Investigators have determined a Jan. 15, 2014, crash during a dogfighting exercise, which destroyed an $85 million F/A-18E Super Hornet and seriously injured the pilot, was "preventable," according to a new report.

The investigation, dated Nov. 24, 2014, was blunt in its assessment: "Bottom line up front, this was a preventable mishap," the investigator wrote. He faulted the unnamed pilot with Strike Fighter Squadron 143 for failure to conduct normal mission cross-check scans operating within established tactical parameters. The investigator also said a lack of proficiency with the Joint Helmet Mounted Cueing System contributed to the crash, as did the fact that the flight brief lacked the substance and depth required to mitigate operational risk management.

The report was signed by Rear Adm. Troy Shoemaker, who led was commander of Naval Air Forces Atlantic at the time of the crash. The two-star has since been named the Navy's "air boss" as head of commander of Naval Air Forces and Naval Air Force Pacific in San Diego.

The crash occurred during one-on-one high aspect basic fighterting maneuvers off the coast of Virginia Beach, Va. The exercises were intense, and the crash occurred on the fourth BFM set of the day. The four sets lasted a combined 3 minutes, 58 seconds, with all but 37 seconds at maximum power. In the fateful fourth run, the pilot was executing a nose low maneuver and lost situational awareness of regarding his altitude, airspeed and rate of descent.

He rolled left to execute the nose low maneuver at 14:29:57, which was 12 seconds after "fights on." He started at 9,900 feet with a 15-degree nose low position at 468 knots. This was well above Top Gun airspeed parameters for this maneuver.

That manual states the pilot should "pay particular attention to your fuel weight and aircraft configuration as you go nose low at lower altitudes. A nose low load-limit maneuver with airspeed in excess of 430 knots in slick F/A-18 E/F configuration may actually require throttle and/or speed brake modulation to bleed into the rate band. It is not uncommon to accelerate uncontrollably once committed nose low in a slick Super Hornet and the aircrew must be aware of pre-emergent energy states and proper body positioning for the high G-load to the bottom of the turn. If excessively fast, modulate throttles in the oblique to manage airspeed before committing your nose low."

The situation quickly went from bad to worse. Within two seconds, the pilot was at 523 knots and 75 degrees nose low in a 7.6 G-pull with throttles at max power. The aircraft's G-limiter began to limit G-available to 5.8 Gs as he accelerated through Mach .905. The airspeed rapidly increased, causing the aircraft to arc and increasing its turn radius and altitude lost.

Investigators found the pilot had lost situational awareness as he focused on maintaining site of his counterpart. During the second BFM set, he had lost sight of the other jet and called "blind" while executing a similar high-speed, nose low maneuver.

"It is reasonable to assume [the pilot] did not want to make the same mistake," the investigator said. Looking up and left in an attempt to keep eyes-on, he failed to conduct normal mission cross-check scans and was likely unaware of rapidly increasing airspeed and rate of descent until warnings alerted him to the situation. This happened just four seconds after the maneuver began.

The pilot cut throttles back to idle power. He went from 78 degrees to 68 degrees nose low, but it was too late. The aircraft was moving at 577 knots in a 5.6 G turn at 4,740 feet. Ejection occurred 11 seconds after the maneuver started, with the aircraft below 2,800 feet and moving in excess of 600 knots.

Optimal ejections occur below 250 knots, according to Naval Air Training and Operating Procedures Standardization. Between 250 and 600 knots, "appreciable forces are exerted on the body, making injection more hazardous," An ejection above 600 knots is "extremely hazardous," and an ejection at speeds above 350 knots can prove fatal when wearing the JHMCS.

A subsequent survey of the 17 squadrons at Naval Air Station Oceana, Va., sought to determine how many knew of the helmet's limitation. None of the 11 squadrons that responded discussed the hazards of brief high-speed helmet ejection contingencies before flights, investigators found.

The pilot had no memory of any activity subsequent to the ejection sequence.

A civilian fishing vessel, the Joyce D, was two to four miles east of the impact site and was radioed by an F/A-18, call sign PARTY 22, from Strike Fighter Squadron 87. The Super Hornet was one of four other aircraft training in the area that heard the mayday call. The pilot directed the civilian vessel to make its way toward the crash site, and fellow Super Hornet pilots flew alongside the vessel to point it in the right direction.

The aircraft carrier Theodore Roosevelt was transiting 25 miles west of the impact area and ordered its search and rescue helicopter launched within four minutes of the crash, which took place at 14:30. Dock landing ship Oak Hill was also in the area and began to proceed to the impact site. It would take 40 minutes for the ship to arrive on scene.

Joyce D neared the scene at 14:54. Because Roosevelt's SAR helicopter was still on deck, PARTY 22 instructed the vessel to pull the pilot from the frigid waters, but to carefully consider his condition to prevent further injury. The SAR helicopter lifted at 15:00.

The civilian fishing vessel threw a survival ring to the pilot several times but reported he was unable to grab the ring. He was asking for help whileen having trouble breathing.

The helicopter arrived at 15:12, as did the Oak Hill. The ship deployed a rigid-hulled inflatable boat with SAR swimmer aboard, which loitered in the area as a backup.

The TRRoosevelt's SAR swimmer swam past the drifting pilot and to the civilian fishing vessel, assuming the pilot was still alongside Joyce D. Two MH-60s from helicopter Sea Combat Squadron 28 that were in the area had arrived on scene to assist, and saw what was happening. One of the helicopters hoisted the pilot and SAR swimmer out of the water. Unable to reach Roosevelt's helicopter crew. BAY RAIDER 46 entered a hover one rotor diameter downwind from the floating pilot and lowered its SAR swimmer. The pilot and swimmer were lifted in one hoist at 15:25. The pilot had been in the water approximately 55 minutes. He was in and out of consciousness, and suffering from hypothermia, broken arms, difficulty breathing, and bruising to the head and face. It took eight minutes to get the pilot to Norfolk Sentara General Hospital.

The investigator concluded the mishap would not have happened if the pilot conducted a normal mission cross-check scans and operated within established high altitude BFM parameters. Subsequent flight simulations also determined the pilot and aircraft would have survived if he had continued with a 7.5 G pull with throttles at idle, or pulled the G-override paddle switch and performed maximum G pull with throttles at idle.

The Navy described the pilot as a male lieutenant junior grade (one of two in the squadron) who was commissioned through Officer Candidate School and designated a Naval Aviator on May 4, 2012. He joined Strike Fighter Squadron 143 in July 2013 and had 188 hours in the Super Hornet, to include 41 flights with the "Pukin Dogs." The squadron's skipper, executive officer, operations officer, and training officer regarded the pilot as "an average to above average nugget aviator who was always well-prepared for any evolution," using a slang phrase for a first-tour flier. WHATS A NUGGET AVIATOR?

The investigation had much to say about personal factors. The pilot was dealing with undisclosed personal issues that limited his flight time leading up to the crash. Investigators found the command allowed the pilot to adequately deal with those personal issues; the squadron's skipper opted further selected to let the pilot stay home whileith the squadron spent two weeks training at Eglin Air Force Base, Fla. In January, the pilot reported his personal issues were resolved. He told investigators he these played no factor in his performance.

In his concluding remarks, the investigator reiterated the responsibility of individual pilots to "constantly and thoroughly evaluate their own personal human factors. Every aviator is different in their ability to manage and compartmentalize personal human factor issues. If a human factor issues leads to a loss of preparation, focus, or execution, a Naval aviator must notify his/her chain of command. … Only [the pilot] knows if personal human factors contributed to his focus, preparation, or execution of the MF and played a role in this mishap."

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