anybody this could happen to the best pilot or the worst pilot it is not an indication of how good a pilot is it's just when the swiss cheese model lines up and everything starts going wrong that's when we get mishaps and stuff so we have to go back to basics we have to you know trust that the system works but at the end of the day it's our responsibility as pilots to um verify that the speed's right you know because a simple cross check when he's at 300 feet going wow i'm at 200 knots might have saved the aircraft or you know reverting to a backup mode you know i don't know enough about the f35 i don't know if i'm sure they practice just turning it off and flying it uh manually without having all the hmd and stuff but you could definitely go around early and then fix it later i mean that's kind of the biggest lesson learned but a lot of stuff going on here um you know like i said i do believe the pilot is still flying so you know i'm not this is not an attempt to throw this person under the bus at all because you know it can happen to anybody and it's it's it's good that we're here to talk about the mistakes that person made and how they can recover and come back to flying versus you know talking about another um tragedy where we lost a pilot so this is one of the the better ones of this year there was another fatality uh around this time frame too uh but it's definitely something we can learn from it's definitely something we can use to get better in general you know whether it's an airliner or it's a fighter because we use automation and everything so anyway what do you think about it let me know in the comments what your thoughts are of this mishap i hope we get some good lessons learned out of it i hope everybody uh is having a great thanksgiving week and um you know if you're able to spend time with your family i hope you're you're doing that and having a great time so thanks for watching we'll see you next time [Music] [Music] off don't be a douche that's rule number one

Channel: C.W. Lemoine

Views: 79,907

Rating: 4.9692402 out of 5

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Id: sof1k5DsIrs

Length: 44min 17sec (2657 seconds)

Published: Mon Nov 23 2020

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https://www.airforcemag.com/app/uploads/2020/10/Eglin-AFB-F35A-AIB-Report_Signed.pdf

https://www.airforcemag.com/eglin-f-35-crash-blamed-on-landing-speed-but-software-helmet-oxygen-also-faulted/

https://www.airforcemag.com/f-35-crash-corrective-measures-must-remain-secret-jpo-says/