Fallon, NV, USA
N404AX
ISRAEL AIRCRAFT INDUSTRIES F21-C2
On March 6, 2012 at 0914 Pacific Standard Time, an Israeli Aircraft Industries (IAI) Kfir F-21-C2 single-seat turbojet fighter type aircraft, registration N404AX, operated by ATAC (Airborne Tactical Advantage Company) under contract to Naval Air Systems Command (NAVAIR) crashed while attempting an emergency landing at Naval Air Station Fallon, Fallon, Nevada. The pilot reported emergency fuel status prior to the accident. The sole occupant pilot aboard was killed and the airplane was destroyed by impact forces and postcrash fire. The weather at the time of the accident was high winds, snow, and visibility of one-half mile. The investigation revealed no evidence of any failure or anomaly of the airplane's powerplants, structures, or systems (including the fuel system). There was no evidence of pilot fatigue or physiological issues. Prior to the accident flight, the pilot participated in a mission briefing which included weather forecast conditions for the day. Although the forecast was calling for snow and low visibility later in the day, there were no forecast conditions below the required minima for the time period of the mission. As the accident pilot prepared for takeoff, he noted conditions were lower than forecast for that time and twice contacted the base weather observer for an update. While it is unknown if any of the mission pilots received updated weather, no other mission pilots cancelled due to weather. Therefore, the pilot was aware that conditions were deteriorating faster than forecast and took appropriate action to obtain updated information. None of the forecast weather was below required minima that would have required him to cancel the flight. As the mission airplanes began returning to NFL following the termination of the exercise due to the weather, the ATC approach controller rapidly became saturated sequencing and separating the airplanes. At the same time, the PAR controller incorrectly set up the precision approach radar as the accident airplane was being vectored to the approach course, which resulted in the accident airplane being vectored off the precision approach. Additionally, the approach controller was saturated and did not efficiently sequence and vector the other returning airplanes, resulting in the accident airplane flying an extended pattern more than 20 miles longer than usual. On the second PAR approach attempt, the accident pilot initiated and executed a missed approach for unspecified reasons, but all ATC directions appeared to be appropriate. After the pilot requested to divert to RNO due to low fuel, the approach controller did not relay that the RNO weather was below minimums, which likely resulted in unnecessary fuel burn from the diversion. Therefore, ATC handling of the accident airplane was deficient, and resulted in 30 miles or more of excess flying distance. Although the reason that the accident pilot abandoned the second approach is not known, the relatively strong winds and low ceilings required would have required a significant amount of attention by the pilot. Review of ATAC training records indicated that the pilot may not have had sufficient currency or proficiency under instrument conditions in the Kfir. Additionally, since most of the pilots experience was in the F/A-18, his lack of instrument experience in the Kfir may not have taken into account the airplanes less sophisticated instrumentation and limited fuel endurance compared to the F/A-18 in his decision making before and during the exercise. During the pilots final attempt to land at NFL it was clear he was aware of his critical fuel status. Review of radar data shows that the accident airplane was roughly aligned for an emergency straight-in approach to runway 7, however, ATC did not relay this option. The pilot elected to make a low altitude approach, first to runway 31L, then when he became misaligned to that runway, transition to a low altitude modified right downwind approach to runway 13R. The airplane then appeared to turn towards taxiway A at about the time the engine flamed out and subsequently impacted the bunker. Examination of the ejection seat concluded that the firing mechanism had not been activated. Although the pilot was aware of his critical fuel state, he elected to attempt a low altitude hazardous maneuver instead of proceeding toward the nearby dry lake bed and ejecting. It is possible that the pilot did not eject because he was concerned about the effects of the high surface winds on a deployed parachute. The pilot's decision making in this accident is a possible indicator of a mindset to complete the assigned mission. On May 18, 2012 another ATAC fighter crashed, fatally injuring the pilot. In that accident the pilot was also likely pressing to complete the mission, leading eventually to the accident. ATAC did not have a crew resource management or safety-risk management program in place for its pilots at the time of these accidents; therefore, it is likely that the pilot's training did not support good aeronautical decision-making concepts. Following a recommendation in a Navy audit in June, 2012, Crew Resource Management training was established. Additionally, since the flight was operating under Public Aircraft Operations the Navy was responsible for oversight of the company. The Navy contract, while setting some requirements for FAA certifications, did not specify to what FAA standards the airplane, pilots, or training were required to conform (such as instrument currency or pilot proficiency). Thus, the oversight environment did not include controls or standards that would be expected in other U.S. commercial aviation operations.
HISTORY OF FLIGHT On March 6, 2012 at 0914 Pacific Standard Time (PST, all times in this report are PST unless otherwise noted, and are based on radar and voice recordings from the U.S. Navy Fallon Air Traffic Control (ATC) facility), an Israeli Aircraft Industries Kfir F-21-C2 single-seat turbojet fighter type aircraft, registration N404AX, operated by Airborne Tactical Advantage Company (ATAC) under contract to Naval Air Systems Command (NAVAIR) crashed while attempting an emergency landing at Van Voorhis Airfield, Naval Air Station Fallon, Fallon, Nevada (NFL). The sole occupant pilot aboard was killed and the airplane was substantially damaged by impact forces and fire. The flight was conducted under the provisions of a contract between ATAC and the U.S. Navy to support adversary and electronic warfare training with the Naval Strike and Air Warfare Center (NSAWC), which includes the Navy Fighter Weapons School (NFWS) commonly known as "Topgun", among others. The airplane was operating as a non-military public aircraft under the provisions of Title 49 of the United States Code Section 40102 and 40125. The accident airplane was to be part of an NFWS training exercise consisting of 11 airplanes and was scheduled to depart at 0730. Four of the airplanes were F/A-18's comprising the "blue team," exercising the training mission. The other seven airplanes, 3 F-16s, 3 F/A-18s, and the accident airplane, comprised the "red team," acting in the adversary or aggressor roles for the training scenario (there were F/A-18 C, E, and F; and F-16 A and B variants participating in the exercise, the variants are not significant for this report so will all be termed F/A-18 or F-16 respectively). The pilots involved in the exercise had all participated in a pre-mission briefing beginning at about 0515 that morning. The briefing included tactical information about the exercise, emergency procedures, radio frequencies, deconfliction procedures, weather, and Notices to Airmen. The airplanes participating in the exercise were assigned radio call sign "Topgun" followed by two digits. The accident airplane's radio call sign was "Topgun29." Prior to takeoff, the accident pilot radioed the duty weather observer (DWO) about the conditions twice, at about 0723 and again at 0745, because snow flurries and gusty winds had begun earlier than forecast. The DWO advised the accident pilot of an advisory which called for variable winds from southwest to northwest at 20-25 knots with peak gusts to 38 knots. The DWO also advised that there were radar-observed snow showers north of the airport that would arrive in about 30 to 45 minutes. At the time, the Fallon terminal area forecast called for greater than seven miles visibility and no other conditions below criteria for the mission, typically five miles visibility with a defined horizon. At about the same time, one of the other red team airplanes who departed early as a weather pathfinder, observed the weather in the exercise area was sufficient. At about 0748, Topgun29 departed and proceeded to the mission area normally. Investigators estimated that the airplane used about 400 liters of fuel during start, taxi, and awaiting clearance. The exercise proceeded according to the brief, with some limitations due to cloud layers. An F-16 that had been conducting an unrelated currency flight in the same area returned to NFL prior to the Topgun exercise. He reported that at about 0834, the cloud base was about 7,600 feet (the initial approach altitude) and observed weather moving in from the north. At about this time, the exercise was concluded and airplanes began to return to NFL. Snow began falling at the airport, and an ATAC employee in their facility on the field radioed the accident pilot on a company frequency to advise him that the weather was deteriorating. The pilot acknowledged and said he was already returning. At this time, the airplane was about 22 miles southeast of the airport at 10,000 feet. The accident pilot was the sixth of the exercise airplanes to check back in with NFL ATC Approach Control (AP) returning to base. The pilots ahead of the accident pilot all experienced steadily worsening weather. Two F/A-18s were able to conduct visual approaches and landed uneventfully. Both pilots reported rapidly deteriorating conditions. The third returning exercise flight landed at 0843 and was the last to conduct a visual approach. The next arrival, Topgun24, was unable to maintain visual contact with the third airplane and was broken off the approach to be radar vectored for a Precision Approach Radar (PAR) procedure. At about this time, the accident pilot and another F/A 18, Topgun 22, established radio contact with NFL AP. AP began the initial sequence of vectors and instructions to the accident pilot at about 0843 (now the first in the sequence of three), and a fourth pilot also made radio contact (Topgun28). AP's task was to provide ATC separation and sequencing to the inbound airplanes toward the initial part of the radar approach, at which point the radar final controller would take over and provide precise navigational guidance to the runway. The Radar Final Controller 1 (RFC1) acquired radar and radio contact with the accident pilot at about 0844 and gave several consecutive course calls of "well right of course and correcting" utilizing the surveillance radar control console (which does not display the precise glide path as the PAR does) while attempting to set up the PAR console. Between eight and nine miles from touchdown, RFC1 instructed the accident pilot to begin descent, but after two more course calls of "well right of course and correcting," informed him "radar contact lost" and instructed him to execute a missed approach at 0846 when the airplane was about 3 miles southeast of the airport at 7,000 feet. The accident pilot then contacted AP who informed him that he was taken out due to a radar "malfunction" and provided vectors for the missed approach pattern. At this time the NFL weather observation indicated winds were from 340° at 21 knots with gusts to 31 knots, visibility one and a half statute miles in light snow. At this time, an additional radar final controller (RFC2) was called over to assist RFC1 with the setup of the PAR equipment. The pilot of Topgun24, who had been holding to conduct a PAR, declared a low fuel state. Topgun24 was handed off to RFC1 and successfully landed at 0856. At about this time, weather was relayed to another pilot indicating ground visibility was ½ mile. Meanwhile the accident airplane tracked further east than a normal radar approach pattern before being vectored to the downwind leg. The total length of the pattern flown by the accident airplane was 53 miles. At 0854 RFC2 began PAR approach guidance to the accident pilot. For about the next minute, RFC2 issued guidance to bring the airplane onto the approach course. At 0855 RFC2 advised the pilot he was approaching the glide path (vertical guidance). The airplanes flight path varied both laterally and vertically from the approach, as the pilot responded to RFC2 instructions. From 0856:38 the airplane's lateral deviation varied from "slightly right of course [and] going further right" to 16 seconds later "going well left of course". RFC2 also advised the pilot that he was "above glide path." At this point the accident pilot said "I need to divert to Reno [International Airport (RNO)]" and initiated a missed approach climb and was instructed to contact AP. At this time, the official weather observation at NFL had dropped to ½ mile visibility. At 0857:28 AP was providing vectors to two other returning airplanes, Topgun 22 and 28, and advised the accident pilot to "maintain 10,000 [feet] and heading 310, standby for further clearance." At 0858:09, AP instructed the pilot to climb to 12,000 feet and change transponder code. AP asked the pilot to "say reason for divert?" the pilot replied that "I haven't got the gas to do this again, [they] got a half mile vis[ibility]", and requested to divert to RNO via a 260 degree heading. AP cleared the pilot to RNO via the Mustang navigational aid and to maintain 12,000 feet. At 0902, Topgun22 successfully landed at NFL and reported braking action poor. At 0903, the accident airplane was about 22 miles west of NFL (28 miles east of RNO), and the pilot advised AP to coordinate with Northern California Terminal Radar Approach Controller (NCT) that he would be emergency fuel. AP called NCT and advised of the pilot's intentions and that he was emergency fuel. NCT acknowledged and stated that Reno was also below weather minimums. At the time, RNO was reporting ½ mile visibility the visibility minima for the Instrument Landing System (ILS) minimum is 1 ½ miles and the non-precision approach minima are at least 2 ½ miles. The accident airplane, like most of the Navy airplanes, was not equipped with an ILS receiver. Shortly after, AP instructed the pilot to contact NCT. He did not relay the weather minimum advisory to the pilot. At 0904, the pilot checked in to the NCT frequency, the controller repeated the advisory about RNO weather and asked the pilot's intentions. The pilot said he would go back to NFL, and NCT provided vectors. At 0905 Topgun28 successfully landed at NFL. The accident pilot made contact with NFL AP at 12,000 feet proceeding direct to NFL and stated he was "critical fuel." AP replied to expect to be number one in the arrival sequence. At 0906 the pilots of Topgun25 and Topgun23 asked AP numerous times if the airport (NFL) was able to accept approaches. There was no response by NFL AP. At 0907, the accident pilot began a transmission which was interfered with by other radio calls. AP then instructed the pilot to fly a heading of 100 degrees and descend to 10,000 feet, "report [the airport] in sight when able." AP also reported NFL conditions were ½ mile visibility in snow, ceiling 15,000, then corrected to 1,500 foot ceiling. The accident airplane was about 18 miles west of NFL, descending through 9,000 feet when the pilot reported he had 8 minutes of fuel remaining and needed a visual descent to the airfield. AP cleared him to the minimum vectoring altitude of 7,400 feet due to the underlying terrain, and said to expect lower in five miles. At 0909 the pilot said "I need lower now, if you don't get me on deck in 5 minutes, I'm gonna hit the deck the hard way." AP asked the pilot if he could accept a "short hook to 31?" The pilot said "I'll give it a shot" and AP cleared the airplane to 6,400 feet. At 0910 the pilot reported the ground in sight and requested a contact approach. (A contact approach is an IFR procedure in which the pilot proceeds to the destination airport by visual reference to the surface. Ground visibility must be at least one statute mile.). AP advised "unable" due to the reported low visibility, and advised him to "climb immediately" due to the minimum vectoring altitude. The airplane continued a rapid descent, reaching about 4,500 feet at 0911. AP reported that at this time, the radio frequency became very hectic, and other aircraft kept calling him asking if the airfield was open. The accident pilot transmitted, "I'm gonna crash this airplane if I don't get down and land" and advised he was proceeding "due regard, is there any traffic between me and the airport?" AP advised that the airplane was at 4,500 feet "below my minimum vectoring altitude, climb to 6,400." The pilot advised he was switching frequencies to the Tower. At this point, the airplane was about 5 miles west of the airport, over the flatter farmland terrain, between 200 and 500 feet above the ground. The pilot contacted the NFL ATC Tower and advised he was "seven miles east (sic)" maneuvering for runway 31(L). The tower controller cleared him to land on 31L. Radar and ground witnesses indicated the airplane turned to a close in downwind for runway 31L, and at about 1.5 miles southwest of the runway threshold the airplane turned to the northwest, but did not align with the runway. The airplane then proceeded northwest bound, at low altitude, parallel to the runway until northwest of the airport. The pilot requested a right base turn for runway 13R, and the tower controller cleared him to land on 13R. At 0914, the airplane made a right turn, about 100 feet above ground level, less than one mile from the runway 13R threshold, and appeared to line up with taxiway A. Witnesses along a nearby road, and on the airfield, reported seeing the airplane crossing the airport perimeter at low altitude, in a high pitch attitude. Some of the witnesses described a "wobbling" motion as it turned toward the southeast. The airplane struck the ground in an open field in the northwest corner of the airport property and impacted a concrete munitions storage building in the Combat Aircraft Loading Area (CALA). Witnesses reported high winds and snow squall conditions in the area of impact. The weather observation immediately following the accident indicated northwesterly winds at 23 knots, gusting to 34 knots, visibility ½ mile in light snow. Navy personnel on the field ran to the wreckage to attempt to rescue the pilot, but could not remain close to the airplane due to fire and explosions from the ejection seat components. Airport fire and rescue responded quickly thereafter. INJURIES TO PERSONS The pilot was fatally injured by multiple blunt force injuries. DAMAGE TO AIRPLANE The airplane was substantially damaged by impact forces and fire. The forward one-third of the airplane, from the nose to a point just aft of the leading edge of the delta wing was highly crushed and fragmented from impact with a steel-reinforced concrete bunker. There was evidence of fire in the forward portions of the airplane and was mostly contained within the bunker. Cockpit and instrument panels were largely consumed or damaged by fire. The aft portions of the airplane sustained less impact damage and little fire damage.. OTHER DAMAGE Two concrete munitions storage buildings sustained damage along with airfield fencing and pavement due to impact forces and post-crash fire. PERSONNEL INFORMATION Pilot The accident pilot, age 51, held an Airline Transport Pilot certificate with no aircraft type ratings. His last flight review was March 2011. He reported 4,679 hours total time, and 79 hours pilot in command in the Kfir. Most of the pilot's flight experience was in the U.S. Navy on F/A-18 and other tactical aircraft. There were no accidents or incidents noted in the pilot's FAA record and he held a valid FAA Class 1 medical certificate with a restriction for corrective lenses for near vision. The accident pilot was a former NSAWC instructor and had worked for ATAC for approximately six months. He had completed the ATAC Kfir training program in September of 2011. The training plan consisted of seven blocks of instruction over approximately 10 days. The final blocks were three transition flights in the airplane, two with a chase plane flown by the instructor pilot and one solo. No instrument approaches were required. A review of ATAC records indicate that from September 13, 2011 until the accident, the pilot had logged 79 hours in the Kfir, of which 4.9 was under instrument meteorological conditions (IMC), and had logged 54 PAR and 14 GCA approaches. 14 of the PAR approaches were logged on flights which also indicated IMC time, but the records did not specify if the approaches were flown under instrument conditions. The pilot had flown a mission from about 1120 to 1300 on the day prior to the accident, in which the airplane drag chute failed. He conducted debriefs and administrative work during the remainder of the afternoon. The previous day was off-duty, but ATAC personnel noted that he likely performed some administrative work as he was the training officer. On a personal blog site five days prior to the accident, the pilot related an event in which a pilot "successfully ejected and was dragged to his death by the surface winds." Air Traffic Controllers The Approach Controller was a U.S Navy Petty Officer. He began air traffic c
fuel exhaustion following missed approaches due to deficient ATC handling under weather conditions which were significantly lower than forecast. The second missed approach may have been initiated due to limited pilot instrument proficiency. Contributing to the severity of the accident was the pilot's decision to attempt an emergency landing in low visibility instead of ejecting when fuel exhaustion was imminent. Also contributing to the accident was an organizational and oversight environment which did not require airman, aircraft, or risk management controls or standards expected of a commercial civil aviation operation.
Source: NTSB Aviation Accident Database
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