ASN Wikibase Occurrence # 269634
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| Date: | Wednesday 17 November 2021 |
| Time: | 10:00 |
| Type: |  Lockheed Martin F-35B Lightning II |
| Owner/operator: | Royal Air Force (RAF), 617 Sqn |
| Registration: | ZM152 |
| MSN: | BK-18 |
| Fatalities: | Fatalities: 0 / Occupants: 1 |
| Aircraft damage: | Destroyed |
| Category: | Accident |
| Location: | Eastern Mediterranean -
 Mediterranean Sea
|
| Phase: | Take off |
| Nature: | Military |
| Departure airport: | HMS Queen Elizabeth (R08) |
| HMS Queen Elizabeth (R08) | |
| Investigating agency: | DSA |
| Confidence Rating: |  Accident investigation report completed and information captured |
An RAF F-35B crashed into the Mediterranean Sea during take-off from HMS Queen Elizabeth. The pilot ejected safely and was rescued.
The aircraft was later recovered from the bottom of the sea.
Causal factor:
Based on all the evidence, the panel concluded that the left intake blank was at the front face of the engine compressor during the aircraft launch and determined this to be the causal factor.
Contributory factors.
The following were contributory factors to the loss of BK-18.
a. In the panel's opinion, if security had been discussed in engineering planning meetings either on 10 Nov 21, in the period leading up to 15 Nov 21, or in the handover notes, it is very likely that more attention would have been paid to the Red Gear being removed correctly. The panel concluded that the omission of security considerations from 617 Sqn's engineering planning cycle was a contributory factor.
b. The panel opined that, if Eng 2 had not been distracted by the storage task, then it is likely that they would have worked on BK-18 at the same time as Eng 1 and, therefore, would have been able to manage the Red Gear more effectively. The panel concluded that the distraction of a peripheral task was a contributory factor.
c. On completing their servicing Eng 1 took the right intake and Power Thermal Management System (PTMS) blanks down to the hangar. They left the exhaust and left intake blanks in place and assumed Eng 2 would collect them. Eng 1 returned to the crew room and left the tools there for Eng 2. However, no formal handover was conducted and they did not discuss the partial removal of Red Gear. In the panel's opinion, had there been a more detailed handover it is highly unlikely that any elements would have been missed. The panel concluded that not removing all elements of Red Gear at the same time was a contributory factor. The panel further concluded that the omission of a handover which included Red Gear was also a contributory factor.
d. The panel opined that if the red intake blank were to be dislodged, but still partially visible in the intake, the use of filtered light in a dark intake would have decreased the likelihood of it being seen. The panel concluded that not using white light for servicing was a contributory factor.
e. In the panel's opinion, if a 100% check of all the Red Gear had been carried out after the mass removal had been completed, the left intake blank in BK-18 would likely have been noticed as missing. In a subsequent search it would likely have been discovered. The panel concluded that the lack of a confirmatory muster after the mass removal of Red Gear was a contributory factor.
f. In the panel's opinion, at all levels of the Lightning programme, Red Gear was not perceived as a threat. This perception caused it to be treated less carefully than other tools and instruments. The panel concluded that the perception that Red Gear was only a risk to other aircraft or personnel, not a threat to airworthiness of the aircraft to which it was fitted was a contributory factor.
g. Items located in the intake duct could only be discovered by someone climbing into the intake to look, not just observing from the ground. No previous UK aircraft had this unobservable area. The panel concluded that lack of familiarity with this design feature and the associated potential for items to be concealed in the intake was a contributory factor.
h. The panel concluded that the UK omission of an independent check of the common duct immediately prior to flight was a contributory factor.
i. The panel found that the use of the pip pin could have prevented the blank from migrating down the intake. The lack of awareness on 617 Sqn of whether the pip pin should be used was a contributory factor.
j. The panel determined that the blank was not adequately designed for windy conditions. The panel concluded that the lack of environmental considerations in the blank design was a contributory factor.
k. The panel determined that Red Gear was an 'orphan asset' which neither the Lightning Force nor the LDT formally managed. The panel concluded that this resulted in the lack of installation and removal procedures being produced for the new blanks, which was a contributory factor.
l. Weather was attributed as the cause of the loss of blanks in a number of reports and was mentioned in the intake blank engineering evaluation report. The panel determined that these issues occurred across the global F-35 user community but were at a level such that it was considered a 'nuisance,' rather than a documented failing. This resulted in learned behaviour of the poor performance of the Red Gear being a feature of F-35B operations. The panel concluded that this normalisation to blanks falling out or becoming detached was a contributory factor.
m. The panel opined that had the requirement for Red Gear to be logged by the rectification controller been retained, it would have been a more robust barrier to the loss of Red Gear. The panel concluded that the change to the 617 Sqn Red Gear management order was a contributory factor.
n. Use of an older version of the annex, the format of the annex, the confused use of columns for comments and the mixed fitment of blanks resulted in a Red Gear log that could not provide an effective barrier to a blank being unaccounted for or misplaced. The panel concluded that the ineffectiveness of the Red Gear log was a contributory factor.
o. Equipment fitted to or removed from aircraft should have been strictly controlled, but on Op FORTIS the GSSOs were ordering the fitment of Red Gear. The dual use of blanks was unique to the F-35B and had not been previously encountered by the UK military. The DASOR demonstrated that GSSOs were still unaware of the potential air safety implications of their actions. The panel concluded that the lack of procedure or policy incorporating the needs of the GSSO whilst maintaining aircraft integrity and good engineering practices was a contributory factor.
p. The Mil CAM deviation process did not identify security as a reason for fitting the blanks. The panel concluded that the omission of identifying security as a reason to fit blanks, with an associated management process, was a contributory factor.
q. The panel found that Red Gear configuration control was not managed by either the LDT or the Mil CAM due to confusion over the global pool policy. The panel determined that responsibility for Red Gear had inadvertently fallen between organisations. The panel opined that this caused omissions to go unnoticed, the resolution of any one of which may have averted the accident to BK-18. The panel concluded that non-allocation of responsibility for assurance of Red Gear was a contributory factor.
r. Given that the F-35 was an international programme, UK reporting was but a small piece of the overall picture. The panel considered it more than likely that other Red Gear issues were going unreported across the F-35 community, so the threat to air safety was under appreciated. The panel concluded that this lack of reporting, assessment and analysis of air safety events relating to Red Gear was a contributory factor.
s. There was no ICAW alerting the pilot that the FADEC was limiting fuel or that the engine had not reached the desired thrust. The panel concluded that the lack of an appropriate warning to the pilot was a contributory factor.
t. The panel concluded that it was almost certain that wind dislodged the left intake blank in BK-18 from its installed position and moved it to a point at which it could not be seen externally on the night of 16 Nov 21. The panel concluded that the tendency for intake blanks to dislodge in high wind was a contributory factor.
u. The panel concluded that the lack of a removal and installation procedure for the blank and pip pin, with associated weather limits, was a contributory factor.
v. The panel determined that carrier operations required even more engineers than the DMSpA figure suggested. The limited workforce available to 617 Sqn worked at a commensurately higher, more fatiguing rate and were therefore potentially more prone to errors. The panel concluded that insufficient workforce availability was a contributory factor.
w. In their report the RAFCAM HF specialists stated that personnel would have been more susceptible to degraded performance, reduced attention and the chances of errors occurring. The panel concluded that accumulative fatigue was a contributory factor.
x. The RAFCAM HF specialists determined that the effect of being in extreme temperatures for prolonged periods was very likely to have heightened the fatigue levels of those personnel. The panel concluded that the increased fatigue, due to the effects of heat stress, on 617 Sqn engineers was a contributory factor.
y. The panel concluded that unavailability of flight servicing training for RAF engineers reduced sqn cohesion, created inefficiency and increased individual fatigue and was a contributory factor.
z. The panel found that 617 Sqn was less well prepared for Op FORTIS than the CSG planners may have been led to believe by the FSOG and OCC. Consequently 617 Sqn faced a higher operating tempo than it was prepared for. The panel concluded that lack of embarked experience within the 617 Sqn engineering team was a contributory factor.
Accident investigation:
 |
|
Sources:
https://news.sky.com/story/pilot-ejects-as-british-f35-jet-from-flagshop-air-carrier-crashes-into-the-mediterranean-12470933
https://aerossurance.com/safety-management/the-loss-of-raf-f-35b-zm152-an-organisational-accident/
https://www.gov.uk/government/publications/service-inquiry-investigating-the-accident-involving-f-35b-zm152-on-hms-queen-elizabeth-on-17-november-2021-interim-report
Media:
A British F35 pilot from HMS Queen Elizabeth ejected during routine flying operations in the Mediterranean this morning.
— Ministry of Defence Press Office (@DefenceHQPress) November 17, 2021
The pilot has been safely returned to the ship and an investigation has begun, so it would be inappropriate to comment further at this time.
Interesting (and disappointing) to find out that the F-35B that was lost from the QE was ZM152; she first flew in June 2019 and is, therefore, one of the newer F-35Bs in the UK fleet, with significantly lower Block IV upgrade requirements than older airframes. Thus a greater loss pic.twitter.com/wHnxHQLVtG
— Justin Bronk (@Justin_Br0nk) December 6, 2021
(FS) # 635 F35 B, “A” Cat, 17 Nov 2021 @Aerossurance @AviationSafety @CanMNews @RCAF_ARC @AusAirForce @RoyalNavy pic.twitter.com/jhNyF6bmpi
— Pat Hort (@Pathort1) January 21, 2022
A £81mn fighter is downed by one of its own intake blanks. A case study on the concept of Organisational Accidents. https://t.co/1gGU0Mc4Q8 #aviationmaintenance #flightsafety #aviationsafety #safetymanagement #riskmanagement #organisationalculture pic.twitter.com/uS4itRZvXb
— Aerossurance (@Aerossurance) August 27, 2023
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 17-Nov-2021 15:34 | gerard57 | Added |
| 17-Nov-2021 15:37 | gerard57 | Updated [Time] |
| 17-Nov-2021 15:40 | gerard57 | Updated [Aircraft type] |
| 17-Nov-2021 19:51 | Iceman 29 | Updated [Embed code, Narrative] |
| 17-Nov-2021 23:01 | Aerossurance | Updated [Embed code, Narrative] |
| 30-Nov-2021 07:15 | Anon. | Updated [Embed code] |
| 07-Dec-2021 08:51 | Aerossurance | Updated [Registration, Cn, Location, Phase, Departure airport, Destination airport, Source, Embed code, Narrative] |
| 07-Dec-2021 08:52 | Aerossurance | Updated [Embed code] |
| 21-Jan-2022 08:21 | Aerossurance | Updated [Embed code] |
| 21-Jan-2022 15:53 | Aerossurance | Updated [Embed code] |
| 25-Jan-2022 22:21 | Iceman 29 | Updated [Embed code, Narrative] |
| 08-Sep-2022 13:25 | Aerossurance | Updated [Operator, Source, Narrative] |
| 14-Aug-2023 17:22 | harro | Updated [[Operator, Source, Narrative]] |
| 26-Aug-2023 10:08 | Aerossurance | Updated [[[Operator, Source, Narrative]]] |
| 27-Aug-2023 11:15 | Aerossurance | Updated [[[[Operator, Source, Narrative]]]] |
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