Pilot error cited in Super Hornet crash
November 30, 2017
By: Geoff Ziezulewicz
A Super Hornet pilot who ejected from his jet April 21 in the West Pacific was less than 950 feet above the water when he got out and was nearly pulled underwater by his parachute cords after hitting the surface, according to the Navy’s command investigation.
The pilot, a Carrier Air Wing 2 captain, was miraculously uninjured in the harrowing incident in the Celebes Sea, south of the Philippines. His name was redacted in a copy of the investigation.
No one was disciplined, but the investigation cites the pilot’s failure to maintain speed and subsequent loss of jet control as a main cause of the crash.
Other factors in the mishap include an inexperienced junior officer in the carrier Carl Vinson’s control tower and a breakdown in communication between the pilot and the tower during “crew resource management,” a set of procedures to mitigate devastating human error in the air.
The report also found the pilot was dealing with compounding emergencies as he struggled to keep the jet under control, and that there was “a perceived rush to land the aircraft” back on the carrier.
“While certain aircrew errors and a lack of experience in the tower precipitated the ejection, none were intentional or due to culpable negligence,” a letter endorsing the report’s findings states.
The captain had about 4,100 total flight hours under his belt and was current in all qualifications, according to the report.
“(He) is well-known and respected in the Naval Aviation community, and is highly regarded by his fellow CVW-2 aviators,” the report states.
The captain took off in a F/A-18E that had just come off a 98-day down status after undergoing an assessment known as a Functional Check Flight Profile A, or FCF-A.
“All involved felt (the captain’s) experience was better suited for (the jet), since it is common for a long time down, post FCF-A aircraft to have minor issues following a successful FCF,” the investigation states.
Before takeoff, the captain was informed of discrepancies that remained on the jet that were not considered major, the report states.
They included a multi-functional information distribution system, or MIDS, that “worked on deck but fell out of the link airborne and would not get back in,” according to the report.
Other issues included a tactical air navigation system that didn’t work until it was overhead the ship.
Such issues appear to have contributed to the captain’s challenges in the cockpit, but are not cited in the report as causes of the crash.
After the end of the mission, which involved 10 jets and strike fighter weapons tactics, the captain reported smelling something burning “with great intensity” before it quickly dissipated, according to the report.
About an hour in, the captain was not receiving information via his MIDS communication system “and was focusing more than normal to visually see other aircraft” as they entered formation to land on the Carl Vinson, the report states.
The captain’s control panel indicated a hydraulic fluid caution, and while circling overhead, his wingman noticed a steady stream of fluid coming from near the captain’s right main landing gear door, according to the report.
He exited the landing formation at that point.
Due to his MIDS system not working, the captain had to consciously look out for other aircraft in a “see and avoid mindset,” the report states.
“Looks like we are tracking to you wanting to get on deck pretty soon,” the air boss on the carrier told the captain.
Several lapses in communication took place between the captain and the lieutenant communicating with him from the carrier’s tower, according to the report.
As hydraulic fluid cautions continued to sound, the captain shut down his right engine and was flying on just his left as he extended his landing gear.
While fighting to keep the jet balanced, and with his MIDS system and other navigational equipment not fully functional, the captain struggled to see the ship or other aircraft.
The captain readied to restart his right engine to balance out a side-to-side drift, known as a yaw, before he landed.
All this time, several audible cautions were going off around the captain, interrupting his communication with the tower, according to the report.
“He was focusing all his attention on flying the jet,” the report states. “Despite over 4,000 flight hours, he never had a situation where the jet was fighting him so much.”
Eventually, the captain brought both throttles to max, and inadvertently sent the left engine into afterburner.
He then reduced both throttles, but the aircraft pitched and went out of control.
The jet was doing about 161 mph at 932 feet above the sea, with the right wing down at a 39-degree angle, when he ejected.
“(The captain) stated the ejection sequence was immediate,” the report states. “He saw the canopy impact the water and began counting while he attempted to find his (quick disconnect) fittings to prepare for water entry. He was able to count to five before his feet hit the water.”
He inflated his life preserver on the second try, but became tangled in his parachute and thought he might be dragged under by the system.
A rescue helicopter was on the scene five minutes later and made visual contact with the captain. A swimmer arrived on scene 22 minutes after he ejected.
The captain reported soreness from the incident, and was shook up about crashing into the water and nearly drowning, the report states.
The lieutenant in the tower “was not experienced enough to handle the emergency situation and provide the necessary F/A-18E/F (flight instructions) to make key decisions,” according to the report.
In the air, the report chided the captain for not being more “proactive and authoritative” with the tower to ensure key information was communicated.
“Even though he was busy handling compound emergencies, he should have had the ability to guide the (lieutenant) to the necessary (instruction) items to read,” the report states.
The lieutenant also initiated a “perceived rush” to get the captain’s jet back on deck that was communicated through the air boss, but the captain should have slowed the situation down to properly handle the emergencies, according to the report.
Restarting the right engine and keeping it idle prevented the jet from balancing out, whereas matching the engines would have countered the asymmetry and allowed the jet to land, even with the other issues, the report states.
The captain was dealing with compound emergencies that affected his ability to maintain proper speed, which led to the buildup of side forces.
His inadvertent left engine afterburner activation led to the intensity of the control loss, according to the report.
“At this point in the emergency, I am confident any aviator in a similar position would have struggled to keep the jet from departing,” the report states.
The lead investigator writes in the report that they spent time in a simulator that reenacted the mishap’s hairiest seconds.
“(The captain) made a very timely and correct decision to eject,” the report states. “The surprise and intensity of the departure, which I saw first-hand in the simulator, could have easily caused a less experienced pilot to delay ejection, resulting in a loss of life.”