UH-1F Eglin AFB 1966   UH-1F DMAFB, AZ 1967   UH-1F Malmstrom AFB 1967   UH-1F Eglin AFB 1969   UH-1F Edwards AFB 1971   UH-1F Ellisworth AFB 1971   UH-1N FT. Bragg 1973   HH-1H Hill AFB 1974   UH-1F F.E. Warren 1975   UH-1F Ellsworth AFB 1982   UH-1F Whiteman AFB 1982   UH-1N Bahamas 1984   UH-1 Ellsworth AFB 1986   UH-1N Edwards-Jan-1991   UH-1N Edwards-Oct-1991   UH-1N Kirtland AFB 1996   UH-1N 1998   UH-1N F.E. Warren AFB 1999   UH-1N Kirtland AFB 2002   TH-lH Ft. Rucker 2009   UH-1N Malmstrom AFB 2010   UH-1N Kirtland AFB 2011   UH-1N Minot AFB 2013   CH-3C Malmstrom AFB 1965   CH-3C Sheppard AFB Mar. 1967   CH-3 Sheppard AFB Nov. 1967   CH-3E Midair in Laos 1970   HH-3E Korea 1973   HH-3E Elmendorf AFB 1974   HH-3E Iceland 1979   CH-3E Patrick AFB, 1984   HH-3E Osan 1984   HH-3E 29-Palms 1988   HH-3E Kadena 1989   CH-3E DMAFB 1989   H-5G Ladd AFB 1951   H-5H Maxwell AFB 1953   H-5 New York 1958   H-13G Niagara Falls 1955   H-13 Bryan AFB, TX 1957   H-19A San Marcos 1952   H-19A O'Neill, NB. 1953   H-19B Alexandria, LA. 1954   H-19B Austria 1954   H-19B France 1954   H-19B Korea 1954   H-19B March AFB 1954   H-19B Rhine Main AB 1955   H-19B Eglin AFB 1955   H-19 Skaneateles Lake, NY 1956   H-19 Ashiya Japan 1957   H-19 Edwards AFB 1957   H-19 Niagra Falls 1959   H-19 Sheppard   H-19B Loring AFB 1960   H-19 Beal AFB 1963   H-19 Larson AFB 1963   H-19 Saigon, RVN 1964   YH-21 Thule AB 1953   H-21 Goose Bay 1954   H-21A San Marcos TX 1955   H-21B Tennesse 1955   H-21 San Diego, CA 1956   H-21 Alaska 1957   H-21 Goose Bay 1958.   SH-21 Greenland 1958   H-21 Elmendorf AFB 1958   H-21 Dugway Proving Grnd. 1958   H-21 Goose Bay 1959   H-21 Greenland 1959   CH-21B Otis AFB 1959   H-21 Indian Springs AAF 1961   H-21 Luke AFB 1961   H-23B Moody AFB 1953   H-43A James Connally AFB 1959   H-43B Loring AFB 1961   H-43B Westover AFB 1961   HH-43B MacDill AFB, FL 1964   HH-43B Stead AFB 1965   HH-43B Clark AB, PI 1966   H-43 Sheppard AFC, TX 1966   HH-43B Phan Rang 1968   HH-43B MacDill AFB 1969   HH-43B Hill AFB 1973   HH-53C Eglin AFB 1969   CH-53C Germany 1975   CH-53C Germany 1976   HH-53C Woodbridge 1977   HH-53C Kadena AB 1979   HH-53B Kirtland AFB 1981   HH-53C Kirtland AFB 1982   MH-53 Philippines 1984   CH-53C Pope AFB 1984   HH-53C Hickam AFB, HI 1985   HH-53C Hill AFB 1986   HH-53H Nellis AFB 1986   MH-53J Korea 1995   HH-53B Vance AFB 1996   HH-53B Cherry Point 1998   MH-53J Ft. Bragg 1999   MH-53M RAF Mildenhall 2000   MH-53 Durango CO 2002   MH-53M USNS Kanawha 2002   MH-53M Afghanistan 2003   MH-53M FOL Hurlburt Fld 2003   MH-53M Kuwait 2003   MH-53M Hurlburt Fld. 2007   UH-60A Pope AFB 1987   HH-60G New York 1991   MH-60G Antigua 1991   HH-60G Great Salt Lake 1992   HH-60G Davis-Monthan AFB 1994   HH-60G Korea 1994   HH-60G Indian Springs 1998   HH-60G Al Jabar AB 1999   HH-60G Avon Park 2001   HH-60G Mt. Hood 2002   HH-60G Afghanistan 2002   HH-60G Afghanistan 2003   HH-60G Afghanistan 2004   HH-60G Angel Fire, NM 2005   HH-60G Kandahar 2007   HH-60G Afghanistan 2009   HH-60G Okinawa 2013   HH-60G Lakenheath 2014   HH-60G Lakenheath 2014 1   HH-60G Lakenheath 2014 2   Ellsworth AFB 1955   Hawaii crash 1963   Patuxent River NAS 1960   Randolph AFB 1957   Spokane River, WA 1959   Tyndall AFB 1961   Wright-Patterson 1956   Spokane River 1972  




07 January 2014





    a. Mission

The MA was the second helicopter in a formation of two HH-60G helicopters during a training mission departing from RAF Lakenheath on 7 January 2014 (Tab K-4 and K-6). The MA followed the flight lead aircraft (FLA) for the duration of the flight. The FLA and the MA comprised the mishap formation (MF). The MA contained two pilots, the mishap pilot (MP) and mishap co-pilot (MCP), and two SMAs, the mishap flight engineer (MFE) and the mishap aerial gunner (MAG), collectively known as the MC. The FLA contained two pilots, the flight lead pilot (FLP) and the flight lead co-pilot (FLCP), and two SMAs, the flight lead flight engineer (FLFE), and the flight lead aerial gunner (FLAG), collectively known as the flight lead crew (FLC) (Tabs K-4, K-6, and BB-233.1 to BB-233.2).

The purpose of the mission was to conduct a training flight to complete the annual checkride for MP (Tab K-12). The checkride required the FLC and MC to perform a nighttime tactical low-level (less than 500 feet above ground level (AGL)) formation, followed by an air-to-ground weapons employment exercises at a nearby range (Tabs K-4, K-12, and V-3.2 to V-3.3). Low-level training at night is essential to prepare HH-60G crews for combat missions (Tab V-3.45 to V-3.46).


The training mission also included a simulated rescue scenario of a downed pilot who had ejected from an F-16 fighter (Tabs K-9 and V-3.5). The requirements of the training mission dictated that the helicopters fly at 100 to 150 feet AGL and approach the rescue location at 110 knots indicated airspeed (KIAS) under cover of darkness to avoid a simulated enemy (Tabs V-18.3, BB-131, and MM-12).


    b. Planning


MP and FLCP developed the mission plan on 6 January 2014 (Tab V-3.4). The plan included takeoff from RAF Lakenheath, orbits at an initial point (IP) south of Blakeney, UK (approximately 36 nautical miles from RAF Lakenheath), and a low-level formation run-in to a pre-defined landing zone (LZ) near Salthouse, UK (approximately 3.54 nautical miles from the IP) (Tab S-16). The planned training mission duration was four hours, with a takeoff time of 1730L and return to RAF Lakenheath at 2130L (see Figure 3 below) (Tab K-4 and K-12).

The 56th Rescue Squadron frequently used the LZ near Salthouse for similar training missions. Because the 7 January 2014 training mission included low-level flying at night, there were limited options for flight routes, given the noise disturbance helicopters cause over populated areas, the necessity to avoid obstacles, and the availability of airspace (Tab V-2.9 and V-4.30).


The mission planning complied with 56 RQS, 48 FW, and Air Force requirements, to include: AFI 11-202, Volume 3, Flying Operations, 22 October 2010; AFI 11-202, Volume 3, Flying Operations, 22 October 2010 USAFE Supplement, 19 March 2012; AFI 11-2HH60, Volume 3, Flying Operations, 5 January 2011; AFI 11-2HH60, Volume 3, Flying Operations, 5 January 2011, Royal Air Force Lakenheath Supplement, 31 December 2012; and the United Kingdom Low Level Flying Handbook, 8 March 2012 (Tab V-3.17, V-4.2, and V-4.30). On 7 January 2014, 56 RQS Assistant Director of Operations properly authorized the mission (Tab K-4).


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


        (1) Bird Information

            (a) Guidance and Bird Location Information

The UK Military Low Flying Handbook (UK Handbook) uses the Bird Avoidance Model Geographical Information Service to provide guidance for avoiding bird strikes during low-level flights. The 56th Rescue Squadron complies with the UK Handbook when flying in Night Rotary Region 5 (NRR 5), in accordance with AFI 11-202, Volume 3, Flying Operations, 22 October 2010, USAFE Supplement, 19 March 2012 (Tabs V-2.12 to V-2.13 and BB-15.6 to BB-15.9). NRR 5 includes the coastline from Blakeney to beyond Salthouse (Tab NN-9). The UK Handbook advises aircrews to consider the bird avoidance guidance during the flight planning process (Tab NN-8). It states rotary wing aircraft in NRR 5 should remain below 500 feet AGL (Tab NN-9). It also states aircrews should cross coastlines at right angles and above 500 feet AGL to avoid bird strikes (Tab NN-8). Operations above 500 feel AGL did not support mission requirements (Tab V-3.43 to V-3.46).


The 56th Rescue Squadron receives bird activity maps monthly from the United Kingdom Ministry of Defense (MOD). These maps indicate bird hazard areas and codes each area by time of day and severity using a low-medium-high hazard scale. The legend defines dusk at one hour before and after sunset (Tab NN-3 and NN-5). The 56th Rescue Squadron posts these maps for aircrew reference during mission planning (Tab V-3.39).


The Norfolk Wildlife Trust (Wildlife Trust) near Cley next the Sea conducts daily bird counts (Tab V-13.8 and V-13.14).


There is no real-time tracking of birds flying over the UK (Tab V-12.4).

            (b) Blakeney Point Nature Reserve

The Blakeney Point Nature Reserve (Blakeney Reserve) located next to Blakeney, UK, is host to large flocks of migratory birds (Tab V-13.9). Consequently, the MOD designated the area as avoid by 500 feet or 2 nautical miles for flying operations (see Figure 3 below) (Tab V-3.40 and NN-9). This restriction was appropriately marked on the maps of the FLC and MC, and the MF did not enter that area (Tab S-15).

A storm surge in early December 2013 caused several flocks of birds to move southeast of the Blakeney Reserve to alternate night roosting locations (Tab V-13.9).

            (c) Bird Activity

The December 2013 and January 2014 UK bird activity maps were available to the FLC and MC (Tab PP-7 to PP-8). The December 2013 UK bird activity map indicated an area of moderate bird activity at dusk to the west of the LZ (Tab NN-3). The January 2014 UK bird activity map indicated an area of low-bird activity over Cley Marshes in the Wildlife Trust at the time of the mishap (Tab NN-5). The map legend defines the mishap area as low bird activity at all times, day and night (Tab NN-5). The effective date of the January 2014 UK bird activity map was 7 January 2014, the day of the mishap (Tab P-7).


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


The 48 Fighter Wing safety briefing for January 2014 instructed all aircrew to assume a moderate en route (as opposed to airfield) bird hazard condition for the duration of the migration season (Tab PP-5 and V-12.6).


The day prior to the mishap (6 January 2014), the Wildlife Trust counted a flock of approximately 400 various geese, along with other birds. On 7 January 2014, the Wildlife Trust counted zero geese (Tab V-13.14).


The sunset was 1602L on 7 January 2014approximately one hour and thirty minutes prior to the scheduled takeoff time. The MF planned to arrive to the LZ at 1756Lalmost one hour after the moderate dusk bird hazard warning expired (Tabs F-4, K-10, K-12, NN-3, and NN-5).

        (2) Roll Call and Crew Mission Briefing

The FLC and MC attended squadron roll call at 1400L on 7 January 2014 (Tab V-3.17 and V-4.2). The roll call briefing discussed aircraft parking locations, maintenance issues, aircraft configurations, airfield notices, weather, bird watch conditions, and other administrative matters (Tab V-3.4). The bird watch condition at the airfield, separate and apart from the en route condition, was low for 7 January 2014 (Tab PP-3).


After roll call, MP completed an Operational Risk Management (ORM) worksheet (K-19). ORM is a decision-making process to systematically evaluate risks, consider possible courses of action, identify risks and benefits, and determine the best course of action for any given situation (Air Force Pamphlet 90-803, Risk management Guidelines and Tools: 11 February 2013, paragraph 1.1). In accordance with the information from the January safety briefing mentioned above, MP identified the bird hazard as moderate and incorporated that hazard condition into the ORM accordingly (Tab K-19).


A detailed crew mission briefing occurred at approximately 1500L (Tab V-3.4 and V-4.2). FLCP briefed the details of the training mission to the FLC and MC (Tab V-3.17 and V-4.6).


The mission briefing complied with 56 RQS, 48 FW, and Air Force requirements, and briefed in accordance with AFI 11-2HH60, Volume 3, Flying Operations, 5 January 2011 (Tab V-3.17, V-4.2, and V-4.30).


    c. Preflight

Prior to departing 56 RQS for the MA, the MC gathered and inspected their Aircrew Flight Equipment (AFE), finding no irregularities (Tabs R-70 and GG-3). The 56 Rescue Squadron Duty Desk Officer (DDO) briefed FLC and MC on weather updates, airfield conditions, flight authorizations, and changes to aircraft tail numbers (due to normal maintenance updates) (Tab V-3.9). The Operations Supervisor then approved the planned ORM before the MC left the squadron area for the MA (Tab K-21).


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


A daytime crew flew the MA prior to the MCs arrival (Tab V-15.13). The MC performed an engine running crew change with the daytime crew (Tab V-15.3). An engine running crew change is a routine procedure where one crew takes the place of another crew while the helicopter engines are still running (Tab V-3.18). The MC met the MA at a previously planned ramp parking location (Tab V-15.13). The daytime crew reported the MA had no issues during the preflight inspection or during flight. The MC then accepted the MA (Tab V-15.13 and V-15.14). The engine running crew change was uneventful (Tab V-4.7 and V-15.13).

    d. Summary of Accident

Taxi, takeoff, and departure of the MA were uneventful (Tab R-30). The MF departed RAF Lakenheath at 1733L and flew to a reserved training area to separate the MF from other aircraft (Tabs K-25 and V-3.2). Aircrews are required to fly below 500 feet AGL in the training area (Tab V-3.47 and V-3.48). The FLC and MC donned their night vision goggles (NVGs) at takeoff (Tab V-4.14 to V-4.15).



Figure 2: Flight Path of the Flight Lead Aircraft (Tab S-16).

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


The FLA and MA arrived at the planned IP, located approximately one mile south of Blakeney, 25 minutes into flight. The MF executed a left orbit and began verifying the status of the simulated downed pilot in accordance with HH-60G procedures (Tabs R-5, S-15, and BB-132). At the IP, winds came from 210 degrees at 20 knots and gusted to 31 knots (Tab F-7). The wind pushed the MF north toward Blakeney (Tabs R-5 and S-16). To comply with noise abatement procedures and address safety concerns, FLP ordered the MF to move the orbit 1.3 miles north and establish a new IP closer to the coastline (Tabs R-5, S-16, V-3.14, and V-4.12). The new IP stayed clear of the nearby Blakeney Reservea known no-fly areaand any known moderate or severe bird hazard areas (Tabs R-5, S-15, V-3.40, NN-3, and NN-5).


The January 2014 UK bird map depicted a low bird hazard for the route between the new IP and LZ near Salthouse (Tab NN-5). The route from the new IP to the LZ crossed over an area known as Cley Marshes in the Wildlife Trust (see Figure 3 below) (Tab S-16).


Once established at the new IP, the formation completed two left orbits (Tab S-16). MP verified the status of the downed pilot (Tab R-5). FLCP announced the rescue plan to be performed at the LZ located approximately 3.5 nautical miles away from the new IP (Tabs S-16 and V-3.27). MP acknowledged the plan (Tab V-3.27). The formation then left the second orbit in an eastward direction, with a heading of 110 degrees (Tab S-16). The MA flew 0.3 nautical miles behind and to the left of the FLA (Tab R-30). Both aircraft flew at an altitude of approximately 110 feet AGL and traveled at 110 KIAS (Tab V-1.11 and MM-12). The FLA and MA were separated by approximately ten seconds (Tabs V-4.15, V-4.16, and MM-12).


Figure 3: Relative Position of the Mishap Formation after Departure

from the Initial Point (Tab V-3.11).

At some point during the MFs approach to the LZ, a flock of birds took flight from Cley Marshes. The sound of the approaching MF likely startled the geese (Tab V-13.2 to V-13.3). The geese took approximately one minute to reach 110 feet AGLthe altitude of the MA (Tabs V-13.3 and EE-6).


No one from the FLC saw any geese on the way to the LZ (Tab V-3.24 and V-4.16). NVGs have a limited field of view and inherently less than perfect visual acuity (Fundamentals of Aerospace Medicine, 4th Edition, Jeffrey R. Davis, Jan Stepanek, Robert Johnson, Jennifer A. Fogarty, Lippincott Williams and Wilkins, Philadelphia, 2008, p. 359). Although NVGs provide better vision at night, it is nevertheless still difficult to see birds (Tab V-311, V-3.23 and V-4.14).

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


Approximately one mile east of the new IP, multiple birds struck the MA (Tabs S-13 and MM-12). At least three geese impacted the MA, destroyed the windscreen, and entered the aircraft (Tabs J-87, J-89, J-90, J-96 to J-98, S-13, and EE-5). The geese struck MP and MCP with such force that it rendered them unconscious. In addition, at least one goose struck MAG in the performance of SMA duties, rendering MAG unconscious (Tabs X-4 and II-77 to II-81). The MA entered a rapid left roll, descended, and impacted the ground (Tab EE-9 and EE-10).

The types of geese that hit the MA weigh between 6 and 12 pounds (Tabs V-13.4 and II-62). A bird weighing 7.5 pounds would impact with 53 times the kinetic energy of a baseball moving at 100 miles per hour (Tab EE-5). The impact from the geese exceeded the design tolerance of the MAs windscreen (Tabs J-87, J-89, J-90, and S-13). Pieces of the windscreen and bird remains were found starting approximately 720 feet behind the location where the MA impacted the ground (Tab S-13).


At least one goose struck the nose of the MA, disabling the Trim and Flight Path Stabilization (FPS) systemstwo key components of the Automatic Flight Control System (AFCS) (Tab EE-7). The AFCS helps improve aircraft performance by assisting the pilot with aircraft control. It has five subsystems. The Trim and FPS systems provide control positioning and force gradient functions, as well as basic autopilot functions when the FPS is engaged. The force gradient functions caused increasing resistance on the cyclic stick (which controls aircraft pitch and roll) the further the cyclic stick is moved from center (Tab BB-222). Because the impact from the geese rendered MP and MCP unconscious and disabled the Trim and FPS, the cyclic stick was free to move randomly (Tabs V-17.12 to V-17.13 and BB-220). The free-floating cyclic stick fell to the left, inducing a rapid left roll (Tab V-17.17 and V-17.18). Once the MA passed 50 degrees angle of bank, the MA began a descent and continued rolling (Tab BB-133). Simulator testing showed that the MA could not recover once it passed 50 degrees at 110 feet AGL (Tab EE-9 and EE-10). The MA continued to roll and descend (Tab EE-7).


    e. Impact

The MA impacted the ground at 1805L in Cley Marshes, 2.4 miles west of the LZ (Tabs J-6 and S-16). At the time of impact, the MA had banked left in excess of 90 degrees, where it had no vertical lift and could not maintain altitude (Tab J-6 and V-17.18). The MA hit the ground approximately three seconds after the initial bird strikes (Tab EE-6). The main wreckage dispersed from west to east over approximately 180 feet in the direction of the LZ and along the route of flight (Tab J-8). The crash was not survivable (Tab J-17).


    f. Egress and Aircrew Flight Equipment

At the time of the mishap, all members of the MC wore the HGU-56/P helmet, which provides ear, eye, and head protection (Tabs R-132, R-155 to R-156, R-158 to R-159, V-1.15, V-1.21, V-4.15, V-4.18 to V-4.19, V-5.10, V-12.2, and GG-5 to GG-6). The helmet is designed to withstand a force of 150 Gs (Tab GG-5 to GG-6). All of the helmets suffered significant cracks in the outer shell (Tabs R-132, R-137 to R-138, and II-77 to II-78). In addition, bird feathers that indicated forceful impact were found on the inside and outside of the helmets of MP, MCP, and MAG (Tabs V-12.2 and II-77 to II-81).

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


The Combat Integrated Armor Carrier system survival vests worn by HH-60G aircrew provides protection and holds survival equipment (Tabs GG-7 to GG-8 and II-92). MFEs vest and helmet were removed during the course of impact (Tabs R-155, V-1.17, V-5.9, II-77 to II-78, and II-92 to II-97). Bird feathers were found at multiple locations on the vests worn by MP, MCP, and MAG (Tab II-78 to II-81). In addition, bird feathers that indicated forceful impact were found on the right torso region of MCPs aviation coveralls (Tab II-109 to II-110, II-121, II-122, and II-155).


All members of the MC wore battery-powered ANVIS-4949 NVGs mounted to their helmets to amplify ambient light and provide visual illumination for the flight (Tabs R-13, R-55, R-131, R-140 to R-141, V-3.22, and BB-292). The NVG field of view is more limited than the human eyes field of view, and causes a loss of peripheral vision. This loss of peripheral vision limits the ability of the person wearing NVGs to sense motion and attitude cues (Tab HH-4 to HH-5). As shown in Figure 4 below, the NVGs are attached to the helmet and sit immediately in front of the eyes (BB-292).

Figure 4: ANVIS-4949 Night Vision Goggles Mounted to

HGU-56/P Helmet (Front and Side Views) (BB-292).

All four of the MCs NVGs were destroyed in the mishap (Tabs R-131, R-140 to R-141, V-1.17, V-1.21, V-4.15, V-4.18, and V-5.10).


Analysis of the seats indicated MP and MCP were seated at the time of impact (Tab II-13). MFE and MAG were likely not seated but were secured by restraint belt in their assigned positions, which is consistent with their duties at the time the mishap occurred (Tabs BB-233.1 to BB-233.2 and II-13).


There was no evidence to suggest aircrew flight equipment was a factor in the mishap.

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


    g. Search and Rescue

Almost immediately after the MA impacted the ground, FLAG announced to the FLC that the MA was no longer visible (Tab V-3.27). FLFE confirmed the MA could not be seen on his side of the aircraft (Tab V-3.27). The FLC immediately stopped all training, attempted to contact the MC by radio, and climbed to a safe altitude (Tab V-3.27). When the MC did not respond, the FLC circled back to Cley Marshes where FLAG noticed a small fire (Tab V-3.27).

The FLC acted as the initial emergency responders, circling back to search for the MA at approximately 1806L. The FLC spotted the MA on the ground and landed north of the crash site, approximately 3 minutes and 30 seconds after the crash (which is the time it took for the FLA to circle back to the mishap site) (see Figure 5 below) (Tabs S-16, V-4.17 and EE-4 to EE-5). FLFE and FLAG exited the FLA and began searching for survivors. FLP followed soon thereafter (Tab V-5.9 and V-5.10). FLCP began coordinating with RAF Lakenheath over the radio for emergency support at approximately 1809L (Tab V-3.27). The three crewmembers from FLA quickly found all four members of the MC and determined there were no survivors (Tab V-5.9 and V-5.10). FLC determined the tide would not affect the immediate area of the crash site and left the MC in place for investigators (Tab R-7). The investigators covered the bodies in white sheets (Tab V-4.18 and JJ-17).

Figure 5: Crash Site (Tab S-12).

    h. Recovery of Remains

The remains of the MC, which were protected from the elements while at the crash site, were taken by UK authorities to the Norfolk Norwich University Hospital on 9 January 2014. The UK authorities transferred the remains to the USAFE Chief of Mortuary Affairs on 11 January 2014 (Tab JJ-18). On 12 January 2014, the 48th Operations Group commander escorted the remains of the MC from the UK to the Armed Forces Medical Examiner System, Dover AFB, Delaware, with full military honors (Tabs V-12.3 and JJ-18).


Figure 6 below is a timeline from beginning at takeoff and ending shortly after impact (Tab EE-4 to EE-5).

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


Composite Time

Summary of Mishap Timeline




MF arrives at first IP; begins left orbit.


Wind pushes MF near populated area. FLP moves IP 1.3 miles north.


MF circles at new IP; verifies status of downed pilot.


MF initiates run-in. Birds begin liftoff.


FLA passes over approximate location of birds.


Birds impact MA.


Geese render MP, MCP, and MAG unconscious.


Goose disables Trim and FPS systems.


Aircraft experiences un-commanded left roll and descent.


MA impacts ground.


FLC unable to contact or see MA; turns around to search.


FLA lands north of impact site; FLC check for survivors.

Figure 6: Summary of Mishap Timeline (Tab EE-4 and EE-5).


    a. Forms Documentation

        (1) General Definitions

Air Force maintenance and inspection histories are documented through Air Force Technical Order (AFTO) 781 series forms and the Integrated Maintenance Data System (IMDS). The 781 series forms are maintained in hardcopy by the airframes unit. In addition to scheduling and documenting routine maintenance actions, these tools allow aircrew to report discrepancies, and maintenance personnel to document actions taken to resolve those discrepancies (Tabs BB-154 and BB-200 to BB-205).

AFTO 781 series forms are divided into active forms and inactive forms. The active forms are those currently in use by maintenance personnel to record aircraft inspections, conditions, and repair actions. The inactive forms consist of historical forms, but the unresolved (open) discrepancies are moved to the active forms for resolution (Tab BB-157 to BB-199).


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


Time Compliance Technical Orders (TCTOs) are used to process aircraft system changes, such as parts upgrades, which must be accomplished within a specific timeframe, depending on the severity of the issue, as indicated by the TCTO. A TCTO may also direct inspections or adjustments to parts or equipment already installed on the aircraft. The change items are routine maintenance actions involving the removal and replacement of parts at a given interval (e.g. flight hours, engine operating hours, engine cycles, calendar days) (Tab BB-136 to BB-138, BB-140, and BB-141).


        (2) Documentation Review


A review of the MAs IMDS information, maintenance logbooks, and active and inactive AFTO 781 series forms did not reveal any issues that were factors in the mishap (Tabs FF-3, FF-4, and FF-7). There were no significant recurring maintenance issues with the MA (Tabs V-7.2, V-7.3, V-8.2, V-8.3, V-9.2, V-9.3, V-11.3, V-16.4 FF-3, FF-4, and FF-7).

            (a) Active Forms

The physical AFTO 781 forms binder was on the MA at the time of the mishap and was recovered (Tabs D-5, D-16, and FF-3 to FF-4). The most recent forms were reviewed, revealing open discrepancies; however, none of the discrepancies were factors in the mishap (Tabs D-5, D-16, and FF-3 to FF-4).


On 7 January 2014, there were seven open discrepancies in the active AFTO 781 series forms (Tabs D-5 to D-31, FF-3, and FF-4). None of the open discrepancies were factors in the mishap. All inspection items were current, and there were no TCTOs or time change items pending that were relevant to the mishap (Tabs D-5 to D-31 and FF-3 to FF-4).


Maintenance personnel completed the MAs preflight inspection prior to 0200L on 7 January 2014, documenting the inspection in both the physical AFTO 781 series forms and in IMDS (Tabs D-5 to D-16 and FF-3 to FF-4). The preflight remained valid for 72 hours (Tab BB-286). The exceptional release was completed prior to the first flight of the day and indicated the MA had a valid preflight inspection and had been released by maintenance for takeoff and flight operations (Tabs D-5, D-10, V-6.3 to V-6.5, and BB-145).


            (b) Inactive Forms (Historical)

The MAs inactive (historical) AFTO 781 series forms had minor documentation errors; however, none of the errors were factors in the mishap (Tab FF-3 and FF-4). The MAs 12-month historical files, including TCTOs, AFTO Form 95s (Significant Historical Data Form), major inspection packages, and archived IMDS data, revealed nothing relevant to the mishap (Tab FF-3 and FF-4).


    b. Inspections

Maintenance personnel conducted inspections on the MA according to schedule and documented the inspections in accordance with applicable Technical Orders (T.O.s) (Tabs FF-3 and FF-4). All inspections were completed satisfactorily (Tabs FF-3 and FF-4). At the time of the mishap, there were no past-due inspections (Tabs D-11, D-17 to D-31, FF-3, and FF-4).


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


        (1) Aircraft Inspections

Phase inspections are scheduled based on flying hour utilization rates and are accomplished upon accrual of the number of flying hours specified in the T.O. (Tabs BB-144 to BB-153 and BB-262 to BB-275). The HH-60G has a 1,200-hour depot inspection cycle, with Phase inspections being conducted after every 600 flight hours logged (Tab BB-262 to BB-275 and BB-278). The MA underwent a routine 1,200-hour depot-level inspection and full overhaul on 12 May 2013 when the MA reached 6,611.9 flying hours (Tabs J-7, FF-3, FF-4, and FF-7). This depot-level inspection and maintenance was performed at Kimhae (also written Gimhae), Korea via a contract with Korean Airlines (KAL) (Tabs J-7, V-8.3, V-16.4, FF-3, FF-4, and FF-7). Several witnesses noted the quality of work performed by KAL was exceptional and a significant improvement to the depot-level maintenance performed by the previous contractor (Tabs V-8.3, V-16.4, FF-3 to FF-4, and FF-7). The MA also underwent 50-hour inspections on 29 August 2013 and 8 November 2013, and a 150-hour inspection on 13 December 2013, with no significant findings (Tabs FF-3 and FF-4).


The preflight inspection lasted approximately two hours and was completed at 0200L on 7 January 2014 (Tabs D-5 to D-31, V-9.2 to V-9.5, and V-16.4 to V-16.7, FF-3, and FF-4). The preflight inspection includes fluid servicing, inlet and exhaust inspection, and a complete walk around inspection of the aircraft (Tabs V-16.4, V-16.5 and BB-286 to BB-289). The preflight inspection was valid at the time the MA departed RAF Lakenheath (Tabs D-11, D-17 to D-31, FF-3, and FF-4).


IMDS data confirmed all inspections were accomplished in accordance with applicable maintenance directives (Tabs D-11, D-17 to D-31, FF-3, FF-4, and FF-7).


        (2) Engine Inspections

Maintenance personnel visibly inspect the HH-60G engine inlets and exhausts before and after every flight (Tab BB-72 to BB-79, BB-156, BB-236 and BB-290). In addition, the engines are inspected before and after every engine run for maintenance (Tab BB-71 and BB-74 to BB-79). Each engine also requires an inspection every 50 flight hours (Tab BB-280 to BB-283). All engine inspections were current for the MA at the time of the mishap (Tabs D-11, D-17 to D-31, FF-3, and FF-4).


Engine components and modules have limited lifetimes that are tracked in the maintenance records by using engine operating time and cycles (Tabs D-5 to D-31, BB-157 to BB-159, FF-3, and FF-4). The IMDS did not show any modules or components due for time change at the time of the mishap (Tabs D-5 to D-31, FF-3, and FF-4).

    c. Maintenance Procedures

All maintenance procedures on the MA were performed in accordance with applicable T.O.s and AFIs (Tabs D-5 to D-36, V-6.2, V-6.3, V-7.5, V-8.5, V-11.5, V-16.5, FF-3 to FF-4, and FF-7).

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


    d. Maintenance Personnel and Supervision

Maintenance procedures are specific to Air Force Specialty Code and consistent with the members Career Field Education and Training Plan. These procedures require personnel to be trained and qualified on: theory of operations, system schematics, isolation of malfunctions, performance of operational checks, parts removal and installation, and various other general maintenance practices (Tab BB-82 to BB-99). Training and qualifications for maintenance personnel are tracked and monitored electronically in the Training Business Area (TBA) system (Tab BB-94.1 to BB-94.4).


All personnel assigned to the 48th Maintenance Group, RAF Lakenheath, who maintained the MA were trained and qualified (Tab FF-3, FF-4, and FF-7). The training records (i.e., AF Forms 623, Individual Training Record Folder, and AF Forms 797, Job Qualification Standard Continuation/Command JQS, and TBA equivalents), and special certification rosters (i.e., staff progress records and staff certification records) for all personnel performing maintenance on the MA reflected proper training and full qualifications on all tasks accomplished (Tab FF-3, FF-4, and FF-7). The operations supervision engaged with maintenance leadership on a daily basis and saw no issues with maintenance practices and procedures (Tabs V-3.36, V-6.2, V-6.3, V-10.3, V-10.4, BB-72, and FF-3 to FF-4).


The maintainers of the MA met or exceeded the Combat Air Force (CAF) standards in all inspected areas (Tab FF-3 to FF-4 and FF-7). Maintenance leadership provided adequate direction, overview, and supervision of maintenance operations for the 748th Aircraft Maintenance Squadron and 56th Helicopter Maintenance Unit (Tabs V-6.2, V-6.3, V-7.5, V-7.6, V-8.4, V-8.5, V-9.4, V-10.3 to V-10.4, V-11.6, V-16.6, and BB-23 to BB-70). Maintenance of the MA was accomplished in an appropriate environment, with adequate time, tools, and support equipment to accomplish the maintenance actions required to support the mission of 56 RQS (Tab V-6.2, V-6.3, V-7.5, V-7.6, V-8.4, V-8.5, V-9.4, V-10.3 to V-10.4, V-11.6, and V-16.6).


There was no evidence to suggest maintenance personnel or supervision were factors in the mishap.

    e. Fuel, Hydraulic, and Oil Inspection Analyses

Following the mishap, fuel samples were taken from the fuel tanks that supplied fuel to the MA (Tabs D-37 to D-41, and FF-3 to FF-4). These samples were tested by the Aerospace Fuels Laboratory, RAF Mildenhall, UK, under an approved waiver to T.O. 42B-1-1, paragraph 5.7 so that the analysis could be conducted overseas (Tabs D-37 to D-41, FF-3, and FF-4). The fuel analysis report shows the fuel used on the MA met specification requirements (Tabs D-37 to D-41, FF-3, and FF-4).

Hydraulic fluid and oil samples taken post-mishap were sent to the Air Force Petroleum Office (AFPET), Wright Patterson Air Force Base, Ohio, for analysis (Tabs D-42 to D-44, and FF-3 to FF-4). The hydraulic fluid and oil analyses reports show the hydraulic fluid and oil used on the MA met specification requirements (Tabs D-42 to D-44, FF-3, and FF-4).


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