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  • UNITED STATES AIR FORCE AIRCRAFT ACCIDENT INVESTIGATION

    BOARD REPORT

    F-16CJ, T/N 92-3890

    UNITED STATES AIR FORCE AIR DEMONSTRATION SQUADRON 57th WING

    NELLIS AIR FORCE BASE, NEVADA

    LOCATION: EL PASO COUNTY

    DATE OF ACCIDENT: 2 JUNE 2016

    BOARD PRESIDENT: COLONEL BRIAN J. KAMP

    Conducted IAW Air Force Instruction 51-503

    [Volume One of One]

  • United States Air Force Accident Investigation Board Report

    F-16CJ Crash, El Paso County, CO

    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

    BLOCK 52 F-16CJ, T/N 92-3890 EL PASO COUNTY, CO

    2 JUNE 2016

    On 2 June 2016 at 13:00 local time an F-16CJ was destroyed by ground impact after the Mishap Pilot (MP) ejected south of Peterson Air Force Base (AFB), CO. The MP sustained a minor injury and no other personnel were injured. The Mishap Aircraft (MA) Tail Number 92-3890 and the MP are assigned to the 57th Wing, United States Air Force Air Demonstration Squadron (USAFADS), Nellis AFB, NV. The MA, valued at $29,466,037.00 (total government loss), was destroyed. There was no known damage to civilian property.

    The mishap occurred as part of a six F-16 aircraft, USAFADS flyby and airshow combination for a United States Air Force Academy graduation ceremony, Colorado Springs, CO. The mission was uneventful until the MA entered the Peterson AFB traffic pattern in preparation for landing. When the MA was positioned on downwind (parallel to, and opposing the active landing runway), the highly experienced MP inadvertently placed the throttle to cutoff position (engine shutdown). This normally requires both (a) an actuation of the throttle cutoff release trigger switch (throttle trigger), which then permits (b) full throttle grip rotation outboard -- enabling the throttle to be retarded aft (pulled backwards), past the cutoff stop. Below the minimum altitude/airspeed required for either an engine restart or flame-out landing, the MP was forced to eject over a grass field in El Paso County, CO.

    The throttle trigger must be physically actuated (depressed, squeezed, pulled) to overcome the spring-force in its un-actuated position. Analysis by Air Force Research Laboratory/Materials Integrity Branch identified intermittent sticking/binding of the MA throttle trigger, causing the throttle trigger to remain in the retracted/stuck position after actuation. The throttle trigger bushing was examined and determined to be damaged and worn due to throttle trigger clevis pin misalignment, along with metallic-particle debris contamination -- both increasing the chance of throttle trigger sticking/binding. In addition, lubricant to the throttle trigger assembly was identified (inconsistent with maintenance technical orders), which exacerbated the debris contamination condition.

    The Accident Investigation Board President found by a preponderance of the evidence the cause of this mishap was a throttle trigger actuation and subsequent malfunction (throttle trigger stuck in retracted position) followed by the MPs inadvertent full-rotation of the throttle grip while retarding the throttle aft to cutoff position. Substantially contributing factors include maintenance Technical Orders that lack sufficient detail to consistently identify either a throttle trigger clevis pin misalignment or a sticking/binding throttle trigger.

  • United States Air Force Accident Investigation Board Report

    F-16CJ Crash, El Paso County, CO

    F-16CJ, T/N 92-3890, 2 June 2016 i

    SUMMARY OF FACTS AND STATEMENT OF OPINION F-16CJ, T/N 92-3890

    2 JUNE 2016

    TABLE OF CONTENTS

    ACRONYMS AND ABBREVIATIONS .........................................................................................iii SUMMARY OF FACTS ................................................................................................................... 1 1. AUTHORITY AND PURPOSE .......................................................................................... 1

    a. Authority .......................................................................................................................... 1b. Purpose ............................................................................................................................. 1

    2. ACCIDENT SUMMARY .................................................................................................... 13. BACKGROUND .................................................................................................................. 2

    a. Air Combat Command ..................................................................................................... 2b. United States Air Force Warfare Center (USAFWC) ...................................................... 2c. 57th Wing......................................................................................................................... 2d. United States Air Force Air Demonstration Squadron .................................................... 2e. F-16 .................................................................................................................................. 3

    4. SEQUENCE OF EVENTS ................................................................................................... 3a. Mission ............................................................................................................................. 3b. Planning ........................................................................................................................... 3c. Preflight............................................................................................................................ 3d. Summary of Accident ...................................................................................................... 4e. Impact .............................................................................................................................. 8f. Egress and Aircrew Flight Equipment ............................................................................. 9g. Search and Rescue (SAR) ................................................................................................ 9h. Recovery of Remains ..................................................................................................... 10

    5. MAINTENANCE ............................................................................................................... 10a. Aircraft Forms & Documentation .................................................................................. 10b. Inspections ..................................................................................................................... 10c. Maintenance Procedures ................................................................................................ 11d. Maintenance Personnel and Supervision ....................................................................... 12e. Fuel, Hydraulic, and Oil Inspection Analyses ............................................................... 12f. Unscheduled Maintenance ............................................................................................. 13

    6. AIRFRAME, MISSILE, OR SPACE VEHICLE SYSTEMS ............................................ 13a. Structures and Systems .................................................................................................. 13b. Evaluation and Analysis ................................................................................................ 18

    7. WEATHER ........................................................................................................................ 23a. Forecast Weather ........................................................................................................... 23b. Observed Weather .......................................................................................................... 24c. Space Environment ........................................................................................................ 24d. Operations ...................................................................................................................... 24

    8. CREW QUALIFICATIONS .............................................................................................. 24a. USAFADS Pilot Waivers .............................................................................................. 24b. Mishap Pilot ................................................................................................................... 25

  • United States Air Force Accident Investigation Board Report

    F-16CJ Crash, El Paso County, CO

    F-16CJ, T/N 92-3890, 2 June 2016 ii

    9. MEDICAL .......................................................................................................................... 26a. Qualifications ................................................................................................................. 26b. Health ............................................................................................................................. 26c. Pathology/Toxicology .................................................................................................... 26d. Lifestyle ..................................................................................................................

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