COMMENTS ON ACCIDENT REPORT

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP71B00590R000200040005-6
• Release Decision: RIPPUB
• Original Classification: T
• Document Page Count: 15
• Document Creation Date: November 17, 2016
• Document Release Date: July 17, 2000
• Sequence Number: 5
• Content Type: MFR

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Copy of IL
MEMORANDUM FOR THE RECORD
SUBJECT: Comments on Accident Report
REFERENCE: Findings and Recommendations of Accident
Board
1. Specific comments pertaining to the findings and recom-
mendations of the Accident Investigation Board reporting on the
accident of A-12 S/N 123, are as follows:
a. FINDINGS:
,(1) Primary cause - do not concur. I agree that
some form of blockage, probably solid ice, occurred in
the total pressure port and gave the pilot erroneous in-
dications that led to the eventual stall. However, the
true cause for this accident was pilot error in that the
pilot failed to take adequate corrective action in a dete-
riorating air speed situation and that he operated the air-
craft in IFR conditions on a VFR clearance. As verified
from information in the aerodynamics section of the
accident report and Attachments 1 and 2, the application
of full power to include after burner or positive flight
control movement to obtain a definite nose down/dive
condition at any time from roll-out of turn down to KEAS
101 would have been sufficient for recovery. In addition,
the pilot could have taken necessary action to remain
VFR which would have in all propability precluded the
accident.
b. CONTRIBUTING CAUSES:
(1.) Ref. a. - Concur. There can be no misunder-
standing between briefing personnel and a pilot flying the
mission. Instructions must be clearly stated by briefing
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personnel and thoroughly understood by the pilot before
attempting to fly the mission.
(2) Ref. b. - Concur.
(3) Ref. c. - Concur, except that I feel this is part
of the primary cause as stated above.
(4) Ref, d. - Concur.
(5) Ref. e. - Concur.
(6) Ref. f. - Do not concur. The F-101 aircraft was
capable of providing chase support; the contributing cause,
as pertains to the part the chase aircraft played in this
accident, should be; "The F-101 aircraft chase procedures
during a critical time of the A-12 flight were inadequate in
that no concrete chase assistance was given to the aircraft
when it experienced pitot static difficulty and the airspeed
started bleeding down."
(7) Ref. g. (added) - Supervisory error in that (1)
chase aircraft duties and responsibilities were neither
clearly defined or adequate; (2) the quality of the briefing
was such that comments regarding weather were either
misunderstood or misinterpreted by the pilot; and (3) pilots1
actions indicate a lack of previous training in. A-12 flight
characteristics at speeds considerably below normal cruise.
(8) Ref. h. (added) - Calculated risk involved in this
project where the operational capability follows along con-
currently with the test program in a new vehicle of this type.
(9) Ref. I. (added) - Material failure in that the total
pressure ports of the pitot system probably became blocked
by ice giving the pilot erroneous readings on. both the Triple
Display and conventional airspeed indicators. This was
followed by unplugging which caused rapid run-down of MACH
and KEAS indications to correct readings, further confusing
the pilot.
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c. NON-CONTRIBUTORY FINDINGS:
(1) Ref. a. - Concur.
(2) Ref. b. - Concur.
(3) Ref. c. - Concur.
(4) Ref. d. - Concur with the thought being put out
here but do not concur that this statement is a finding.
The phrase is written as a recommendation. It should
be a contributing cause and state: "Pilot did not cross-
check normal pitot static pressure instruments against
his Triple Display Indicator when operating at other
than design cruise speed."
(5) Ref. e. - Concur.
(6) Ref. f. - Concur.
(7) Ref. g. - Concur.
(8) Ref. h. - Concur.
(9) Ref. 1. - Concur.
(10) Ref. j. Concur.
(11) Ref. k. Concur.
d. RECOMMENDATIONS:
(1) Recommendations for Primary Cause:
(a) Ref. a. - Concur.
(b) Ref. b. - Concur.
(2) Recommendations for Contributing Causes:
(a) Ref. a. - Concur with the additional provision
that briefing procedures and briefing material be reviewed
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to insure that pilots and staff personnel alike understand
their responsibilities in the conduct of briefings for A-12
missions.
(b) Ref. b. - Do not concur. The lack of a recom-
mendation for this contributing cause is unacceptable.
To prevent possible recurrence of another pilot getting
into this situation, the Accident Board should have
recommended that all A-12 pilots be rebriefed on all
phases of this accident with particular emphasis on the
operation of the MACH trim system and the part it played
in leading to the eventual stall.
(c) Ref. c. - Do not concur. The lack of a recom-
mendation for this contributing cause is also unacceptable.
The pilot was in a deteriorating airspeed situation which
called for after burner power and/or a definite nose down
(100 dive) correction. All A-42 pilots should be rebriefed
on slow speed flying characteristics of the aircraft with
emphasis on the Drag/Thrust/Airspeed/ and SAS relation-
ship under such conditions, and the proper corrective
action to be taken in a decreasing airspeed situation. This
information should also be incorporated into the training
program for new pilots in initial/checkout training.
(d) Ref. d. - Concur.
(e) Ref. e. - Concur.
(f) Ref. f. - Do not concur. Recommendation as
written is not inclusive enough. The review of chase
support should include a thorough review of existing
chase aircraft SOPts, chase pilot responsibilities, etc.,
to insure that any departure from the briefed mission
conduct or format is immediately detected and reported
by the chase aircraft.
e. RECOMMENDATIONS ON NON-CONTRIBUTING FINDINGS:
(I) Ref. a. - Concur. In addition, the necessity for con-
ducting factual, understandable and concise briefings must be
re-emphasized to staff personnel.
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(2) Ref. b. Concur.
(3) Ref. c. Concur.
(4) Ref. d. Concur.
c5) Ref. e. - Concur.
(6) Ref. f. - Concur.
(7) Ref. g. - Concur.
(8) Ref. h. - Concur.
(9) Ref. i. Concur.
(10) Ref. j. Concur.
(11) Ref. k. (added) - Normal and emergency pro-
cedures should be revised to incorporate appropriate cor-
rective action for the pilot who finds himself in this sit-
uation.
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(12) Ref. 1. - (added) - That an A-12 flight simulator
be purchased and put into operation at at the earliest
opportunity so that pilots can be more realistically trained
in A-12 flight characteristics and emergency procedures.
JACK C. LEDFORD
Colonel USAF
Assistant Director
(Special Activities)
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Primary Caues: The prip/Ty cause of this accident waa materiel failure
in that the total pressure ports of the pitot systam probably became
blocked by ice, which gave the pilot false increaaed airspeed and Mach
roadinge on both the TDI and conventional indicated airapeed :system, this
was followed by unpluggina which caused rapid rundawn of Mach and KEAS back
to correct readings at approximately 160 KEAS, further confusing the pilot.
NOTE: This pitot heating system was designed and qualified in accordane
with MIL-P-25632A.
2, Contributing Causos?
a. The pilot failed-to comply with briefing instructions, that he abort
this uiaaion if he encounter6d In conditions and/orrany undercaot that
would prevent visual observations for the INS and V/H Sensor.
b. The Mach Trim subsystem of the AFCS, receiving the came erronecua
Mach signal? as the TDI, addcd nose up tria to the aircraft, thus further
increasing the angle of attadt and incroasing the rate of airapeod blood
off which led to the stall.
c. Pilot failod to take adoquate corrective action after evaluation
of. inetru=at readings.
d. Woathor contributod to tido accident in that pitot icing moot
probably occurred.whon flying thru visible moisture just prior to the tura
, at Wondovor, and instrumznt conditions existod during the final phase of
flight.
o. There is no altornato pite'e-static source which the pilot could
havo usod to choelz instruznt roadIngec,
Z. The F-101B aircraft %as unable to provide chase support during the
critical time the A-12 was ar,prioncing pitot-static diffloulty and
air ,- d 14- '-oding don, d?Lle to tho wic:o margin in sub-sonic flight
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3. Non-contributory Finding:
a. Although this aircraft was designed for a relatively unexplored
flight envelop, there were no provisions for an inflight recorder. A
crash resistant flight recorder would have been invaluable in re-constructing
this accident.
b. A direct reading angle of attack indicator if available to the
pilot during this situation, would have provided hi with a positive
indication of his true angle of attack and the approaching stall condition.
L. Electrical distribution of AC power is unsatisfactory in that
there is no back uP for inverter failure.
d. When operating on the TX, at other than design cruise,apeed,
cross chocking of normal pressure indicators zhould be emphasized.
e. Pilot did not follow check list on engine start this flight.
f. The left main parachute canopy release lock could not be
released by pilot after touch down.
g. Seat cushion was lost during ejection. Lose of the seat
cushion itself is not hazardous, but ordinarily the scat cushion is a
mapact-light wv;ight sleeping bag needed for cold weather survival.
h. Personal oxygen hoses were pulled loose from under parachute
leg straps. At ejection these linos pull from beneath the leg straps and
could cause damage%o the suit.
i. No warning device J.; 7s,-...:;orporated into the triple display indicator.
J. No hypoxia warning device (a suitable cockpit gauge with rod light/
or horn is available) is installed in this type aircraft.
k. Sabotace was not a contributing factor in this, accident.
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RECOMMENDATIONS
1. Recommendations for Prim%rv Cauno:
a. Further testing and/or evaluation of the A-12 pitot static
system for adequacy of hoating and wiring roaliability, with appropriate
modifications if indicated, be accomplished prior to releasing the aircraft,
from its present VFR restrictions.
b. A study to deterMine the feasibility of the installation of an
alternate pitot source and.a cockpit warning device to indicate nitot
heat failure should be accomplished as soon as possible. If this study
indicates the practicability-of these inatallations they should be accomp-
lished prior to release frcm VFR restrictions.
2. Recommenlations for Contributirses:
a. The necesaity of strict adherence to briefing instructions Should
be stressed. with all pilots.
b. None.
0. None.
d. All Al2 flights should be restricted to Tht conditions until the
pitot-st'-itic system has adequately been modified as outlined above.
o. An alternate pitot-static eourco ohould be installed in Al2 try)
:type aircraft to provide pilot the opportunity to switch to this source.
to check his instruments should they appear strange at any time.
f. The problem of dnaee eupport of the Al2 aircraft should be
reviewed to determine the changing requirements from here forward and to
suggest changes in the typo or types of chase aircraft should such be
required.
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3. Recommendations on Non-contributory Pindlng;s:
a, A crash resistant flight recorder should be installed in Al2 type
aircraft for all test and training missions.
b. A direct reading angle of attack indicator should be developed
for this aircraft capable of operation throughout the fliJoht envelope.
c. A spare inverter Should be provided with switching provisions to
any one of the three primary inverters.
d, Pilot, training should emphacise that when operating at other than
design cruise speed cross Checking of the normal pitot-static indicators
19 required.
0. Pilot training will emphasize the importance of following the_
check list.
f. Evaluate the present parachute canopy release for the purpose of
making improvomonts which will make the releaGemore compatible with the"
parachute and full pressure suit.
o. A nylon lanyard should be attached to the seat cushion to prevent
its loss during ejection.
h. Provide a hose restraint to prevent flaying of oxygen hoses during
ejection.
1. Evaluate, and if feasible, incorporate a self monitoring warning
device for the TDI.
J. Provide a hypoxia warning device to monitor pilots' oxygen supPly
system.
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Tho abovo findinv and recealmendattonu 1.Nre drafted and Ivproved by
the fo11owiN.:5 mambar5 of the,board.
CHARLES E. WIMBERLY
Colonal, USAF
Bo.&rd President
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ILLEGIB
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6. A light system will be installed to indicate when current is flow-
ing in the pitot tube deicing system. It will be de-activated at
M = 1.5.
. ?
7. The recommenda.tions in thejaccith.,nt report havir to do
personnel equipment will be put into effect, but I do not
Alould change the.main parachute canopy release lock.
8. We will expedite the revision to the seat ejec.-tn svstern to allow
the seat to be Jettisoned in spite of a failure of the canopy arming
system.
Sincerely,
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