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UNITED STATES AIR FORCE AIRCRAFT ACCIDENT INVESTIGATION ... · PDF file United States Air Force Accident Investigation Board Report Class A, Sheppard AFB Under 10 U.S.C. § 2254(d)

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  • UNITED STATES AIR FORCE

    AIRCRAFT ACCIDENT INVESTIGATION

    BOARD REPORT

    T-6A, T/N 07-3890

    89TH FLYING TRAINING SQUADRON

    80TH FLYING TRAINING WING

    SHEPPARD AIR FORCE BASE (AFB), TEXAS

    LOCATION: 21 MILES NE OF SHEPPARD AFB, TEXAS

    DATE OF ACCIDENT: 1 MAY 2019

    BOARD PRESIDENT: COLONEL EDWARD S. BREWER

    Conducted IAW Air Force Instruction 51-307

  • United States Air Force Accident Investigation Board Report

    Class A, Sheppard AFB

    Under 10 U.S.C. § 2254(d) the opinion of the accident investigator as to the cause of, or the factors

    contributing to, the accident set forth in the accident investigation report, if any, may not be considered as

    evidence in any civil or criminal proceeding arising from the accident, nor may such information be

    considered an admission of liability of the United States or by any person referred to in those conclusions

    or statements.

    EXECUTIVE SUMMARY

    UNITED STATES AIR FORCE

    AIRCRAFT ACCIDENT INVESTIGATION

    T-6A, T/N 07-3890

    21 MILES NE OF SHEPPARD AIR FORCE BASE, TEXAS

    1 MAY 2019

    At 1313 hours local time on 1 May 2019 a T-6A Texan II, tail number 07-3890, crashed 21 miles

    northeast of Sheppard Air Force Base (AFB), TX. The mishap crew (MC) included a mishap

    instructor pilot (MIP), 97th Flying Training Squadron (FTS), who supervised the mishap pilot

    (MP), 89 FTS. The MP was conducting a transition sortie in the Pilot Instructor Training course

    from the front seat. The MC ejected and sustained minor injuries. The mishap aircraft (MA) was

    assigned to the 80th Flying Training Wing, Sheppard AFB, TX.

    While setting up a training maneuver with building cloud formations, the MIP flew the MA in an

    unintentional nose-high trajectory with decreasing airspeed. In an attempt to regain airspeed, the

    MIP tried to lower the nose of the aircraft towards the horizon and penetrated the weather. Next,

    the MIP attempted to roll wings level while still in a nose-high attitude with insufficient airspeed

    and high-power setting. As a result, the MA departed controlled flight in a power-on, inverted

    spin. The MC attempted to recover the MA until the MIP assessed the MA unrecoverable and

    commanded ejection at approximately 10,800 feet mean sea level. The MA, valued at

    approximately $5.7 million, impacted the ground and was destroyed. There were no casualties

    and no loss of civilian property.

    The Accident Investigation Board President, by a preponderance of evidence, determined the cause

    of the mishap to be pilot error. Specifically, the MIP flew the MA into an aerodynamic stall due

    to fixation on environmental factors. Then the MIP did not follow the prescribed memorized,

    critical-action checklist, inhibiting recovery.

  • United States Air Force Accident Investigation Board Report

    Class A, Sheppard AFB

    T-6A, T/N 07-3890, 1 May 2019

    i

    SUMMARY OF FACTS AND STATEMENT OF OPINION

    T-6A, T/N 07-3890

    1 MAY 2019

    TABLE OF CONTENTS

    ACRONYMS AND ABBREVIATIONS ...................................................................................... iii SUMMARY OF FACTS ................................................................................................................ 2

    1. AUTHORITY AND PURPOSE ...........................................................................................2 a. Authority .........................................................................................................................2 b. Purpose ............................................................................................................................2

    2. ACCIDENT SUMMARY .....................................................................................................2 3. BACKGROUND ..................................................................................................................3

    a. Air Education and Training Command ...........................................................................3 b. The 80th Flying Training Wing ......................................................................................3

    c. The 89th Flying Training Squadron ................................................................................3 d. The T-6A Texan II ..........................................................................................................4

    4. SEQUENCE OF EVENTS ...................................................................................................4 a. Mission ............................................................................................................................4 b. Planning ..........................................................................................................................4

    c. Preflight ...........................................................................................................................5 d. Summary of Accident .....................................................................................................5

    e. Impact ............................................................................................................................11 f. Egress and Aircrew Flight Equipment (AFE) ...............................................................12

    g. Search and Rescue (SAR) .............................................................................................12 h. Recovery of Remains ....................................................................................................13

    5. MAINTENANCE ...............................................................................................................13

    a. Forms Documentation ...................................................................................................13 b. Inspections ....................................................................................................................14

    c. Maintenance Procedures ...............................................................................................14 d. Maintenance Personnel and Supervision ......................................................................15 e. Fuel, Hydraulic, Oil, and Oxygen Inspection Analyses ................................................15

    f. Unscheduled Maintenance .............................................................................................15 6. AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS ............................................16

    a. Structures and Systems .................................................................................................16 (1) Flight Control Surfaces ......................................................................................... 16

    (2) Landing Gear System ............................................................................................ 16 (3) Engine.................................................................................................................... 16

    b. Evaluation and Analysis ...............................................................................................17 7. WEATHER .........................................................................................................................17

    a. Forecast Weather ...........................................................................................................17

    b. Observed Weather .........................................................................................................17 c. Space Environment .......................................................................................................18 d. Operations .....................................................................................................................18

  • United States Air Force Accident Investigation Board Report

    Class A, Sheppard AFB

    T-6A, T/N 07-3890, 1 May 2019

    ii

    8. CREW QUALIFICATIONS ...............................................................................................18 a. Mishap Instructor Pilot ..................................................................................................18 b. Mishap Pilot ..................................................................................................................19

    9. MEDICAL ..........................................................................................................................20

    a. Qualifications ................................................................................................................20 b. Health ............................................................................................................................21 c. Pathology.......................................................................................................................21 d. Lifestyle ........................................................................................................................21 e. Crew Rest and Crew Duty Time ...................................................................................21

    10. OPERATIONS AND SUPERVISION .............................................................................21 a. Operations ...............................................................................................

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