 
A Practical Guide to Human Factors Analysis and Classification System (HFACS) 7.0

By Chuan HE

Copyright 2020 Chuan HE

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If there is a wrong way to do it, that is the way you will do it.

\- Murphy's Law

Preface

It has been repeatedly found again and again that human error is partially responsible for accidents of complex systems, and human errors turned out to be the primary contributing cause for about 80% to 90% of the accidents in complex and high risk systems, such as nuclear power plants, aviation, gas and oil, medical domains, etc. Safety research shows that human error is a major cause of industrial and transportation accidents, as opposed to mechanical failures. For example, statistic data shows that more than 80% of the US Naval aviation accidents are caused mainly by human errors.

To analyze the accidents and identify the underlying causes, many human factor models, or frameworks, have been designed and applied. The human factor model serves as a tool to provide a measurement standard to categorize the human errors, allowing deep dive into the accident event rebuild especially with human interactions, and eventually identifying the root cause of the human factors for the accidents. The root cause collection and accurate analysis of human factors provides valuable information and guidance for improvement of the safety and robustness of system designs, operation manuals, protocols, training designs, and maintenance procedures.

However, textual reports are difficult for human beings to analyze and understand, thus it makes sense to use standardized classification codings. This will enable the development of a safety database for people to efficiently analyze the information, to search for patterns, similarities, and trends among accidents. The resulting analysis can be valuable not only in the development of data driven safety interventions and mitigation strategies, but also in evaluating their effectiveness.

Learning is the key to prevent future similar accidents by human mistakes. A learning theory is described as a body of principles given by psychologists and educators to explain how people acquire skills, knowledge, and attitudes. Various learning theories are used in training programs helping to improve and accelerate the learning process. Key concepts such as desired learning outcomes, objectives of the training, and depth of training.

Many theories have been created over the years attempting to explain how people learn. Even though not all people agree, most do agree that learning may be explained by a combination of two approaches: behaviorism and the cognitive theories.

Behaviorism

Behaviorism believes that animals and humans learn in the similar way, stressing the importance of having a particular form of behavior reinforced by someone to shape or control what is learned. With behaviorism instructors manipulate students with stimuli, induce the desired behavior or response, and reinforce the behavior with appropriate rewards. In general, it emphasizes positive reinforcement rather than no reinforcement or punishment. Other features of behaviorism are considerably more complex than this simple explanation.

Cognitive theory

Cognitive theory focuses on what is going on inside people's mind. Learning is not just a change in behavior; it is a change in the way a student thinks, understands, or feels. There are several branches of cognitive theory, and two of them are the information processing model and the social interaction model.

A good human factor analysis system shall contain four critical elements: reporting, just, flexible, and learning culture. However, under-reporting, incomplete recordings, and insufficient conditions and contexts description are common to many accident reporting systems, that commonly failed to show a complete picture of the accidents. To enable learning, it is a must to collect reliable and accurate human factors data to avoid future similar accidents.

One such model, which is commonly seen as a good reporting system, and which is widely used in aviation and other industries, is the HFACS, Human Factors Analysis and Classification System. It is a comprehensive accident investigation and analysis tool with focuses both on the act of the individual preceding the accident, and on other contributing factors in the system.

In this book, we introduce Human Factor in Chapter 1, HFACS 7.0 content in Chapter 2, and practical human factor analysis examples for aviation accidents using HFACS 7.0 in Chapter 3.

Chapter 1. Human Factor

Industrial facilities and plants continuously experience incidents and accidents, specifically during their construction and operation phases. Medical, road vehicle, aviation industries all have the same situation.

According to National Safety Council (2011), estimated total costs of industrial accidents in 2009 were around $168.9 billion, including:

\- wage and productivity loss ($82.4 billion)

\- medical ($38.3 billion)

\- administrative ($33.1 billion)

\- motor vehicle damage ($2 billion)

\- employers' uninsured costs ($10.3 billion)

\- and fire loss costs ($2.8 billion)

In US 2011, industrial accidents caused approximately 3,600 fatalities and 5.1 million disabling injuries in industrial facilities and plants, which means on average a death rate of 1 every 2.5 hours and an injury rate of 1 every 6 seconds.

During a 14-year study period, NTSB recorded a total of 371 major airline crashes, 1,735 commuter/air taxi crashes, and 29,798 general aviation crashes. Sequence-of-events data linkage were available for 329 (89%) of the major airline crashes, 1,627 (94%) of the commuter/air taxi crashes, and 27,935 (94%) of the general aviation crashes. Crashes without the sequence-of-events data were significantly more likely than crashes with the sequence-of-events data to have occurred away from airports and to have involved less experienced pilots. However, these two groups of crashes have similar compositions of pilot age and gender, time of crash, type of aircraft, and basic weather conditions.

The study shows results as below:

At the bivariate level, several pilot characteristics were significantly associated with pilot error in general aviation crashes and commuter/air taxi crashes. Of the general aviation crashes involving pilots under age 20, 94% were attributed to pilot error, compared with about 85% of general aviation crashes involving older pilots (p < 0.001). Age-related variation in the prevalence rates of pilot error was statistically insignificant for major airline crashes and commuter/air taxi crashes.

Total flight time showed an effect on pilot error only in general aviation crashes, with the prevalence rate decreasing progressively from 91% for pilots in the lowest quartile to 79% in the highest quartile (p < 0.001). A further examination revealed that the protective effect of total flight time against pilot error existed only in general aviation crashes under visual meteorological conditions (VMC).

General aviation crashes involving student/private pilots were more likely to be attributed to pilot error than other general aviation crashes. A lower prevalence of pilot error was also observed in commuter / air taxi crashes involving pilots who held airline transport certificates, as compared with commuter/air taxi crashes involving commercial pilots.

Female pilots accounted for 0.3% of major airline crashes, 3% of commuter/air taxi crashes, and 4% of general aviation crashes. Partly reflecting the effect of lesser flight experience, a higher proportion of general aviation crashes and commuter/air taxi crashes involving female pilots were caused by pilot error than those involving female pilots. Female pilots who were involved in general aviation crashes recorded an average 888 total flight hours (SD 2,845 h), compared with 2,411 h (SD 4,426 h) for their male counterparts (p < 0.001). A striking gender discrepancy in total flight time also existed among pilots who were involved in commuter/ air taxi crashes [mean total flight time: 5,795 h (SD 4,891 h) for males and 3,257 h (SD 2,269) for females, p < 0.001].

With regard to crash circumstances, instrument meteorological conditions (IMC) were associated with a significantly higher prevalence of pilot error, irrespective of the type of flight operations. An elevated prevalence of pilot error was found in major airline crashes and general aviation crashes occurring on airports, as compared with crashes away from airports. Whereas the proportion (40%) of major airline crashes that occurred at nighttime (6 pm to 5:59 a.m.) was considerably higher than that for commuter/ air taxi crashes (33%) and for general aviation crashes (22%), the prevalence of pilot error was similar between daytime and nighttime crashes in each of the three aviation categories.

Helicopters constituted 18% of commuter/air taxi crashes and 6% of general aviation crashes; and pilot error was less prevalent in helicopter crashes than in airplane crashes. More than half (53%) of the fatal major airline crashes were attributed to pilot error, compared with 36% of the nonfatal major airline crashes (p = 0.03). The prevalence of pilot error was also significantly higher in fatal commuter/air taxi crashes and fatal general aviation crashes.

Chapter 1.1. Accident Causes

To analyze the causes of accidents, need to consider interactions between four factors: technical, environmental, organizational, and human factor.

Technical factor is most studied, and receives the most focus by researches, resulting with many theories and practices deployed to safety critical systems which reduces system failures significantly, eg. diagnostic technology, redundancy and backup design, robustness and fault tolerant controls. It has a focus on equipment malfunction and failure caused by random failure or design flaws, with the nature that the system no longer meets its designed specifications and could not provide the designed functionalities any more. In many cases, the system failures also lead to stressful or confusing situations for human controllers which finally results in improper, insufficient, untimely or incorrect human responses that eventfully develop as catastrophes.

Environmental factors involve the physical surroundings of the operators or equipment which could affect performance, eg. weather conditions, noise, and illumination. The analysis of General Aviation (GA) databases from 2003 to 2007 shows that of 8,657 aviation accidents, 1,740 were weather related either as the primary cause or as a contributing factor.

Organizational factors are about inadequate procedures and training, insufficient standards / requirements / processes, and company / management induced pressure. For aviation industry, the Chief Pilot very much determines the safety culture of the organization. High personal standards serve as an example to other pilots. The regulatory standard is the minimum safety standard in any instance. The Chief Pilot may use a method of their choice to meet the regulatory standard. Attaining a good safety culture in an organization may be a long and slow process, but will ultimately pay dividends through reduced costs through safe operations. A poor safety culture is more likely to produce behaviors which contribute to an accident. Historical disaster like Chernobyl was caused by a poor safety culture, specifically infringements of safety rules.

Human factor is the scientific discipline about the understanding of interactions among humans and other system elements, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance. Thus human factors are associated with human error. A definition to human factor given by Reason is "encompassing all those occasions in which a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to the intervention of some chance agency." Examples of human error include, but are not limited to:

\- inattention

\- memory lapses

\- complacency

\- and mistakes

While there have been significant reductions in accidents resulting from technological failures, industrial incidents/accidents due to human error have significantly increased, representing a contributing cause of about 80%.

In Threat and error management (TEM), three basic components are defined for aviation: threats, errors, and undesired aircraft states.

Threats

Threats are 'events or errors that occur beyond the influence of the flight crew, increase operational complexity, and which must be managed to maintain the margins of safety'. When undetected, unmanaged or mismanaged, threats may lead to errors or even an undesired aircraft state.

Errors

Errors are 'actions or inactions by the pilot that lead to deviations from organizational or pilot intentions or expectations'. When undetected, unmanaged or mismanaged, errors may lead to undesired aircraft states.

Undesired aircraft states

Undesired aircraft states are defined as 'an aircraft deviation or incorrect configuration associated with a clear reduction in safety margins'. Undesired aircraft states are considered the last stage before an incident or accident. Thus, the management of undesired aircraft states represents the last opportunity for flight crews to avoid an unsafe outcome, and hence maintain safety margins in flight operations.

Figure: Operations threat and error model

Above figure is a common pictorial model used for training airline flight crews, originally developed by Continental Airlines. It shows how the three components of the TEM model fit together, and how they can lead to undesired aircraft states if not properly managed. The number of arrows in the diagram represents the expected number of threats, errors and consequences (incidents and accidents), conveying the idea that crews will generally need to manage many more threats than errors, and likewise, manage more errors than consequences. The height of the diagram refers to time available before an occurrence occurs relative to when threats and errors usually appear. The width of the diagram represents the amount of resources available for crews to manage the situation. Generally, there are more resources available to manage threats when they first occur compared to later when these threats have already led to an error.

Hazard is a present condition, event, object, or circumstance that could lead to or contribute to an unplanned or undesired event. For example, a nick in the propeller represents a hazard.

Risk is the future impact of a hazard that is not controlled or eliminated.

The level of risk posed by a given hazard is measured in terms of severity, which is the extent of possible loss, and probability, which is likelihood that a hazard will cause a loss. Another element in assessing risk is exposure, the number of people or resources affected.

Figure: Breakdown of all fatal accidents by causal group ( for all causal factors) for the ten-year period 1997 to 2006

Figure: Breakdown of fatal accidents by aircraft class and causal group (for all causal factors) for the ten-year period 1997 to 2006

Figure: Breakdown of fatal accidens by nature of flight and causal group (for all causal factors) for the ten-year period 1997 to 2006

Chapter 1.2. Human Errors

Humans are capability limited. Humans are fallible.

The primary objective of safety professional is to identify resulting errors, reduce their chances of occurrence, and minimize their impact. These goals can only be achieved by gaining safety status information of the organization, information usually collected in accident reports.

For example, people forget. A consideration of why people forget may point the way to help them remember. Several theories explain forgetting, including disuse, interference, and repression.

DISUSE

Disuse theory suggests that a person forgets the things which are not used. Since the things which are remembered are those used on the job, a person concludes that forgetting is the result of disuse. But the explanation is not quite that simple. Experimental studies show that a hypnotized person can describe specific details of an event which normally is beyond recall.

INTERFERENCE

The basis of the interference theory is that people forget something because a certain experience has overshadowed it, or that the learning of similar things has intervened. This theory might explain how the range of experiences after graduation from school causes a person to forget or to lose knowledge. In other words, new events displace many things that had been learned. From experiments, at least two conclusions about interference may be drawn. First, similar material seems to interfere with memory more than dissimilar material; and second, material not well learned suffers most from interference.

REPRESSION

Freudian psychology advises that some forgetting is repression due to the submersion of ideas into the subconscious mind. Material that is unpleasant or produces anxiety may be treated this way by the individual, but not intentionally. It is subconscious and protective. The repression theory does not appear to account for much forgetfulness, but it does tend to explain some cases.

In general, human error is viewed as an inappropriate or unacceptable human decision or action that degrades, or has the potential of degrading, efficiency, safety, or system performance.

Human error is frequently cited as the major contributing cause of several significant industrial disasters such as Bhopal, and Chernobyl. The situation will most likely to continue as humans are inherently fallible. While some were cognitively oriented, others have taken a more holistic approach.

Significant research on human error conducted by Rasmussen (1982) defined three levels of human behavior based on the level of cognition involved, knowledge based, rule-based, and skill-based behaviors. Knowledge-based activities are those involved in creating a plan to solve a new situation or problem. While rule-based behaviors are activities that are conducted using a set of stored instructions or procedures, skill-based behaviors are routine activities conducted spontaneously. With experience and practice, performance shifts from knowledge-based to skill-based; further, the level of conscious demand increases as we transfer from skill-based to rule-based reaching the highest conscious control levels for knowledge-based activities.

Reason supplemented Rasmussen's work by defining the error associated with the human behavior as "unsafe acts" committed by an operator at the front line preceding an adverse event. Unsafe acts take many forms including slips, lapses, mistakes, and violations, the first two being execution failures that usually occur when the plan of action is adequate but the actions performed are not carried out as intended. These two are related to failures of attention, recognition, memory, or selection. On the other hand, mistakes occur when a plan is completed as anticipated, but it proves to be inadequate to achieve its intended outcome.

The last form of unsafe acts, violations, which are classified as either routine or exceptional, include deviations from the established rules and regulations that increase the probability of committing an error resulting in a negative outcome. While routine violations represent less serious deviations from rules and regulations tolerated by authority personnel, thus habitual in nature, exceptional violations are severe departures from rules and protocols that are not condoned by such personnel.

Sarter and Alexander (2000) categorized human error based on operator task performance as either errors of omission or commission. Whereas errors of omission occur when an operator fails to execute a necessary task at the intended time, errors of commission occur when the operator carries out an action in the inappropriate way or at the imprecise time, such classification affects the likelihood to detect errors.

Human factor is seen as an important topic for aviation industry and is addressed in trainings. For example, in 1999 Aviation Instructor's Handbook, it contains the following chapters:

\- The Learning Process

\- Human Behavior

\- Effective Communication

\- The Teaching Process

\- Teaching Methods

\- Critique and Evaluation

\- Instructional Aids and Training Technologies

\- Instructor Responsibilities and Professionalism

\- Techniques of Flight Instruction

\- Planning Instructional Activity

\- Professional Development

with introductions for Control of Human Behavior, Human Needs, Defense Mechanisms, The Flight Instructor as a Practical Psychologist. Human Needs consist of Physical, Safety, Social, Ego, and Self-Fulfillment. Defense Mechanisms consist of Compensation, Projection, Rationalization. Denial of Reality, Reaction Formation, Flight, Aggression, and Resignation. The Flight Instructor as a Practical Psychologist consists of Anxiety, Normal Reactions to Stress, Abnormal Reactions to Stress, and Flight Instructor Actions Regarding Seriously Abnormal Students.

Figure: Top-ten causal factors, in terms of onboard fatalities, allocated for all fatal accidents for the ten-year period 1997 to 2006

Figure: Top-ten circumstantial factors allocated for all fatal accidents for the ten-year period 1997 to 2006

Figure: Top-ten circumstantial factors, in terms of onboard fatalities, allocated for all fatal accidents for the ten-year period 1997 to 2006

Chapter 1.3. Human Error Models

Human error has traditionally been viewed in two ways: the earlier persons approach and the more recent systems approach. In the mid-twentieth century, the persons approach was dominant, with systems being considered error-free and need to be protected from the unreliable humans committing errors and violations at the sharp end, operational level, causing failures. In this approach, errors occur due to such psychological factors in an individual as forgetfulness, poor motivation, inattention, carelessness and complacency. Since this responsibility lies solely on the individual, the recommendations for addressing such errors included automation, training, employee selection, development of in-depth procedures, and the firing of the operator whose actions led to the accident; however, these steps were ineffectual as human error continued to be a major cause of accidents.

To address this situation, many accident models have been proposed to understand accidents and the role of human error. These single element models included the physiological perspective, the behavioral perspective, the organizational perspective, the cognitive perspective, and the psychosocial perspective.

During the last decades, however, the view of human error has changed from the persons to the systems approach. In systems approach, human error is viewed as a symptom of deeper failures in the system rather than the failure of the human who is essential in creating safe systems. As a result, safety professionals focus on examining the system to reveal the latent factors, the organizational and technical elements, that created the conditions causing the operator to commit an error. Examples of latent factors include poor design, maintenance failure, ineffectual automation, inadequate supervision, manufacturing defects, inadequate training, inappropriate or poorly defined procedures, and inadequate equipment. Therefore, human error is no longer considered the major cause of accidents; instead, it is viewed as an outcome of the latent conditions in the system.

Many models have been proposed in the systems approach to understand human errors. While some models aid in the investigation process of accidents, others provide a systematic way of understanding accidents. System approach models include a combination of many factors including human factor, include the SHEL Model, the Swiss Cheese model, the wheel of misfortune, the incident cause analysis method (ICAM), and the human factors analysis and classification system.

Chapter 1.4. Swiss Cheese Model

It is generally accepted that aviation accidents are typically the result of a chain of events that often culminate with the unsafe acts of aircrew. The aviation industry is not alone in this belief, as the safety community has embraced a sequential theory of accident investigation since Heinrich first published his axioms of industrial safety in 1931. However, it was not until Reason published his "Swiss cheese" model of human error in 1990 that the aviation community began to examine human error in a systematic manner. It becomes one of the most largely regarded system models of accident causation.

Swiss Cheese Model (SCM)

Swiss Cheese Model is a system approach to human error, which takes into consideration that humans are prone to error; thus, barriers and safeguards are developed to prevent system breakdown.

In SCM, accidents can be tracked to four levels of failure:

\- unsafe acts

\- preconditions for unsafe acts

\- unsafe supervision

\- and organizational influence

The ideal system resembles a stack of slices of Swiss cheese, with the cheese representing the barriers and safeguards against failures, while the holes representing the errors still remaining. The system is prone to an accident when the holes, errors, in each level in the system line up allowing faults to propagate.

The holes or errors in the defensive system are the active and latent failures that cause nearly all accidents. An active failure, which is the act of the operator resulting in an immediate accident, is usually apparent, meaning it can quickly be attributed as the cause of an accident. On the other hand, the hard to detect latent errors usually occur at higher organizational levels and may reside in the system for an extended period of time.

SCM second version reduced the number of levels to three: organization, task/environment, and individual. Further, it included a latent failure path leading from the organization directly to the defenses, a path that takes into account accidents not involving active failures, for example the Challenger disaster.

SCM third version was developed in 1997. In this version, the top rectangle represents the components of an accident with undefined defenses, whereas the lower triangle illustrates the system producing the event: unsafe acts of operator, local workplace conditions, and organizational factors. The arrows differentiate the directions in which an accident occurs and in which it is investigated. The main concept in the three versions is that accidents are a result of latent and active failures within the system composed of the organization, environment, and individuals that interact negatively with one another, thus breaching the defenses of the system and producing loss.

The Swiss Cheese Model is widely accepted because it integrates a majority of the human error perspectives previously described. However, SCM lacks practicability to be used in real accident analysis. It lacks of identification of the failures, and the nature of the holes cause the model to be purely theoretical. Thus people encountered certain level of difficulties when applying this model on real accidents.

Chapter 2. HFACS7.0

In their 1998 work A Human Error Approach to Aviation Accidents, Douglas Weigmann and Scott Shappell recognized the value of a unified framework for analyzing human error perspectives at all levels of the organization. However they recognized that the specific nature of the "holes" was ill-defined. If one could identify the failed or absent defense, the hole could be plugged to prevent mishap.

The Human Factors Analysis and Classification System was specifically developed to define the latent and active failures identified in the Swiss Cheese model, after extensive analysis of hundreds of accident reports and thousands of human causal factors. Analogous to the Swiss Cheese model, HFACS also defined four levels of failure, each of which corresponds to one of four layers in the model.

As a primary accident investigation tool, HFACS assists accident investigators in their search for causal factors, active and latent, within each level of HFACS. It serves as a checklist for determining possible contributing factors.

As a secondary analysis tool, HFACS can be used to evaluate accident collections to see trends, which is a hint to pin point weaknesses in a certain area. For example, a study analyzed 14,571 GA accidents from 1990 to 1999 using HFACS, finding that skill-based errors were the dominant type of aircrew errors. Therefore, safety strategies need to be directed towards reducing such errors. In addition, despite slight fluctuations, the data indicate that the error trends have not changed significantly over time, suggesting that the safety intervention efforts had no real effect.

As an advanced analytical tool, HFACS can identify recurrent error pathways among its categories, providing people with additional information to guide resources towards a more focused intervention.

A study "Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS" by US Federal Aviation Administration, shows:

Unsafe Acts of Operators

The unsafe acts of operators (aircrew) can be loosely classified into one of two categories: errors and violations (Reason, 1990). While both are common within most settings, they differ markedly when the rules and regulations of an organization are considered. That is, while errors represent authorized behavior that fails to meet the desired outcome, violations refer to the willful disregard of the rules and regulations. It is within these two overarching categories that HFACS describes three types of errors (decision, skill-based, and perceptual) and two types of violations (routine and exceptional).

Errors

Decision errors. One of the more common error forms, decision errors, represents conscious, goal-intended behavior that proceeds as designed, yet the plan proves inadequate or inappropriate for the situation. Often referred to as honest mistakes, these errors typically manifest as poorly executed procedures, improper choices, or simply the misinterpretation and/or misuse of relevant information.

Skill-based errors. In contrast to decision errors, the second error form, skill-based errors, occurs with little or no conscious thought. Indeed, just as decision errors can be thought of as "thinking" errors, skill-based errors can be thought of as "doing" errors. For instance, little thought goes into turning one's steering wheel or shifting gears in an automobile. Likewise, basic flight skills such as stick and rudder movements and visual scanning refer more to how one does something rather than where one is going or why. The difficulty with these highly practiced and seemingly automatic behaviors is that they are particularly susceptible to attention and/or memory failures. As a result, skill-based errors frequently appear - the breakdown in visual scan patterns, inadvertent activation/ deactivation of switches, forgotten intentions, and omitted items in checklists. Even the manner (or skill) with which one flies an aircraft (aggressive, tentative, or controlled) can affect safety.

Perceptual errors. While decision and skill-based errors have dominated most accident databases and have, therefore, been included in most error frameworks, the third and final error form, perceptual errors, has received comparatively less attention. No less important, these "perceiving" errors arise when sensory input is degraded, or "unusual" as is often the case when flying at night, in the weather, or in other visually impoverished environments. Faced with acting on imperfect or incomplete information, aircrew run the risk of misjudging distances, altitude, and decent rates, as well as responding incorrectly to a variety of visual/vestibular illusions.

Violations

Routine violations. Although there are many ways to distinguish between types of violations, two distinct forms have been identified based on their etiology. The first, routine violations tend to be habitual by nature and are often enabled by a system of supervision and management that tolerates such departures from the rules (Reason, 1990). Often referred to as "bending the rules," the classic example is that of the individual who drives his/her automobile consistently 5-10 mph faster than allowed by law. While clearly against the law, the behavior is, in effect, sanctioned by local authorities (police) who often will not enforce the law until speeds in excess of 10 mph over the posted limit are observed.

Exceptional violations. These types of violations, on the other hand, are isolated departures from authority, neither typical of the individual nor condoned by management. For example, while authorities might condone driving 65 in a 55 mph zone, driving 105 mph in a 55 mph zone would almost certainly result in a speeding ticket. It is important to note that, while most exceptional violations are appalling, they are not considered "exceptional" because of their extreme nature. Rather, they are regarded as exceptional because they are neither typical of the individual nor condoned by authority.

Preconditions for Unsafe Acts

Simply focusing on unsafe acts, however, is like focusing on a patient's symptoms without understanding the underlying disease state that caused it. As such, investigators must dig deeper into the preconditions for unsafe acts. Within HFACS, three major subdivisions are described: 1) condition of the operator, 2) personnel factors, and 3) environmental factors.

Condition of the Operator

Adverse mental states. Being prepared mentally is critical in nearly every endeavor; perhaps it is even more so in aviation. With this in mind, the first of three categories, adverse mental states, was created to account for those mental conditions that adversely affect performance and contribute to unsafe acts. Principal among these are the loss of situational awareness, mental fatigue, circadian dysrhythmia, and pernicious attitudes such as overconfidence, complacency, and misplaced motivation.

Adverse physiological states. Equally important, however, are those adverse physiological states that preclude the safe conduct of flight. Particularly important to aviation are conditions such as spatial disorientation, visual illusions, hypoxia, illness, intoxication, and a whole host of pharmacological and medical abnormalities known to affect performance. It is important to understand that conditions like spatial disorientation are physiological states that cannot be turned on or off – they just exist. As a result, these adverse physiological states often lead to the commission of unsafe acts like perceptual errors. For instance, it is not uncommon in aviation for a pilot to become spatially disoriented (adverse physiological state) and subsequently misjudge the aircraft's pitch or attitude (perceptual error), resulting in a loss of control and/or collision with the terrain.

Physical and/or mental limitations. The third and final category of substandard conditions, physical/mental limitations, includes those instances when necessary sensory information is either unavailable, or if available, individuals simply do not have the aptitude, skill, or time to safely deal with it. In aviation, the former often includes not seeing other aircraft or obstacles due to the size and/or contrast of the object in the visual field. Likewise, there are instances when an individual simply may not possess the necessary aptitude, physical ability, or proficiency to operate safely. After all, just as not everyone can play linebacker for their favorite professional football team or be a concert pianist, not everyone has the aptitude or physical attributes necessary to fly aircraft.

Personnel Factors

Often times, things that we do to ourselves will lead to undesirable conditions and unsafe acts as described above. Referred to as personnel factors, these preconditions have been divided into two general categories: crew resource management and personal readiness.

Crew resource management (CRM). It is not hard to imagine that when all members of the crew are not acting in a coordinated manner, confusion (adverse mental state) and poor decisions in the cockpit can ensue. Crew resource mismanagement, as it is referred to here, includes the failures of both inter- and intra-cockpit communication, as well as communication with Air Traffic Control (ATC )and other ground personnel. This category also includes those instances when crewmembers do not work together as a team, or when individuals directly responsible for the conduct of operations fail to coordinate activities before, during, and after a flight.

Personal readiness. Individuals must, by necessity, ensure that they are adequately prepared for flight. Consequently, the category of personal readiness was created to account for those instances when rules such as disregarding crew rest requirements, violating alcohol restrictions, or selfmedicating, are not adhered to. However, even behaviors that do not necessarily violate existing rules or regulations (e.g., running ten miles before piloting an aircraft or not observing good dietary practices) may reduce the operating capabilities of the individual and are, therefore, captured here as well.

Environmental Factors

Although not human per se, environmental factors can also contribute to the substandard conditions of operators and hence to unsafe acts. Very broadly, these environmental factors can be captured within two general categories: the physical environment and the technological environment.

Physical environment. The impact that the physical environment can have on aircrew has long been known and much has been documented in the literature on this topic. The term physical environment refers to both the operational environment (e.g., weather, altitude, terrain), as well as the ambient environment, such as heat, vibration, lighting, and toxins in the cockpit. For example, flying into adverse weather reduces visual cues, which can lead to spatial disorientation and perceptual errors. Other aspects of the physical environment such as heat can cause dehydration, which reduces a pilot's alertness level, producing a subsequent slowing of decision-making processes or even the inability to control the aircraft. Likewise, a loss of pressurization at high altitudes or maneuvering at high altitudes without supplemental oxygen in unpressurized aircraft can result in hypoxia, which leads to delirium, confusion, and a host of unsafe acts.

Technological environment. Pilots that often find themselves in a technological environment that can also have a tremendous impact on their performance. Within the context of HFACS, the term technological environment encompasses a variety of issues, including the design of equipment and controls, display/interface characteristics, checklist design, and automation, to name a few. Indeed, one of the classic design problems first discovered in aviation was the similarity between the controls used to raise and lower the flaps and those used to raise and lower the landing gear. Such similarities often caused confusion among pilots, resulting in the frequent raising of the landing gear while still on the ground. Likewise, automation designed to improve human performance can have unforeseen consequences. For example, highly reliable automation has been shown to induce adverse mental states such as overconfidence and complacency, resulting in pilots following the instructions of the automation even when "common sense" suggests otherwise.

In contrast, unreliable automation can often result in a lack of confidence and disuse of automation even though aided performance is safer than unaided performance.

Unsafe Supervision

Clearly, aircrews are responsible for their actions and, as such, must be held accountable. However, in some instances, they are the unwitting inheritors of latent failures attributable to those who supervise them. To account for these latent failures, the overarching category of unsafe supervision was created within which four categories (inadequate supervision, planned inappropriate operations, failed to correct known problems, and supervisory violations) are included.

Inadequate supervision. This category refers to failures within the supervisory chain of command as a direct result of some supervisory action or inaction. At a minimum, supervisors must provide the opportunity for individuals to succeed. It is expected, therefore, that individuals will receive adequate training, professional guidance, oversight, and operational leadership, and that all will be managed appropriately. When this is not the case, aircrew can become isolated, thereby increasing the risks associated with day-to-day operations.

Planned inappropriate operations. The risk associated with supervisory failures come in many forms. Occasionally, for example, the operational tempo and/or schedule are planned such that individuals are put at unacceptable risk and, ultimately, performance is adversely affected. As such, the category of planned inappropriate operations was created to account for all aspects of improper or inappropriate crew scheduling and operational planning, which may focus on such issues as crew pairing, crew rest, and managing the risk associated with specific flights. Failed to correct known problems. The remaining two categories of unsafe supervision, the failure to correct known problems and supervisory violations, are similar, yet considered separately within HFACS. The failure to correct known problems refers to those instances when deficiencies among individuals, equipment, training, or other related safety areas are "known" to the supervisor, yet are allowed to continue uncorrected. For example, the failure to consistently correct or discipline inappropriate behavior certainly fosters an unsafe atmosphere but is not considered a violation if no specific rules or regulations were broken.

Supervisory violations. This category is reserved for those instances when supervisors willfully disregard existing rules and regulations. For instance, permitting aircrew to operate an aircraft without current qualifications or license is a flagrant violation that may set the stage for the tragic sequence of events that may follow.

Organizational Influences

Where decisions and practices by front-line supervisors and middle-management can adversely impact aircrew performance, fallible decisions of upper-level management may directly affect supervisors and the personnel they manage. Unfortunately, these organizational influences often go unnoticed or unreported by even the best-intentioned accident investigators. The HFACS framework describes three latent organizational failures:

1) resource management

2) organizational climate

3) operational processes

Resource management. This category refers to the management, allocation, and maintenance of organizational resources, including human resource management (selection, training, staffing), monetary safety budgets, and equipment design (ergonomic specifications). In general, corporate decisions about how such resources should be managed center around two distinct objectives – the goal of safety and the goal of on-time, cost-effective operations. In times of prosperity, both objectives can be easily balanced and satisfied. However, there may also be times of fiscal austerity that demand some give and take between the two. Unfortunately, history tells us that safety is often the loser in such battles, as safety and training are often the first to be cut in organizations experiencing financial difficulties.

Organizational climate. The concept of an organization's culture has been described in many ways; however, here it refers to a broad class of organizational variables that influence worker performance. One telltale sign of an organization's climate is its structure, as reflected in the chain-of-command, delegation of authority and responsibility, communication channels, and formal accountability for actions. Just like in the cockpit, communication and coordination are vital within an organization. However, an organization's policies and culture are also good indicators of its climate. Consequently, when policies are ill-defined, adversarial, or conflicting, or when they are supplanted by unofficial rules and values, confusion abounds, and safety suffers within an organization.

Operational process. Finally, operational process refers to formal processes (operational tempo, time pressures, production quotas, incentive systems, schedules, etc.), procedures (performance standards, objectives, documentation, instructions about procedures, etc.), and oversight within the organization (organizational self-study, risk management, and the establishment and use of safety programs). Poor upper-level management and decisions concerning each of these organizational factors can also have a negative, albeit indirect, effect on operator performance and system safety.

Chapter 2.1. HFACS7.0 Introduction

DOD HFACS is a taxonomic incident coding system developed for the US Marine Corps aviation sector and for application by practitioners to aid in investigating and analyzing the role of human factors in accidents and incidents.

HFACS comprises four taxonomies: "unsafe acts," "preconditions of unsafe acts," "unsafe supervision," and "organizational influences." The structure of these taxonomies is based on Reason's "Mark 1" Swiss Cheese Model, with elements of Bird loss causation model. The taxonomies contain 17 categories among them which are used for coding contributing factors. Examples of these categories include "skill based error," "violation-routine," "adverse mental state," and "inadequate supervision."

HFACS's development has been consistently documented in publications, including the publication of error trends from aviation incident reports using the HFACS coding methodology and a wide ranging number of reliability studies. Many studies have reported a successful level of reliability for HFACS with success ranging from a percentage agreement of 60% to 85%.

Human factors describe how our interaction with tools, tasks, working environments, and other people influence human performance. Human factors are the leading cause of DoD mishaps. The DoD HFACS model presents a systematic, multidimensional approach to error analysis and mishap prevention. Mishap investigators use DoD HFACS in the mishap analysis.

In the HFACS there are 4 levels and 17 categories of factors. The levels are:

Level 1: Unsafe acts of operators

Level 2: Preconditions for unsafe acts

Level 3: Unsafe supervision" (lower management layer in Reason's model)

Level 4: Organizational influences" (higher management layer in Reason's model)

The DOD HFACS Version 7.0 taxonomy is defined. The levels are:

Level 1: Acts

Level 2: Preconditions

Level 3: Supervision

Level 4: Organizational influences

Chapter 2.2. HFACS7.0 Purpose

HFACS organizes the human factors identified in the investigation. It is designed for use by all members of an investigation board in order to accurately record all aspects of human performance associated with the individual and the mishap or event. HFACS helps investigators to:

\- Perform a more complete investigation

\- Classify particular actions (or inactions) that sustained the mishap sequence

\- Contribute to the AFSAS database as a repository for detecting mishap trends and preventing future mishaps

Chapter 2.3. HFACS7.0 Description

In HFACS, active failures are the actions or inactions of individuals that are believed to cause or contribute to the mishap. Traditionally referred to as "error," they are the last "acts" committed by individuals, often with immediate consequences. In contrast, latent failures are pre‐existing conditions within an organization which indirectly affect the sequence of mishap events. These latent failures may lie undetected for some period of time prior to their manifestation as an influence on an individual's actions during a mishap.

Swiss Cheese model describes the four levels within which active failures and latent failures may occur during complex operations. The holes in the layers represent failed or absent hazard mitigation controls which may contribute to the overall mishap circumstances. Working backward from the mishap, the first level of Reason's model depicts those Acts that most immediately lead to a mishap. Most causal factors are uncovered at this level, however, Reason's model forces investigators to address the latent failures, or "holes", within the causal sequence of events which may be overlooked if the focus is limited to individual actions only. Latent failures and conditions are described within the context of Reason's model as Preconditions, Supervision, and Organizational Influences.

Chapter 2.4. HFACS7.0 Application

Mishaps are the result of individual and organizational factors that are further categorized as causal and/or contributory. Individuals whose actions impacted the outcome of the mishap should be identified as "mishap persons" and investigated. Their acts and preconditions will be identified at the Person Level within AFSAS. The context in which these acts and preconditions occurred will be captured as supervisory and organizational factors and will be identified at the Mishap Level. These factors are attributed to the mishap itself and not to a specific person.

Investigators will be guided on the utilization of HFACS v7.0 through a series of questions within AFSAS. For Class A, Class B, and Class E Physiological mishaps, investigators will be required to answer all questions and provide input at the nanocode level. For Class C and D mishaps and Dull Sword Events, investigators will be permitted to use nanocodes but they will not be required; they will answer the questions only. These new coding rules have been embedded in AFSAS to guide the investigator. Each human factor code that the investigator identifies must be rated as causal or contributory for its influence on the mishap.

\- Causal factors are deficiencies which, if corrected, would likely have prevented or mitigated damage and/or injury. Cause does not imply blame. Events/conditions that are highly probable results of other events/conditions are not causal and should be rated as contributory.

\- Contributory factors are independent events/conditions that do not directly result in damage and/or injury, but are integral to the progression of the mishap sequence. Contributory factors allow progression of other events/conditions. If an event/condition is considered to be both contributory and causal, rate it only as causal.

HFACS in aviation safety analysis

Aviation fulfills all of the conditions that allow us to include it into a class of complex systems with a very strong influence of the human factor. In such systems, the HFACS method of analysis is applicable in analyses of causes of incidents and accidents.

In this method the analysis examines not only the active errors and omissions directly leading to the event but also extends the analysis to higher levels of the system design. Accidents and incidents in aviation must be considered in the context of a system in which they occur. It consists of three elements: air traffic, the air traffic control (ATC) system and the physical and organizational environment.

According to the structure, the HFACS applied to an analysis of the causes of incidents includes four levels:

1. Acts. This is a group of active errors committed (e.g. bad decisions or incorrect assessment of input information) and negligence resulting, for example, from routine. It may include even deliberate violation of adopted rules.

2. Preconditions. Making mistakes at the first level is usually reinforced by a combination of factors which have a direct impact on the operators involved in the traffic (pilots, ATC controllers). This group of errors includes, in particular, issues in interpersonal communication, the physical and mental state of important participants of the events, as well as the state of the environment, both physical and technological.

3. Supervision. Because of the possible negative effects, the air transport system has numerous supervision mechanisms. Irregularities and especially neglect in this area may contribute to premises to make mistakes.

4. Organizational influences. The management of the organization, and in particular high level managers' approach to safety issues, can play a key role in the development of the whole causal chain, which can finally produce an air accident.

Air traffic consists of the aircraft that move according to pre-established routes which are agreed upon and coordinated by Air Traffic Control services. Depending on the phase of the flight, these are: ACC (Area Control Center) – for aircraft in the cruise phase of the flight, APP (Approach control) – for aircraft approaching landing and climbing after take-off, and TWR (Tower control) for taking off and landing aircraft. Every ATC service supervises a specific part of airspace which is divided into elementary sectors. These can be combined dynamically into larger structures in the case of low traffic. The most important element of these services are the air traffic controllers (ATCos) who ensure safe and suitably arranged traffic flow in control sectors under their supervision. In their control decisions, ATCos have to take into account the state of the environment, and in particular meteorological conditions, but also of the non-physical environment, e.g. procedures and regulations that to a large degree govern the organization of air traffic. The non-physical environment is defined by international organizations, particularly the ICAO (International Civil Aviation Organization), the national civil aviation authorities, as well as the management system of the ATC structure.

Chapter 2.5. HFACS7.0 Benefits

1. Structured analysis of human error patterns

\- Detailed, complete and operationally focused

2. Gets to the "Why", not just the "What"

\- More accurate root cause determination

\- Permits more effective risk management

3. Data-driven approach

\- Supports research across the DoD

\- Easily applied to both new mishaps and previous reports

4. Can be used for more than just operational situations

\- As a brainstorming tool for risk management

\- In developing interview questions

\- Applies to both on‐ and off‐duty mishaps

Above are the four aspects that summarizes the benefits of HFACS 7.0.

Chapter 2.6. HFACS7.0 Structure

The structure of HFACS 7.0 is:

ACTS

\- Performance-Based Errors (AE100)

\- Judgment & Decision-Making Errors (AE200):

\- Violations (AV000)

PRECONDITIONS

\- Environment

\-- Physical Environment (PE100)

\-- Technological Environment (PE200)

\- Physical and Mental State

\-- Physical Problem (PC300)

\-- State of Mind (PC200)

\-- Sensory Misperception (PC500)

\-- Mental Awareness (PC100)

\- Teamwork (PP100)

SUPERVISION

\- Supervisory Violations (SV000)

\- Planned Inappropriate Operations (SP000)

\- Inadequate Supervision (SI000)

ORGANIZATIONAL INFLUENCES

\- Resource Problems (OR000)

\- Personnel Selection & Staffing (OS000)

\- Policy & Process Issues (OP000)

\- Climate/Culture Influences (OC000)

Chapter 2.7. HFACS7.0 Factors

ACTS

"Active Failures or Actions"

PERFORMANCE-BASED ERRORS (AE100): are factors that occur when a specific action is performed in a manner that leads to a mishap.

AE101: Unintended Operation of Equipment

AE102: Checklist Not Followed Correctly

AE103: Procedure Not Followed Correctly

AE104: Over‐Controlled/Under‐Controlled Aircraft/Vehicle

AE105: Breakdown in Visual Scan

AE107: Rushed or Delayed a Necessary Action

AE101 Unintended Operation of Equipment: is a factor when an individual's movements inadvertently activate or deactivate equipment, controls or switches when there is no intent to operate the control or device. This action may be noticed or unnoticed by the individual.

AE102 Checklist Not Followed Correctly: is a factor when the individual, either through an act of commission or omission, makes a checklist error or fails to run an appropriate checklist.

AE103 Procedure Not Followed Correctly: is a factor when a procedure is performed incorrectly or accomplished in the wrong sequence.

AE104 Overcontrolled/Undercontrolled Aircraft/Vehicle/System: is a factor when an individual responds inappropriately to conditions by either over‐ or undercontrolling the aircraft/vehicle/system. The error may be a result of preconditions or a temporary failure of coordination.

AE105 Breakdown in Visual Scan: is a factor when the individual fails to effectively execute visual scan patterns.

AE107 Rushed or Delayed a Necessary Action: is a factor when an individual takes the necessary action as dictated by the situation but performs these actions too quickly or too slowly.

JUDGMENT & DECISION‐MAKING ERRORS (AE200): are factors that occur when an individual proceeds as intended, yet the plan proves inadequate or inappropriate for the situation, e.g. "An honest mistake."

AE201: Inadequate Real‐Time Risk Assessment

AE202: Failure to Prioritize Tasks Adequately

AE205: Ignored a Caution/Warning

AE206: Wrong Choice of Action During an Operation

AE201 Inadequate Real‐Time Risk Assessment: is a factor when an individual fails to adequately evaluate the risks associated with a particular course of action and this faulty evaluation leads to inappropriate decision-making and subsequent unsafe situations.

AE202 Failure to Prioritize Tasks Adequately: is a factor when the individual does not organize, based on accepted prioritization techniques, the tasks needed to manage the immediate situation.

AE205 Ignored a Caution/Warning: is a factor when a caution or warning is perceived and understood by the individual but is ignored by the individual.

AE206 Wrong Choice of Action During an Operation: is a factor when the individual, through faulty logic or erroneous expectations, selects the wrong course of action.

VIOLATIONS (AV000): are factors when the individual intentionally breaks the rules and instructions. "Violations are deliberate."

AV001: Performs Work-Around Violation

AV002: Commits Widespread/Routine Violation

AV003: Extreme Violation - Lack of Discipline

AV001 Performs Work‐Around Violation: is a factor when the consequences/risk of violating published procedures was recognized, consciously assessed and honestly determined by the individual, crew or team to be the best course of action. Routine "work‐arounds" and unofficial procedures that are accepted by the community as necessary for operations are also captured under this code.

AV002 Commits Widespread/Routine Violation: is a factor when a procedure or policy violation is systemic in a unit/setting and not based on a risk assessment for a specific situation. It needlessly commits the individual, team, or crew to an unsafe course‐of‐action. These violations may have leadership sanction and may not routinely result in disciplinary/administrative action. Habitual violations of a single individual or small group of individuals within a unit can constitute a routine/widespread violation if the violation was not routinely disciplined or was condoned by supervisors.

AV003 Extreme Violation – Lack of Discipline: is a factor when an individual, crew or team intentionally violates procedures or policies without cause or need. These violations are unusual or isolated to specific individuals rather than larger groups. There is no evidence of these violations being condoned by leadership. These violations may also be referred to as "exceptional violations."

PRECONDITIONS

"Latent Failures or Conditions"

ENVIRONMENT: The environment surrounding a mishap is the physical or technological factors that affect practices, conditions, and actions of individual(s).

PHYSICAL ENVIRONMENT (PE100): are factors such as weather, climate, fog, brownout (dust or sand storm) or whiteout (snow storm) that affect the actions of individual.

PE101: Environmental Conditions Affecting Vision

PE103: Vibration Affects Vision or Balance

PE106: Heat/Cold Stress Impairs Performance

PE108: External Force or Object Impeded an Individual's Movement

PE109: Lights of Other Vehicle/Vessel/Aircraft Affected Vision

PE110: Noise Interference

PE101 Environmental Conditions Affecting Vision: is a factor that includes obscured windows; weather, fog, haze, darkness; smoke, etc.; brownout/whiteout (dust, snow, water, ash or other particulates); or when exposure to windblast affects the individual's ability to perform required duties.

PE103 Vibration Affects Vision or Balance: is a factor when the intensity or duration of the vibration is sufficient to cause impairment of vision or adversely affect balance.

PE106 Heat/Cold Stress Impairs Performance: is a factor when the individual is exposed to conditions resulting in compromised performance.

PE108 External Force or Object Impeded an Individual's Movement: is a factor when acceleration forces greater than one second cause injury or prevent/interfere with the performance of normal duties. Do not use this code to capture G-induced loss of consciousness.

PE109 Lights of Other Vehicle/Vessel/Aircraft Affected Vision: is a factor when the absence, pattern, intensity or location of the lighting of other vehicle/vessel/aircraft prevents or interferes with safe task accomplishment.

PE110 Noise Interference: is a factor when any sound not directly related to information needed for task accomplishment interferes with the individual's ability to perform that task.

TECHNOLOGICAL ENVIRONMENT (PE200): are factors when automation or the design of the workspace affects the actions of an individual.

PE201: Seat and Restraint System Problems

PE202: Instrumentation and Warning System Issues

PE203: Visibility Restrictions (not weather related)

PE204: Controls and Switches are Inadequate

PE205: Automated System Creates an Unsafe Situation

PE206: Workspace Incompatible with Operation

PE207: Personal Equipment Interference

PE208: Communication Equipment Inadequate

PE201 Seat and Restraint System Problems: is a factor when the design of the seat or restraint system, the ejection system or seat comfort has poor impact‐protection qualities.

PE202 Instrumentation and Warning System Issues: is a factor when instrument factors such as design, reliability, lighting, location, symbology, size, display systems, auditory or tactile situational awareness or warning systems create an unsafe situation.

PE203 Visibility Restrictions (not weather related): is a factor when the lighting system, windshield/windscreen/canopy design, or other obstructions prevent necessary visibility. This includes glare or reflections on the windshield/windscreen/canopy. Visibility restrictions due to weather or environmental conditions are captured under PE101.

PE204 Controls and Switches are Inadequate: is a factor when the location, shape, size, design, reliability, lighting or other aspect of a control or switch are inadequate.

PE205 Automated System Creates an Unsafe Situation: is a factor when the design, function, reliability, symbology, logic or other aspect of automated systems creates an unsafe situation.

PE206 Workspace Incompatible with Operation: is a factor when the workspace is incompatible with the task requirements and safety for an individual.

PE207 Personal Equipment Interference: is a factor when the individual's personal equipment interferes with normal duties or safety.

PE208 Communication Equipment Inadequate: is a factor when communication equipment is inadequate or unavailable to support task demands. This includes electronically or physically blocked transmissions. Communications can be voice, data or multi-sensory.

PHYSICAL AND MENTAL STATE: The mental and physical states of individuals are how people know, think, learn, understand, perceive, feel, hurt, guess, recognize, notice, want, wish, hope, decide, expect, remember, forget, imagine, and believe.

PHYSICAL PROBLEM (PC300): are medical or physiological conditions that can result in unsafe situations.

PC302: Substance Effects (alcohol, supplements, medications, drugs)

PC304: Loss of Consciousness (sudden or prolonged onset)

PC305: Physical Illness/Injury

PC307: Fatigue

PC310: Trapped Gas Disorders

PC311: Evolved Gas Disorders

PC312: Hypoxia/Hyperventilation

PC314: Inadequate Adaptation to Darkness

PC315: Dehydration

PC317: Body Size/Movement Limitations

PC318: Physical Strength & Coordination (inappropriate for task demands)

PC319: Nutrition/Diet

PC302 Substance Effects (alcohol, supplements, medications, drugs): is a factor when the individual uses legal or illegal drugs, supplements, energy drinks or any other substance with measurable effect that interferes with performance.

PC304 Loss of Consciousness (sudden or prolonged onset): is a factor when the individual has a loss of functional capacity/consciousness due to G-LOC, seizure, trauma or any other cause.

PC305 Physical Illness/Injury: is a factor when a physical illness, injury, deficit or diminished physical capability causes an unsafe situation. This includes pre-existing and operationally‐related medical conditions, over-exertion, motion sickness, etc.

PC307 Fatigue: is a factor causing diminished physical/mental capability resulting from chronic or acute periods of prolonged wakefulness, sleep deprivation, jet lag, shift work or poor sleep habits.

PC310 Trapped Gas Disorders: is a factor when gasses in the middle ear, sinuses, teeth or intestinal tract expand or contracts.

PC311 Evolved Gas Disorders: is a factor when inert-gas evolves in the blood causing an unsafe situation. This includes chokes, CNS, bends, paresthesias or other conditions caused by inert-gas evolution.

PC312 Hypoxia/Hyperventilation: is a factor when the individual has insufficient oxygen supply to the body and/or breathing above physiological demands causes impaired function.

PC314 Inadequate Adaptation to Darkness: is a factor when the normal human limitation of dark‐adaptation rate affects safety, for example, when transitioning between aided and unaided night vision.

PC315 Dehydration: is a factor when the performance of the individual is degraded due to dehydration as a result of excessive fluid losses due to heat stress or due to insufficient fluid intake.

PC317 Body Size/Movement Limitations: is a factor when the size, strength, dexterity, mobility or other biomechanical limitations of an individual creates an unsafe situation. It must be expected that the average individual qualified for that duty position could accomplish the task in question.

PC318 Physical Strength & Coordination (inappropriate for task demands): is a factor when the relative physical strength and/or coordination of the individual is not adequate to support task demands.

PC319 Nutrition/Diet: is a factor when the individual's nutritional state or poor dietary practices are inadequate to fuel the brain and body functions resulting in degraded performance.

STATE OF MIND (PC200): are factors when an individual's personality traits, psychosocial problems, psychological disorders or inappropriate motivation creates an unsafe situation.

PC202: Psychological Problem

PC203: Life Stressors

PC204: Emotional State

PC205: Personality Style

PC206: Overconfidence

PC207: Pressing

PC208: Complacency

PC209: Motivation

PC215: Mentally Exhausted (Burnout)

PC202 Psychological Problem: is a factor when the individual met medical criteria for a psychiatric disorder.

PC203 Life Stressors: is a factor when the individual's performance is affected by life circumstance problems (includes relationship issues, financial stressors, recent move, etc.).

PC204 Emotional State: is a factor when the individual is under the influence of a strong positive or negative emotion and that emotion interferes with duties.

PC205 Personality Style: is a factor when the individual's personal interaction with others creates an unsafe situation. Examples are authoritarian, over‐conservative, impulsive, invulnerable, submissive or other personality traits that result in degraded performance.

PC206 Overconfidence: is a factor when the individual overvalues or overestimates personal capability, the capability of others or the capability of aircraft/vehicles or equipment.

PC207 Pressing: is a factor when the individual knowingly commits to a course of action that excessively presses the individual and/or their equipment beyond reasonable limits (e.g., pushing self or equipment too hard).

PC208 Complacency: is a factor when the individual has a false sense of security, is unaware of, or ignores hazards and is inattentive to risks.

PC209 Motivation: is a factor when the individual's motivation to accomplish a task/mission is excessive, weak, indecisive or when personal goals supersede the organization's goals.

PC215 Mentally Exhausted (Burnout): is a factor when the individual has the type of exhaustion associated with the wearing effects of high operational and/or lifestyle tempo in which operational requirements impinge on the ability to satisfy personal requirements and leads to degraded effectiveness.

SENSORY MISPERCEPTION (PC500): are factors resulting in degraded sensory inputs (visual, auditory or vestibular) that create a misperception of an object, threat or situation.

PC501: Motion Illusion – Kinesthetic

PC502: Turning/Balance Illusion – Vestibular

PC503: Visual Illusion

PC504: Misperception of Changing Environment

PC505: Misinterpreted/Misread Instrument

PC507: Misinterpretation of Auditory/Sound Cues

PC508: Spatial Disorientation

PC511: Temporal/Time Distortion

PC501 Motion Illusion – Kinesthetic: is a factor when physical sensations of the ligaments, muscles or joints cause the individual to have an erroneous perception of orientation, motion or acceleration. (If this illusion leads to spatial disorientation you must code PC508.)

PC502 Turning/Balance Illusion – Vestibular: is a factor when stimuli acting on the balance organs in the middle ear cause the individual to have an erroneous perception of orientation, motion or acceleration. (If this illusion leads to spatial disorientation you must code PC508.)

PC503 Visual Illusion: is a factor when visual stimuli result in an erroneous perception of orientation, motion or acceleration. (If this illusion leads to spatial disorientation you must code PC508.)

PC504 Misperception of Changing Environment: is a factor when an individual misperceives or misjudges altitude, separation, speed, closure rate, road/sea conditions, aircraft/vehicle location within the performance envelope or other operational conditions.

PC505 Misinterpreted/Misread Instrument: is a factor when the individual is presented with a correct instrument reading but its significance is not recognized, it is misread or is misinterpreted.

PC507 Misinterpretation of Auditory/Sound Cues: is a factor when the auditory inputs are correctly interpreted but are misleading/disorienting or when the inputs are incorrectly interpreted and cause an impairment of normal performance.

PC508 Spatial Disorientation: is a factor when an individual fails to correctly sense a position, motion, or attitude of the aircraft/vehicle/vessel or of oneself. Spatial Disorientation may be unrecognized and/or result in partial or total incapacitation.

PC511 Temporal/Time Distortion: is a factor when the individual experiences a compression or expansion of time relative to reality. This is often associated with a "fight or flight" response.

MENTAL AWARENESS (PC100): are factors of an attention management or awareness failure that affects the perception or performance of individuals.

PC101: Not Paying Attention

PC102: Fixation

PC103: Task Over‐Saturation/Under‐Saturation

PC104: Confusion

PC105: Negative Habit Transfer

PC106: Distraction

PC107: Geographically Lost

PC108: Interference/Interruption

PC109: Technical or Procedural Knowledge Not Retained after Training

PC110: Inaccurate Expectation

PC101 Not Paying Attention: is a factor when there is a lack of state of alertness or a readiness to process immediately available information. The individual has a state of reduced conscious attention due to a sense of security, self-confidence, boredom or a perceived absence of threat from the environment. This may often be a result of highly repetitive tasks.

PC102 Fixation: is a factor when the individual is focusing all conscious attention on a limited number of environmental cues to the exclusion of others.

PC103 Task Over-Saturation/Under-Saturation: is a factor when the quantity of information an individual must process exceeds their mental resources in the amount of time available to process the information.

PC104 Confusion: is a factor when the individual is unable to maintain a cohesive and orderly awareness of events and required actions and experiences a state characterized by bewilderment, lack of clear thinking or (sometimes) perceptual disorientation.

PC105 Negative Habit Transfer: is a factor when the individual reverts to a highly learned behavior used in a previous system or situation and that response is inappropriate for current task demands.

PC106 Distraction: is a factor when the individual has an interruption of attention and/or inappropriate redirection of attention by an environmental cue or mental process.

PC107 Geographically Lost: is a factor when the individual is at a different location from where one believes they are.

PC108 Interference/Interruption: is a factor when an individual is performing a highly automated/learned task and is distracted by another cue/event that results in the interruption and subsequent failure to complete the original task or results in skipping steps in the original task.

PC109 Technical or Procedural Knowledge Not Retained after Training: is a factor when the individual fails to absorb/retain required information or is unable to recall past experience needed for safe task completion.

PC110 Inaccurate Expectation: is a factor when the individual expects to perceive a certain reality and those expectations are strong enough to create a false perception of the expectation.

TEAMWORK (PP100): factors refer to interactions among individuals, crews, and teams involved with the preparation and execution of a task/mission that resulted in human error or an unsafe situation.

PP101: Failure of Crew/Team Leadership

PP103: Inadequate Task Delegation

PP104: Rank/Position Intimidation

PP105: Lack of Assertiveness

PP106: Critical Information Not Communicated

PP107: Standard/Proper Terminology Not Used

PP108: Failed to Effectively Communicate

PP109: Task/Mission Planning/Briefing Inadequate

PP101 Failure of Crew/Team Leadership: is a factor when the crew/team leadership techniques failed to facilitate a proper crew/team climate, to include establishing and maintaining an accurate and shared understanding of the evolving task and plan on the part of all crew/team members.

PP103 Inadequate Task Delegation: is a factor when the crew/team members failed to actively manage the distribution of tasks to prevent the overloading of any individual member.

PP104 Rank/Position Intimidation: is a factor when the differences in rank of the team/crew caused the task performance capabilities to be degraded. Also, conditions where formal or informal authority gradient is too steep or too flat across a crew/team and this condition degrades collective or individual performance.

PP105 Lack of Assertiveness: is a factor when an individual failed to state critical information or solutions with appropriate persistence and/or confidence.

PP106 Critical Information Not Communicated: is a factor when known critical information was not provided to appropriate individuals in an accurate or timely manner.

PP107 Standard/Proper Terminology Not Used: is a factor when clear and concise terms, phrases, hand signals, etc. per service standards and training were not used.

PP108 Failed to Effectively Communicate: is a factor when communication is not understood or is misinterpreted as the result of behavior of either sender or receiver. Communication failed to include backing up, supportive feedback or acknowledgement to ensure that personnel correctly understood announcements or directives.

PP109 Task/Mission Planning/Briefing Inadequate: is a factor when an individual, crew or team failed to complete all preparatory tasks associated with planning/briefing the task/mission.

SUPERVISION

"Direct Supervisory Chain of Command"

SUPERVISION: Supervision is a factor in a mishap if the methods, decisions or policies of the supervisory chain of command directly affect practices, conditions or actions of the individual(s).

SUPERVISORY VIOLATIONS (SV000): are factors when supervisors willfully disregard instructions or policies.

SV001: Failure to Enforce Existing Rules (supervisory act of omission)

SV002: Allowing Unwritten Policies to Become Standard

SV003: Directed Individual to Violate Existing Regulations

SV004: Authorized Unqualified Individuals for Task

SV001 Failure to Enforce Existing Rules (supervisory act of omission): is a factor when unit (organizational) and operating rules have not been enforced by a supervisor.

SV002 Allowing Unwritten Policies to Become Standard: is a factor when unwritten or "unofficial" policy is perceived and followed by the individual, although it has not been formally recognized by the organization.

SV003 Directed Individual to Violate Existing Regulations: is a factor when a supervisor directs a subordinate to violate existing regulations, instructions or technical guidance.

SV004 Authorized Unqualified Individuals for Task: is a factor when an individual has not met the general training requirements for the job/weapon system and is considered non-current but supervision/leadership inappropriately allows the individual to perform the task for which the individual is non‐current.

PLANNED INAPPROPRIATE OPERATIONS (SP000): are factors when supervision fails to adequately plan or assess the hazards associated with an operation and allows for unnecessary risk.

SP001: Directed Task Beyond Personnel Capabilities

SP002: Inappropriate Team Composition

SP003: Selected Individual with Lack of Current or Limited Experience

SP006: Performed Inadequate Risk Assessment – Formal

SP007: Authorized Unnecessary Hazard

SP001 Directed Task Beyond Personnel Capabilities: is a factor when supervisor/management directs personnel to undertake a task beyond their skill level or beyond the capabilities of their equipment.

SP002 Inappropriate Team Composition: is a factor when the makeup of the crew/team should have reasonably raised safety concerns in the minds of members involved in the task, or in any other individual directly related to the scheduling of this task.

SP003 Selected Individual with Lack of Current or Limited Experience: is a factor when the supervisor selects an individual whose experience is not sufficiently current or proficient to permit safe task execution.

SP006 Performed Inadequate Risk Assessment – Formal: is a factor when supervision does not adequately evaluate the risks associated with a task or when pre-mission risk assessment tools/programs are inadequate.

SP007 Authorized Unnecessary Hazard: is a factor when supervision authorizes an activity or task that is unnecessarily hazardous without sufficient cause or need.

INADEQUATE SUPERVISION (SI000): are factors when supervision proves inappropriate or improper and/or fails to identify hazards; recognize and control risk; provide guidance, training and/or oversight.

SI001: Supervisory/Command Oversight Inadequate

SI002: Improper Role‐Modeling

SI003: Failed to Provide Proper Training

SI004: Failed to Provide Appropriate Policy/Guidance

SI005: Personality Conflict with Supervisor

SI006: Lack of Supervisory Responses to Critical Information

SI007: Failed to Identify/Correct Risky or Unsafe Practices

SI008: Selected Individual with Lack of Proficiency

SI001 Supervisory/Command Oversight Inadequate: is a factor when the availability, competency, quality or timeliness of leadership, supervision or oversight does not meet task demands. Inappropriate supervisory pressures are also captured under this code.

SI002 Improper Role‐Modeling: is a factor when the individual's learning is influenced by the behavior of supervisors and when that learning manifests itself in actions that are either inappropriate to the individual's skill level or violate standard procedures.

SI003 Failed to Provide Proper Training: is a factor when one‐time or recurrent training programs, upgrade programs, transition programs or any other local training is inadequate or unavailable, etc. (Note: the failure of an individual to absorb the training material in an adequate training program does not indicate a training program problem.)

SI004 Failed to Provide Appropriate Policy/Guidance: is a factor when policy/guidance or lack of a policy/guidance leads to an unsafe situation.

SI005 Personality Conflict with Supervisor: is a factor when a supervisor and individual member experience a "personality conflict" that leads to a dangerous error in judgment/action.

SI006 Lack of Supervisory Responses to Critical Information: is a factor when information critical to a potential safety issue was provided but supervisory/management personnel failed to act upon it (failure to close the loop).

SI007 Failed to Identify/Correct Risky or Unsafe Practices: is a factor when a supervisor fails to identify or correct risky behaviors or unsafe tendencies and/or fails to institute remedial actions. This includes hazardous practices, conditions or guidance.

SI008 Selected Individual with Lack of Proficiency: is a factor when a supervisor selects an individual that is not proficient in a task, mission or event.

ORGANIZATIONAL INFLUENCES

"Upper-Level Management, Command Level"

ORGANIZATION: An organization is the communications, actions, omissions or policies of upper-level management that directly or indirectly affect supervisory practices, conditions or actions of the operator(s).

RESOURCE PROBLEMS (OR000): are factors when processes or policies influence system safety, resulting in inadequate error management or creating an unsafe situation.

OR001: Command and Control Resources are Deficient

OR003: Inadequate Infrastructure

OR005: Failure to Remove Inadequate/Worn‐Out Equipment in a Timely Manner

OR008: Failure to Provide Adequate Operational Information Resources

OR009: Failure to Provide Adequate Funding

OR001 Command and Control Resources are Deficient: is a factor when installation resources are inadequate for safe operations. Examples include: command and control, airfield services, battlegroup management, etc.

OR003 Inadequate Infrastructure: is a factor when support facilities (dining, exercise, quarters, medical care, etc.) or opportunity for recreation or rest are not available or adequate. This includes situations where leave is not taken for reasons other than the individual's choice.

OR005 Failure to Remove Inadequate/Worn-Out Equipment in a Timely Manner: is a factor when the process through which equipment is removed from service is inadequate.

OR008 Failure to Provide Adequate Operational Information Resources: is a factor when weather, intelligence, operational planning material or other information necessary for safe operations planning are not available.

OR009 Failure to Provide Adequate Funding: is a factor when an organization or operation does not receive the financial resources to complete its assigned task/mission.

PERSONNEL SELECTION & STAFFING (OS000): are factors if personnel management processes or policies, directly or indirectly, influence system safety and results in poor error management or creates an unsafe situation.

OS001: Personnel Recruiting and Selection Policies are Inadequate

OS002: Failure to Provide Adequate Manning/Staffing Resources

OS001 Personnel Recruiting and Selection Policies are Inadequate: is a factor when the process through which individuals are screened, brought into the service or placed into specialties is inadequate.

OS002 Failure to Provide Adequate Manning/Staffing Resources: is a factor when the process through which manning, staffing or personnel placement or manning resource allocations are inadequate for task/mission demands.

POLICY AND PROCESS ISSUES (OP000): are factors if these processes negatively influence performance and result in an unsafe situation.

OP001: Pace of Ops-tempo/Workload

OP002: Organizational Program/Policy Risks not Adequately Assessed

OP003: Provided Inadequate Procedural Guidance or Publications

OP004: Organizational (formal) Training is Inadequate or Unavailable

OP005: Flawed Doctrine/Philosophy

OP006: Inadequate Program Management

OP007: Purchasing or Providing Poorly Designed or Unsuitable Equipment

OP001 Pace of Ops‐tempo/Workload: is a factor when the pace of deployments, workload, additional duties, off-duty education, PME or other workload-inducing conditions of an individual or unit creates an unsafe situation.

OP002 Organizational Program/Policy Risks not Adequately Assessed: is a factor when the potential risks of a large program, operation, acquisition or process are not adequately assessed.

OP003 Provided Inadequate Procedural Guidance or Publications: is a factor when written direction, checklists, graphic depictions, tables, charts or other published guidance is inadequate, misleading or inappropriate.

OP004 Organizational (formal) Training is Inadequate or Unavailable: is a factor when one-time or initial training programs, upgrade programs, transition programs or other training that is conducted outside the local unit is inadequate or unavailable.

OP005 Flawed Doctrine/Philosophy: is a factor when the doctrine, philosophy or concept of operations in an organization is flawed or accepts unnecessary risk which leads to an unsafe situation or unmitigated hazard.

OP006 Inadequate Program Management: is a factor when programs are implemented without sufficient support, oversight or planning.

OP007 Purchasing or Providing Poorly Designed or Unsuitable Equipment: is a factor when the processes through which aircraft, vehicle, equipment or logistical support are acquired allows inadequacies or when design deficiencies allow inadequacies in the acquisition.

CLIMATE/CULTURE INFLUENCES (OC000): are factors where the working atmosphere within the organization influences individual actions resulting in human error. (e.g. command structure, policies and working environment).

OC001: Organizational Culture (attitude/actions) Allows for Unsafe Task/Mission

OC003: Organizational Over-confidence or Under-confidence in Equipment

OC004: Unit Mission/Aircraft/Vehicle/Equipment Change or Unit Deactivation

OC005: Organizational Structure is Unclear or Inadequate

OC001 Organizational Culture (attitude/actions) Allows for Unsafe Task/Mission: a factor when explicit/implicit actions, statements or attitudes of unit leadership set unit/organizational values (culture) that allow an environment where unsafe task/mission demands or pressures exist.

OC003 Organizational Over-confidence or Under-confidence in Equipment: is a factor when there is organizational over- or under-confidence in an aircraft, vehicle, device, system or any other equipment.

OC004 Unit Mission/Aircraft/Vehicle/Equipment Change or Unit Deactivation: is a factor when the process of changing missions, aircraft/vehicle/equipment or an impending unit deactivation creates an unsafe situation.

OC005 Organizational Structure is Unclear or Inadequate: is a factor when the chain of command of an individual or structure of an organization is confusing, non-standard or inadequate and this creates an unsafe situation.

Chapter 3. Practical examples

In this chapter we provide practical examples of applying HFACS 7.0 for analyzing aviation accidents.

Each sub-chapter contains one accident analysis, with accident summary, and human factor analysis.

Chapter 3.1. KC-135R, T/N 63-8877

LOCATION: 6 MILES SOUTH OF CHALDOVAR, KYRGYZ REPUBLIC

DATE OF ACCIDENT: 3 MAY 2013

1. ACCIDENT SUMMARY

On 3 May 2013, at approximately 1448 hours local time (L), the mishap aircraft (MA), a KC-135R, tail number 63-8877, Transit Center at Manas, Kyrgyz Republic, crashed approximately 6 miles south of Chaldovar, Kyrgyz Republic. The mishap crew (MC), which consisted of the mishap pilot (MP), the mishap co-pilot (MCP), and the mishap boom operator (MBO), perished during the accident. Following the loss of its tail section, the MA exploded inflight and further separated into three main sections, impacted the earth, and burned. The three impact points were craters in hilly terrain used for grazing livestock. Approximately 228 cubic meters of soil were contaminated with jet fuel and each crater contained a pattern of burned grass and trees about 35 meters diameter on average. The MA was destroyed upon impact, with total loss to government property estimated at $66.3 million.

Figure: Impact Craters

2. HUMAN FACTORS

(1) AE103 Procedural Error

Procedural Error is a factor when a procedure is accomplished in the wrong sequence or using the wrong technique or when the wrong control or switch is used. This also captures errors in navigation, calculation or operation of automated systems.

The Inflight Manual contains a chapter on emergency procedures. This section is arranged in two subsections, within each of these subsections, the procedures are divided into two categories, critical and non-critical. These procedures constitute the minimum required steps to be taken by a crewmember to ensure survival. When an airborne emergency occurs, the following rules always apply: 1) Fly The Airplane: Establish a safe airspeed, attitude, and thrust setting. Maintaining airplane control is paramount. 2) Stop – Think – Collect Your Wits: Make a thorough evaluation of each emergency prior to initiating corrective action.

The Inflight Manual's Dutch Roll Recovery Procedures warnings section states that pilots should "not attempt to damp dutch roll manually with the rudder" and "improper excitation and recovery techniques cause higher than normal cumulative stresses in the vertical stabilizer...". Also, the "sudden reversal of rudder direction at high rudder deflections, due to improper rudder application or abrupt release, can result in overstressing the vertical fin".

The MP assumed control of the MA approximately one minute before the MA's moment of failure. When the MP took control of the MA it was in a pronounced dutch roll, as shown by widely divergent sine waves. The MP used rudder to roll in and out of a turn at waypoint DW. Additionally, during the turn, the MA experienced a series of alternating small rudder inputs. These alternating small rudder inputs, caused by the MA's dutch roll-induced acceleration forces varying the MP's foot pressure on the rudder pedals, sharply increased the dutch roll oscillations. The MP's use of rudder was not in compliance with the Inflight Manual dutch roll procedure and the warnings regarding use of rudder and rudder reversal due to overstressing the vertical fin.

(2) OP004 Organizational Training Issues/Programs

Organizational Training Issues/Programs are a factor when one-time or initial training programs, upgrade programs, transition programs or other training that is conducted outside the local unit is inadequate or unavailable and this creates an unsafe situation.

Dutch roll recognition and recovery training is only accomplished in the simulator during the Pilot Initial Qualification (PIQ) course and is not re-accomplished in the simulator during upgrade and continuation training. The proficiency level required for dutch roll recognition is "familiarization," meaning each pilot must only discuss this topic and is not required to perform the maneuver. The KC-135 simulator dutch roll profile is planned in straight and level flight at flight level 390, a gross weight based on 100,000 pounds of fuel and a speed of .77 mach. The Inflight Manual prohibits pilots from practicing dutch roll recognition and recovery in the aircraft, specifically stating "intentionally-induced dutch roll and aerobatics of any kind are strictly prohibited".

After KC-135 PIQ, dutch roll recognition and recovery procedures are not included in aircraft commander upgrade training or continuation training. Pilots accomplish the continuation simulator profiles during aircraft commander upgrade. The aerodynamic malfunctions reviewed during upgrade and continuation training focus on other rudder issues such as unscheduled rudder deflections. These malfunctions are single episodes; an instructor can put in unscheduled rudder deflection right or left and you could choose between those two, but it's not a continuous or variable input.

Insidious onset of dutch roll is impossible to replicate in KC-135 simulator training due to mechanical limitations. In order to have a flight simulator enter a dutch roll phenomenon, simulator instructors utilize two predominant techniques. The first has one of the pilots push the rudder in about three inches and pop it out and the other involves activating a programmed simulator malfunction, such as hard over-rudder, for a couple seconds, and then take it out which will also induce rolling motions and bank angles of 45 degrees or more roll. The flight simulator dampens dutch roll on its own with little pilot input. The simulator cannot reproduce dutch roll in a continuous motion. Dutch roll recovery procedure calls for ensuring the SYD is on. However, there is no training profile in which the SYD is completely inoperative or where the SYD is providing erroneous inputs. A former KC-135 Instructor Pilot and current simulator operator, who experienced severe dutch roll in flight, confirmed the current simulator training does not reproduce a severe dutch roll.

The MP did not receive any instruction on dutch roll recognition or recovery procedures during upgrade or continuation training.

The MCP had recently requalified for FPQ duties. The MCP performed local requalification training; however, dutch roll recognition and recovery procedures are not required. The MCP did not perform dutch roll recognition or recovery during recent requalification simulator training. Boom operators are not required to receive any training on dutch roll recognition or recovery.

(3) SP002 Crew/Team/Flight Makeup/Composition

Crew/Team/Flight Makeup/Composition is a factor when, in the opinion of the investigator, the makeup of the crew or of the flight should have reasonably raised obvious safety concerns in the minds of crewmembers involved in the mission, or in any other individual directly related to the scheduling of this mission.

Each crewmember assigned positions on the MC had recently requalified or upgraded. The MP upgraded within two months prior to deployment. The MCP had four aircraft flights over an approximate 15-month period prior to deploying due to a 10-month DNIF period. The MBO returned from an approximate 3.7-year period of operating UAS and requalified in the KC-135 six weeks prior to deploying.

The MP had a grand total of 1427.7 hours flying time prior to deploying on 17 April 2013 (this includes primary, secondary, other, and student time). The MP had 1,048.7 total flying hours in KC-135 (this includes primary and secondary pilot time only). The MP was upgraded to aircraft commander on 28 February 2013. The MP had been an aircraft commander for 49 days from time qualified until date of deployment on 17 April 2013. The MP had 9.9 hours as an aircraft commander and 14 hours of simulator time from the date of qualification until date of deployment on 17 April 2013 (this includes primary and secondary pilot time only).

The MCP was initially qualified as an FPQ on 13 April 2011 and was actively flying for approximately 10 months prior to being placed on DNIF status on 16 February 2012. Once on DNIF status, the MCP remained DNIF for nearly 10 months. The MCP was returned to flying status for five months prior to deploying on 17 April 2013. The MCP had a grand total of 573.1 hours flying time prior to deploying on 17 April 2013 (this includes primary, secondary, other, and student time). The MCP had 296.6 total flying hours in the KC-135 (this includes primary and secondary pilot time only). The MCP requalified as an FPQ on 7 March 2013. The MCP had been an FPQ for 41 days from date of requalification until date of deployment on 17 April 2013. The MCP had 0.0 aircraft flying hours, and 12 hours of simulator time as an FPQ from time of requalification until date of deployment on 17 April 2013 (this includes primary and secondary pilot time only).

The MBO had 3,351.2 total hours as a KC-135 boom operator and 1,802.5 total hours as a sensor operator. The MBO had recently requalified as an instructor boom operator (IB) after nearly four years out of the aircraft where he performed duties as sensor operator in a UAS. The MBO requalified as an IB on 15 February 2013. The MBO required a waiver for concurrent instructor requalification training. The lack of formal training availability at Altus AFB, OK, led to a local IB requalification. The MBO had been an IB for 61 days and had 11.4 hours (this includes primary, secondary, and instructor time only) as a boom operator and 8 hours of simulator time from the date of requalification until date of deployment on 17 April 2013.

(4) OP003 Procedural Guidance/Publications

Procedural Guidance/Publications is a factor when written direction, checklists, graphic depictions, tables, charts or other published guidance is inadequate, misleading or inappropriate and this creates an unsafe situation.

The Inflight Manual procedures state in separate sections that rudder should or should not be used depending on if there is a rudder malfunction or if there is a dutch roll phenomenon. Additionally, the Inflight Manual has the following multiple, physically separated sections addressing ways to troubleshoot lateral control difficulty.

(a) There are 21 emergency procedures discussing lateral control difficulties referencing the rudder, and they are spread out over 177 pages between 3-37 and 3-214.

(b) Relevant information on dutch roll damping characteristics is located on page 6-21, but does not exist in the Dutch Roll Recovery procedures paragraph on page 3-37. Specifically, the information that increased altitude reduces natural dutch roll dampening is omitted on page 3-37 of the Inflight Manual.

(c) The Inflight Manual procedure for Lateral/Directional Control Difficulty Due to Yaw Damper Malfunction states, "adequate rudder authority should be available to counteract any yaw induced by a yaw damper failure" provided no additional failures occur such as loss of an engine. Under the Unscheduled Roll description, it states that the "roll control force is adequate to counteract the effect of any single component malfunction, such as unscheduled full rudder deflection...". The guidance to use the rudder that is implied under the Lateral/Directional Control Difficulty Due to Yaw Damper Malfunction is not in alignment with the Unscheduled Roll description and the warning to not use rudder that is stated in the Dutch Roll Recovery procedures on page 3-37 of the Inflight Manual.

Additionally, the FCAS description states "pilots can override the FCAS inputs or establish a different reference point by applying rudder pedal force". However, when the yaw and roll induced by a yaw damper failure develops into a dutch roll, this guidance does not align with the warning stated in Dutch Roll Recovery procedures on page 3-37 of the Inflight Manual.

The boldface warning for Unscheduled Rudder Deflection is "Rudder Power – OFF" and applies when the rudder moves uncommanded. The procedure for Rudder Hunting directs disengagement of the EFAS, then the SYD, and then the powered rudder. Rudder hunting is erratic movement or slow deflection/oscillation of the rudder, yet the first step of the Rudder Hunting procedure does not match that of the boldface.

(d) The checklist for Dutch Roll Recovery states that "the primary means of controlling dutch roll is the yaw damper...engage or attempt to engage the yaw damper any time dutch roll is recognized, even when the yaw damper is assumed to be on". However, the checklist for Lateral and Directional Control Difficulty Due to Yaw Damper Malfunction states, "to disengage the yaw damper, set the yaw damper switch to OFF". The Inflight Manual does not consider the possibility that the SYD itself is causing the control difficulty (i.e. dutch roll) as shown by its lack of being addressed in the Dutch Roll Recovery checklist.

(e) The boldface warning for Unscheduled Rudder Deflection is located on page 3-207. The paragraph that immediately follows is for Creeping Stabilizer, which is unrelated to the rudder. A pilot would have to flip backwards 123 pages to page 3-84 for the Rudder Malfunction Analysis paragraph, thus using up valuable time in a potentially emergent situation.

Chapter 3.2. HH-60G, T/N 88-26109

LOCATION: CLEY NEXT THE SEA, NORFOLK, UNITED KINGDOM

DATE OF ACCIDENT: 7 JANUARY 2014

1. ACCIDENT SUMMARY

On 7 January 2014, at approximately 1805 local time (L), the mishap aircraft (MA), an HH-60G, Tail Number 88-26109, experienced multiple bird strikes during a training mission and impacted privately-owned, grass-covered marshland near Cley next the Sea, UK. All four members of the mishap crew (MC) were fatally injured on impact. There were no civilian injuries or fatalities. The MA was destroyed upon impact . The cost to the United States government is estimated at $40,302,061. Damage to private property consisted of minimal burning to grass at the crash site. Numerous media outlets reported the mishap.

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

2. HUMAN FACTORS

Operational Injury/Illness (PC303) is a factor when an injury is sustained or illness develops from the operational environment or during the mission, and the injury or illness results in an unsafe situation.

At least three geese struck the MA at 130 knots ground speed with 5,300 foot-pounds of force, breached the windscreen of the MA, and rendered MP and MCP unconscious. MP and MCP were injured and thus unable to control the MA, resulting in an unsafe situation.

Sudden Incapacitation/Unconsciousness (PC304) is a factor when the individual has an abrupt loss of functional capacity or conscious awareness.

The force of impact from geese immediately rendered MP, MCP, and MAG unconscious.

Chapter 3.3. F-16C, T/N 89-2019, and F-16C, T/N 89-2034

LOCATION: MOLINE, KANSAS

DATE OF ACCIDENT: 20 OCTOBER 2014

1. ACCIDENT SUMMARY

On 20 October 2014, at 1421 hours (in local time), two F-16Cs, tail numbers (T/N) 89-2019 and 89-2034, collided during an Air Combat Maneuvers (ACM) training mission near Moline, Kansas. Mishap pilot 1 (MP1), was an instructor pilot with approximately 2,400 hours of flight time in the F-16. Mishap pilot 2 (MP2) was a relatively inexperienced student pilot with 106 flying hours in the F-16. MP1 successfully ejected and experienced minor injuries, while MP2 was unharmed. Mishap aircraft 1 (MA1), T/N 89-2019, impacted the ground in a field near Moline, Kansas and was destroyed with a loss valued at $20,104,852. Mishap aircraft 2 (MA2), T/N 89-2034, sustained significant damage to the right wing but was able to safely land at Tulsa International Airport (IAP), Oklahoma. Repair cost for MA2 is estimated at $2,335,990. The environmental clean-up cost was estimated at $50,000.00 for contaminated soil removal and reclamation. The mishap did not result in significant damage to private property.

Figure: MA1's Crash Site Photo

Figure: MA2 Post-Mishap

2. HUMAN FACTORS

(1) AE202 Task Misprioritization

Task Misprioritization is a factor when the individual does not organize, based on accepted prioritization techniques, the tasks needed to manage the immediate situation.

The following events represent misprioritization errors made during the engagement.

MP2 was the SF during the entire mishap engagement. The SF's highest priorities are maintaining visual and flight path de-confliction. MP2 was not de-conflicting from MP1. From shortly before the merge until collision, MP2 focused exclusively on MP3 and did not maintain visual on MP1. MP2 mistakenly assumed that he was de-conflicted from MP1.

MP2 made his "ENGAGED" call too late. MP2 realized that he was targeted by MP3 and was more defensive than MP1 at the merge, which is the latest point he should have called "ENGAGED". MP2 called "ENGAGED" 8 seconds after the merge. This is a key mistake for if he would have obtained the engaged fighter role he would have been relieved of his primary responsibilities of flight path de-confliction and maintaining the visual and able to give his full attention to fighting his best BFM.

Conversely, MP1 realized that MP2 was more defensive and testified that he should have exercised his option to call "2 PRESS" and initiate the change to make MP2 the engaged fighter. MP1's failure to initiate this role exchange also represents a task misprioritization because the most defensive fighter should have priority over the flight lead to be the EF.

(2) PC 103 Cognitive Task Oversaturation

Cognitive Task Oversaturation is a factor when the quantity of information an individual must process exceeds their cognitive or mental resources in the amount of time available to process the information.

MP2 showed signs of task oversaturation during the engagement. During the second engagement, he was behind normal pacing due to a reduced range of separation from the adversary. In a short period of time, MP2 was required to: 1) Turn to bracket the adversary, 2) defend against an attack from MP3, 3) maintain visual of MP1, 4) acquire TALLY of MP3 with the aid of HMCS, 5) set up for the merge, 6) make radio calls, 7) perform Anti-G Straining Maneuver, 8) keep sight of MP3 during hard turn, 9) fight his best 1 v 1 BFM, and 10) kill MP3. Based on MP2's relative inexperience, he may have been overwhelmed by having to make a number of nearly simultaneous decisions.

(3) PC 102 Channelized Attention

Channelized attention is a factor when the individual is focusing all conscious attention on a limited number of environmental cues to the exclusion of others of a subjectively equal or higher or more immediate priority, leading to an unsafe situation. Channelized attention may be described as a tight focus of attention that leads to the exclusion of comprehensive situational information.

The following event represents a channelized attention error made during the engagement.

From a point shortly before the merge until impact, MP2 channelized his attention on killing MP3. He fully understood there had been no role exchange and he was still the SF. MP2 failed to maintain visual and flight path de-confliction with MP1 due to his exclusive focus on MP3.

(4) PP106 Communicating Critical Information

Communicating critical information is a factor when known critical information was not provided to appropriate individuals in an accurate or timely manner.

The following errors in Communicating Critical Information occurred during the engagement: MP2 made an "engaged" call that MP1 did not hear. Additionally, this call was not made in a timely manner, and as a result, MP1 did not have time to respond even if he did hear it.

MP2 never called "blind" when he lost visual of MP1. MP2 had visual on MP1 until shortly before he merged with MP3. MP2 never had visual on MP1 again until after the collision and never made a "blind" call that would be typically expected within approximately two seconds of losing visual on the engaged fighter.

(5) PC504 Misperception of Operational Conditions

Misperception of Operational Conditions is a factor when an individual misperceives or misjudges altitude, separation, speed, closure rate, road/sea conditions, aircraft/vehicle location within the performance envelope or other operational conditions and this leads to an unsafe situation.

MP1 continued as the EF when MP2 merged with MP3 and continued to pursue MP3 during MP2's left turn. MP1 believed that MP2 turned right at the merge. MP2 turning right at the merge would have de-conflicted MP1 and MP2's flight path to allow MP1 to engage MP3. The misperceived turn resulted in MP2 belly-up, blind, and quickly on a collision course without MP1s awareness.

Chapter 3.4. F-16CM, T/N 91-0375

LOCATION: CENTCOM AOR

DATE OF ACCIDENT: 1 DECEMBER 2014

1. ACCIDENT SUMMARY

On 1 December 2014 at 04:58:10 hours local time (L) (02:58:10 hours Zulu time (Z)) the Mishap Aircraft (MA), an F-16CM, Tail Number (T/N) 91-0375, to a classified base of operation (BO) in the CENTCOM AOR, impacted the ground 9.5 nautical miles (nm) southeast of the BO airfield. The Mishap Flight (MF) was a combat mission in support of Operation Inherent Resolve in the CENTCOM AOR. The mishap occurred in an unpopulated area. The Mishap Pilot (MP) did not attempt to eject from his aircraft and died immediately upon impact. The MA was destroyed with a loss valued at $30,796,852. Host nation forces recovered the remains of the MP and transported them to U.S. forces at the BO. The mishap caused neither civilian injuries nor damage to civilian property. Many U.S. and international media sources reported on the mishap.

Figure: F-16CM Fighting Falcon

2. HUMAN FACTORS

(1) Human Factor 1 - Vision Restricted by Meteorological Conditions (PE102)

In accordance with AFI 91-204, Attachment 6, page 139, Vision Restricted by Meteorological Conditions is a factor when weather, haze, or darkness restrict the vision of the individual to a point where normal duties were affected.

The mishap occurred at 04:58:10L, after moon set, and prior to sunrise. The ambient illumination for the mishap location was 1.66 mlx at the time of the mishap. Witness testimony indicates that the external visibility was dark with minimal cultural lighting and nearly absent of visual cues at night. The lack of cloud cover reduced the impact of what minimal cultural lighting was available northeast of the airfield. Night approach airfield lighting is not visible outside of 5 nm. Other than minimal cultural lighting to the distant northwest, no discernible horizon was visible to the unaided eye at approach altitudes.

While NVGs would normally be stowed during this phase of flight, it is unknown if the MP was using NVGs at the time of impact. Use of NVGs during the final five minutes of flight may have given the MP a discernible horizon, but no ambient visual cues necessary to reliably detect sink rate or altitude. Regardless of NVG use, only a thorough scan of the cockpit instruments would have given the MP the necessary information to maintain intended altitudes, pitches and descent rates as reflected in Air Force Manual (AFMAN) 11-217, Volume (V) 3, 23 February 2009, Flying Operations Supplemental Flight Information, pages 161, 165, 167-168, and 170.

Pursuant to AFMAN 11-217, V3, page 171, a proper visual scan includes a cross-check of the environment outside the aircraft, along with aircraft flight instruments. Together, AFMAN 11-217, V1, 22 October 2010, Flying Operations Instrument Flight Procedures, page 26, and AFMAN 11-217, V3, page 171, provide the pilot situational awareness with respect to an accurate estimation of the aircraft's attitude and orientation.

Since visual cues from the environment outside the cockpit were degraded, cockpit instruments were the sole reliable indicator of the MA's orientation with the earth as noted by AFMAN 11-217, V3, page 26. As discussed in AFMAN 11-217, V1, page 14, visual cross-referencing of flight instruments, such as the Attitude Director Indicator (ADI), Vertical Velocity Indicator (VVI), Air-speed Indicator (AI) and altimeter, provides essential data about aircraft orientation, required to offset any diminished visual ambient cues. In accordance with AFMAN 11-217, V1, page 14, good instrument cross-check and control of the aircraft by reference to the primary flight instruments is integral to U.S. Air Force pilot training and techniques. This training aims to prevent the effects of spatial disorientation even when visual cues outside the cockpit are absent.

(2) Human Factor 2 - Task Misprioritization (AE202)

In accordance with AFI 91-204, Attachment 6, page 138, Task Misprioritization is a factor when the individual does not organize, based on accepted prioritization techniques, the tasks needed to manage the immediate situation.

The MP was qualified and experienced in instrument flying and executing cockpit visual scan patterns. The MP demonstrated an adequate instrument scan during the RTB by maintaining level flight at 5,200' MSL for 48 seconds during the initial turn to the west, and at 4,300' MSL for 15 seconds. However, from 3,500' MSL, 90 seconds prior to impact, the MP began a steady descent of 1,740 fpm which increased to over 2,000 fpm passing 3000' MSL, 32 seconds prior to impact. After passing through 3,500' MSL, the MP did not significantly arrest his descent rate prior to impact, indicating a loss of altimeter checks from his visual scan technique.

Flight path analysis demonstrates the MP was navigating properly on the horizontal plane, but not the vertical plane. During the last 16 seconds of flight, the MP executed a 40 degree turn using up to 42 degrees of bank, and intercepted the localizer course. However, during the same period, the MA maintained an unusually high and steady descent rate of 2,200 fpm through the last second of flight. In addition, 6 seconds prior to impact, the MP made a radio call to the MW asking if he was receiving the glide slope. The MP misprioritized navigation and supervising his wingman to the exclusion of altitude in his instrument scan.

(3) Human Factor 3 - Spatial Disorientation (Type 1) Unrecognized (PC-508)

In accordance with AFI 91-204, Attachment 6, page 138, Spatial Disorientation is a failure to correctly sense a position, motion or attitude of the aircraft or of oneself within the fixed coordinate system provided by the surface of the earth and the gravitational vertical. Spatial Disorientation (Type 1) Unrecognized is a factor when a person's cognitive awareness of one or more of the following varies from reality: attitude, position, velocity, direction of motion, or acceleration. Proper control inputs are not made because the need is unknown.

Visual references provide the most important sensory input to the brain and its ability to maintain spatial orientation during flight. They provide information about distance, speed, depth, and orientation. Pursuant to Air Force Tactics, Techniques and Procedures (AFTTP) 3-3.F-16, 29 June 2012, Paragraph 9.3.2, as the MP flew on a westerly heading, he may not have been able to identify the true horizon, even with his NVGs on. The MP would have had to rely on his instruments and heads-up display (HUD) along with primary performance instruments for orientation.

According to AFMAN 11-117, V3, pages 154-155, vision can be divided into two types, focal and ambient vision. The distinction between focal and ambient vision is important when considering the role of vision in determining spatial orientation during flight. When there is good visibility and a clearly defined horizon, the pilot naturally employs the peripheral ambient visual system for spatial orientation. The task requires little conscious processing. When flying at night, or under instrument meteorological conditions (IMC), a pilot determines aircraft orientation using flight instruments, which must be learned, and requires the use of focal vision in accordance with AFMAN 11-217, V3, page 161. The focal visual system used in instrument flying is not the natural orientation mechanism and requires more cognitive processing than when external visual cues are used for orientation. Thus, pursuant to AFMAN 11-217, V3, page 155, spatial disorientation is more likely to occur during flight at night or in IMC.

The use of visual cues not only maintains spatial orientation, it also controls inappropriate input from the vestibular system. With time and practice, an aviator develops the ability to suppress vestibular miscues. This vestibular suppression occurs primarily through visual dominance. Vestibular suppression occurs more easily in high visibility situations using primarily ambient visual cues derived outside the cockpit. Aviators learn to suppress vestibular input even in low visibility conditions by using focal vision cues derived from the aircraft instruments using an intact visual scan.

Analysis of the MA's flight path demonstrates a steadily increasing descent from 4,300' MSL to the surface of the earth with only a momentary level off. Based upon control inputs, as the MA approached 3,500' MSL, the MP leveled off momentarily, but immediately reinitiated the descent as the MA airspeed climbed above 250 kts. The MP appropriately reduced power to idle, but maintained his pitch setting. This resulted in the intended lower airspeed, but also the reestablishment of a descent rate. These control inputs indicate a loss of focus by the MP on his instrument cross-check and a reflexive response to a vestibular illusion caused by a prolonged steady descent.

Since the vestibular system registers accelerations, it would stop providing inputs once a relatively steady descent was reached. Any attempt to decrease or arrest the steady descent would cause the body to sense a pitch up/climb. If the pilot does not monitor attitude, altitude, and VVI during this critical time, the vestibular illusion can cause him to put the aircraft back into a descent. This vestibular illusion is also known as the "elevator illusion" referencing the common circumstance of a long elevator descent with no visual references.

According to the flight path data, the MA passed through 3,100' MSL in a steady 1,500 fpm descent. The MP then pushed the stick forward and increased his descent angle. Pursuant to AFMAN 11-217, V1, page 160, had the MA been at 3500' MSL, then the MP's flight control inputs would have been the correct actions to descend to 3,000' MSL, however, the MA was already in an unrecognized descent. Given the MP's unperceived 1,500 fpm descent rate from the ongoing elevator illusion, his flight control inputs further increased the actual descent rate to between 2000-3000 fpm. At 2,300' MSL (160' above ground level (AGL)) and sinking at 3,000 fpm, the MP turned to the right, and increased power in a 1.3G turn to the final approach course. Without a thorough instrument visual scan, this additional G Force would stimulate the MP's vestibular system to register another false pitch up sensation exacerbating the elevator illusion and reinforcing the decision to continue the descent.

(4) Human Factor 4 - Risk Assessment – During Operation (AE201)

In accordance with AFI 91-204, Attachment 6, page 138, Risk Assessment – During Operation is a factor when the individual fails to adequately evaluate the risks associated with a particular course of action. This faulty evaluation leads to inappropriate decision and subsequent unsafe situation. This failure occurs in real-time when formal risk-assessment procedures are not possible.

After the MW's aircraft had a landing gear door malfunction, the MP directed the mishap flight to reduce weight by burning down fuel over the BO. After sufficient weight reduction, the MP directed the MF to join the instrument approach inside the IAF below the MSA. This was common practice in the 77 EFS utilized to compensate for the lack of radar approach control at the BO airfield.

The MP's decision to descend below MSA removed a safety buffer that would have given the MP extra time to re-establish altitude awareness in his instrument visual scan.

Chapter 3.5. AC-130J, T/N 09-5710

LOCATION: EGLIN AIR FORCE BASE, FLORIDA

DATE OF ACCIDENT: 21 APRIL 2015

1. ACCIDENT SUMMARY

On 21 April 2015, at approximately 12:18:40 hours local time (L), the mishap aircraft (MA), AC-130J, tail number (T/N) 09-5710, departed controlled flight, inverted, and subsequently experienced an over G during the dive recovery on a medium risk flying qualities mission. The MA was recovered and landed safely at 13:24:36L. There were no significant injuries to the aircrew or to anyone on the ground. The AF rendered the aircraft a total loss due to exceedances of the Design Limit Load (DLL). The loss is valued at an estimated $115,600,000.

Figure: MA simulation created from flight data

2. HUMAN FACTORS

a. AE104 Overcontrolled/Undercontrolled Aircraft/Vehicle/System

Overcontrolled/Undercontrolled Aircraft/Vehicle/System is a factor when an individual responds inappropriately to conditions by either over- or undercontrolling the aircraft/vehicle/system. The error may be a result of preconditions or a temporary failure of coordination.

Evidence supports that the MP overcontrolled the rudder during test point 59 while transitioning from the SIDESLIP Special Alert to the RUDDER Special Alert to the left. The MP stabilized at the SIDESLIP Special Alert for nearly 10 seconds, applying approximately 125 lbs of rudder pedal force. As the MTC began to clear the MP to proceed to the second Special Alert, the MP was already increasing rudder pedal force; within two seconds of increasing force, he reached 180 lbs. Less than one second later, the RUDDER Special Alert annunciated immediately after the MTC finished the words "continue nose left, second alert" at approximately 14.5o AoS (per design for the test point conditions), with a force of 204 lbs. The rudder pedal force peaked at 229 lbs one and a half seconds later, and already greater than 17o AoS. At approximately four seconds after the RUDDER Special Alert annunciated, the MP modulated rudder pedal force back down to 160 lbs but the AoS was already greater than 21o and getting worse. The MP eventually reduced all pressure against the left rudder, but the aircraft had already departed from controlled flight.

According to previous flight test data provided by the OEM to the Air Force in July 2013, the rudder force required to achieve 14.5o AoS for 100 percent flaps is approximately 150 lbs. The 150 lbs required was less than 180 lbs of force reached within two seconds of being cleared to continue to the second alert and much less than the 229 peak force used. Therefore, the aircraft was overcontrolled for the test point conditions.

Overcontrolling can happen for a variety of reasons. One of the possible reasons is the difficulty of the task. Several test pilots commented on how difficult the task is due to the variation in sensitivity on the rudder pedals required for each test point condition compounded by the waffling flight characteristics of the Dutch Roll. Test Pilot 1 (TP1) stated the following:

"So, you are doing a fine motor skill task with your quadriceps, right? And so, it's about like trying to drive a finish nail with a sledgehammer, okay? Um, it's not an easy task to do that and you have to move in very small discrete increments. And the task is different at higher speeds than it is at slower speeds. At higher speeds you've got a lot of force your pressing on the rudder, at the slower speeds, -- you know, and so you are kind of metering force. At the slower speeds you are metering position because your -- because your forces get a lot lighter and so you don't want to -- you don't want to just honk on like you were doing up at those faster speeds. So, as you build down in speed, you're, I don't want to say you're changing your technique, but you are probably changing how you, at least when I do it, how I -- how I am monitoring what I am doing, and I'm using the flight test display is feedback on the position when we're doing it...So, um, I mean, there is probably 100 different ways of how to officially work through these tests point, you know, whether you do it all left leg, all right leg, whatever. The reason why we were swapping between the two is, honestly, is fatigue. Because, although left seat instrumented so the left seat guys are the ones doing all the test points when it comes to this. Um, and so as you, um, as you work through it, just by the nature of the way we are doing it, you know -- luckily when you get to the slowest speeds it's the lightest forces, because you're tired by then, but you also got to watch what you're doing because you're tired by then. Um, make sure that you're not over controlling the rudder, so a lot depended upon the pilot to monitor his fatigue level and there were a couple of flights where I would turn around look at the flight testing units and say were done today. You know, three hours of me doing this and my legs are shot. And so, but its, um, but yeah, there's just no other way to do it, I mean, we were slowly and incrementally stepping out trying to nibble at the edge of this thing without, without, you know, running over the top -- running over a cliff somewhere. And so, there was no other good way to do it, um, other than build down speed and build up in rudder force. I mean, it was the only way that made sense as far as from a safety standpoint, but obviously there is a, there is a lot of pilot technique and an pilot ability stuff that comes in there, because, you know, the difference between, you know, the first point the next point may be, you know, three quarters of an inch of rudder travel, you know. You know, when you're going from first alert to the second alert, that is two degrees of side slip and so it may literally be an inch or less of rudder travel to get you to that point...So, you get out and trying to nail a test point and trying to nail a position there in the nose is kind of wanting to hunt on you a little bit, and so it just -- some days it was easier than others to get that thing to stop where you wanted it to."

Evidence also supports that the MP undercontrolled the rudder during the recovery.In accordance with 1C-130(A)J-1, page 2E-8, HIGH SIDESLIP RECOVERY PROCEDURES:

"If either RUDDER Special Alert occurs, immediately apply the indicated rudder to center the sideslip display on the HUD. . . If rudder overbalance is encountered (one pedal pushes against the pilot's foot as the rudder floats towards the stop), the rudder pedal must be pushed back immediately towards center. Rudder pedal force to accomplish this can vary from 50 lbs at slow speeds to over 200 lbs at 180 knots".

Similarly the test team recognized this possibility when applying for the waiver. The test team wrote:

"If the pilot continues to push the pedals, the rudder pedal force continues to decrease until the rudder floats toward full deflection by itself. This is called rudder overbalance. If this condition occurs, the other pedal must be pushed to bring the rudder back toward center (opposite rudder pedal, 50 – 200+ lbf required). If this is not accomplished quickly, the airplane reaches extreme sideslip and may roll to a high angle of bank. Up to 5,000 feet of altitude loss could occur during the recovery"

According to the data, the MP released left rudder pedal force but never applied right rudder pedal force as required by the procedure. Immediately after the MA was recovered, the MP told the MCP, "Well I was trying to not overcontrol". Therefore, the aircraft was undercontrolled for the recovery from departure from controlled flight.

Several test pilots cited their reluctance to be aggressive with the rudders and felt reducing rudder pedal force was preferred to being too aggressive with applying rudder inputs. During a previous test point on the mishap flight, the MP stated, "For the most part we don't dance on the rudders at all during the recoveries". He later commented, "I think in the back of -- any pilot of an aircraft of a rudder or fin, it's always in the back of our minds that large abrupt motions on the rudder can cause an overstress condition and, you know, could have structural damage". However this reluctance to use the rudder seems more tied to spatial disorientation than anything else since the MP answered, "I think if I had known what I know now, and I knew that what we were in was a sideslip departure or a spin motion, I wouldn't have hesitated to apply the correct procedure".

b. AE206 Wrong Choice of Action During an Operation

Wrong Choice of Action During an Operation is a factor when the individual, through faulty logic or erroneous expectations, selects the wrong course of action.

The test cards, THAW, and waiver directed, "Recover IAW PTO (extreme AoA procedures)" for a departure from controlled flight. The first steps of the extreme AoA procedures include "1. Lower the nose, apply appropriate rudder (step on the ball or 'dog house,' as indicated by the special alert and reduce asymmetric power. (Set all power levers to FLT IDLE if the nose is very low.) 2. Once the turn rate stops, neutralize the rudder and recover from the dive...". The MP never stepped on the right rudder as previously discussed. Also, the MP never reduced the throttles completely even though he was instructed by the MCP. Furthermore, during the event, the MCP directed the MP, "Nose down, nose down" to lower the nose and the MP responded "pushing, pushing, pushing". The MP pushed the nose down and rolled right, but the aircraft continued to yaw even more to the left.

According to the MP, he was disoriented during the departure from controlled flight and all that made sense was airspeed; he thought it was the one thing he could control so he pushed forward on the control column. This action, along with his right roll inputs exacerbated the left yaw condition due to a flight dynamics phenomenon known as "coupling".

The MP admitted had he known that the rudder was locked, he would have applied correct rudder, "if I knew exactly we were in an overbalanced condition and the fin was stalled or was beginning to stall, I don't think I would have hesitated to put the correct action in".

There are various reasons why the wrong choice of action was applied. One reason may be confusion. Confusion will be further discussed in an upcoming section. Another possibility includes an inaccurate expectation or disposition by the test team to think departures from controlled flight would occur during a stall. When Test Pilot 2 (TP2) was asked if it would have made sense to use the high AoS recovery procedure for SHSS test points instead of the extreme AoA procedure, the witness responded, "We had one data point that basically said it worked" referring to the fact that he thought during the February 2014 departure the aircraft was recovered by breaking the stall. However, according to the non-safety privileged analysis of the first departure, the aircraft self-recovered due to coupling dynamics that reduced sideslip. If the pilots expected the aircraft to depart during a stall rather than a sideslip excursion, this could have predisposed them to take actions to recover from a stall rather than an overbalance. The waiver that allowed the test team to proceed to the RUDDER Special Alert contained the fact that opposite rudder pedal force must be used to overcome a rudder overbalance and could require between 50 and 200 lbs or force. The guidance goes on to say, "If this is not accomplished quickly, the airplane reaches extreme sideslip and may roll to a high angle of bank. Up to 5,000 feet of altitude loss could occur during the recovery," which is basically what happened.

c. PE202 Instrumentation and Warning System Issues

Instrumentation and Warning System Issues is a factor when instrument factors such as design, reliability, lighting, location, symbology, size, display systems, auditory or tactile situational awareness or warning systems create an unsafe situation.

The current design of the aircraft's sideslip warning system visual cues provides only limited real-time positional information beyond the SIDESLIP Special Alert (2o) and freezes at the RUDDER Special Alert. The sideslip warning system visual cues consist of a sideslip indicator and sideslip limit fence symbols in the HUD. The space between these symbols represents the difference between the airplane sideslip angle and the sideslip limit. When the sideslip indicator touches the "fence," the SIDESLIP Special Alert is activated; if sideslip continues to increase until the sideslip indicator extends halfway through the "fence," the RUDDER Special Alert is activated. After RUDDER Special Alert is activated, the sideslip indicator does not move beyond half way through the fence, regardless of a continual increase in sideslip. The PTO 1C-130(A)J-1 does not make it clear that the sideslip indicator freezes once it bisects the fence and according to TP1, this fact was not understood by the test team.

TP1 stated:

"Um, a little hard to define where that second alert is other than just eyeballing it. What I didn't realize, until after we started a lot more in-depth discussion on this, and I guess I should have, as many as these test points as I've done, is once it gets to the second alert it does not move any further. So it stops, so, you have no indication past -- if you've gone past that point and if so how far. With the OEM's assumption being is that once you've hit that point you don't need to be going any further than that so I'm not going to tell you how much further you can go. So, so if I were to change that, I would change that mechanization somehow to, to show if I've gone past that how far past that I have gone".

Similarly, the MTC observed, "...there is an audio alert that you get, but there is hysteresis in the audio alert. So, if you were to touch the fence and come away from the fence, the audio alert will continue to sound...So, if the audio is sounding, that means we're -- could be getting close to the test point...or at the test point or past the test point".

Therefore, the test crews had no indication if they were stabilized beyond the RUDDER Special Alert. The MP stated, "I think the biggest and obvious one [human factor] was I didn't have a good way to tell what the motion of the aircraft was, that the sideslip had continued to increase. I had no cultural references. And the one piece, the doghouse, stopped moving, and I wasn't able to use it to help me determine what the aircraft was doing".

d. PC508 Spatial Disorientation

Spatial Disorientation is a factor when an individual fails to correctly sense a position, motion, or attitude of the aircraft/vehicle/vessel or of oneself. Spatial Disorientation may be unrecognized and/or result in partial or total incapacitation. The MP describes his challenge correctly to sense motion, confusion about what was happening and how he tried to respond below: "As I moved from initial alert to the second alert, I recognized the rate that I was not intending to occur, and I decreased the pressure I was putting on the pedal. Near the same time the flight test engineer recognized my force being removed from the pedal and called "recover." I further reduced my pressure on the pedal as far as I could, and the resulting motion of the aircraft as I did that instantaneously and debilitating disoriented me. I couldn't quite recognize why the aircraft was continuing to do what it was doing. Out of all the things that I could see, in my field of view, the only thing that I could recognize as status of the aircraft was the airspeed. I saw the airspeed bleeding down at a rate that was not inconsistent with I saw since that's the only thing I could verify at the time. I attempted to decrease the pitch of the aircraft by pushing forward on the yoke to arrest the decrease in airspeed. The elevator did not move with the authority that I was hoping it would have, and the airspeed continued to decrease... I recall not fully having my SA about me. When the FT called recover, I was -- I don't know the appropriate word, but I was disoriented in a way that I don't remember ever feeling before in an aircraft. It was almost like the aircraft was doing something that I couldn't figure out why it was doing it. And while hindsight may appear like it was something that I caused when I removed the force on the rudder, I couldn't ascertain what the aircraft was actually doing. And so the only thing I could actually latch onto was the airspeed decreasing, and I believe a left rolling tendency. That's the only thing that I could definitely say the aircraft was doing, and so I tried to correct those two conditions by putting in right roll and pushing forward on the yoke to eliminate the decrease in airspeed...We were far south in the water ranges; so I had no cultural references to ascertain motion of the aircraft; so I was fully dependent on the HUD and the instrumentation inside the aircraft".

During his interview, the MCP stated, "At one point, I remember looking at the water and I just remember the water—it was very difficult to make a reference of which way was what because of the water. We still had the HUD, but the water was—there was no ground reference". This is consistent with the first AC-130J departure event in 2014 according to a witness who stated that the crew thought they were spinning to the right when in fact they were spinning to the left. The MP and MCP described conditions that are most conducive to spatial disorientation including lack of visual references, loss of situational awareness, and distraction.

e. PC104 Confusion

Confusion is a factor when the individual is unable to maintain a cohesive and orderly awareness of events and required actions, and instead experiences a state characterized by bewilderment, lack of clear thinking or (sometimes) perceptual disorientation.

The MP described some of his confusion during the MA's departure from controlled flight, saying to the MCP after recovery, "I was unsure, bringing the power back if the reverse gyroscopic effects would undo something". He later stated, "I was trying to analyze everything . . . I was just, I was trying to contemplate everything. There were just too many things". During the MP's interview, he stated, "I couldn't quite recognize why the aircraft was continuing to do what it was doing. Out of all the things that I could see, in my field of view, the only thing that I could recognize as status of the aircraft was the airspeed. I saw the airspeed bleeding down at a rate that was not inconsistent with I saw since that's the only thing I could verify at the time".

f. OP003 Provided Inadequate Procedural Guidance or Publications

Provided Inadequate Procedural Guidance or Publications is a factor when written direction, checklists, graphic depictions, tables, charts or other published guidance is inadequate, misleading, or inappropriate.

Test card 14 contained a table and chart that identified expected activation of the SIDESLIP Special Alert and the RUDDER Special Alert. These predictions would have the test crew not expect the RUDDER Special Alert for high power settings (greater than 10,000lb total horsepower) to activate prior to 16o AoS. In fact, the RUDDER Special Alert activates at 14o AoS for high power settings. The Board retrieved a document believed to be the source for test card 14 which identified a Lockheed Martin employee as the author. The data contained within the table and chart conflict with a subsequent version of expected alert activation Lockheed Martin provided after the mishap. The expected alert activations identified in the chart provided by Lockheed Martin after the mishap are 1.5o lower than the alert activations identified in test card 14 for both sideslip and rudder activation.

Despite these errors, they likely did not contribute substantially to how the MP flew the aircraft. He stated, "It was more up to me to use the cues and the HUD to determine what rudder position would be required for me to get those alerts". What they did affect was the boundaries placed on the IADS display and therefore what a safety monitor may be looking at.

g. PC106 Distraction

Distraction is a factor when the individual has an interruption of attention and/or inappropriate redirection of attention by an environmental cue or mental process.

The MP stated he was distracted after the MA's departure from controlled flight just prior to the dive recovery by an unsecured item, possibly a checklist, hitting him in the head as the MA inverted.

Chapter 3.6. MQ-1B, T/N 07-3207

LOCATION: CENTCOM AOR

DATE OF ACCIDENT: 28 APRIL 2015

1. ACCIDENT SUMMARY

On 28 April 2015, at approximately 0116 local time (L), the mishap remotely piloted aircraft (MRPA), an MQ-1B, T/N 07-3207, Missouri (MO) lost its Ground Data Terminal (GDT) line of sight (LOS) antenna link, departed the runway on initial takeoff and crashed in the CENTCOM AOR. The MRPA sustained extensive damage with the loss valued at $4.66 million. There were no injuries or damage to other government or civilian property.

Figure: MQ-1B

2. HUMAN FACTORS ANALYSIS

a. Checklist Not Followed Correctly – DoD HFACS AE102 (Acts)

Checklist Not Followed Correctly is a factor when the individual, either through an act of commission or omission, makes a checklist error or fails to run an appropriate checklist.

The first instance of this factor is during initial ground operations, at approximately 0025L, when the MP failed to correctly accomplish the 'Aircraft Initial Link' checklist by not switching from the default to the assigned frequency. This error was not caught or fixed for the duration of ground operations or attempted takeoff.

The second instance of this factor is during the MRPA lost link event on takeoff roll at 0116L, when the MSO failed to correctly accomplish the 'Link Failure Below 2,000 Feet AGL or on the Ground' CAP. This is a one-step checklist that must be performed immediately without reference to a written checklist. It was approximately 6 seconds from the time the MP called the CAP until the MSO executed the CAP by flipping the GDT switch off.

b. Not Paying Attention – DoD HFACS PC101 (Mental Precondition)

Not Paying Attention is a factor when there is a lack of state of alertness or a readiness to process available information immediately. The individual has a state of reduced conscious attention due to a sense of security, self-confidence, boredom or a perceived absence of threat from the environment. This may often be a result of highly repetitive tasks.

The checklist states that the GDT Tx1 should be switched from the default frequency to the operating frequency shortly after initial link is established. The MP stated that he ran the initial link checklist. The GA report shows that the GDT Tx1 was left on the default frequency for the duration of ground operations through attempted takeoff. There is no evidence of extenuating circumstances which would account for the failure of the MP to complete the required frequency change.

c. Fatigue – DoD HFACS PC307 (Physical Problem Precondition)

Fatigue is a factor causing diminished physical/mental capability resulting from chronic or acute periods of prolonged wakefulness, sleep deprivation, jet lag, shift work or poor sleep habits.

The day prior to the mishap shift (26 April 2015), the MP was on day shift, arriving for duty at 1000L and returning to quarters at 1900L. He arrived for duty the next day at 1815L (27 April 2015) to work the mid-shift. In order to transition from day-shift to midshift, he stayed awake until 0445L and slept until 1645L (27 April 2015). When he arrived on shift the day of the mishap, the MP scored his 'Circadian Rhythm' a 4 correlating to the statement 'Sleep Pattern Interrupted (War Time Ops), Able to Go Back to Sleep (4-6)'. The MP also selected a 4 in the Fatigue section, correlating to the statement 'Tired, but manageable now, need day off soon).

d. Negative Habit Transfer – DoD HFACS PC105 (Mental Precondition)

Negative Habit Transfer is a factor when the individual reverts to a highly learned behavior used in a previous system or situation and that response is inappropriate for current task demands.

The single time-critical step in the 'Link Failure Below 2,000 Feet AGL or on the Ground' checklist is executed differently and by a different member of the crew depending on which phase of operation the crew is engaged in. During LR operations, this step is accomplished by the MSO moving the GDT power switch to the off position. During Mission Control Element (MCE) operations, this step is accomplished by the pilot via pull-down menu on the control screen.

The MSO completed initial qualification training in October 2013 and at the time of the mishap had approximately 930 flight hours. In preparation for his deployment, the MSO recently completed LR training at the end of January 2015, receiving approximately 11 hours of flight time in the formal training course. Once complete with LR training, the MSO returned to home station for roughly 1.5 months before deploying. During this time he returned to Creech AFB and flew an LR currency sortie. Once at the deployed air base in the CENTCOM AOR, the MSO entered the local seasoning program and accomplished the required 15 takeoff and landing events between 1 April and 27 April 2015. Throughout initial qualification, his currency ride, and seasoning, all LR operations the MSO conducted had been under the supervision of an Instructor Sensor Operator or an experienced Sensor Operator. The mishap sortie was the first time the MSO had performed LR operations unsupervised . Of the 930 flight hours he had, only approximately 30 hours had been during LR operations.

In the 15 months the MSO had been qualified, 97% of his flight hours were spent in MCE operations, where the crew member responsible for executing the critical CAP step is the pilot. In MCE operations, the MSO is not the one to perform the critical step. Only after the MP directed the MSO to "Get up" and called for the CAP a third time did the MSO realize that, in this circumstance, (LR operations), he was responsible for performing the CAP by standing up and turning the GDT power off.

Chapter 3.7. C-130J, T/N 08-3174

LOCATION: JALALABAD AIRFIELD, AFGHANISTAN

DATE OF ACCIDENT: 2 OCTOBER 2015

1. ACCIDENT SUMMARY

On 2 October 2015, the mishap aircraft (MA), a C-130J, T/N 08-3174, departed JAF on the second scheduled leg of a contingency airlift mission at 0015 hours local time (L). The mishap crew (MC) from the 774th Expeditionary Airlift Squadron (EAS) at Bagram Airfield (BAF), Afghanistan, consisted of the mishap pilot (MP), the mishap copilot (MCP), and two mishap loadmasters (MLs) (hereinafter Mishap Loadmaster 1 (ML1) and Mishap Loadmaster 2 (ML2)). Additionally, two Fly-Away Security Team (FAST) members, five contractors travelling as passengers, and 39,386 pounds of cargo were aboard the aircraft. The MCP performed an adjusted maximum effort (AMAX) takeoff reaching a maximum nose-up pitch attitude of 42 degrees while climbing to approximately 700 feet above ground level (AGL). Approximately 12 seconds after takeoff, the MA entered a stall due to the high pitch angle. The MP and MCP were unable to recover from the stall. At approximately 0016L, the MA impacted the ground 14 degrees nose-low in 28 degrees of right bank at an airspeed of 111.5 knots and was destroyed. All eleven personnel onboard died upon impact. Additionally, three Afghan Special Reaction Force (ASRF) members on the ground were killed. Total Department of Defense (DoD) damage cost was $58,363,044, which includes the loss of the MA worth $51,606,131 and cargo worth $6,756,913. Additionally, a JAF guard tower and perimeter wall were damaged.

Figure: C-130J Hercules

2. HUMAN FACTORS ANALYSIS

b. Inadequate Real-Time Risk Assessment

Inadequate Real-Time Assessment is a factor when an individual fails to adequately evaluate the risks associated with a particular course of action, and this faulty evaluation leads to inappropriate decision-making and subsequent unsafe situations.

The MP placed a hard-shell NVG case forward of the left seat control yoke during the ERO. The ERO continued for approximately 50 minutes after the elevator was blocked. The blocking of flight controls during loading operations was a nonstandard procedure and there was no regulatory guidance to accompany the proper placement and removal of an object blocking the controls. The ERO checklist did not include a step requiring the pilots to check the flight controls prior to departure and therefore, it was incumbent on the MP and the MCP to remember to remove the hard-shell NVG case. The MP did not adequately evaluate the risk associated with blocking the elevator controls with the hard-shell NVG case.

c. Distraction

Distraction is a factor when the individual has an interruption of attention and/or redirection of attention by an environmental cue or mental process.

The MC landed at JAF at 2313L and began the ERO at 2316L. During the cargo offload, ML1 requested that the MP raise the elevator to provide more clearance for the high-profile cargo during ERO operations. For the next six minutes, there were changes in the elevator deflection between the range of positive 6 and positive 13 degrees of deflection. At 23:26:06L (DFDR time 5087) the elevator position increased to positive 20 degrees deflection momentarily before settling to a position between six to eight degrees positive deflection. This occurred immediately before the MP told the MCP that the "NVG case is holding...the elevator". The elevator position remained steady between six to eight degrees positive deflection until the takeoff roll.

During the 50 minutes after the MP placed the case forward of the yoke, the MP's and MCP's attention was redirected towards discussing loading operations, aircraft gross weight, climb-out procedures, and TOLD. Neither the MP nor the MCP referenced the case again.

d. Wrong Choice of Action During an Operation

Wrong choice of action during an operation is a factor when the individual, through faulty logic or erroneous expectations, selects the wrong course of action.

During the takeoff sequence, the MA lifted off the ground greater than three knots below the calculated AMAX takeoff speed. The MCP, who was performing the takeoff, recognized a control problem identified on the CVR at 00:15:56L. Two seconds later, the MCP incorrectly identified the flight control malfunction by stating "Trim failure". The first stall warning indication occurred three seconds after the verbal misidentification of a trim malfunction. Due to the rapid progression of the nose-up pitch attitude, the mishap pilots had eleven seconds from MA liftoff until the first stall warning indication to identify and correct the malfunction.

e. Environmental Conditions Affecting Vision

Environmental Conditions Affecting Vision is a factor that includes obscured windows; weather, fog, haze, darkness; smoke, etc.; brownout/whiteout (dust, snow, water, ash or other particulates); or when exposure to windblast affects the individual's ability to perform required duties.

Three inter-related environmental conditions affecting vision were factors in this mishap: nighttime operations, use of NVGs, and reliance on the HUD in conjunction with the ACAWS notifications.

The MA landed at JAF at 2313L. The weather was VMC with 9,000 meters visibility. The predicted lunar illumination at takeoff was approximately 81 percent. Due to the operations occurring at night, the MC wore NVGs. It was standard operating procedure for aircrews operating on NVGs to dim the cockpit lights and increase the brightness of the HUD.

NVGs permit aircrews to operate more effectively in low-illumination environments. The field of view (FOV) the NVGs provide is less than the eye's natural FOV, particularly in peripheral vision. Therefore, a person must constantly process two input components to his visual system. The two components are focal vision, which is primarily responsible for object recognition, and ambient vision, which is responsible for spatial orientation. This reliance on focal vision increases the aviator's workload and ultimately decreases the recognition of peripheral cues.

The information provided by the HUD, combined with the ACAWS, allowed aircrews to maintain their visual scan external to the aircraft with only occasional crosschecks of the HDD to monitor aircraft systems. Due to the HDD design, internal crosschecks of aircraft systems were normally done without the aid of NVGs. Prior to the takeoff roll, the MCP and MP checked the horsepower setting. After this, all information required to perform the takeoff was available in the HUD.

During the AIB's simulations at Little Rock Air Force Base, the AIB Pilot Member (AIB/PM) dimmed flight deck lighting to replicate nighttime operations. The hard-shell NVG case placed forward of the yoke became inconspicuous to all three AIB pilots during the course of multiple takeoff sequences.

f. Inaccurate Expectation

Inaccurate Expectation is a factor when the individual expects to perceive a certain reality and those expectations are strong enough to create a false perception of the expectation. The MP initially expected the MC would need to perform an AMAX takeoff instead of a normal takeoff. The MP then verified that the load weight was 40,300 pounds. After running the TOLD calculations, the MP acknowledged that they had 750 feet of runway available beyond what was required for takeoff. AIB calculations showed this matched the distance required to perform a normal takeoff. When later asked by the MCP, the MP confirmed that they would perform an AMAX takeoff.

The decision to perform an AMAX takeoff resulted in a planned rotation speed of 111 knots instead of 122 knots associated with a normal takeoff. During the MS, the MA lifted off at 107.5 knots, only a few knots below the planned rotation speed. For a normal takeoff, had the MA lifted off at 107.5 knots instead of 122 knots, it may have provided a more pronounced alert of the problem to the mishap pilots, allowing them to abort the takeoff. The MP's inaccurate expectation that an AMAX takeoff was required led to an unnecessary AMAX takeoff.

g. Fixation

Fixation is a factor when the individual is focusing all conscious attention on a limited number of environmental cues to the exclusion of others.

At liftoff, the MP reported "You're a little early;" the MCP replied "It's going off on its own". Six seconds after liftoff, the MCP became aware of a problem with the MA. He then misidentified the problem as trim failure and the MP instructed him to "Go emergency". During the five seconds from when the MCP first realized something was wrong (00:15:56L) to the first ACAWS stall warning (00:16:01L), both MP and MCP focused their attention on a trim failure problem. The mishap pilots neither verbalized a different flight control problem nor attempted to reduce power to control the increasing aircraft pitch.

Chapter 3.8. MQ-9A, T/N 08-4044

LOCATION: AFGHANISTAN

DATE OF ACCIDENT: 18 NOVEMMBER 2015

1. ACCIDENT SUMMARY

On 18 November 2015, at approximately 2338 Zulu (Z) time (19 November 2015, 0408 local time), an MQ-9A, tail number 08-4044, assigned to the 27th Special Operations Wing at Cannon Air Force Base (AFB), New Mexico, and deployed to Kandahar International Airport, crashed in an open field near the base after declaring an in-flight emergency (IFE) shortly after take-off. The Launch and Recovery Element (LRE) mishap crew (MC), consisting of one mishap pilot (MP) and one mishap sensor operator (MSO), noticed high oil pressure immediately upon take-off, declared an IFE, and attempted a left-traffic pattern return to the active runway. The mishap aircraft (MA) crashed on left crosswind north of the airfield, destroying the aircraft, four missiles and one bomb. The estimated value of the loss was $14,391,950. There were no fatalities or damage to private property.

2. HUMAN FACTORS ANALYSIS

b. Applicable Environmental Factors/Technological Environment Factors

(1) PE202 Instrumentation and Sensory Feedback Systems: Instrumentation and Sensory Feedback Systems is a factor when instrument factors such as design, reliability, lighting, location, symbology or size are inadequate and create an unsafe situation. This includes Night Vision Displays, Heads-Up Display, off-bore-site and helmet mounted display systems and inadequacies in auditory or tactile situational awareness or warning systems such as aural voice warnings or stick shakers.

(2) Per a warning in the checklist, high oil pressure is associated with impending engine loss. The MQ-9A provides a visual signal for high oil pressure in both the Heads-Up Display and the Heads-Down Display; however, it does not provide an auditory or tactile warning. Accordingly, the pilot and sensor operator must look at the gauges in order to determine if the oil pressure is too high and may not recognize the condition prior to engine failure.

c. Applicable Conditions of Individuals/Cognitive Factors

(1) PC103 Cognitive Task Oversaturation: Cognitive Task Oversaturation is a factor when the quantity of information an individual must process exceeds their cognitive or mental resources in the amount of time available to process the information.

(2) Prior to the mishap, MP noticed that the brakes were not working effectively on MA. She chose to accomplish the final checklist steps while MA was taxiing. Concurrently, the tower provided a weather report differing from the pre-briefed weather. While winds had not been a factor during the deployment, the tower reported significant gusts, requiring MC to recalculate some of the flight parameters. The checklist and recalculations distracted MC and they did not notice the visual-only caution and warning of high oil pressure until takeoff. At that point, there was insufficient runway to put the aircraft back down and MA lost its engine prior to completing an emergency landing.

Chapter 3.9. F-16C, T/N 93-0531 and F-16C, T/N 92-3899

LOCATION: LOUISVILLE, GEORGIA

DATE OF ACCIDENT: 7 JUNE 2016

1. ACCIDENT SUMMARY

On 7 June 2016, at approximately 2114 local (L), two F-16C aircraft, tail numbers 92-3899 and 93-0531 (Mishap Aircraft 1 – MA1 and Mishap Aircraft 2 – MA2 respectively), assigned to the 169th Fighter Wing (169 FW), McEntire Joint National Guard Base (JNGB), SC, collided mid-air during a training mission, an opposed night Suppression of Enemy Air Defense (SEAD) sortie. Both pilots (Mishap Pilot 1 –MP1 and Mishap Pilot 2 –MP2, respectively) ejected safely with only minor injuries. Both aircraft impacted the ground near Louisville, GA and were destroyed. The total aircraft loss is valued at approximately $60,798,131.00. Non-Department of Defense (DoD) property damage was limited to fire damage to cash timber.

Figure: F-16C Fighting Falcon

Figure: MA2's right wingtip with upward blunt force indentation

2. HUMAN FACTORS ANALYSIS

a. Inaccurate Expectation

"Inaccurate Expectation" is when an individual expects to perceive a certain reality and those expectations are strong enough to create a false perception of the expectation IAW DoD Human Factors Analysis and Classification System (HFACS) version 7.0 (nanocode PC110).

Both MP1 and MP2 inaccurately judged their positions relative to each other following MP2's "Bingo" call. Both had the mental model of pursuing the other aircraft following MP1's final left turn. When presented with new data that conflicted with their expectations, each pilot was unable to process and translate the data into timely actions necessary to avoid the mishap.

Six seconds prior to the collision, MP1 was presented with HUD radar data showing MA1 and MA2 pointing directly at each other with only 1.5 nm of separation. MP1 had expected MA2 to be six miles away headed north. His expectation that MP2 was headed away from him was so strong that he ignored that data and switched to an air-to-ground priority mode for SEAD operations. This action removed critical information, which would have warned MP1 of imminently collapsing distance.

During MP1's final left turn, MP2 visually tracked MA1's light moving from right to left on the horizon. Per his testimony, MP2's last recalled distance from MA1 just prior to his left turn was "three-ish" nm, later verified as 3.8 nm by his A/A TACAN display. Based on an expectation that MA1 was continuing with a southern heading, MP2 was unaware that MA1 had in fact reversed direction and was headed toward him. Over the next 14 seconds, MP2 attempted to acquire a visual boresight lock on MA1, did not attempt to clarify an earlier ambiguous radio call from MP1 to "track north", or cross check distance with his A/A TACAN. Although data reflected a descent from the sanctuary altitude, MP2 stated that he did not know if he was or was not descending during his boresight lock attempts. When he achieved the desired radar lock approximately six seconds before collision at a range of 2,500 feet separation, MP2 was presented with an immediate "Break X" symbol in his HUD. MP2 did not process the immediate peril due to his expectation that MA1 was moving away from him.

Each pilot's expectation that the other was moving away hampered timely evasive maneuvering. Lockheed Martin analysis of the flight controls showed no significant control inputs by either pilot until less than one second prior to the collision.

b. Fixation

"Fixation" is a factor when the individual is focusing all conscious attention on a limited number of environmental cues to the exclusion of others IAW DoD HFACS version 7.0 (nanocode PC102).

MP2 was flying in a night visual wedge formation, which requires use of all available tools to ensure aircraft separation and deconfliction. Night flying is challenging as there is degradation of both visibility and depth perception. MP2 had A/A TACAN and A/A FCR available to him as positional aides. As MP2 tracked MA1, he descended from his sanctuary altitude while maintaining visual contact. MP2 maneuvered to place MA1's lights in the center of his HUD, maintaining a pure pursuit course, never referencing his A/A TACAN. During this 14-second block of time, MP2 made at least nine switch actuations in an attempt to acquire an FCR visual mode boresight lock on MA1. He was unaware of MA1's turn to the northeast due to fact that he exclusively relied on visual cues, and did not confirm MA1's maneuver with available sensors.

MP1 similarly over relied on visual cues and did not confirm closing distance with A/A TACAN following his unannounced left turn. MP1 immediately identified MA2 by the sequenced flashing lights and acquired a visual boresight lock on MA2. MP1 relied on an inaccurate mental perception of MA2's relative position and did not crosscheck his A/A TACAN, confirm his radar data or clarify MA2's position on the radio. Unlike MP2 however, MP1 maintained his briefed sanctuary altitude.

c. Failure to Prioritize Task Adequately

"Failure to Prioritize Task Adequately" is a factor when the individual does not organize, based on accepted prioritization techniques, the tasks needed to manage the immediate situation IAW DoD HFACS version 7.0 (nanocode AE202).

MP1 did not call "Knock it off" following MP2's "Bingo" call. Per AFI 11-214, an immediate "Knock it off" or "Terminate" radio transmission was required to have been called by the flight lead (MP1) to unequivocally cease tactical maneuvering and allow the mishap flight to begin administrative maneuvering back to base. MP1's failure to call "Knock it off" created a misprioritization between tactical and administrative maneuvering. Without a "Knock It Off" call, MF continued tactical operations, further degrading radio communication between MP1 and MP2.

At the point MP2 called "Bingo", the overall mission objective of an Instructor Pilot Upgrade sortie for MP1 had already been met. No other member of the MF had training requirements. MP1 acknowledged that the training rules required termination. Nevertheless, MP1 assessed that he "wanted them [ME-3, ME-4] to have that quick opportunity before I knock(ed) off the fight". The delay in a "Knock it off" call was secondary to MP1's desire to continue tactical maneuvering for the MF so that additional training could be achieved. MP1 prioritized unnecessary training over a timely "Knock it off" call as required by AFI 11-214.

d. Failure to Effectively Communicate

"Failure to Effectively Communicate" is a factor when communication is not understood or misinterpreted as the result of behavior of either sender or receiver. Communication failed to include backing up, supportive feedback or acknowledgement to ensure that personnel correctly understood announcements or directives in accordance with DoD HFACS version 7.0 (nanocode PP108).

Approximately 17 seconds prior to impact, after MP1 had nearly completed his left turn, transcripts show that MP1 made an unclear radio call ("Sorry, two, you can continue tracking north"). Although MP1's communication was delayed, he believed MP2 would have turned north and would still be approximately six miles away from MA1. MP2 acknowledged the call five seconds later ("Copy that"). MP2 believed that "tracking north" was not a directive to change heading, but instead meant the mishap element would eventually flow north together in a visual wedge formation. The other pilots interviewed also agreed that a "track north" instruction was ambiguous and would have merited further clarification. Neither MP attempted to make a clarifying radio call.

e. Complacency

"Complacency" is a factor when the individual has a false sense of security, is unaware of, or ignores hazards and is inattentive to risks IAW DoD HFACS version 7.0 (nanocode AE206).

Cross-checking visual cues with other sensor data, altitude separation, and informative radio calls are required to ensure aircraft deconfliction as both depth perception and visibility are degraded during night operations. Prior to the mishap, MP2 stated he was flying a night visual wedge formation and that his intent was to flow south with MP1. Both MP1 and MP2 testified that they were in a visual wedge formation. MP2 stated that, because he was in a visual formation, he did not need to adhere to his sanctuary altitude, believing instead that the sanctuary altitude was only for sensor formations. MP2 observed MA1's external lights moving from right to left on the horizon but did not monitor with A/A TACAN or FCR to confirm MA1's maneuver. Review of HUD video, showing MP2's attempted boresight lock indicated that the member was complacent in relying on visual cues as his primary means of deconfliction. MP2 did not crosscheck his visual perception against his available sensor data or attempt to clarify on the radio. MP2's statement that he did not need to utilize his sanctuary altitude and decision not to crosscheck his visual observations against available instrumentation during night visual wedge formation led to a false sense of security, ignoring hazards, and was inattentive to risks.

Chapter 3.10. MQ-9A, T/N 10-4113

LOCATION: NEVADA TEST AND TRAINING RANGE

DATE OF ACCIDENT: 7 JUNE 2016

1. ACCIDENT SUMMARY

On 7 June 2016, at approximately 2230 Greenwich Mean Time (GMT), the mishap aircraft (MA), an MQ-9A, tail number (T/N) 10-4113, assigned to the 432d Wing (432 WG), Creech Air Force Base (AFB), Nevada (NV) and operated by the 26th Weapons Squadron (26 WPS), 57th Wing (57 WG), Nellis AFB, NV crashed while on a proficiency flight in the NTTR. The MA impacted the ground on U.S. government property. The MA was destroyed at a loss of $11,063,339.00. There were no fatalities, injuries, or damage to civilian property.

Figure: MQ-9A

2. HUMAN FACTORS ANALYSIS

TASK MISPRIORITIZATION (AE 202): Task Misprioritization is a factor when the individual does not organize, based on accepted prioritization techniques, the tasks needed to manage the immediate situation. MP reported that he was working on the handover checklist, which included loss link headings. The immediate dilemma however (reduced energy state and approaching stall) was not timely observed. MP noted "I started to realize the plane was stalling while I was in the other [handover] checklist procedures ... I do not recall when the AOA indications or stall reengaged ... At that moment in time I was prioritizing the [handover] checklist".

Chapter 3.11. MQ-1B Predator, T/N 04-3129

LOCATION: USCENTCOM AOR

DATE OF ACCIDENT: 2 FEBRUARY 2016

1. ACCIDENT SUMMARY

On 2 February 2016, at approximately 2322 Zulu time (Z), the mishap remotely piloted aircraft (MRPA), an MQ-1B Predator, T/N 04-3129, conducted a combat support mission in the United States Central Command (USCENTCOM) area of responsibility (AOR). At the time of the mishap, the mishap launch and recovery element (MLRE) from the 414th Expeditionary Reconnaissance Squadron operated the MRPA from a deployed location. The MRPA experienced datalink problems, departed controlled flight, and crashed in an area south of the intended base of landing. The estimated cost of aircraft and munitions is $4.1 million. No one reported any injuries or deaths, only minor damages to a cultivated field.

Figure: MQ-1B Predator

2. HUMAN FACTORS ANALYSIS

a. Human Factor 3 – PC508 – Spatial Disorientation (Type 1) Unrecognized

The intermittent downlink resulted in frozen, erroneous, and/or unreliable HUD video. MP based control inputs on information that did not accurately reflect reality, resulting in spatial disorientation.

Chapter 3.12. F-22A, T/N 07-4146

LOCATION: NAVAL AIR STATION FALLON, NEVADA

DATE OF ACCIDENT: 13 APRIL 2018

1. ACCIDENT SUMMARY

At approximately 1745 Zulu (Z), 1045 Local (L) time, on 13 April 2018, the mishap pilot (MP), flying the mishap aircraft (MA), an F-22A Raptor, T/N 07-4146, took off from runway 31 Left (31L) at NAS Fallon, Nevada for a TOPGUN graduation exercise. The MP initiated a military power (MIL) takeoff and rotated at 120 knots calibrated airspeed (KCAS). Rotation occurs when the pilot initiates back stick pressure to lift the nose of the aircraft off the ground and set the takeoff pitch attitude. Once the MP recognized his visual cues for takeoff, he raised the landing gear handle (LGH) to retract the landing gear (LG). After main landing gear (MLG) retraction, the MA impacted the runway with all but the nose landing gear (NLG) doors fully closed.

The MA impacted approximately 2,905 ft from the runway threshold on the centerline and slid approximately 6,514 ft until it came to rest 9,419 ft from runway threshold. While the MA was sliding down the runway, the MP shut off both engines. Once the plane was at a complete stop, the MP safely egressed the MA. There were no injuries, fatalities, or damage to civilian property.

Figure: MA contacted the runway

2. HUMAN FACTORS ANALYSIS

a. Introduction

Human factors contributing to this mishap were evaluated using the Department of Defense Human Factors Analysis and Classification System, 01 October 2015 (DoD-HFACS).

b. AE103 Procedure Not Followed Correctly:

Procedure Not Followed Correctly is a factor when a procedure is performed incorrectly or accomplished in the wrong sequence.

(1) Incorrect Application of TOLD

A normal F-22 takeoff sequence begins with the pilot advancing the throttles and accelerating to the computed rotation speed. The pilot then applies slight aft stick pressure to raise the nose to 10-12 degrees pitch attitude. While holding this pitch attitude, the aircraft will become airborne at the computed takeoff speed (Tab DD-4). The computed rotation and takeoff speeds vary based on weight of the aircraft and pressure altitude and are calculated prior to takeoff. For the MA on the day of the mishap, the rotation speed and takeoff speed should have been 143 KCAS and 164 KCAS respectively. However, the MP rotated at 120 KCAS, and the MA first registered weight off wheels at 135 KCAS (Tab DD-4). The MA momentarily became airborne, but there was insufficient lift for the MA to maintain flight.

(2) Prematurely Raised Landing Gear Handle

A normal F-22 takeoff ends when the pilot ensures that a positive rate of climb is established and retracts the LG. Common indicators of a positive rate of climb in the F-22 include visual cues, the climb dive marker (CDM) above the horizon, and an increasing vertical velocity indicator (VVI). Takeoff should occur at calculated takeoff speed, and LG should be retracted after the airplane is safely airborne. Therefore, LG retraction should not occur prior to takeoff speed.

During the mishap sortie, after rotation and achieving weight off wheels, the MP described using peripheral vision, and the surroundings getting smaller to determine he was airborne. The MP quickly retracted the LG upon recognizing those visual cues. He did not utilize the CDM or VVI to verify a positive rate of climb. While the MP sensed that the MA was airborne and raised the LGH 1.0 second after weight off wheels, the MA's speed was 22 knots below takeoff speed. The lift being generated at this point was insufficient to maintain flight, which resulted in the MA settling back to the runway on its belly.

(3) Damage to Alpha Probe

Per TOD, before every flight, one qualified crew chief is required to inspect the left and right alpha probes for damage or obstruction. Damage is defined by "noticeable to the touch by rubbing hand or thumb nail over suspected damage area". If either probe is damaged, the jet is considered to be non-mission capable and the jet is to be grounded pending further maintenance action. On the day of the mishap, the MA was inspected, but no damage was noted. The AIB MRT identified a right alpha probe transducer with multiple small nicks within the first two inches. It is unclear, however, when this damage occurred.

c. PC109 Distraction

Distraction is a factor when the individual has an interruption of attention or inappropriate redirection of attention by an environmental cue or mental process. During previous sorties flown, the MP had consistent timing of LG retraction. During five sorties flown over a five-month period prior to the mishap, the MP's LG retraction timing was comparable to his peers; his rates averaged 5.6 seconds after initiating rotation and 2.1 seconds after weight-off-wheels indication. For each sortie flown from a sea level airfield, the MP retracted the LG after the aircraft had achieved takeoff speed. During the mishap sortie, the MP retracted the LG twice as fast as his usual timing after weight off wheels. During the interview of the MP, he did not indicate any stressors or distractions in the cockpit during the mishap takeoff sequence. He noted some fatigue, but not excessive fatigue that would affect safety of flight. The MP also stated that there were no aircraft systems issues on the day of the mishap, and ground operations prior to takeoff were normal. No abnormal radio calls were made during his taxi or takeoff sequence. Although the MP did not remember any specific distractions, it is worth noting that the timing of his LG retraction was faster than his previous sorties.

d. PP109 Task or Mission Planning or Briefing Inadequate

Task or Mission Planning or Briefing Inadequate is a factor when an individual, crew or team fails to complete all preparatory tasks associated with planning or briefing the task or mission.

(1) Incorrect TOLD

Most mission planning for the Fallon TDY was completed earlier in the week while the 90 FS was TDY to Tyndall AFB for WSEP. During mission planning, PM1 created line-up cards for each of the three cross-country sorties and the sortie at NAS Fallon. The TOLD on all four cards was based on an 80 degrees Fahrenheit (F) day and was not recalculated for each airfield during the cross-country trip. The TOLD on the cards was computed using a 90 FS Excel spreadsheet tool that assumes JBER conditions including sea level elevation and a 10,000 foot runway length. The 90 FS tool was created to increase mission planning efficiency as it allows the user to skip manually calculating TOLD for each mission. However, at NAS Fallon, the field elevation is 3,934 feet and the runway length is 13,961 feet. Additionally, PM1 used a temperature of 80 degrees F whereas the temperature on the day of the mishap was 46 degrees F. Therefore, the TOLD on the MP's line-up card was incorrect for the mishap sortie at NAS Fallon.

(2) Inadequate Flight Briefs

IAW AFI 11-2F-22v3 paragraph 2.4.1, flight leads are responsible for presenting a logical briefing that will promote safe, effective mission accomplishment. This AFI also specifically states that a briefing will "review takeoff data, and ensure every member of the flight understands it" (Tab BB- 19). A briefing was conducted on each leg of the cross-country, but did not cover the specific TOLD considerations for the mission airfields.

On the day of the mishap, a mass brief was conducted from 0800-0820L for all TOPGUN graduation exercise participants during which the local operating procedures, weather, NOTAMS, and SIIs were covered. There was not a formal brief among the four 90 FS pilots, though they did have informal discussions at breakfast and prior to entering their respective jets. During that time, they discussed hydration, procedures to get to the airspace, airspace deconfliction, and high-G maneuvering. However, at no point did the pilots discuss TOLD considerations.

e. SI007 Failed to Identify Unsafe Practices

Failed to Identify Unsafe Practices is a factor when a supervisor fails to identify unsafe tendencies and fails to institute remedial actions. This includes hazardous practices, conditions or guidance.

(1) Improper Rotation Technique

The MP stated, "There is a technique that I heard from somewhere (I don't know where, whether it was at the B-Course or the 90th) to initiate [rotation] – if you have a 136 [rotation speed], kind of standard below 2,000 feet – that you initiate aft stick pressure at 120 so that the nose is up at that rotation speed, and that has been my habit pattern". Data from five sorties flown over a five-month period prior to the mishap clearly shows that the MP initiated rotation at 120±5 KCAS.

This technique of rotating early does not appear to be limited to the MP. Data from multiple sorties flown by 90 FS pilots. The data shows that in 64.3% of sorties, rotation was initiated greater than 5 knots prior to the calculated rotation speed; in 52.1%, rotation occurs at 120±5 KCAS. In 80.4% of these sorties, takeoff was accomplished greater than 5 knots prior to takeoff speed. All pilots who were interviewed noted that they check their TOLD before takeoff. After the mishap, at a pilot meeting attended by 20 to 30 F-22 pilots, about half noted that they consistently use an early rotation technique. There is a clear trend of rotating early among a significant number of F-22 pilots, including the MP, despite being aware of computed TOLD.

Rotating early has two major negative effects on TOLD. First, by rotating early you are increasing your induced drag at a premature point, thus slowing down the jet's acceleration and extending your takeoff roll. This invalidates the abort speeds that are calculated by the applicable technical order. More importantly in the case of this mishap, early rotation usually leads to getting airborne prematurely in ground effect, which is the effect of additional buoyancy produced by a cushion of air below a vehicle moving close to the ground. The AIB discovered that 80.4% of all pilots sampled became airborne greater than 5 knots before achieving their takeoff speed. At sea level, this technique doesn't "hurt" the pilot substantially because of the acceleration and power of the F-22; however, it builds a bad habit which can be compounded when flying at high elevation airfields. This technique has further consequences when the pilot retracts the LG too early. Becoming airborne in ground effect can have similar visual signals to becoming airborne at the correct takeoff speed, resulting in the pilot initiating LG retraction. The technique of rotating early has led to 26.8% of sampled pilots retracting their LGH prior to achieving takeoff speed, and 10.7% of those pilots retracting their LGH over 10 knots slower than their takeoff speed. This technique can create a situation where the LG is retracted prior to their aircraft achieving a safe, flyable airspeed.

Because every F-22 base (except Nellis) is at sea level, F-22 pilots do not have much experience taking off at high elevation airfields. It should be noted that while taking off at a high elevation airfield such as Colorado Springs (KCOS), Sheppard AFB (KSPS), and NAS Fallon, there are no observed changes to any of the sampled pilots' rotation speeds or takeoff speeds. Every pilot continued to fly the aircraft as if he were taking off at his home airfield, with many still using the incorrect technique of rotating at 120 knots regardless of TOLD. This caused 91% of the aircraft to become airborne >=5 knots prior to achieving takeoff speed, with 54.5% of them becoming airborne at least 20 knots early. By focusing only on these cross-country sorties, we see that 81.8% of the pilots retracted their gear prior to achieving takeoff speed at these high elevation airfields. This data suggests that pilots are not referencing their airspeed prior to retracting the gear, but instead relying on a visual sensation of the aircraft leaving the ground, as well as having an "internal clock" which tells them when to retract the gear based off of "experience". Because acceleration is slower at high elevation airfields, it takes noticeably longer to accelerate to the required takeoff speed. Specifically, during the mishap, the MA's military thrust was approximately 87% what it would have been at sea level. It should be noted that in 72.7% of these cases, the pilots retracted their gear prior to even achieving a takeoff speed that would have been normal at sea level, which continues to suggest that they are not referencing airspeed data even while flying at sea level. This has put many pilots and aircraft at an unnecessary risk.

f. OP004 Formal Training

Formal Training is a factor when one-time or initial training programs, upgrade programs, transition programs or other training that is conducted outside the local unit results in undesirable outcomes. The F-22 B-Course teaches pilots the fundamentals of flying the F-22. Data from multiple sorties from two recent B-Course classes was analyzed by the AIB. This sample set showed that 64.3% of the students rotated greater than 5 knots below the computed rotation speed and 44.0% rotated at 120±5 KCAS. The data shows that 100% of the students retracted their LG after achieving takeoff speed. There is a clear trend of rotating early among a significant number of F-22 student pilots at the B-Course.

g. OC003 Organizational Overconfidence in Equipment

Organizational Overconfidence in Equipment is a factor when there is organizational overconfidence in an aircraft, vehicle, device, system, or any other equipment. The F-22 engines produce more thrust than any other current fighter engine. Most pilots acknowledged that the high thrust of the aircraft provides confidence that the jet will easily get airborne. One pilot commented that the F-22 community "takes it for granted that we have a lot of power and that this jet will generally take off from any runway that you want it to take off from".

Another commented, "I can't think of a time where I've been concerned with TOLD . . . based on the thrust available". Multiple pilots, including the MP, noted that the TOLD is emphasized more in the T-38 community than the F-22. Due to the lower thrust to weight ratio of the T-38, adherence to TOLD is more critical for safety of flight. There is a clear perception among F-22 pilots that the aircraft has sufficient thrust and braking capability to overcome deviations from TOLD. This perception has led to a decreased emphasis on TOLD.

Chapter 3.13. HH-60G, T/N 92-6466

DATE OF ACCIDENT: 15 March 2018

BOARD PRESIDENT: Brigadier General Bryan P. Radliff

1. ACCIDENT SUMMARY

On 15 March 2018, at approximately1840 Zulu time (Z), 2140 Local time (L), the mishap aircraft (MA), an HH-60G, T/N 92-6466, assigned to the 332d Air Expeditionary Wing (AEW), and operating within the USCENTCOM AOR, struck a galvanized steel cable and subsequently impacted an uninhabited desert area. Four MA flight crewmembers and three members of the Guardian Angel (GA) team were fatally injured in the mishap. The MA was destroyed upon impact, there were no other injuries or fatalities, and there was no damage to private property.

Figure: HH-60G Wire Strike Protection System

2. HUMAN FACTORS ANALYSIS

DoD HFACS 7.0 lists potential human factors that can play a role in aircraft mishaps. Human factors describe how a person's interaction with tools, tasks, working environments, and other people influence human performance. All human factors as prescribed in DoD HFACS 7.0 were considered.

Four human factors were identified as being relevant to the mishap: (1) Misinterpreted/Misread Instrument; (2) Interference/Interruption; (3) Inaccurate Expectation; (4) Environmental Conditions Affecting Vision.

a. PC505 Misinterpreted/Misread Instrument

Misinterpreted/Misread Instrument is a factor when the individual is presented with a correct instrument reading but its significance is not recognized, it is misread or is misinterpreted.

The MF pilots developed and were familiar with the flight plan route. There were no reported navigation system or equipment problems. After completing HAAR, the MP navigated the MF toward the HLZ and then erroneously navigated to a waypoint beyond their intended destination. Although the MCP made a correct estimated arrival time to the HLZ, the MP misinterpreted the time to be arrival at a waypoint prior to the intended HLZ. No route corrections were made by anyone in the MF. The MWC had accurate navigation data and also failed to recognize instrument indicators directing the MF to the HLZ.

b. PC108 Interference/Interruption

Interference/Interruption is a factor when an individual is performing a highly automated/learned task and is distracted by another cue/event that results in the interruption and subsequent failure to complete the original task or results in skipping steps in the original task.

The MP had multiple duties in addition to navigation of the MF. In the time after completing HAAR and leading up to time of mishap, the MP received multiple interrupting requests for information. The MP coordinated with the MW regarding landing zone plan changes, MC requests for pre-landing power calculations and JTAC information requests. These non-navigation related tasks consumed the vast majority of the MP and MF's time following HAAR, and reduced their time available to identify their navigation error.

Crew Resource Management (CRM) is the effective use of all available resources--people, weapon systems, facilities, and equipment, and environment -- by individuals or crews to safely and efficiently accomplish an assigned mission or task. The MF lacked effective CRM in the performance of their duties to aviate, navigate and communicate, which resulted in their failure to verify navigation information being provided by MP.

c. PC110 Inaccurate Expectation

Inaccurate expectation is a factor when the individual expects to perceive a certain reality and those expectations are strong enough to create a false perception of the expectation.

The MF had the perceived reality that the MF was south of the intended destination. Based on their route study, the MF also expected a south to north approach to the HLZ. Therefore, even the turn to the north, while in error, supported the MF's perception of an approach to the HLZ. And when the MF's navigation equipment indicated an overflight of the HLZ, the perception of the MF was strong enough to create the perception that the MF was on track to the HLZ. The MF understood the approach to the HLZ would be safe and did not expect hazards on their planned approach.

d. PE101 Environmental Conditions Affecting Vision

Environmental Conditions Affecting Vision is a factor that includes obscured windows; weather, fog, haze, darkness, smoke, etc.; brownout/whiteout (dust, snow, water, ash or other particulates); or when exposure to windblast affects the individual's ability to perform required duties.

Night navigation involves inherent challenges such as darkness affecting visual acuity and includes hazards due to vision illusions. The aircrew members of the MC had battery-powered AN/AVS-9G night vision goggles (NVGs) mounted to their helmets as their primary means of maintaining night vision. NVGs enable aircrew to operate in a night environment, but when compared to the human eye under daylight conditions, vision under NVGs is limited. This results in a decreased level of situational awareness, amplified by certain human factors and environmental limitations. NVGs have a more reduced field of view compared to the human eye, particularly in peripheral vision, requiring an active and aggressive scan on the part of the NVG user in order to compensate appropriately during flight. Current NVGs have a resolution capability of 20/25 to 20/40 Snellen visual acuity, less than "normal day vision," which is 20/20. Of note, this visual acuity of 20/25 to 20/40 is the best that aircrew can expect to attain under optimal conditions. When flying with NVGs "detection ranges decrease and recognition of objects, terrain and targets can be severely limited". Current HH-60G Tactics, Techniques, and Procedures contains a warning stating, "electric power lines, unlit towers, poles, antennas, dead trees, and all types of wires are extremely difficult to see while conducting NVG operations".

Factors such as low or zero lunar illumination present on the night of the mishap degraded visual acuity and significantly limited the MF's ability to see obstacles until at close range. This also negatively impacted the MF's ability to use visual geographic references to improve their situational awareness of their actual location.

Chapter 3.14. F-15C, T/N 84-0008

LOCATION: NEAR KADENA AIR BASE, JAPAN

DATE OF ACCIDENT: 11 JUNE 2018

1. ACCIDENT SUMMARY

On 11 June 2018, at approximately 0617 hours local time (L), the Mishap Aircraft (MA), an F-15C, T/N 84-0008, crashed into the Pacific Ocean approximately 70 miles south of Kadena AB. The MA broke apart upon impact with a loss valued at $42,360,014.00. The Mishap Pilot (MP) ejected from the MA and sustained serious injuries. Japan Air Self Defense Force rescue forces flying a UH-60J helicopter, from Naha International Airport, rescued and transported the MP to a military hospital at Camp Foster, Japan. There were no fatalities or damage to civilian property. There was media interest as reported by local, national, and international agencies.

Figure: F-15C

2. HUMAN FACTORS ANALYSIS

a. Introduction

A human factor is any environmental factor or psychological factor a human being experiences that contributes to or influences performance during a task. The following human factors were relevant to the mishap:

b. PC508 Spatial Disorientation (SD)

This is a factor when an individual fails to correctly sense a position, motion, or attitude of the aircraft/vehicle/vessel or of oneself.

Contributing factors to spatial disorientation in this mishap were: workload (fixation), weather, misperception of the changing environment, and slowed instrument cross check, which led to the perception that the MP was turning parallel to the horizon.

SD occurred: (1) as the nose pitched up, (2) during the nose drop, and (3) during the roll and subsequent inverted, negative G spin of the MA.

In aviation, there are three distinct types of SD. Type I is unrecognized disorientation; the pilot is unaware that anything is wrong, and controls the aircraft in response to the false sensations of attitude and motion. Type II is recognized disorientation; the pilot is aware that something is wrong but may not realize that the source of the problem is SD. Type III is incapacitating disorientation; the pilot knows something is wrong, but the physiological or emotional responses to the disorientation are so great that the pilot is unable to recover the aircraft.

The MP was maneuvering defensively, in a high AOA turn. At some point after the level reversal to the right and attempting to continue in a right descending turn, the MP lost awareness of orientation to the horizon. Specifically the MP testified that MP was in 80-90 degrees right bank (pulling across the horizon) in a parallel orientation when, in fact, the KITS data, MW flight data, and MW testimony confirmed that the MP reoriented to a 65 degrees nose-high climb perpendicular to the horizon. In the events leading up to out of control flight, the MP most likely experienced Type I, unrecognized SD. The MP was "unaware" of high pitch and slow airspeed.

Causes of SD can be attributed to workload and phase of flight such as air-to-air maneuvering associated with Aerial Combat Maneuvering (ACM) and/or BFM. Because of the nature of an air-to-air mission, the pilot's attention is directed outside the aircraft, which increases the potential for channelized attention and slows effective instrument cross check. During the defensive posturing, the pilot was looking back over the shoulder to the belly of the MW. Simultaneously, utilization of a good crosscheck is required to avoid entering an unusual attitude. The MP was on a northeasterly heading at this time, where ragged clouds and sun glare obscured the horizon. It is possible that this environmental factor could result in an incorrect assessment of pitch and roll relative to the horizon.

Prior to the MP departing controlled flight, the MA went 65 degrees nose low with 110 degrees right bank (inverted). The MP had no recollection of the MA shifting from 65 degrees nose high to 65 degrees nose low, but only sensed the nose stopped tracking. The MP's lack of awareness that the MA was reversing from nose high to nose low was likely due to the observed weather conditions stated above, coupled with the MP's focus on maintaining sight with the MW.

Furthermore, once in a negative G situation, the MP thought the MA was in an upright position and was unable to assess the negative AOA and negative G. The severe pitch and roll oscillations combined with negative and lateral Gs likely contributed to the SD.

As the above examples illustrate, unrecognized SD had a significant impact on the MP, which contributed to the out of control flight and ejection from the MA. Some of the following sections will discuss the additional factors that contributed to the MP's SD: misperception of the changing environment, fixation, wrong choice of action, and external force or object impeded an individual's movement.

c. PC507 Misperception of the Changing Environment

This is a factor when an individual misperceives or misjudges altitude, separation, speed, closure, rate, and aircraft location within the performance envelope or other operational conditions. Misperception of an object, threat, or situation results in degraded sensory inputs. When present in an aircrew member, this can negatively affect situational awareness conditions.

Situational awareness (SA) is defined as an aircrew member's continuous perception of self and aircraft in relation to the dynamic environment of flight, threats, and mission, and the ability to forecast then execute tasks based on that perception.

While the MP did not recall any forecast weather related issues, the observed weather was significant for cloud cover both above and below the fight, in addition to the sun being displayed low on the horizon. Added to this, the MP was flying in a vertical fight with reference to the other aircraft (i.e. the MW). These conditions can result in disorientation and could have contributed to the MP's misperception of the MA's position relative to the horizon.

The following sequence of events illustrate how the misperception of the changing environment by the MP lead to loss of SA of the MA's position relative to the horizon (i.e., the ground or in this case the ocean) along with the MA's energy state, pitch angle, and attitude.

The MP did not recall the MA's nose high position and perceived the MA was in a steep right hand turn. However, the MP had oriented and maintained a lift vector on the MW resulting in a nose high attitude relative to the horizon and a subsequent decrease in airspeed. Further, the MP misperceived that the MA had decreased tracking during a right hand turn due to excessive AOA when KITS data showed that the MA was nose high for approximately 15 seconds. At this point, the MA likely either stalled due to an excessive AOA spike as demonstrated in the simulator or the MP excessively unloaded and over a span of six seconds, the nose dropped from 65 degrees nose high to 65 degrees nose low.

Then at some point during this nose high to nose low transition, the MP pushed the stick forward with full right rudder still engaged resulting in the snaproll. Abrupt forward stick inputs combined with a high roll or yaw rate may induce an auto roll/spin or cause a departure. The forward stick inputs when applied in this negative G situation caused the out of control flight. If the MP had recognized the negative G scenario and acted to use aft stick, this would have aided in recovery of the MA before it transitioned to a sustained departure situation.

d. PC102 Fixation

This occurs when the individual is focusing all conscious attention on a limited number of environmental cues to the exclusion of others.

During the sequence of events, the MP performed the necessary defensive BFM to remain engaged with the MW. This type of maneuvering requires the defensive player (i.e., the MP) to be looking outside of the aircraft over the shoulder through the top of the canopy. The MP was most likely channelized or fixated on the MW aircraft position, attitude, angle-off, and closure. The combination of the cloud cover both above and below the fight, in addition to the sun located low on the horizon presented conditions where visual illusions in regards to the horizon were most likely to occur resulting in the loss of SA and misperception of the MA's positional relationship to the horizon.

e. AE206 Wrong Choice of Action During Operation

This a factor when the individual, through faulty logic or erroneous expectations, selects the wrong course of action.

When there is a misperception of the current situation, the pilot cannot accurately predict the future status, which negatively affects decisions and subsequent actions. This misperception results in wrong choice of action. In the case of the MP, these wrong choices of action were the following: (1) unload of the stick with high AOA and full rudder, (2) not using aft stick to counter the negative Gs, and (3) maintaining full right rudder, which under negative G was a pro-left rolling input. Where the first action led to the MA departure, the second and third actions sustained the MA departure condition (inverted, negative G spin) with negative AOA and negative Gs.

In the events leading up to the first wrong choice of action, the MP stated the MA was tracking relatively parallel across the horizon, when KITS data showed the MA had transitioned to flying well above and perpendicular to the horizon. The MP did not recall this change in flight path.

Further, the MP did not recall executing a tree (vertical) maneuver when engaged in defensive BFM with the MW. The MP misperceived the situation compared with the MW testimony and KITS data. Since the MP was unaware of the MA's high pitch attitude and resultant low airspeed, the MP failed to recognize the nose was falling down and to the right.

The MP thought excessive AOA was causing the MA to not track across the horizon. This is consistent with the MP being unaware of the MA's high pitch attitude and decreasing airspeed. The MP assessed that by unloading pressure off the stick, it would help the MA's tracking. While the exact moment the MP initiated the unload cannot be determined, once the MA's nose started falling it continued over a span of six seconds dropping from 65 degrees nose high to 65 degrees nose low.

At some point during this nose high to nose low transition, the MP executed the second wrong choice of action when continuing to apply full right rudder resulting in the snaproll. The MP recognized the MA's departure and executed the first two steps of the Out of Control/Departure Recovery Procedure; Smoothly Neutralize and Release Controls and Apply Rudder Smoothly and Opposite Roll/Yaw.

The MP recalled feeling light in the seat, a sensation of "eyeballs out," with a more significant force that pushed the MP to the right side of the cockpit. The MP sensed the forces as mostly yaw due to a perceived spin and was unaware of the negative G situation. When the MP reapplied right rudder in the negative G condition it sustained the right yaw and left roll coupling of the MA rather than countering it.

The MP, likely due to disorientation caused by the combined negative and lateral G forces, did not recognize the negative G condition and was unable to execute the last sentence of Step 2's warning to "counter any negative G with aft stick.

Wrong choice of action is affected by numerous factors. One concept in particular, temporal or time distortion is worthy of discussion in this section as it refers to the MP. Temporal or time distortion occurs when our attentional capacities are highly taxed. Any high stress situation has the potential to create an environment that is conducive to temporal distortion. Due to the low ejection at the time of departure, the MP stated the time available to assess the situation was approximately three seconds.

Unlike the other HFACs, temporal/time distortion occurred at a point in the sequence of events where the MP reacted in a "fight or flight" response. In this case, fight would be defined as continuing to troubleshoot the issues with the MA and attempts to recover the aircraft through identification of the correct checklist with the immediate threat, given the low altitude, being both loss of life and the aircraft. Flight would be defined as ejecting from the aircraft because of the survival instinct.

The MP was aware that the altitude at the time of aircraft departure was below the minimum uncontrolled ejection altitude of 6,000 feet AGL . After application of right rudder failed to recover the aircraft to controlled flight, the MP focused on getting out of the aircraft. Analysis of the KITS altitude data reveals that approximately 9-10 seconds expired while the MP assessed the situation and executed the out-of-control/departure recovery checklist prior to deciding to eject from the MA. The MP recalled the challenges faced during this compressed time interval including both lateral and negative G forces pinning the MP to the right of the cockpit.

KITS data showed the MP had two seconds after the MA departure before falling below the 6,000 feet AGL ejection minimum. The additional eight seconds spent fighting the MA (attempting to recover, giving it "the old college try,") likely contributed to an extremely low altitude ejection (1,100 feet AGL). The ejection was further delayed by an unsuccessful first attempt as the MP's right hand gripped and pulled the emergency manual chute handle.

Furthermore, as the negative G situation progressed, the "ground rush" of the cloud deck at 1,000 feet to 3,000 feet MSL and seeing 3,000 feet to 3,500 feet MSL on the altimeter, the MP decided to eject.

f. PE108 External Force or Object Impeded an Individual's Movement

This is a factor when acceleration forces greater than one second cause injury or prevent/interfere with the performance of normal duties.

Negative G flight characteristics are extremely disorienting. As described above, the MP was lifted out of the seat and pinned to the right side of the cockpit due to lateral and negative G forces. Based on KITS data, the MP experienced negative longitudinal G forces ranging from -0.5 to -1.5 Gs for approximately 15 seconds. This contributed to the MPs inability to fly the MA with hands on stick and throttles as the MP had to brace with the right hand against the canopy and controlled the MA with left hand, which is not normal or expected operations.

These gravitational forces delayed the ejection by impeding the MP's ability to actuate the handles correctly. Specifically, during the first ejection attempt the MP inadvertently grabbed the emergency manual chute handle with the right hand and applied insufficient force with the left hand to activate the ejection seat. Recognizing the error, the MP visually confirmed hands on the correct handles and ejected successfully by pulling both ejection handles.

g. OP004 Organizational (Formal) Training is Inadequate or Unavailable

This is a factor when initial training programs, upgrade programs, transition programs or other training conducted outside the local unit is inadequate or unavailable. The MP experienced a negative G departure from controlled flight with a snap roll entry to the left that transitioned to an inverted, negative G spin condition. During F-15C initial qualification at the formal training unit (FTU), negative G scenarios are taught academically and briefed on every BFM sortie, but there is no practical hands-on simulator training specifically for negative G auto rolls or inverted spins. Positive G auto rolls/spins are taught but in only one simulator training flight in the initial qualification training (IQT) course. A review of MP's training records at the FTU revealed auto rolls/spins were only taught hands-on during one simulator training sortie each.

Through interviews with instructor pilots (IPs)/leadership from the 44 FS at Kadena AB, the board learned there is no requirement nor tracking mechanism during continuation training to ensure F- 15 pilots are proficient to recover from a negative G auto roll or inverted, negative G spins.

Specifically, negative G spins and negative G auto rolls are not tracked as individual required maneuvers in EP or tactical simulators. Pilots testified they did not remember doing a negative G out of control departures recovery. Additionally, actual accomplishments are not tracked in EP simulators, and monthly SEPT or BFM sortie briefs typically only cover positive G auto roll/spin situations and recoveries. Pilots also testified the simulator is a poor replicator of the forces experienced.

In this scenario the MP did not recognize the negative G aspect of the departure and therefore applied right rudder to counter the auto roll rather than left rudder (in the direction of the roll) as recommended in the Flight Manual to speed the recovery. Additionally, the MP did not counter the negative G with aft stick as recommended by the Flight Manual.

h. OP003 Provided Inadequate Procedural Guidance or Publications

This is a factor when written direction, checklists, graphic depictions, tables, charts or other published guidance is inadequate, misleading or inappropriate.

Negative G flight characteristics, negative G auto rolls/spins, and recovery of the aircraft in negative G situations are included in the T.O. series for the F-15C. However, the steps in the Out of Control/Departure Recovery checklist are written for a positive G auto roll or spin. In the handheld checklist, only a single warning mentions countering negative G with aft stick. There is no mention of negative G auto roll recovery considerations in the checklist.

Chapter 3.15. T-38C, T/N 68-8152

LOCATION: Laughlin AFB, Texas

DATE OF ACCIDENT: 13 November 2018

1. ACCIDENT SUMMARY

On the night of 13 November 2018, mishap instructor pilot one (MIP1) and mishap instructor pilot two (MIP2) flew a local training mission in a T-38C, tail number (T/N) 68-8152, assigned to the 87th Flying Training Squadron (FTS), 47th Flying Training Wing (FTW), Laughlin AFB, TX. Shortly after touchdown on a touch-and-go, the aircrew heard a noise. The mishap aircraft (MA) then experienced a four degree pitch up and a four degree right heading change followed by increasing angle of attack, right bank, and continuing right heading change. The MA remained airborne for a short time, and then touched down in the grass approximately 55 feet from the edge of the runway, approximately 195 feet from runway centerline in an approximate heading of 13 degrees to the right of the centerline. The right wheel touched down followed by the left wheel approximately 175 feet later. The aircraft remained on the ground for an additional approximate 350 feet, approximately 525 feet total, before again becoming airborne over a shallow depression in the ground. The MA impacted the ground approximately 605 feet later in an approximate 45 degree right bank angle. The Mishap Crew (MC) initiated ejection. MIP2 ejected successfully and received only minor injuries. MIP1's sequenced ejection, however, was interrupted when the aircraft impacted the ground, and MIP1 was fatally injured.

Figure: MIP1 Assumes Control of Aircraft (Approximate)

2. HUMAN FACTORS ANALYSIS

a. Introduction

Human factors describe how our interaction with tools, tasks, working environments, and other people influence human performance.

b. AE102 Checklist Not Followed Correctly

HFACS Code AE102, Checklist Not Followed Correctly, is a factor when the individual, either through an act of commission or omission, makes a checklist error or fails to run an appropriate checklist.

Maintaining aircraft control is the most important part of any emergency. TO 1T-38C-1 states:

When an emergency occurs, three basic rules are established that apply to most emergencies while airborne. They should be remembered by each aircrew member.

1. Maintain aircraft control.

2. Analyze the situation and take proper action.

3. Land as soon as practical.

If an engine operates abnormally or fails during flight, TO 1T-38C-1 advises pilots to reduce drag to a minimum and maintain airspeed and directional control while investigating to determine the cause. Single-engine directional control can normally be maintained at all speeds above stall. After the MA's right engine experienced a compressor stall, the MA rolled and yawed to the right. MIP1 did not apply throttle or stick and rudder inputs sufficient to maintain control of the MA, and at 19:23:57, the MA over-flew the side of the prepared surface.

The flight manual directs the single-engine go-around checklist any time thrust is questionable on takeoff and a decision is made to continue takeoff. The first two actions of the SINGLE-ENGINE GO-AROUND checklist are: 1. THROTTLE(S)-MAX, 2. FLAPS-60%. Pilots are warned that continuing a takeoff on a single engine should be attempted only at maximum thrust. Pilots are warned that, with other than 60% flaps, single-engine capability is impaired to such an extent that the combination of temperature, pressure altitude, and gross weight may make takeoff impossible. MIP1 did not move throttles to MAX until 19:24:02, 10 seconds after hearing a noise and one second before commanding ejection. The MC did not raise flaps to 60% at any point during the emergency.

After the MA took off following the compressor stall, a blinking boxed STALL indication on the HUD and MFD plus a modulated aural tone indicated that the MA was approaching an aerodynamic stall. In this situation, pilots are trained to execute a traffic pattern stall recovery. Stalls can be terminated by simultaneously moving throttles to MAX, relaxing backstick pressure, and rolling wings level. MIP1 did not move throttles to MAX or roll wings level as the stall indications continued.

c. PC504 Misperception of Changing Environment

HFACS Code PC504, Misperception of Changing Environment, is a factor when an individual misperceives or misjudges altitude, separation, speed, closure rate, road/sea conditions,

aircraft/vehicle location within the performance envelope or other operational conditions.

While both MIP1 and MIP2 had practiced emergency procedures for compressor stall scenarios, neither had previously experienced an actual compressor stall. The flight manual describes compressor stall indications at low altitude and high airspeed as follows: Pop, bang, or buzz with rapid engine rotational speed drop or high EGT. During a post-mishap interview, MIP2 noted that the sound he heard in the aircraft was not similar to the sound associated with compressor stalls during emergency procedure simulator training. MIP2 stated that he initially identified the emergency as a blown tire rather than a compressor stall or engine problem.

Touch-and-go landings are the only time the T-38C flight manual refers to a critical phase of flight. The slow airspeed, close proximity to the ground, and multiple tasks that must be accomplished during a touch-and-go landing increase the complexity of emergencies and limit the time available for applying critical procedures.

TO 1T-38C-1 advises that ejection is preferable to landing on an unprepared surface. The MA overflew the right side of the prepared surface at 19:23:57 and touched down in the grass at 19:24:00. The MA landing light illuminated the grass in the field to the right of the runway approximately one second before the MA touched down. This is the first time there is any indication that MIP1 or MIP2 knew they were no longer over the runway surface and were so close to the ground . The MA remained on the ground until 19:24:02. Neither crewmember commanded ejection until 19:24:03, six seconds after departing the runway and three seconds after touching down off the prepared surface.

d. PE101 Environmental Conditions Affecting Vision

HFACS Code PE101, Environmental Conditions Affecting Vision, is a factor that includes obscured windows; weather, fog, haze, darkness; smoke, etc.; brownout/whiteout (dust, snow, water, ash or other particulates); or when exposure to windblast affects the individual's ability to perform required duties.

Darkness limits pilots' ability to accurately perceive the external environment, contributing to visual illusions that can interfere with safe flight. Altitude and rate of descent are more difficult to judge close to the ground. Sloping or featureless terrain, sloping runways, varying runway widths, runway lighting intensity, and (or) weather phenomena can cause visual illusions at night. One well-known hazard occurs during take-off on dark, moonless or overcast nights where the terrain off the runway is devoid of ground lights and no horizon is discernable. As an aircraft lifts off into such a "black hole", pilots relying on external visual cues may fail to accurately assess their climb angle and proximity to terrain. During flight operations that rely upon external cues for guidance, misperception of the environment is more likely at night than during the day. Visual references and depth perception change with night operations.

Multiple times during the MS, the MC commented on the darkness of the airfield environment, both while taxiing with the landing light on and while airborne.

18:44:26 MIP1: "Me as well... I'm just here... It is [...] dark out here dude."

18:44:36 MIP2: "I was gonna say dude, I'm not getting a ton of lume right now out of this, this thin quarter moon or whatever."

18:44:42 MIP1: "I-I've got this landing light out in front of me and I got [...] nothing dude. I can't see [...]."

18:46:49 MIP2: "Yea, It's dark."

18:46:52 MIP1: "It's really dark dude."

19:00:48 MIP2: "Ooh buddy, man, that is, that is it is darker than usual."

19:00:50 MIP1: "I'm fine, I'm fine. It's freaking dark dude, it is really dark. It is mad dark, dude."

19:05:12 MIP1: "That's pretty late, dude...The uh, I don't see the light on top of that shack to be honest with you. That's what I was looking for."

19:05:22 MIP2: "Uh, I can't. Yea I can't really see anything out here."

19:05:23 MIP1: "That's true, dude."

19:05:25 MIP2: "But uh, oh well. I can't. I can't really see anything out here."

During a post mishap interview, MIP2 described the appearance of the runway environment on approach stating, "It's a black hole. It is – it is either way you slice it but off the perch you perch into a black hole". He also described the environment where the emergency occurred explaining that "once the nose points away from the runway there's no horizon out off [runway] 31". The MA's high pitch angle and its landing light's downward angle when airborne further limited the illumination of the ground until sufficient bank and proximity allowed the MC to see the grass.

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