Crash of a Boeing 737-81Q at Jacksonville NAS

Date & Time: May 3, 2019 at 2142 LT
Type of aircraft:
Operator:
Registration:
N732MA
Survivors:
Yes
Schedule:
Guantánamo Bay - Jacksonville
MSN:
30618/830
YOM:
2001
Flight number:
LL293
Crew on board:
7
Crew fatalities:
Pax on board:
136
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7500
Captain / Total hours on type:
2204.00
Copilot / Total flying hours:
7500
Copilot / Total hours on type:
18
Aircraft flight hours:
38928
Aircraft flight cycles:
15610
Circumstances:
According to both pilots, the takeoff, climb, and cruise portions of the flight were uneventful. The No. 1 (left) thrust reverser was not operational and deferred for the flight in accordance with the airplane’s minimum equipment list. The captain was the pilot flying for the accident flight, and the first officer was the pilot monitoring. The captain was also performing check airman duties for the first officer who was in the process of completing operating experience training. During the approach to Jacksonville Naval Air Station (NIP), the flight crew had two runway change discussions with air traffic controllers due to reported weather conditions (moderate to heavy precipitation) near the field; the pilots ultimately executed the area navigation GPS approach to runway 10, which was ungrooved and had a displaced threshold 997 ft from the threshold, leaving an available landing distance of 8,006 ft. As the airplane descended through 1,390 ft mean sea level (msl), the pilots configured it for landing with the flaps set at 30º and the landing gear extended; however, the speedbrake handle was not placed in the armed position as specified in the Landing checklist. At an altitude of about 1,100 ft msl and 2.8 nm from the runway, the airplane was slightly above the glidepath, and its airspeed was on target. Over the next minute, the indicated airspeed increased to 170 knots (17 knots above the target approach speed), and groundspeed reached 180 knots, including an estimated 7-knot tailwind. At an altitude of about 680 ft msl and 1.6 nm from the threshold, the airplane deviated further above the 3° glidepath such that the precision approach path indicator (PAPI) lights would have appeared to the flight crew as four white lights and would retain that appearance throughout the rest of the approach. Eight seconds before touchdown, multiple enhanced ground proximity warning system alerts announced “sink rate” as the airplane’s descent rate peaked at 1,580 fpm. The airplane crossed the displaced threshold 120 ft above the runway (the PAPI glidepath crosses the displaced threshold about 54 ft above the runway) and 17 knots above the target approach speed, with a groundspeed of 180 knots and a rate of descent about 1,450 ft per minute (fpm). The airplane touched down about 1,580 ft beyond the displaced threshold, which was 80 ft beyond the designated touchdown zone as specified in the operator’s standard operating procedures (SOP). After touchdown, the captain deployed the No. 2 engine thrust reverser and began braking; he later reported, however, that he did not feel the aircraft decelerate and increased the brake pressure. The speedbrakes deployed about 4 seconds after touchdown, most likely triggered by the movement of the right throttle into the idle reverse thrust detent after main gear tire spinup. The automatic deployment of the speedbrakes was likely delayed by about 3 seconds compared to the automatic deployment that could have been obtained by arming the speedbrakes before landing. The airplane crossed the end of the runway about 55 ft right of the centerline and impacted a seawall 90 ft to the right of the centerline, 9,170 ft beyond the displaced threshold, and 1,164 ft beyond the departure end of runway 10. After the airplane came to rest in St. Johns River, the flight crew began an emergency evacuation.
Probable cause:
An extreme loss of braking friction due to heavy rain and the water depth on the ungrooved runway, which resulted in viscous hydroplaning. Contributing to the accident was the operator’s inadequate guidance for evaluating runway braking conditions and conducting en route landing distance assessments.
Contributing to the continuation of an unstabilized approach were
1) the captain’s plan continuation bias and increased workload due to the weather and performing check airman duties and
2) the first officer’s lack of experience.
Final Report:

Crash of a Cessna 208 Caravan I in the Dry Tortugas National Park

Date & Time: Apr 23, 2019 at 1200 LT
Type of aircraft:
Operator:
Registration:
N366TA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Dry Tortugas - Key West
MSN:
208-0249
YOM:
1996
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
2407
Captain / Total hours on type:
27.00
Aircraft flight hours:
9506
Circumstances:
The pilot landed the seaplane into an easterly wind, then noticed that the surface wind was greater than forecast. Unable to taxi to the beaching location, he elected to return to his destination. He maneuvered the airplane into the wind and applied takeoff power. He described the takeoff run as "bumpy" and the water conditions as "rough." The pilot reported that the left float departed the airplane at rotation speed, and the airplane subsequently nosed into the water. The pilot and passengers were assisted by a nearby vessel and the airplane subsequently sank into 50 ft of water. Inclement sea and wind conditions prevented recovery of the wreckage for 52 days, and the wreckage was stored outside for an additional 13 days before recovery by the salvage company. Extensive saltwater corrosion prevented metallurgical examination of the landing gear components; however, no indication of a preexisting mechanical malfunction or failure was found.
Probable cause:
The pilot's decision to attempt a takeoff in rough sea conditions, resulting in damage to the floats and the sinking of the seaplane.
Final Report:

Crash of a Piper PA-46-350P Malibu Mirage in Shreveport: 2 killed

Date & Time: Feb 28, 2019 at 1039 LT
Operator:
Registration:
N428CD
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Shreveport - Vernon
MSN:
46-36232
YOM:
1999
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1393
Captain / Total hours on type:
323.00
Aircraft flight hours:
1901
Circumstances:
The instrument-rated private pilot and passenger departed into instrument meteorological conditions with a 600-ft cloud ceiling in an airplane that was about 550 lbs over gross weight. Air traffic control data showed the airplane in a climbing left turn that continued beyond the assigned heading. After reaching 1,400 ft msl, the airplane continued turning left and its altitude and speed began to vary. The airplane continued in a left spiral, completing more than two full circles, then decelerated in a right turn and rapidly descended until impact with terrain. Examination of the flight control system revealed no evidence of mechanical malfunctions and downloaded engine data indicated normal engine operation. Downloaded data from the autopilot system revealed three in-flight error codes. The first error code, which likely occurred about 1 minute after takeoff, would have resulted in the autopilot, if it was engaged at the time, disengaging. The subsequent error codes likely occurred during the erratic flight profile, with the autopilot disengaged. Before the accident flight, the pilot had informed a mechanic, who is also a pilot, of intermittent issues with the autopilot system and that these issues were unresolved. The mechanic had flown with the accident pilot previously and assessed his instrument flying skills as weak. The flight instructor who provided initial flight training for the turbine engine transition stated the pilot's instrument flying proficiency was poor when he was hand flying the airplane. Toxicology testing revealed that the pilot had used marijuana, and his girlfriend stated the pilot would take a marijuana gummy before bedtime to sleep more soundly. However, given that no psychoactive compounds were found in blood specimens, it is unlikely that the pilot was impaired at the time of the accident. The instrument conditions at the time of the accident, the airplane's erratic flightpath, and the pilot's reported lack of instrument proficiency when flying by hand support the likelihood that the pilot experienced spatial disorientation sometime after takeoff. In addition, given the reports of the intermittently malfunctioning autopilot that had not been fixed, it is likely the pilot experienced an increased workload during a critical phase of flight that, in combination with spatial disorientation, led to the pilot's loss of airplane control.
Probable cause:
The pilot's conduct of a departure into instrument meteorological conditions (IMC), which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident was the pilot's poor instrument flying skills and his decision to depart into IMC with an unresolved autopilot maintenance issue.
Final Report:

Crash of a Boeing 767-375ER off Anahuac: 3 killed

Date & Time: Feb 23, 2019 at 1239 LT
Type of aircraft:
Operator:
Registration:
N1217A
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Miami - Houston
MSN:
25685/430
YOM:
1992
Flight number:
5Y3591
Location:
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
11172
Captain / Total hours on type:
1252.00
Copilot / Total flying hours:
5073
Copilot / Total hours on type:
520
Aircraft flight hours:
91063
Aircraft flight cycles:
23316
Circumstances:
On February 23, 2019, at 1239 central standard time, Atlas Air Inc. (Atlas) flight 3591, a Boeing 767-375BCF, N1217A, was destroyed after it rapidly descended from an altitude of about 6,000 ft mean sea level (msl) and crashed into a shallow, muddy marsh area of Trinity Bay, Texas, about 41 miles east-southeast of George Bush Intercontinental/Houston Airport (IAH), Houston, Texas. The captain, first officer (FO), and a nonrevenue pilot riding in the jumpseat died. Atlas operated the airplane as a Title 14 Code of Federal Regulations Part 121 domestic cargo flight for Amazon.com Services LLC, and an instrument flight rules flight plan was filed. The flight departed from Miami International Airport (MIA), Miami, Florida, about 1033 (1133 eastern standard time) and was destined for IAH. The accident flight’s departure from MIA, en route cruise, and initial descent toward IAH were uneventful. As the flight descended toward the airport, the flight crew extended the speedbrakes, lowered the slats, and began setting up the flight management computer for the approach. The FO was the pilot flying, the captain was the pilot monitoring, and the autopilot and autothrottle were engaged and remained engaged for the remainder of the flight. Analysis of the available weather information determined that, about 1238:25, the airplane was beginning to penetrate the leading edge of a cold front, within which associated windshear and instrument meteorological conditions (as the flight continued) were likely. Flight data recorder data indicated that, during the time, aircraft load factors consistent with the airplane encountering light turbulence were recorded and, at 1238:31, the airplane’s go-around mode was activated. At the time, the accident flight was about 40 miles from IAH and descending through about 6,300 ft msl toward the target altitude of 3,000 ft msl. This location and phase of flight were inconsistent with any scenario in which a pilot would intentionally select go-around mode, and neither pilot made a go-around callout to indicate intentional activation. Within seconds of go-around mode activation, manual elevator control inputs overrode the autopilot and eventually forced the airplane into a steep dive from which the crew did not recover. Only 32 seconds elapsed between the go-around mode activation and the airplane’s ground impact.
Probable cause:
The NTSB determines that the probable cause of this accident was the inappropriate response by the first officer as the pilot flying to an inadvertent activation of the go-around mode, which led to his spatial disorientation and nose-down control inputs that placed the airplane in a steep descent from which the crew did not recover. Contributing to the accident was the captain’s failure to adequately monitor the airplane’s flightpath and assume positive control of the airplane to effectively intervene. Also contributing were systemic deficiencies in the aviation industry’s selection and performance measurement practices, which failed to address the first officer’s aptitude-related deficiencies and maladaptive stress response. Also contributing to the accident was the Federal Aviation Administration’s failure to implement the pilot records database in a sufficiently robust and timely manner.
Final Report:

Crash of a Cessna 208 Caravan I near Caracaraí

Date & Time: Feb 9, 2019 at 1040 LT
Type of aircraft:
Operator:
Registration:
PR-RTA
Survivors:
Yes
Schedule:
Manaus - Caracaraí
MSN:
208-0380
YOM:
2004
Country:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The single engine floatplane departed Manaus-Eduardo Gomes Airport on a charter flight to the area of the Xeriuini River near Caracaraí, carrying eight passengers and two pilots bound for a fish camp. Due to the potential presence of obstacles in the river due to low water level, the crew decided to land near the river bank. After landing, the left wing impacted a tree and the aircraft rotated to the left and came to rest against trees on the river bank. All 10 occupants evacuated safely and the aircraft was damaged beyond repair.
Probable cause:
The following findings were identified:
- Attention,
- Judgment,
- Perception,
- Management planning,
- Decision making processes,
- Organization processes,
- Support systems.
Final Report:

Crash of a Convair C-131B Samaritan off Miami: 1 killed

Date & Time: Feb 8, 2019 at 1216 LT
Type of aircraft:
Operator:
Registration:
N145GT
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Nassau - Miami
MSN:
256
YOM:
1955
Flight number:
QAI504
Location:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
23000
Captain / Total hours on type:
725.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
305
Aircraft flight hours:
12701
Circumstances:
According to the first officer, during the first cargo flight of the day, the left engine propeller control was not working properly and the captain indicated that they would shut down the airplane and contact maintenance if the left engine propeller control could not be reset before the return flight. For the return flight, the engines started normally, and both propellers were cycled. The captain and the first officer were able to reset the left propeller control, so the airplane departed with the first officer as the pilot flying. The takeoff and initial climb were normal; however, as the airplane climbed through 4,000 ft, the left engine propeller control stopped working and the power was stuck at 2,400 rpm. The captain tried to adjust the propeller control and inadvertently increased power to 2,700 rpm. The captain then took control of the airplane and tried to stabilize the power on both engines. He leveled the airplane at 4,500 ft, canceled the instrument flight rules flight plan, and flew via visual flight rules direct toward the destination airport. The first officer suggested that they return to the departure airport, but the captain elected to continue as planned (The destination airport was located about 160 nautical miles from the departure airport). The first officer's postaccident statements indicated that he did not challenge the captain's decision. When the flight began the descent to 1,500 ft, the right engine began to surge and lose power. The captain and the first officer performed the engine failure checklist, and the captain feathered the propeller and shut down the engine. Shortly afterward, the left engine began to surge and lose power. The captain told the first officer to declare an emergency. The airplane continued to descend, and the airplane impacted the water "violently," about 32 miles east of the destination airport. The captain was unresponsive after the impact and the first officer was unable to lift the captain from his seat. Because the cockpit was filling rapidly with water, the first officer grabbed the life raft and exited the airplane from where the tail section had separated from the empennage. The first officer did not know what caused both engines to lose power. The airplane was not recovered from the ocean, so examination and testing to determine the cause of the engine failures could not be performed. According to the operator, the flight crew should have landed as soon as practical after the first sign of a mechanical issue. Thus, the crew should have diverted to the closest airport when the left engine propeller control stopped working and not continued the flight toward the destination airport.
Probable cause:
The captain's decision to continue with the flight with a malfunctioning left engine propeller control and the subsequent loss of engine power on both engines for undetermined reasons, which resulted in ditching into the ocean. Contributing to the accident was the first officer's failure to challenge the captain's decision to continue with the flight.
Final Report:

Crash of a Beechcraft B200 Super King Air off Kake: 3 killed

Date & Time: Jan 29, 2019 at 1811 LT
Operator:
Registration:
N13LY
Flight Type:
Survivors:
No
Schedule:
Anchorage - Kake
MSN:
BB-1718
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
17774
Captain / Total hours on type:
1644.00
Aircraft flight hours:
5226
Circumstances:
The pilot of the medical transport flight had been cleared by the air traffic controller for the instrument approach and told by ATC to change to the advisory frequency, which the pilot acknowledged. After crossing the initial approach fix on the RNAV approach, the airplane began a gradual descent and continued northeast towards the intermediate fix. Before reaching the intermediate fix, the airplane entered a right turn and began a rapid descent, losing about 2,575 ft of altitude in 14 seconds; radar returns were then lost. A witness at the destination airport, who was scheduled to meet the accident airplane, observed the pilot-controlled runway lights illuminate. When the airplane failed to arrive, she contacted the company to inquire about the overdue airplane. The following day, debris was found floating on the surface of the ocean. About 48 days later, after an extensive underwater search, the heavily fragmented wreckage was located on the ocean floor at a depth of about 500 ft. A postaccident examination of the engines revealed contact signatures consistent with the engines developing power at the time of impact and no evidence of mechanical malfunctions or failures that would have precluded normal operation. A postaccident examination of the airframe revealed about a 10° asymmetric flap condition; however, significant impact damage was present to the flap actuator flex drive cables and flap actuators, indicating the flap actuator measurements were likely not a reliable source of preimpact flap settings. In addition, it is unlikely that a 10° asymmetric flap condition would result in a loss of control. The airplane was equipped with a total of 5 seats and 5 restraints. Of the three restraints recovered, none were buckled. The unbuckled restraints could suggest an emergency that required crewmembers to be up and moving about the cabin; however, the reason for the unbuckled restraints could not be confirmed. While the known circumstances of the accident are consistent with a loss of control event, the factual information available was limited because the wreckage in its entirety was not recovered, the CVR recording did not contain the accident flight, no non-volatile memory was recovered from the accident airplane, and no autopsy or toxicology of the pilot could be performed; therefore, the reason for the loss of control could not be determined. Due to the limited factual information that was available, without a working CVR there is little we know about this accident.
Probable cause:
A loss of control for reasons that could not be determined based on the available information.
Final Report:

Crash of a Piper PA-46-310P Malibu off Guernsey: 2 killed

Date & Time: Jan 21, 2019 at 2016 LT
Operator:
Registration:
N264DB
Flight Phase:
Survivors:
No
Schedule:
Nantes - Cardiff
MSN:
46-8408037
YOM:
1984
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3500
Captain / Total hours on type:
30.00
Aircraft flight hours:
6636
Circumstances:
The pilot of N264DB flew the aircraft and the passenger from Cardiff Airport to Nantes Airport on 19 January 2019 with a return flight scheduled for 21 January 2019. The pilot arrived at the airport in Nantes at 1246 hrs on 21 January to refuel and prepare the aircraft for the flight. At 1836 hrs the passenger arrived at airport security, and the aircraft taxied out for departure at 1906 hrs with the passenger sitting in one of the rear, forward-facing passenger seats. Figure 1 shows the aircraft on the ground before departure. The pilot’s planned route would take the aircraft on an almost direct track from Nantes to Cardiff, flying overhead Guernsey en route (Figure 2). The Visual Flight Rules (VFR) flight plan indicated a planned cruise altitude of 6,000 ft amsl and distance of 265 nm. The aircraft took off from Runway 03 at Nantes Airport at 1915 hrs, and the pilot asked Air Traffic Control (ATC) for clearance to climb to 5,500 ft. The climb was approved by Nantes Approach Control and the flight plan was activated. The aircraft flew on its planned route towards Cardiff until it was approximately 13 nm south of Guernsey when the pilot requested and was given a descent clearance to remain in Visual Meteorological Conditions (VMC). Figure 3 shows the aircraft’s subsequent track. The last radio contact with the aircraft was with Jersey ATC at 2012 hrs, when the pilot asked for a further descent. The aircraft’s last recorded secondary radar point was at 2016:34 hrs, although two further primary returns were recorded after this. The pilot made no distress call that was recorded by ATC. On February 4, 2019, the wreckage (relatively intact) was found at a depth of 63 meters few km north of the island of Guernsey. On February 6, a dead body was found in the cabin and recovered. It was later confirmed this was the Argentine footballer Emiliano Sala. The pilot's body was not recovered.
Probable cause:
Causal factors
1. The pilot lost control of the aircraft during a manually-flown turn, which was probably initiated to remain in or regain VMC.
2. The aircraft subsequently suffered an in-flight break-up while manoeuvring at an airspeed significantly in excess of its design manoeuvring speed.
3. The pilot was probably affected by CO poisoning.
Contributory factors
1. A loss of control was made more likely because the flight was not conducted in accordance with safety standards applicable to commercial operations. This manifested itself in the flight being operated under VFR at night in poor weather conditions despite the pilot having no training in night flying and a lack of recent practice in instrument flying.
2. In-service inspections of exhaust systems do not eliminate the risk of CO poisoning.
3. There was no CO detector with an active warning in the aircraft which might have alerted the pilot to the presence of CO in time for him to take mitigating action.
Final Report:

Crash of a Piper PA-46-350P Malibu off Mayport: 2 killed

Date & Time: Dec 20, 2018 at 0904 LT
Registration:
N307JM
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Kissimmee - Princeton
MSN:
46-36253
YOM:
2000
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
390
Captain / Total hours on type:
30.00
Aircraft flight hours:
3785
Circumstances:
The aircraft impacted the Atlantic Ocean near Mayport, Florida. The private pilot and pilot-rated passenger were fatally injured. The airplane was destroyed. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Instrument meteorological conditions prevailed at the time and the flight was operating on an instrument flight rules (IFR) flight plan. The personal flight originated from Kissimmee Gateway Airport, Orlando, Florida, about 0821, and was destined for Princeton Airport, Princeton/Rocky Hill, NJ. According to preliminary air traffic control radar and voice data provided by the Federal Aviation Administration (FAA), at 0859:02, one of the airplane's occupants contacted the Jacksonville Air Route Traffic Control Center (ZJX ARTCC) R-73 sector controller and reported passing through Flight Level (FL) 220 for FL230. The controller advised the pilot there were moderate and some heavy precipitation along the route of flight extending for 200 nautical miles. The occupant acknowledged the controller and advised they would be watching the weather. FAA radar data indicated at 0900:22 the flight reached FL227. Preliminary review of weather data revealed that this altitude was above the freezing level, and at that time the flight entered an area of weather radar returns with intensities between 10 to 30 dBZ (which equated to light to moderate precipitation). While in the weather radar-indicated precipitation, the flight climbed to FL230. At 0902:14, while at the edge of the precipitation, the airplane started a slight left turn before entering a right turn at 0902:28 at FL226. The turn had not been directed by the controller or announced by either occupant. Between 0902:28 and 0903:10, the airplane descended from FL226 to FL202. At 0903:10, the airplane was descending through FL202 when the controller attempted to contact the flight, but there was no reply. The controller attempted to communicate with the flight several more times, and at 0903:27 in response to one attempt, while at 14,500 feet mean sea level (msl), an occupant advised, "were not ok we need help." The controller asked the pilot if he was declaring an emergency and "whats going on." At 0903:35, while at 12,600 feet msl an occupant stated, "I'm not sure whats happening", followed by, "I have anti-ice and everything." At 0903:40 the controller asked the flight if it could maintain altitude, an occupant responded that they could not maintain altitude. The controller provided vectors to a nearby airport west of their position, but the flight did not reply to that transmission or a subsequent query. At about 0904:32 (which was the last communication from the airplane), while at 3,300 feet msl, an occupant advised the controller that the airplane was inverted and asked for assistance. The last radar recorded position with altitude read-out of the flight was at 0904:40, at an altitude of 1,700 feet msl, and 30.40069° north latitude and -81.3844° west longitude. The U.S. Coast Guard initiated a search for the missing airplane, but the wreckage was not located and the search was suspended on December 22, 2018. A privately-funded search for the airplane was initiated and the wreckage was located and recovered on February 6, 2019. The recovered wreckage was retained for further investigation.
Probable cause:
An in-flight loss of control following an encounter with supercooled large droplet icing conditions, which ultimately resulted in an uncontrolled descent and subsequent inflight breakup. Also causal was the pilot’s failure to maintain an appropriate airspeed for flight in icing conditions.
Final Report:

Crash of a Lockheed KC-130J Hercules in the Pacific Ocean: 5 killed

Date & Time: Dec 6, 2018 at 0200 LT
Type of aircraft:
Operator:
Registration:
167981
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Iwakuni - Iwakuni
MSN:
5617
YOM:
2009
Flight number:
Sumo 41
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The crew departed Iwakuni Airport on a refuelling mission over the Pacific Ocean under callsign 'Sumo 41'. Following a night refuelling operation, the four engine airplane collided with a McDonnell Douglas F/A-18 Hornet. Both aircraft went out of control and crashed into the ocean some 200 miles off Muroto Cape, Japan. The United States Marine Corps confirms that two Marines have been found. One is in fair condition and the other has been declared deceased by competent medical personnel. All five crew members from the Hercules are still missing after two days of SAR operations and presumed dead. The KC-130 Hercules was assigned to Marine Aerial Refueler Transport Squadron 152 (the Sumos), 1st Marine Aircraft Wing.
Probable cause:
The CDA-RB’s report determined four interconnected causal factors led to the 6 December 2018 mishap. First, the flight lead (F/A-18 call sign, Profane 11) requested, and received approval for, an un-briefed, non-standard departure from the C-130 tanker (call sign, Sumo 41). This departure placed the mishap pilot (F/A-18 call sign, Profane 12) on the left side of the tanker. A standard departure would have placed both F/A-18s on the right side of the tanker. Second, Profane 11 chose an authorized, but not optimized, lighting configuration. After tanking, Profane 11 placed his external lights in a brightly lit overt setting, while the C-130’s lights remained in a dimly lit covert setting. These circumstances set the conditions for Profane 12 to focus on the overtly lit Profane 11 aircraft, instead of the dimly lit tanker. Third, Profane 12 lost sight of the C-130 and lost situational awareness of his position relative to the tanker resulting in a drift over the top of the C-130 from left to right. Fourth, Profane 12 was unable to overcome these difficult and compounding challenges created by the first three factors. As a result, when Profane 12 maneuvered his aircraft away from Profane 11, he moved from right to left and impacted the right side of the tanker’s tail section. It must be noted, this specific set of circumstances would have been incredibly difficult for any pilot, let alone a junior, or less proficient pilot to overcome.
The CDA-RB determined the previous 2018 mishap command investigation did not capture a completely accurate picture of the event. The CDA-RB determined portions of the investigation contained a number of inaccuracies. Specifically, the 2018 command investigation incorrectly concluded medication may have been a causal factor in the mishap, the mishap pilot was not qualified to fly the mission, AN/AVS-11 night vision devices contributed to the mishap, and the previously mentioned mishap in 2016 had not been properly investigated. These conclusions are not supported by the evidence, and are addressed in detail in the CDA-RB report. While the 2018 CI contains a few inaccuracies, the CDA-RB does confirm the command investigation’s conclusions related to organizational culture and command climate as contributing factors to the mishap.
The CDA-RB made 42 recommendations to address institutional and organizational contributing factors. As a result, the Assistant Commandant directed 11 actions to address manpower management, training, operations, and medical policies. The Director of the Marine Corps Staff will lead the coordination of all required actions to ensure proper tracking and accomplishment.