HH-60G

RAF LAKENHEATH, ENGLAND

07 January 2014

UNITED STATES AIR FORCE

AIRCRAFT ACCIDENT INVESTIGATION

BOARD REPORT

HH-60G, TAIL NUMBER 88-26109

56TH RESCUE SQUADRON

48TH FIGHTER WING

ROYAL AIR FORCE LAKENHEATH

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LOCATION:  CLEY NEXT THE SEA, NORFOLK,

UNITED KINGDOM

DATE OF ACCIDENT:  7 JANUARY 2014

BOARD PRESIDENT:  BRIGADIER GENERAL JON A. NORMAN

CONDUCTED IN ACCORDANCE WITH AIR FORCE INSTRUCTION 51-503

EXECUTIVE SUMMARY

AIRCRAFT ACCIDENT INVESTIGATION

HH-60G, TAIL NUMBER 88-26109

CLEY NEXT THE SEA, NORFOLK, UNITED KINGDOM

7 JANUARY 2014

On 7 January 2014, at approximately 1805 local time (L), the mishap aircraft (MA), an HH-60G, Tail Number 88-26109, assigned to the 56th Rescue Squadron, 48th Fighter Wing, Royal Air Force (RAF) Lakenheath, United Kingdom (UK), experienced multiple bird strikes during a training mission and impacted privately-owned, grass-covered marshland near Cley next the Sea, UK. The four crewmembers were fatally injured in the mishap. There were no civilian injuries or fatalities. The MA was destroyed upon impact. The cost to the United States government is estimated at $40,302,061. Damage to private property consisted of minimal burning to grass at the crash site.

The purpose of the training mission was to conduct a nighttime rescue scenario of a downed F-16 pilot. The training mission included two aircraft, the flight lead aircraft and the MA, collectively known as the mishap formation MF. All members of the flight lead crew and mishap crew wore night vision goggles. The MF departed RAF Lakenheath at 1733L and proceeded to an initial point to verify the status of the simulated downed pilot and conduct threat analysis. Strong winds pushed the MF toward a populated area. To avoid causing a noise disturbance, the MF reestablished its initial point to the north near the coastline.

The MA departed the new initial point at 1804L, flying east at approximately 110 feet above ground level and 110 knots indicated air speed toward a landing zone near Salthouse, UK. The flight path took the MF over Cley Marshes in the Norfolk Wildlife Trust near Cley next the Sea. A flock of geese took flight from Cley Marshes, likely startled by the noise of the approaching helicopters, and struck the MA. At least three geese penetrated the windscreen, rendering the mishap pilot and mishap co-pilot unconscious, and at least one goose struck the mishap aerial gunner in the performance of special mission aviator duties, rendering the mishap areal gunner unconscious. In addition, at least one goose hit the nose of the MA, disabling the Trim and Flight Path Stabilization systems. With the mishap pilot and mishap co-pilot unconscious and the Trim and Flight Path Stabilization disabled, the MA’s cyclic stick, which controls pitch and roll of the aircraft, was free to move randomly. The MA banked left to a point where it had no vertical lift. Without vertical lift, and without pilot input to correct the left roll, the MA was not able to remain airborne or maintain controlled flight. The MA impacted the ground at 1805L—approximately three seconds after being struck by the geese.

The Accident Investigation Board President found by clear and convincing evidence that multiple bird strikes caused the mishap by rendering the mishap pilot and mishap co-pilot unconscious and disabling the Trim and Flight Path Stabilization systems.

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. 

SUMMARY OF FACTS AND STATEMENT OF OPINION

HH-60G, TAIL NUMBER 88-26109

7 JANUARY 2014

TABLE OF CONTENTS

IN MEMORIAM ............................................................................................................................. iii

DEFINITIONS ............................................................................................................................... iv

TABLE OF FIGURES ...................................................................................................................... v

MAP OF UNITED KINGDOM .......................................................................................................... vi

ACRONYMS AND ABBREVIATIONS ................................................................................................ vii

SUMMARY OF FACTS .................................................................................................................. 1

    1.  AUTHORITY AND PURPOSE ................................................................................................. 1

        a.  Authority ........................................................................................................................1

        b.  Purpose ..........................................................................................................................1

    2.  ACCIDENT SUMMARY ..........................................................................................................1

    3.  BACKGROUND ....................................................................................................................1

        a.  United States Air Forces in Europe ....................................................................................2

        b.  Third Air Force .................................................................................................................2

        c.  48th Fighter Wing ............................................................................................................2

        d.  56th Rescue Squadron.....................................................................................................2

        e.  HH-60G Pave Hawk ........................................................................................................3

    4.  SEQUENCE OF EVENTS .......................................................................................................4

        a.  Mission ...........................................................................................................................4

        b.  Planning ..........................................................................................................................4

            (1)  Bird Information ........................................................................................................5

            (2)  Roll Call and Crew Mission Briefing ..............................................................................6

        c. Preflight ............................................................................................................................6

        d.  Summary of Accident ......................................................................................................7

        e.  Impact ............................................................................................................................9

        f.  Egress and Aircrew Flight Equipment ..................................................................................9

        g.  Search and Rescue .........................................................................................................11

        h.  Recovery of Remains ......................................................................................................11

    5.  MAINTENANCE ....................................................................................................................12

        a.  Forms Documentation .....................................................................................................12

            (1)  General Definitions .....................................................................................................12

            (2)  Documentation Review ..............................................................................................13

        b.  Inspections ......................................................................................................................13

            (1)  Aircraft Inspections ....................................................................................................14

            (2)  Engine Inspections .....................................................................................................14

        c.  Maintenance Procedures ...................................................................................................14

        d.  Maintenance Personnel and Supervision ............................................................................15

        e.  Fuel, Hydraulic, and Oil Inspection Analyses .......................................................................15

        f.  Unscheduled Maintenance .................................................................................................16

        g.  Aircraft Performance ........................................................................................................16

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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    6.  AIRFRAME SYSTEMS ...........................................................................................................16

        a.  Structures and Systems .................................................................................................16

            (1)  Airframe ..................................................................................................................16

            (1)  Airframe ..................................................................................................................16

            (2)  Rotor System ..........................................................................................................16

            (3)  Engines ....................................................................................................................17

            (4)  Transmission and Powertrain ....................................................................................17

            (5)  Flight Controls/Hydraulic Systems .............................................................................17

            (6)  Other Considerations ................................................................................................19

        b.  Evaluation and Analysis ...................................................................................................19

            (1)  Integrated Vehicle Health Monitoring System .............................................................19

            (2)  Cockpit Voice/Flight Data Recorder ...........................................................................20

            (3)  Analysis ...................................................................................................................20

    7.  WEATHER ..........................................................................................................................20

        a.  Forecast Weather ..........................................................................................................20

        b.  Observed Weather .........................................................................................................21

        c.  Space Environment ........................................................................................................21

        d.  Operations ....................................................................................................................21

        e.  Weather Impacts on Bird Locations ................................................................................21

    8.  CREW QUALIFICATIONS .....................................................................................................21

        a.  Mishap Pilot ...................................................................................................................21

        b.  Mishap Co-pilot .............................................................................................................22

        c.  Mishap Flight Engineer ....................................................................................................22

        d.  Mishap Aerial Gunner......................................................................................................23

    9.  MEDICAL ...........................................................................................................................23

        a.  Qualifications .................................................................................................................23

        b.  Health ...........................................................................................................................23

        c.  Pathology.......................................................................................................................24

        d.  Lifestyle .........................................................................................................................24

        e.  Crew Rest and Crew Duty Time ......................................................................................24

    10.  OPERATIONS AND SUPERVISION .......................................................................................24

        a.  Operations .....................................................................................................................24

        b.  Supervision ....................................................................................................................25

    11.  HUMAN FACTORS .............................................................................................................26

        a.  Introduction ...................................................................................................................26

        b.  Applicable Factors ..........................................................................................................26

    12.  GOVERNING DIRECTIVES AND PUBLICATIONS ...................................................................26

        a.  Publically Available Directives and Publications Relevant to the Mishap ...............................26

        b.  Other Directives and Publications Relevant to the Mishap ..................................................27

    13.  ADDITIONAL AREAS OF CONCERN ....................................................................................28

STATEMENT OF OPINION .............................................................................................................29

    1.  OPINION SUMMARY ............................................................................................................29

    2.  BACKGROUND ...................................................................................................................29

    3.  CAUSE ..............................................................................................................................30

    4.  CONCLUSION ....................................................................................................................31

INDEX OF TABS ......................................................................................................................... 33

Cover Photo Credit:  Airman First Class Trevor T. McBride

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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IN MEMORIAM

On 7 January 2014, four Airmen from the 56th Rescue Squadron took flight on a training exercise in an HH-60G Pave Hawk. As the moon lit the English countryside, tragedy claimed their lives. These four Airmen were known to those they loved as brother, son, father, husband, sister, daughter, mother, wife, and friend.

The Air Force has many missions. Its fighters provide close air support to troops advancing on the ground. Its bombers drop destructive payloads on enemy assets. But the unique mission of the 56th Rescue Squadron is to search and rescue—to seek out and save the lost, the wounded, and the fallen, day or night, in inclement weather, and in the face of hostile forces. These four Airmen took flight on 7 January 2014 to be ready, at a moment’s notice and under any circumstance, to find and recover those in need of refuge.

Our Airman’s Creed calls on those in uniform to “never leave and Airman behind.” Each day, these four Airmen practiced and applied the craft of rescue. Together they are credited with saving hundreds of lives. Those they loved should stand tall knowing that these four embodied all that it means to be an Airman.

Although their lives ended in an unexpected instant, their sacrifice did not spark in that moment—it crescendoed over lifetimes of dedication to serving their country and those they loved. Their legacies will be found in the countless hours supporting the mission of the Air Force, in the late nights helping a son or daughter with homework, and in the laughter shared with friends.

Their dedication shall forever be in our memories through the Rescue Motto, “These things we do… that others may live.”

DEFINITIONS

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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TABLE OF FIGURES

Figure 1:  Two HH-60G Pave Hawk helicopters Fly over Royal Air Force Lakenheath ....................3

Figure 2:  Relative Position of the Mishap Formation after Departure from the Initial Point ............8

Figure 3:  Flight Path of the Flight Lead Aircraft. ..........................................................................7

Figure 4:  ANVIS-4949 Night Vision Goggles Mounted to HGU-56/P Helmet ...............................10

Figure 5:  Crash Site ................................................................................................................11

Figure 6:  Summary of Mishap Timeline ....................................................................................12

Figure 7:  Flight Controls in HH-60G Cockpit .............................................................................18

Figure 8:  Nose Compartment Avionics .....................................................................................19

Figure 9:  Mishap Pilot’s Flight Times .........................................................................................22

Figure 10:  Mishap Co-pilot’s Flight Times .................................................................................22

Figure 11:  Mishap Flight Engineer’s Flight Times........................................................................23

Figure 12:  Mishap Aerial Gunner’s Flight Times..........................................................................23

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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MAP OF UNITED KINGDOM

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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ACRONYMS AND ABBREVIATIONS

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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The above list was compiled from the Summary of Facts, the Statement of Opinion, the Index of Tabs, and Witness Testimony (Tab V).

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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SUMMARY OF FACTS

1. AUTHORITY AND PURPOSE

a. Authority

On 7 February 2014, Lieutenant General Noel T. Jones, Vice Commander, United States Air Forces in Europe (USAFE), appointed Brigadier General Jon A. Norman to conduct an aircraft accident investigation of a mishap that occurred on 7 January 2014 involving an HH-60G aircraft near Cley next the Sea, Norfolk, United Kingdom (UK). The aircraft accident investigation was conducted in accordance with Air Force Instruction (AFI) 51-503, Aerospace Accident Investigations, at Royal Air Force (RAF) Lakenheath, UK, from 21 February 2014 through 23 March 2014. Board members included a Medical Member, Legal Advisor, Human Factors Member, Pilot Member, Recorder, Maintenance Member, Aircrew Flight Equipment Member, and Court Reporter (Tab Y-3).

b. Purpose

This board is a legal investigation convened to inquire into the facts surrounding the aircraft accident, to prepare a publicly-releasable report, and to gather and preserve all available evidence for use in litigation, claims, disciplinary actions, administrative proceedings, and for other purposes (Tab BB-102).

2. ACCIDENT SUMMARY

On 7 January 2014, at approximately 1805 local time (L), the mishap aircraft (MA), an HH-60G, Tail Number 88-26109, assigned to the 56th Rescue Squadron (56 RQS), 48th Fighter Wing (48 FW), RAF Lakenheath, experienced multiple bird strikes during a training mission and impacted privately-owned, grass-covered marshland near Cley next the Sea, UK (Tabs J-6, Q-11, and CC-23). All four members of the mishap crew (MC) were fatally injured on impact (Tabs N-10, Q-9 to Q-11, DD-3, DD-5, and DD-7). There were no civilian injuries or fatalities (Tab V-1.17, V-3.28, V-4.20, and V-5.10). The MA was destroyed upon impact (Tab S-12). The cost to the United States government is estimated at $40,302,061 (Tab P-5). Damage to private property consisted of minimal burning to grass at the crash site (Tab V-3.27). Numerous media outlets reported the mishap (Tab OO-3 to OO-9).

3. BACKGROUND

The MA belonged to 56 RQS, 48 FW, Third Air Force (3 AF), United States Air Forces in Europe (USAFE) stationed at RAF Lakenheath, UK (Tab K-12).

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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    e. HH-60G Pave Hawk

The HH-60G Pave Hawk is a twin-engine, medium-lift helicopter (Tab CC-16). Its primary mission is to conduct day or night personnel recovery operations into hostile environments to recover isolated personnel during war (Tab CC-11 and CC-15). The HH-60G is a highly modified version of the Army Black Hawk helicopter and features upgraded communications and navigation systems. All HH-60G helicopters have forward-looking infrared systems that greatly enhance nighttime low-level personnel recovery operations (Tab CC-15). The HH-60G is also tasked to perform military operations other than war, including civil search and rescue, medical evacuation, disaster response, and humanitarian assistance (Tab CC-11 and CC-15).

The standard HH-60G crew is comprised of two pilots and two special mission aviators (SMAs). They fill the pilot, co-pilot flight engineer, and aerial gunner crew positions. In addition to ensuring safe and effective operations while the helicopter is in the air. After a mission, the pilot ensures all required debriefing is accomplished. The co-pilot assists the pilot with all on-the-ground and in-the-air operations (Tab BB-233.1 to BB-233.2).

The SMA fulfilling the flight engineer duties is the systems expert for the helicopter. Among other things, the flight engineer is responsible for computing the weight & balance of the helicopter prior to flight and ensuring all equipment is aboard and properly secured. During flight, the flight engineer operates the rescue hoist and cargo sling, and monitors aircraft systems for proper performance. The SMA fulfilling the aerial gunner duties is responsible for the inspection, security, and operation of the helicopter’s armament, defensive, and radio systems. All four crewmembers visually scan outside the aircraft during flight for threat and obstacle avoidance using overlapping sectors (Tab BB-233.2).

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Figure 1: Two HH-60G Pave Hawk helicopters Fly over Royal Air Force Lakenheath

HH-60G, TAIL NUMBER 88-26109, 7 JANUARY 2014

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