USAF INVESTIGATION OF MAJOR AIRCRAFT ACCIDENT A-12 S/N 125 5 JANUARY 1967

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP71B00590R000100010001-4
• Release Decision: RIPPUB
• Original Classification: S
• Document Page Count: 195
• Document Creation Date: December 9, 2016
• Document Release Date: January 27, 2001
• Sequence Number: 1
• Publication Date: January 5, 1967
• Content Type: REPORT

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ECT.-Lrcraft tientAc Investigati- Coard &ecommendaeiJr
Chase aircraft requiring refueling will only be scheduled in one of
two ways depending on the route flown by the primary aircraft..
a. Refueling after - chase pilot will observe depart-
ure from tanker aircraft, then join tanker and take a full load of fuel.
Chase pilot will then continue practice contacts ending with a top off
refueling approximately 15 minutes after the completion of refuel-
ing. (This procedure will permit the chase aircraft to have the maximum
amount of fuel available for the longest practicable time.)
b. Refueling before - chase aircraft will rendezvous with
tanker 45 minutes prior to ARCP, refuel as in the above procedure
and complete refueling (with a full fuel load) not later than 30 minutes
prior to ARC2. ? This will permit tanker aircraft to reposition for
rendezvous ar. chaSe aircraft to have sufficient fuel to observe
refLeIim:.
k. Heat :est s2acers have been removed from all aircraft.
1. Underside surface of head rest ramp and top surface of the.drogue
parachute pack are being redesigned by LAC so as to provide a smooth
interface.
m. (1) LAC is to provide a fix (and testing) of the rotary actuator
straps. l'-odification is expected to begin the week of 20 Feb 67.
(2)
The Lt-ATIa:ic SLE-c, belt release mechaflism and a manual release lever
eadied by LAO. iieth items are to be discussed during the
..:encoung meeting of Life Support personnel. It is possible that a
-..eotype may be available at this meeting.
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The shoulder harness loops have been sewn (inspected and corrected)
to meet the specifications of T.J. 13A-1-1.
The prototype emergency face plate heater and prototype cover for
.:},:yen controller assembly are to be presented and discussed all=
ial equipment meeting/evaluation. These items are to be tested and
if acceptable put into use as soon as possible.
q. A D-ring cable cutter is being designed by LAC. No prototype
production date available at this time.
r. All future modifications to the ejection system will be received only
through testing and qualification prior to issuance of TCTO kits or
service bulletins. Additionally a test program will be set up to test
all new equipment with our present esuipment.
Deputy Commander for Operations
2
Stat-Pk&
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, 1 ,
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PILOT RECOVERY'
2356Z 155-6L .
----- 'PLANNED FUEL 8_740 LBS
REPORTED FUEL 4 000 LBS
A NNED ir FUEL RESERVE 7,400 L: 17,Ir r NolGirff /".3 r
11
II0003Z 1603L e 23.59Z 1559L
?'PILOT ADVISES BAILOUT( 21-TOW FUEL LIGHT REPORTED
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MINSINIIIIIIII/1/1111111111111111/11111&.
GROSS WEIGHT
70
AIRSPEED THRUST REQUIREMENTS 36000'
TOPSECRET OXCART
SOURCE - LOCKHEED REPORT
N O. 3 SP - 237A ?
55
50
26
45
24
o 22
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20
18
0 I
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14
12
10
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%POWER
5.100Nomm4maiRooR 1;#44404,0 TURN
? ? ?
MIL POWER
96';
KEAS.
amsorti
TOPSECRET OXCART
121,
147.
160
190
MACH. NO. I
280
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THIS IS A PROJECT OXCART DOCUMENT
SPECIAL HANDLING REQUIRED
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iCHECKLIST
3
USAF ACCIDENT/INCIDENT REPORT z
AND INDEX il -f
f sh
k- 0
;a
I
..
b
el
0
A
AF FORM 711 AZ
141
.
B
AF FORM 711a
R
$
C
AF FORM 711b
W
D
AF FORM 711c I
F1
E
AF FORM 711d
F
AF FORM 7110
G
AF FORM 711f 1k1
H
AF FORM 711g g
1
I
UNSATISFACTORY REPORT W
....?,....'
J
TEARDOWN DEFICIENCY REPORT r44
,.......--
.........,-
K
LIST OF TECHNICAL ORDERS NOT COMPLIED WITH
I_
L
AFro FORMS 781 SERIES ?
M
AF FORM 5
N
STATEMENTS
?
4,.....,
,.
0
REBUTTALS
I
...?
,.
P
ORDERS APPOINTING INVESTIGATING BOARD
I
....
Q
BOARD PROCEEDINGS
-
4
1._.s
-k...
R
DD FORM 175 OR DD FORM 1010
S
DD FORM 365 (Weight and Balance Clearance Form F)
.4'
1
T
STATEMENT OF DAMAGE TO PRIVATE PROPERTY
44
U
CERTIFICATE OF DAMAGE (List of Parts Damaged), MANHOURS REQUIRED TO REPAIR, AND COST
II
1-
..,...
'
V
TRANSCRIPTS OF RECORDED COMMUNICATIONS
W
ANY ADDITIONAL SUBSTANTIATING DATA REPORTS
I'
?41'
X
OTHER AF FORMS (Failure and Consumption Reports, Etc.)
Y
DIAGRAMS (Fall Out?Impact Area, Etc.)
14-
-f----
....-
1
PHOTOGRAPHS
Whenever "Applicable but not attached" column Is marked for any of the elbows Items, Information must he entered under remarks to Indicate what action has been taken or will be
taken to obtain the required attachment. Lettered tabs shown above will be inserted for corresponding attached Items, 144 Tab N will always be used for Statements, Tob P for
Orders Appointing Investigating Board, etc. Tabs will be omitted on those hams net applicable.
REPAARKS1
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FOR OFFICIAE USE ONLY
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AFPORN
DIC 1 711h
*OA INVIOI*11111T PIIINTIMAS OFPItt 1141 OF
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USAF ACCIDENT INCIDENT INDEX
TAB
A ? AF FORM 711 ? USAF Accident/Incident Report
? AF FORM 711a ? Ground Accident Report (Not applicable for Acft Accidents)
? AF FORM 711b ? Aircraft Accident/Incident Report
O ? AF FORM 711c ? Aircraft Maintenance Materiel Report
E ? AF FORM 711d ? Missile Accident/Incident Report
F ? AF FORM 711e Explosives Accident/Incident Report
G ? AF FORM 711f ? Nuclear Accident/Incident Report
H ? AF FORM 711g ? Life Sciences Report of an Individual
I ? Unsatisfactory Report
? Teardown Deficiency Report
K ? List of Technical Orders Not Complied With
L ? AFTO Forms 781 Series
M ? AF FORM 5
N ? Statements
0 ? Rebuttals
P ? Orders Appointing Inves Board
Q ? Board Proceedings
R ? DD FORM 175 or DD FORM 1080
S ? DD FORM 365 (Wgt-Balance)
T ? Private Property Damage
U ? Damage to Aircraft
V.? Communication ? Transcripts
W ? Additional Data
X ? Other Forms
Y ? Diagram
Z ? Photos
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USAF ACCIDENT/INCIDENT REPORT
(Fill in all spaces applicable. If additional space is needed, use additional sheet(s).)
I. DATE OF OCCURRENCE (Year, month and day)
1967, Jan 5, Thursday
2. VEHICLE(S)/MATERIEL INVOLVED
(TMS 8. Serial Ni., if applicable)
_ A-12 #125
3. FOR GROUND ACCIDENTS ONLY
(Base Code and Report Serial Nr.)
N/A
A. PLACE OF OCCURRENCE: STATE, COUNTY; DISTANCE AND DIRECTION 7.1igm NEAREST TOWN. _IF ON
BASE, IDENTIFY. IF OFF BASE GIVE DISTANCE FROM NEAREST BASE. 37U 32N- 114u 301W
7 mile
Nevada, Lincoln Co., 2NM mileS SW LeithAe0 ?llis AFrom E
5. HOUR AND TIME ZONE LOCAL
1630 PST
6.
gi DAY NIGHT
[2 DAWN DUSK
7. ORGANIZATION POSSESSING
Major Command
N/A
OWNING VEHICLE
Subcommand or AF
OR MATERIEL AT TIME OF MISHAP
Air Division
Wing
Group
1
Squadron or Unit
Name and Base Code
8.
25X1A
(List organizations of second
vehicle, if they differ from
1 I
Item 7 above)
9. B
10. LIST OF PERSONNEL DIRECTLY INVOLVED
' (For aircraft include operator and all other persons whether in plan* or not. If more space is required to list all personnel, use additional sheet(s).)
Last Name First Nome M.I.
Grade
Service No.
Assigned Duty
Aero
Rating
Injury
to Individual
_
25X1A
11. NARRATIVE DESCRIPTION OF ACCIDENT; Give a detailed history of flight, or chronological order of facts and circumstances leading to the mishap as applicable, the results of
investigation and analysis to include discussion of all cause factors listed, findings, and recommendations, and any corrective action taken. (Continuo on revers*, if more spoca needed.)
(Continued on following page)
FOR OFFICIAL USE ONLY
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12. AUTHENTICATIO
.CERTIFICATION BY (Title)
APProtfelderSOCRell21101
, Board President
i
TYPED NAME AND GRADE .
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sIGikURE F
.1D 0 9* - 100 ,1 d : ' OC
_
DATE
1- f
'' 7
AF jaRn 711 PREVIOUS EDITION OF THIS FORM IS OBSOLETE.
* U.S. GOVERNMENT PRINTING OFFICE; lees OF-669347
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Item 11, AF Form 711, "Narrative Description of Accident"
A. HISTORY OF FLIGHT:
On 5 January 1967,11111111111111,11 was scheduled to fly Article
Number 130 on a routine training g with a 1000 local takeoff. (ref-
erence Tab W, Flying Schedule)
At the 0730 operations briefing Article 130 was cancelled for main-
tenance. DCOT, substituted
for
sortie scheduled for a 1200 takeoff in Article 125. The A!!!!!!!!!!!!!,1 25X1A
two air refuelings and two cruise performance legs. Mission planning was
accomplished by the mission planning staff. Two F-101 aircraft were
scheduled as chase aircraft for applicable portions of the mission.
The formal briefing for the pilot and chase pilot was conducted at
1030 by the operations staff. (reference Tab V, Transcript of Premission
Briefing). Prior to 1030,
on mission requirements. had conducted informal briefings
with
suited on schedule after
which he was driven to the aircraft.
25X1A
'25X1A
25)(1A
25X1A
2X1A
The aircraft had been pre-flighted by the maintenance ground crew in
accordance with existing procedures. The Interior Pre-Flight, Starting
Engines and Before Taxiing checks were accomplished without discrepancy.
The aircraft was taxied-to the runway and cleared for takeoff. Take-
off was 1159 local (1959Z). The first refueling was scheduled in Yuletide
Special Operating Area with a 2015Z ARCT and a 31,000 pound on load.
Initial contact was established at 2018Z and air refueling completed at 25X1A
2035Z (:36 flight time) lONM beyond end refueling point with an actual
transfer of 36,000 pounds. (reference Tab N, Statement by 0 25X1A-
25X1A
-
25xiA
in Dutch 45 stated that was all the fuel he could take. Dur-
ing the climb, reported turbulence from 48,000 to 52,000 feet and
the Auto Pilot disengaged and a circuit breaker popped which would not 25X1A
reset (reference Tab V, Transcript of Dictect Tape), reported
that due to turbulence he was changing his climb schedule. 25X1A
made a report 657NM DTG to position six. This is ten miles
past his planned level off point at which he should have been at
feet with 42,000 pounds fuel. He reported at 66,000 feet with 45,000
pounds fuel. Creference Tab V, Dictect Tape).
At first cruise "how goes it" check point, (1:06 flight time)
reported 36,700 pounds, actual fuel against 36,100 pounds programmed. The
entire leg was above fuel program running from 500 pounds at first check
point to 1100 pounds at position eight. (reference Tab V, Dictect Tape).
There were no deviations plotted from the planned track. 25X1A
At the start descent point of 260NM DTG (distance to go) from the
sOcond ARCP in the Yuletide Area, was 1100 pounds above the planned
fuel and four minutes late, (1:47 flight time) at level off altitude of
29,000 feet, 52NM DTG, fuel remaining was 14,000 pounds. Twenty-two miles
Latex, reported he was below Bingo fuel. (reference Tab V, Dictect
Tape). This meant fuel remaining is below 11,500 pounds. He lost an 25X1A
additional two minutes due to the 52 mile level off instead of the sched-
uled 20 mile Bottom Out Point, After VHF-contact with his tanker, Cute
stated he wanted fuel right now. Refueling was completed with
four digtnnneots and a climbing flight path from 30 to 33 thousand feet
for the last six Minutes of refueling. Tane r stated refueling was average
or better. At end of refueling, Dutch 45 was advised his position was over
25X1A
25X1A
25X1A
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25X1A
25X1A
25X1A
Current VOR (2:35 flight time) and on load was 61,000 pounds, 1000 pounds
over briefed0 stated he needed another 4 to 5 thousand pounds.
He was advised the tanker was dry as they had refueled the chase plane with
4,000 pounds prior to refueling (reference tab N, Statement by
IIIIIIIIIIIIII(that was a non-scheduled refueling). 25X1A
contacted Bungalow and advised he was around 4000 pounds short
and would have to cut short his,tturning point on, the second cruise control
leg., He requested this information be passed to all agencies. He also
stated he was happy to cut it short as he was hand flying the entire mis- 25X1A
sion with an inoperative auto pilot. (reference Tab N, Statement from
"Bungalow" and statement) 25X1A
25X1A
gave a report at planned level off where he should have been
at feet with 42,400 pounds of fuel. He gave his altitude as
feet with 40,300 pounds of fuel. This is 2100 pounds below the fuel curve.
Twenty-seven miles later he reported his level off altitude as feet
with 39,800 pounds of fuel remaining. Because he was still climbing, this 25X1A
would put him approximately 2300 pounds below the curve.
25X1A
After this point there are two more entries on Dictect
25X1A
that mention fuel, however, they do not include a location or DTG from a
fix. The tape had been severely damaged in the wreckage and only small
pieces of the last portion have been recovered. There is sufficient infor-
mation to plot actual fuel consumption for the second cruise control leg.
The FAA Center reported flight path and the Signal Conditioner and
Data Monitor (SCUM) printout, both plot out very well together; however
the SUM plots the route flown 53 miles greater than planned and show the
route flown very close to "as briefed" with the pilot electing to fly the
complete, rather than the alternate or shorter mission. Verification of
the times show the actual flight continued to run four to six minutes
late during the entire second cruise leg. 25X1A
At 2320Z (3:21 flight time) the HF Single Side Band Tape
in the Command Post recorded A-OK chirps. Two minutes later on 25X1A
his first HF voice transmission reported he was just rolling out of the
far east turn and running 800 to 1000 pounds short on fuel which was due
partially to the 53 additional miles flown; however he expected to make
up the deficiency (reference Tab V, Transcript of HF/UHF Transmissions)
His planned fuel at this point was 23,300 pounds. This would give him an
actual fuel reading of 22,300 pounds. 25X1A
last fuel check point is Position 16, Cimarron, N.M., 25X1A
13,800 pounds of fuel is required if he is to continue to home plate. If
he has less than 13,800 he was briefed to land at Albuquerque. The flight
plan time to this point is 3:36. passed Position 16 at 3:42 flight
time proceeding towards home plate. At 23:45Z, 3:46 flight time,
reports he is abeam Farmington with 7500 pounds of fuel. This position 25X1A
plots 15 miles east of abeam Farmington from the SCDM. He cannot explain
the excessive loss of fuel but he thinks he can make home plate okay. 7500
pounds is the planned reserve he should have on arrival over home plate
(reference tab V, HF Tape). Normal fuel consumption would have put him
abeam Farmington with 11,800 pounds of fuel.
At approximately 305NM from the Base, 3:49 flight time, the SCUM
shows a reduction of speed started. At 260NM, 3:51 flight time, the SCUM
shows him leaving altitude feet with a continuous descent. At
23:56.49Z he reports 120NM with 3900 pounds and he should be able to make it
to home plate. At 0000:26Z he reported 85NM and 2700 pounds. At 0001:56Z
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25X1A
25X1A
he reported, "I'm going to have to jump out of this thing at 22 two II
chirps interrupt transmission) - flaming out."
showing low fuel started at that time and continued till 2402224Z at
which time total power was lost Or aircraft impacted with the ground.
Total flight time was estimated at 4 hours 3 minutes. At time of impact
the aircraft was estimated to be in a 69 degree dive angle, wings near
level. The scatter pattern of wreckage was on an average heading of 240
degrees (reference Tab Y, Wreckage Di4gram). Captain Sharp witnessed the
crash while flying in an F-105 at approximately eight thousand feet at
an estimated five miles Northeast of the impact point. Due to twilight
in addition to a frontal passage the wreckage was not located till 2306Z
on the 6th of January.
Examination of the wreckage revealed complete disintegration upon
impact. All identifiable components were examined. Analysis and witness
statement reveal the aircraft was intact immediately prior to impact with
the exception of a lower wing fillet and the canopy and seat. There was
no indication of in-flight fire or explosion and all burining was indica-
tive of post impact fire.
When the pilot initiated the ejection sequence, the canopy separated
and both over-the-shoulder cameras tore loose from the canopy and were
never recovered. All recording tapes aboard the aircraft were partially
destroyed; however, many items of significant data were recovered from
the tapes as shown in Tab "V".
Careful examination of the existing wreckage did indicate that the
aircraft did not have an engine, hydraulic, oil, flight control, electric,
electronics or structural failure prior to impact. Examination of the
instrumentation data did indicate the possibility of an erroneous fuel
indication, fuel leak, or fuel exhaustion may have existed.
The pilot ejected but was fatally injured when he failed to separate
from the seat before impact. 'During descent, the pilot relayed in a calm,
rational voice to both ground and airborne agencies, an intent to eject
upon flameout of the engines. The full knowledge of an impending require-
ment for ejection provided ample time for pre-ejection preparation. As
best can be determined, ejection was accomplished somewhere between the
altitudes of 20M and 35M and above 295 KIAS. Speed was established by
the fact that the speed sensor permitted actuation of the four second delay
mode only in the ejection system.
The pilot utilized the primary ejection system (D-Ring) and there was
no indication of any canopy removal difficulties. All seat initiators
fired normally including the lap belt initiator and the rotary actuator
(man/seat separator) fired and reeled in 13 inches of tape. The pilot
apparently never left the seat for some undetermined reason. He was fatally
injured upon impact with the ground approximately eight miles east of the
aircraft impact area.
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B. INVESTIGATION AND ANALYSIS
1, Witness statements, cockpit tape recorder data (Dictect)? recorded HF radio trans-
missions., and SO&DM flight data monitors, were used to reconstruct the flight performance
around both navigation legs. Initial review indicated that three possibilities existed
which would have resulted in fuel depletion near the point of flame out.
A full fuel offload was not obtained during the air refueling preceeding the last
navigation leg, Had the pilot disregarded all briefed fuel minimums and extended the flight
profile beyond the point of safe return, fuel quantities remaining during the descent to
land would have approximated those reported by HF radio prior to flame out. However, the
cockpit tape recorder and HF radio transmissions show that indicated fuel remaining over
check points was essentially as programmed at the planned turning point. The pilot was
using a redu red power climb and cruise procedure which during previous tests has reduced
fuel consumption by the approximate amount short after refueling. Therefore it is entirely
possible that indicated fuel reserves were at specified minimums by the time he reached the
turn and the possibility that he krowingly disregarded briefed minimums was not subetant-
iated by data recorded.
A rapid fuel leak which occurred after the last planned check point for diversion
to a suitable alternate could have resulted in siphoning all the remaining fuel from one of
the tanks, This would account for the near normal fuel consumption during descent after the
defective tank contents had emptied but would Inot have explained similar sudden loss of
fuel during approach to the tanker for refueling after the previous, cruise profile. A fuel
leak of such proportions would have been readily apparent to the tanker crew and chase pilot
during refueling. The two sudden drops in fuel quantity apparently occurred with approxi-
mately the same amount indicated on the guage and were too similar to be ignored. All
possibilities of increasing fuel consumption during approach to the tanker such as the use
of afterburner were considered, but the high rate of indicated fuel depletion could not be
explained without a malfunction of some type.
The possibility of a gross fuel quantity guage error which disappears when the tank,
containing a faulty, fuel probe empties, was thoroughly investigated. Tanks three and five
empty at about the fuel quantity orethe sudden decrease occurred. Tests were conducted
which indicate that this possibiliy does exist. Both flight profiles were reconstructed
with the assumption that the actual fuel quantity on board the aircraft was between three
and four thousand pounds less than indicated after both refuelings. Applying this assump-
tion, the amount of fuel offloaded and the reported quantities remaining at various points
along the route assume a logical sequence. The board reached the conclusion that the most
probable cause of fuel depletion resulted from a faulty quantity indicating system and that
the error rapidly decreases subsequent to an indicated fuel remaining of 14000 pounds.
2. Ekamination of the wreckage revealed complete disintegration upon impact. The air-
craft was intact immediately prior to impact with the exception of a lower wing fillet and
the canopy and seat. There was no inflight fire or explosion. All burning was indicative
of post impact fire. During ejection sequence the canopy separated from the aircraft in a
normal manner and impacted approximately nine miles east of the wreckage. Analysis of the
Dictect, SC&DM? and Flight Recorder tapes was difficult because of damage sustained at impact.
The over shoulder cameras were missing from the canopy. Maintenance forms and records were
reviewed and no discrepancies were noted. Due to disintegration of the aircraft and com-
ponents, integrity of systems could not be specifically determined; however, investigation
revealed no structural, engine or flight control failure prior to flame out and/or ground
impact.
3. Detailed examination at the site of the pilot/seat impact area established that the
pilot had not separated completely from the seat and was fatally injured at time of impact.
Subsequent investigation of the recovered ejection system components revealed that all Sys-
tems functioned normally to the point of man/seat separation. Analysis of the components
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of the lap belt release mechanism end tests conducted to simulate separation conditions,
could not absolutely establish a single primary cause for the failure of man/seat
separation; however, it was determined that a number of possible causes for the failure
of the man to separate from the seat could be deduced. First, the lap.belt release
mechanism could have been bound by excessive tension or side-loading on the lap belt
at the time of automatic lap belt firing. Second. the intrusion of a foreign object
into the lap belt release housing could have prevented the release function. Third,
the drogue parachute pack could have been jammed into the headrest spacer extension
restricting parachute travel from under the headrest. Finally, any combination of two
or more conditions that would provide tension to the lap belt or shoulder harness dis-
engagement from the lap belt could have caused failure of the pilot to separate from
the seat. The pilot could have failed to manually release the lap belt due to excessive
seat gyration, visual restrictions and/or obstructions in the vicinity of the lap belt
manual release lever within the brief time span available before impact with the ground.
FINDINGS:.
1. Eximarzaagg.: The primary cause of this accident was fuel depletion from
an undetermined cause. The most probable cause was a fneJ. gauging error resulting in
a higher than actual indicated fuel quantity reading.
2. gsjairlaultinCeses: Pilot factor in that at ..he time he reported 7500 pounds
fuel remaining, he could have diverted to Albuquerque.
3. LddaignAl_Eindingt
a. The location of the Dictet recorder and the construction of the SC&DM
tape cassette does not afford adequate protection.
b. The pilot was qualified and properly briefed to conduct the mission.
c. Control tower and the SCUM tape did not have an accurate time hack
with WWV.
d. During the second refueling the chase aircraft refueled first and took
4000 pounds of fuel which if available to the primary aircraft would probably have en-
abled the aircraft to return to home base.
e. A precise method of determining fuel quantity in the tanks during ground
fueling does not exist.
f. Fuel quantity calibration procedures are not optimized in that the
calibration is not made in the sequence the fuel is used.
g.
Changing of a fuel probe could change system calibration significantly.
h. That the primary cause for the failure of the pilot to Ci an.4 ?,eparate
from the seat could not be determined.
. The most probable causes for the pilot fatling to separate from the
seat were
1. Failure of the lap belt to release due to binding or a foreign
object intrusion into the release mechanism housing.
2. Man-seat separator actuated pushing the man and chute pack upward
and the seat kit forward. The chute pack jammed against the headrest spacer extension
and with constant pressure by the separator belts, the pilot could not separate from the
seat.
Appfejunrin errase 2001/08/29 : CIACMIK79?1/4106V6K60(84b0010001-4
(special Handling Required. See AFR 127-4)
Approved For Reit ase 2001/08/29 : CIA-RDP71B00590MIt0100010001-4
RECOMPIENDATIONS
a. Consider the relocation of the Dictat recorder in the canopy.
b. Explore the possibilities of making the SCUM tape cassette crash proof.
c. Establish a requirement to defuel aircraft after each flight comparing the
fuel indicator quantity to actual off loaded fuel quantity. An allowable difference
limit should be established.
d. On all ground fuelings the aircraft should be filled fram a zero-fuel condi-
tion and then off loaded to desired fuel quantity. Tolerances must be established for
difference in indicator and tanker readings, both at the full and off load points.
e. Fuel tank dip stick capability should be provided.
f, A requirement for fuel system calibration should be established when any major
component, such as a probe, is changed.
g9? Fuel system quantity calibration proceedures Should be amended to conduct the
calibration in the sequence the fuel is used from the tanks.
h. The Dictect be redesigned to allow a break between each conversation.
i. The last point at Which the pilot has the capability to divert to a suitable
alternate should be identified on route maps.
Jo Local procedures be published for training refueling missions that
1. The tanker will have required and scheduled fuel aboard plus 10,000
pounds, conditions permitting.
2. Chase missions are scheduled so that no possibility of interference
with refueling of the primary receiver occurs.
lc. That the headrest spacer be immediately removed from all aircraft,
1. ? That the underside surface of the headrest ramp and the top surface of the
drogue parachute pack be provided a, smooth interface.
m. That the rotary actuator (man/seat separator) straps be repositioned to pro-
vide maximum forward thrust to the man/parachute mass and the eight nuts and bolts
on the front of the seat securing the rotary actuator straps be reversed.
n. That the lap belt automatic release mechanism be reworked to prevent tension
or side load binding of the pawl latch lever and a readily accessible manual lap belt
release lever be developed.
o. That the shoulder harness loops be sewn to prevent slipping over the automatic
lap belt latch lever holeeing.
p. That the development of emergency face plate heater and the protective cover
for the oxygen controller assembly be expedited.
q. That a D-ring cable cutter be Installed.
r. That all future modifications to the ejection system receive thoreegh testing
and qualification prior to issuance of TCTO kits or service bulletins?
FOR
a
Approved For5e5058/29 :
ee 12744
FmgiNA#64
A
Approved Fokaplease 2001/08/29 : CIA-RDP7113005919400100010001-4
USAF ACCIDENT INCIDENT INDEX
TAB ?
A ? AF FORM 711 ? USAF Accident/Incident Report
? AF FORM 711a ? Ground Accident Report (Not applicable for Acft Accidents)
C ? AF FORM 711b ? Aircraft Accident/Incident Report
? AF FORM 711c ? Aircraft Maintenance Materiel Report
E ? AF FORM, 711d ? Missile Accident/Incident Report
F ? AF FORM 711e ? Explosives Accident/Incident Report
G ? AF FORM 711f Nuclear Accident/Incident Report
H ? AF FORM 711g ? Life Sciences Report of an Individual
I ? Unsatisfactory Report
J ? Teardown Deficiency Report
K ? List of Technical Orders Not Complied With
L ? AFTO Forms 781 Series
M ? AF FORM 5 z
? Statements
0 ? Rebuttals
P ? Orders Appointing Inves Board
Q ? Board Proceedings
R ? DD FORM 175 or DD FORM 1080
S ? DO FORM 365 (Wgt-Balance)
T ? Private Property Damage
U ? Damage to Aircraft
V ? Communication ? Transcripts
W ? Additional Data
X ? Other Forms
Y ? Diagram
Z ? Photos
Approved For Release 2001/08/29 : CIA-RDP71600590R000100010001-4
Approved For Release 2001/08/29 : CIA-RDP71B00590R0.00100010001-4
AIRCRAFT ACCIDENT/INCIDENT REPORT
To be filled out for principal a rcrof t involved. (Appropriate blocks only should he filled out on secondary aircraft.)
I. ACCIDENT/INCIDENT CLASSIFICATION (Check one)
Major Minor
Flight Accident Resulting in Aircraft Damage LA L1J Accident Not Resulting in Aircraft Damage
Aircraft Non-flight Accident El Eli Air Force Aircraft Incident
2. Aircraft/Serial Number
#125
3. Type, Model, Series, Block No.
A-12
II. Assignment/Status Code (AFM 65-110)
N/A,
5. If aircraft was being ferried or delivered indicate gaining and losing organizations, date of transfer, ultimate destination
N/A
6. CLEARANCE:
From Edwards AFB
1m Edwards AFB J To
7. Filed:
Ctmbination VFR/IFR _
VFR VFR? ON TOP IFR Local Other A Direct Airway (Controlled)
8. Flight reference at time of accident
9. Duration of Flight
10. Mission of flight
X Instrument
Contact Actual Sim. Other Unit
Firs.
Mins.
3
X-1
Training
11. ALTITUDE
DATA
Cleared Alt. MSL
Ab ove -F1,60Gt.
L
Altitude above terrain acdt se.
quence began
Ft
Altitude MSL impact point
Ft.
Highest altitude MSL flown
Time flown highest alt.
Firs Min
12. Fire and explosion
a. Fire:
data
_53,0011. _3_600_
13. Airfield data: Applicable to takeoff and landing .accidents occurring
Field elevation in use Ft
within 2 miles of airfield N/A
Composition of rnwy. Asphalt_
_:1 ___53_,...
Concrete?
Nonek_ Inflight
.Ground_
Length of runway in use Ft Other (Specify)
Result of grd.
impact? Yes?No?X
Length of overrun Ft. Composition of overrun (Specify)
b. Explosion:
Distance of touchdown from runway n Surface condition. Dry? Wet? Icy?
NoneL. Inflight?
Ground_
Heading of runway o Other (SpecifY)
Result of grd.
impact? Yes No X
Conditions affecting occurrence; e.g., type of instrument or lighting approach aid used, obstructions, barrier, airspeed, gross
weight, forced landing
14. (If answer is
Violations
"Yes," to either
Yes
IA
question,
No
discuss under item 11, Al' Form 711)
Breaches of air discipline LJ Yes
till
No
15. PHASE OF OPERATION1
landing approach,
Enroute
e.g. take off
flareout
Descent
roll, initial climb, normal flight, acrobatics,
16. TYPE OF ACCIDENT: e.g. gear-up landing, mid-air collision, abandoned aircraft,
fire or explosion in flight, undershoot, overshoot
Abandoned Aircraft
17. WEATHER AT
TIME AND PLACE OF ACCIDENT:
(If a factor in the accident, attach
statement of weather officer)
Sky conditions
6000v overcast
Visibility
15f
Wind direction and velocity
i 010? 30-40 KTS
Temperature
0
42
Dew point
, io,o
Alt. setting
29.64
Other weather conditions
N/A
PILOT(S) INVOLVED
(FLIGHT CREW)
18. OPERATOR (Person
a. LAST NAME (Jr.,
at controls at time
II, etc.) FIRST
of accident)
NAME MIDDLE NAME
GRADE
CIV
1
COMPONENT SERVICE NUMBER
N/A
NATIONALITY
USA
YR. OF BIRTH
1933
b. POSITION IN
Front orrelMit
AIRCRAFT AT TIME OF
X Rear
ACCIDENT
or Right Seat
c. ASSIGNED
AC
DUTY ON FLIGHT ORDER
IP p X CP Other (Specify)
d. ASSIGNED ORGANIZATION
Major Command
N/A
Subcommand or Al'
Air Division
I Wing
Group
Squadron or Unit
Base
e. ATTACHED ORGANIZATION
Major Command
N/A
FOR FLYING
Subcommand or AF
Air Division
I Wing
Group
Squadron or Unit
Base
f. ORIGINAL AERONAUTICAL
AND DATE RECEIVED
RATING
g. PRESENT AERONAUTICAL RATING
AND DATE RECEIVED
h. INSTRUMENT CARD
Type
i. AFSC
Primary
Pilot
30 March 55
Date of expiration 29 Dec 67
Duly
19. OTHER PILOT
a. LAST NAME (Jr.,
II, etc.) FIRST
NAME MIDDLE NAME
GRADE
COMPONENT
SERVICE NUMBER
NATIONALITY
YR. OF BIRTH
b. POSITION IN
Front or Left Seat
AIRCRAFT AT TIME OF
Rear or Right
ACCIDENT
Seat Other_
c. ASSIGNED
AC
DUTY ON FLIGHT ORDER
IF P CP Other
(Specify)
d. ASSIGNED ORGANIZATION
Major Command1
Subcommand or Al'
Air Division
I Wing
Group
Squadron or Unit
Base
e. ATTACHED ORGANIZATION
Major Command
FOR FLYING
1 Subcommand or AF
Air Division j Wing
Group Squadron or Unit
Base
f. ORIGINAL AERONAUTICAL RATING
g. PRESENT AERONAUTICAL RATING
h. INSTRUMENT CARD
Type
i. AFSC
Primary
Date of expiration
Duty
NOTE: IF MORE THAN TWO PILOIS_AgyjedallafR_EttaaEA2maaw2narjkacoyaatvzsmaormomkonj.;L___
AF DEC 6271 lb
PREVIOUS EDITION OF THIS FORM IS OBSOLETE ?.__.
*7r-rn E
25X1A
25X1A
FOR OFFICIAL USE ONLY
(Special Handling Required. See AFR 127-41
Approved For Release 2001/08/29 : CIA-RDP71B00590R020100010001-4
25X1A
20. FLYING EXPERIENCE (Attach copy of AF Form 5 for Pilot(s) involved as outlined in AFR 127-4.)
ASSIGNED DUTY ON FLIGHT ORDERS:
(Give last names only. Litt all flight times to nearest hour.)
Pilot
Co-Pilot
Inst. Pilot
Acft. Crndr.
Student Pilot
a. Total flying hours (Including AF time, student and other
accredited time):
3356
b. Total Jet Time:
3067
c. Total 1st Pilot/IP hours, all Aircraft:
3044
cl. Total Weather Instrument Hours:
176
e. Total 1st Pilot/IP hours this Model:
375
f. Total 1st Pilot/IP hours last 90 Days:
41
g. Total 1st Pilot/IP hours last 90 Days this Model:
23
h. Total 1st Pilot/1P hours weather and hood last 90 Days:
8
i. Total Pilot hours night lost 90 Days:
3
j. Total Pilot hours last 30 Days:
14
k. Total 1st Pilot/IP hours last 30 Days:
14
I. Total 1st Pilot/IP hours last 30 Days.this Model:
8
m. Date and Duration last previous flight this Model:
30 Dec 1+20
n. Date of last proficiency flight check:
8 June 66
21 CAUSATIVE AGENCY
Cause Factors (Check one primary and all applicable contributing and probable factors.)
Primary Contributing Probable
Operators
Primary Contributing Probable
Other Personnel
(Specify)
Pilot X
Co-Pilot
Materiel Failure or Malfunction
Controller (Drones)
Engines
Crewmembers (Other than Operator)
Airframe
(Specify)
Landing Gear
Other (.Specify) Fuel System X
Supervisory Personnel
(Specify)
Airbase or Airways
Weather
Maintenance Personnel
Misc. Unsafe Conditions
Type of pers. and orgn. level
(Specify)
Undetermined LI
22. DAMAGE
Damage
VA
to Aircraft
Destroyed 0 Minor
EliSubstantial None
Damage
Yes
Beyond Economical Repair
No
Manhours to Repair
Cost (Est.)
Description of Damage (Describe briefly extent of damage to aircraft and any property
Aircraft was totally destroyed
25X1A
damage incurred)
25X1A
FOR OFFICIAU USE ONLY
(Special Handling Required,, See AFIZ .121.4)
23. / .? AUTHENTICATION
_
President 11' f. ,X." 11, USAF
,61: ii ,
t
Main ''-ri _I'
II
I
Member
AF DEC 62 71 1 b
Hpl-?uuuiuuuiuuui-
PRINT:niu orricr IV63 OF 669741
Page 2
Approved FoNgplease 2001/08/29 : CIA-RDP7113005944000100010001-4
USAF ACCIDENT INCIDENT INDEX
TAB
A ? AF FORM 711 ? USAF Accident/Incident Report
B ? AF FORM 711a ? Ground Accident Report (Not applicable for Acft Accidents)
C ? AF FORM 711b ? Aircraft Accident/Incident Report
? AF FORM 711c ? Aircraft Maintenance Materiel Report
E ? AF FORM 711d ? Missile Accident/Incident Report
F ? AF FORM 711e ? Explosives Accident/Incident Report
G ? AF FORM 711f ? Nuclear Accident/Incident Report
H ? AF FORM 711g ? Life Sciences Report of an Individual
I ? Unsatisfactory Report
J ? Teardown Deficiency Report
K ? List of Technical Orders Not Complied With
L ? AFTO Forms 781 Series
M ? AF FORM 5
N ? Statements
0 ? Rebuttals
P ? Orders Appointing Inves Board
Q ? Board Proceedings
R ? DD FORM 175 or DD FORM 1080
S ? DD FORM 365 (Wgt-Balance)
T ? Private Property Damage
U ? Damage to Aircraft
V ? Communication ? Transcripts
W ? Additional Data
X ? Other Forms
Y ? Diagram
Z ? Photos
Approved For Release 2001/08/29 : CIA-RDP71600590R000100010001-4
Approved For Riggoase 2001/08/29 : CIA-RDP71B0059ORQD0100010001-4
A 11CRAFT MAINTENANCE/MATER1EL REPORT
Use this form when AF aircraft accident/incident involves inadequacy, malfunction or failure of AF materiel.
! 1. AIRCRAFT TM & SERIAL NUMBER
A-12
8/i'-.1 06928 (125
2. SPECIAL REPORTS DATA
a. Were Previous UR's Submitted on Factor(s)
Involved?
Yes No
b. No. and Date of UR's Submitted as Result of This Accident (Attach copy)
Not 1..pnlicab1e
c. Is
TDR Requested?
III Yes No
D
d. No. of T.O.'s Not Complied With at Time of Accident (List TO. Nos. and titles on
separate sheet(s)?Tab K)
27 Service Bullrtins were not coranlik.1
`..!..1.th
i'-...' CRAFf :-: ST
IjCAL DATA
Item
Aircraft
Part, Component or Accessory
ii Identic.c.:?ion of Aircraft/Part, etc.
.1
A-12
...i, Force Acceptance Date
25 Feb 1963
Total Flight Hours
338:57
None
Last Overhaul Date
, Overhauling Activity (Name and location)
.I.. /A
Hours Since Overhaul
1-JA
.1, Hours Since Last Periodic Inspection
2'3:37
Date of Last Periodic Inspection
0 Ct 29 1966
1
Type of Last Periodic Inspection
.PhaSf? 1
L
4. ENGINE HISTORICAL DATA
I (Complete a separate column for each engine involved. Also, complete a separate column for each power plant component involved.)
Installed Position
...,.
,
1
2
' Engine Model and Series
YJT11D - 201i
YJT11D - 20.11
Engine Serial Number
F648209
P64.8223
Total Engine Hours
285:18
230:24
, Number of Major Overhauls
...
2
. Hours Since Last Major Overhaul
9902
35:10
Date of Last Overhaul
27 Dec 1965
12. July 1Q66
Overhaul Activity
Prctt L Whi-bne-v Fratt L L'hitne;ir
i Date Lost Installed
29 Oct 1966 28 Oct. -I966
Hours Since Last Installed
93:12 .:11:25
Date of Last Periodic Inspection
26 July 1266 None since Over:lp.ul
Type of Last Periodic Inspection
75 IIT P E -
IFuel (Type and octane rating)
F.',I.A_ 523C PIA. 5230
i 5. NRE DATA NO INFLICHT FIRE OR EXPLOSIC
(To be completed when fire or chemical explosion occurs, not resulting from ground impact. Indicate: P?Probable or K?Known, in squares below.)
1
a. MATERIEL FAILURE CAUSING /HE FIRE
I
b. IGNITION SOURCE
c. COMBUSTIBLE MATERIAL
I
e-lectrical System
Propulsion System
Electrical System
Static Electricity/
Lightning
Cargo
Hydraulic Fluid
,
1 Fuel System
Other (Specify)
Pneumatic System
Other (Specify)
Electrical Insulation
lubricating Oil
Hydraulic System
Propulsion System
Explosives
Other (Specify)
Pneumatic System
Unknown
Unknown
Fuel
Unknown
. AIRCRAFT FIRE EXTINGUISHING SYSTEM
a, FIRE/OVERHEAT WARNING
Fixed
Portable
Fixed
Portable
Fire Detector
Overheat Indicator
iExtinguished Fire
Not Activated and Not
Near Fire
Operated Properly ?
,I Reduced Fire
If Discharged, Chemical
Used
Not Operated, but Near Fire
i No Effect When
Discharged
If Discharged, Amount
of Chemical Used
Not Operated and Not Near Fire
I Activated but Did Not
Discharge
Other Pertinent Into.
Not Installed
Not Activated but
Near Fire
Other (Specify)
I
SHUT Cii'ij PROCEDL:..j
RESULTS OF ALLOYING FIRE TO BURN OUT
9. EFFECT O.: FIRE
MARK ONE
I
Extinguished Fire
. Colastrophic
Reduced FireI
i i.-.creased Severity of Mishap
No Effect
I i ..,43.7,,ange in Severity of Mishap
1--
' Unknown
e
INot Accomplished
'j Unknown
Appro -? ? -- -.
- ?? s: ? i -B* 1600590R000100010001 -I
a FORM
DEC 62 71 1 c
--Jo+
PREV.OUS EDITION OF THIS FORM IS OBSOLETE. c Erin FOR OFFICIAL USE ONLY
T Wntirilina Rom C",-. ALD 1 01 Al
Approved Forvairlease 2001/08/29 : CIA-RDP711300598$800100010001-4
TION OF INITIAL FIRE
iLOCA6.
Known
Probable
Known
Probable
Known
Probable
Boggage Compartment
Aft of Firewall
Wheel Well
Bomb Boy
Forward of Firewall
Cargo-Passenger Compartment
Cockpit/Crew Quarters
Rocket Pod
Other (Specify)
Engine Section
Tire/Wheel/Brake
Unknown
7. MISCELLANEOUS CHEMICAL
EXPLOSION DATA
Known
Probable
Known
Probable
Initial Ignition Occurred in an Explosive Manner Prior to Ground
Impact.
Intensity of Explosion Was Sufficient To Cause or Appreciably
Contribute to In-Flight Airframe Break-Up.
Explosion Occurred After Fire and Before Ground Impact.
Other Significant Data (Specify)
Explosion Occurred Subsequent to Ground Impact.
Unknown or Not Available.
8. AIRCRAFT MAINTENANCE OFFICER'S ANALYSIS AND SPECIFIC ACTION TAKEN
Describe difficulties involved and relationship of the various components to the accident. Describe specific action token. For Fire Data describe the fire and/or chemical explosion.
Cover in detail any noted deficiencies, malfunctions of fire detecting and extinguishing equipment, or questionable procedures. When discussing specific equipment, give the name of
manufacturer, part numbers, etc., and state whether or not a UR has been submitted. Include any additional information or opinion of possible value to future technical analysis of this report.
SEE IIIDIVIDUAL GROUP REPORTS IN TAB 'TIP OF THIS REPORT.
t
II
li
SECRET
FOR OFFICIAL USE ONLY
(Special Handling Required. See AFR 1274)
Approved For Release 2001/08/29: CIA-RDP71600590R000100010001-4
Approved For Release 2001/08/29 : CIA-RDP71600590R000100010001-4
'`ome "sal
USAF ACCIDENT INCIDENT INDEX B
TAB
A ? AF FORM 711 ? USAF Accident/Incident Report
? AF FORM 711a ? Ground Accident Report (Not applicable for Acft Accidents)
C ? AF FORM 711b ? Aircraft Accident/Incident Report
? AF FORM 711c ? Aircraft Maintenance Materiel Report
E ? AF FORM 711d ? Missile Accident/Incident Report
F ? AF FORM 711e ? Explosives Accident/Incident Report
G ? AF FORM 711f ? Nuclear Accident/Incident Report
H ? AF FORM 711g ? Life Sciences Report of an Individual
I ? Unsatisfactory Report
J ? Teardown Deficiency Report
K ? List of Technical Orders Not Complied With
L ? AFTO Forms 781 Series
M ? AF FORM 5
N ? Statements
0 ? Rebuttals
P ? Orders Appointing Inves Board
Q ? Board Proceedings
R ? DD FORM 175 or DD FORM 1080
S ? DD FORM 365 (Wgt-Balance)
T ? Private Property Damage
U ? Damage to Aircraft
V ? Communication ? Transcripts
W ? Additional Data
X ? Other Forms
Y ? Diagram
Z ? Photos
Approved For Release 2001/08/29 : CIA-RDP71600590R000100010001-4
25X1A Approved For Ree 2001/08/29 : CIA-RDP71B00590R0W00010001-425mA
LIFE SCIENCES REPORT OF AN INDIVIDUAL INVOLVED IN AN AP ACCIDENT/INCIDENT
SliC.:TON A. Am:Cr:AFT ACC:IX:NT/INCIDENT
GEN2RAL
CIVILIAN
b. Assigned Base and Command
c. Aircraft Type, Model, Series (as
applicable)
A-12 (#125)
1 d. Primary AFSC
. , ...-
e. Duty Assignment
Test Pilot
f. Current Rating
Comm. Pilot
g. Age
33
h. Height i, Weight j. Years of Educ.
67 161 14 years
k. Activity at time of Accident/Incident
PILOT
2
/ MEDICAL DATA
a. Degree of Injury:
None ._____Minor _Major _Fatal Missing
b. Days Hospitalized
0
c. Days in Quarters
0
d. Total Days to be Lost
N/A
____X _
, e. Waiver
Yes, No____X Specify
f. If Fatal: Was Autopsy
Form Submitted to AFIP? YesNa See Autopsy Report
W e il ; e gni% ki S ults rn:.'1(Pe7
.
to AFIP? Yes X No Frozen X FixeciNr A6725-6
I
g. Diagnosis: Describe Fatalities, Injuries and Causes (Use Basic Diagnostic Nomenclature,
Multiple fractures, contusions and lacerations
L altitude without benefit of deployed parachute.
'0
AFR 160-13). Specify Primary Injury in non-fatal or primary cause of death in fatal.
sustained in free fall from high
3 PHYSIOLOGICAL INCIDENT (Complete
Items 1, 2, 3, 4, 5, 6, 7, and 10 as applicable)
a.: Type Mission Training
b. Duration of Flight 4+03
c. Single Ship _ Formation
d. Ind. Alt at time of i nl, Pprox 73,000M5:.!
Cabin Alt at time of inc.26M
f. Time at Alt. 4+03 hrs. Aircraft Pressurization
ground checked on 5 Jan 67. Refer to Pilotls Suit e,..: I
a. Did you use On Preflight?
Check i'es. Eci No
h. Regulator SettingVIA ..D Last Check on 5 3-...,,,,
I.
-full ressure Suil;
Type Regulator Used I
67
t:8m iystem Pressure at takeoffil ircraft 02 System
at time of incdt Normal Chec70pc. cords I
. ?
1,,,st Check of On System
,,,, ' 5 Jen 67
k. Type of Mask ..:N /A_ Adequate Fit: Yes
Checked within 15 days 30 days Over
No
30
I. Time Lapse between incident and examination Abbrof 72eT.s
elepsed.timebetwecn accton an ,uto-,,
l:fitly be ow reezinl
pay Rm ienttemp sip
m. Specify Tests (Specify Type and Re.J.t-A-Tiv --, rITTE
ILL; i.ILINe, SUthD TO AFIP
CO Blood Sugar
FROM USAF HOSPITAL NELL'S
High CO,
n. Attach a diagram of the flight profile involved, use additional sheet(sCin FLIGHT
ROUTE AND PROFILE IN ACCIDENT REPORT (TAB Y
4 PSYCHOPHYSIOLOGICAL
Check only factors present. Explain the basis for your determination
FACTORS
in Item 10. Cite all clinical and lab evidence
FACTOR.FACTOR
Not
Sg
CONTRIBUTED TO ACCIDENT
Not
Sig
CONTRIBUTED TO ACCIDENT
Definite
Probable
Possible
Definite
Probable
Possible
Aging
X
Freoccupation/ Channelized
Attention
X
Alcohol
X
Other
X
Air Sickness
X
fatigue (Auto-Pilot mop)
X
Auditory Interference
X
0-Forces
X
Body Build
X
Hyperventilation
X
Boredom
X
Hypoxia
X
Cardiovascular
X
Illness
X
Discipline
X
Language Barrier
X
Distraction
X
Missed Meals
7r
I.
Drugs and/or Self-Medication
V
.a..
Motivation/Morale
X
Dysbarism (Specify)
X
Spatial Disorientation
X
Emotional Disturbances
X
Task Over-saturation
X
Anxiety
X
Unconsciousness
X
Fear
X
Vertigo
X
Get-Horr.eitis
X
Visual Restriction
X
Irratic.r:ol Behavior
X
Other Related Factors (Explain)
X
Over Confidence
X
No Factors Present
Panic
X
5 ENVIRONMENTAL FACTORS (Check on y factors present. Explain the basis for your determination in Item 10 Cite all clinical and lab evidence)
FACTOR
Not
Sig
CONTRIBUTED TO ACCIDENT
FACTOR
Not
Sig
CONTRIBUTED TO ACCIDENT
Definite
Probable
Possible
Definite
Probable
Possible
Air Pressure, i.e. Rapid
Decompression, Pressure Loss,
Etc., Specify
X
Smoke, fumes
X
Cold
X
Vibration
X
Deceleration Forces
X
Weather
X
Heat
X
Windblast
X
Light Intensity
X
Other Related Factors, Specify
X
Noise
X
No Factors Present
6 TRAINING RELATED TO THIS ACCIDENT/INCIDENT (Give Dates Accomplished)
a. Ejection Seat Training: Seat Simulator 1953 Ejection Seat Tower 1953 Previous Ejection Dec 1958 - F-101HOURS
Total Flying Time 3356:00
Lectures/Demonstrations Other (Explain)
This model 375:00
b. Survival Training: Yearly Review with Field Trips
USAF School: Ground X Water....._ Arctic X Jungle X Lectures/Demonstrations AUK
?
c. Parachute TroininaL
IT 0 0Para -Sail Over Wnter, PLF Training
Jump School: Nr Previous Jumps Lec ures/Demonstrations Other
ci. Physi:dogical Training
Mar 64 Noce Arca 51
e. Last Chamber Flight
D.,17 Nov 66 Place Area 51 ?
f. Type Flight I
Full Press Suit 1
.,.,. AFSC or Other Training
h. Name of Course or OJT
i. Dates Attended
j. Aptitude Scores Applicable
.j.::.'dxil Pilot Trng
Basic Pilot Trnp-
153
Unknown
???
01 -0 11 ii
a z-iii; G ,; ! le,':,i 0 '411
eel ses ,
(Special
Handling Required, See
APR 127-4)
A?. FORM
vvrvh-it rrtinnt.1 tir. T11111 l*C111-1 1. c:11,-.(1.1r--rt.
Approved For ReNialie 2001/08/29 : CIA-RDP71B00590R0841100010001-4
PERSONAL, PROTECTIVE AND SU.IVIVAL EQUIPMENT
Specify o'l applicable items of equipment on appropriate line and specifically indicate all types of clothing worn and
any other equipment that inRuenced operation.
NOT
AVAILABLE
AVAILABLE
Not
Used
Used
ITEM
EXAMPLE
TYPE
Functioned
Failed
Heed Protection
P-4B, HGU-2/P, HGU-6/P
X
Eye Protection
Visor, Glasses
X
Ear Protection
Ear Plugs, Muff
X
Oxygen Mask
MBU-5/P MBU-3/P
Full Pressure Suit
X
1 Clothing Worn
K-2B, A/P-225-2 S
_.Nr. GN -S970 -10/5
-3
Cio,hing, Survival
Sleeping Bag, Down-Filled Suit
X
Gloves
3-3A, MG-1
X
Footgear
Alert Boots, Combat Boots
Body Restraints
Seat Belt, Shoulder Harness Seat
Belt Fired but
Failed to
Open
0 Life Vest
LPU-2/P
Incorporated into
Suit
X
Life Raft
PK-2,E-2B inporporated
into Scat
Kit
X
Survival Kit, Container
Global, MD-1
Special Type
X
Communications
URC-211SARAH, Automatic
Pecked in Pare chute
X
Other Signaling Devices
Flares, Mirrors, Whistle
X
Rations
Food/Water, Provided/Forged
X
Survival Equipment
Rifle, Fishing Gear
X
Seat
Fwd/itiiii Facing, aia-jiaCti. Parachute
Jammed Under
Seat Heedrest
,
Other Equipment
flashlight, etc (Specify) 211X. Sur
Kit Stored in Ri
nt Ler Pocket
X
8 ESCAPE
a. General: (Check or fill in
as appropriate)
Water
Mtns --X--.fce/Snow_Z_
-Deep-Rough,
Hilly --.- Desert
Swamp- Other (Exp)
Ejection IGround
.- Landing Surface:
Bailout
Ri Flat-
Calm, Shallow
-L-Wooded-
Shallow-Deep-Unknown
b. Surface Winds, Knots 3Q-_:24,a......._ (estimate if unk) Dragged: Yes No 5g Difficulty releasing Chute Canopy: Yes No N/A
c. Reason for Jump (if more than one indicate):
Fuel Exhaustion X Eire Engine Failure_Mid-Air Collision
Loss of Control
(Exp)
_Other
d. Attitude of Aircraft: Slight at Separatoz.fu4o.p,i0n9d.anC
.
Level Inverted Diva -_, Bank Spin Spiral Climb (A;glailatic Lep uelt firea out Jalier
he
-;,o Re
_...\- _ - _
L
e. Altitude above Surface2214-3212: IAVLpprox 3 50if not known, approx.) Seat Catapult, Ballistic Rocket X
f. Difficulties Initiating Escape iN one - Canopy and Seat il,ject Normal.
Centrifugal Force-Canopy/Hatch Failure-Injury-Actuating Controls (Specify)
Automatic
Other
(Exp)
Lap Belt fired but Failed
to Re le cc
g. Difficulties During and After
Clothing/Equipment Interference
Held onto Seat Actuating
Escape:
, Pilot Unable to 1:anually
A Seat entangled in Shroud Lines
Open
legs/Arms entangled
Lap Belt
in Shroud Lines Automatic
Lap
Headrest
Belt Malfundion X
Controls _Did not Separate
X NoDiff.___otherPrOParachute
Jammed Under
h. Seat Separation Device Installed;
Foiled: Webbing
Yes X No
Functioned
JOITIN
,ed Fare
Properly, Yes .X. No
Initiator Other (Exp)
chute Under Seat Headrest
I. Type Parachute: Seat Back
Parachute equipped with Zero Delay
Lanyard:
Yes No -X
Connected to 0-ring:
NA
Yes_ No _
Automatic Lanyard Connected; And Pulled
when Pilot Separated from
S Yes ).__;..._ No _59 e.t on ConAact wit
Canopy release: Single Double
Canopy; 28'_ 30'
N
35 I X
-
NOTE: A narrative statement will be prepared by each ejectee
the event of a fatality, the statement will be prepae.d
and/or survivor to include all information
by the Flight Surgeon. see HASSUKI'M
pertinent to escape and
SEOUENCE
survival. The statement will be attached to this form. In
OF EVENTS" (attached)
9 RESCUE AND/OR SURVIVAL
a. Survival involved (Survival implies any water landing and anytime over 1 hour before rescue on land) Yes- No --X.
b. Distance nearest Rescue (military base) 6 7 NM
Timeody Found ,,
before Ames L. 0 Hrs
Transmitted distress signal:
Transmitted position fix:
'
Yes
.Lo uas
Yes........XNo
No
e Mods of Exposure; Frostbite Immersion Sea Sickness
Insect Bites Sunburn Dehydration
Other (Explain) Fatal Injuries
d. Primary kclor In MO: Radio/Beacon
.1is O
Sea Marker.E byeCVO ry Position
Flores Mirror Flashlight
(Specify)
Fix X Chaff Local Population Other (Specify) V1 SUP 1 Si .:frbting. of 'Jive. eke ?(,' Fi r
e. TypeliWUrNone Required
Boa(' r overFilf Rescue
Ground Party, Military
Local
Population Helicopter/other
Aircraft
?
(Specify)
(Walked Out) Other (Specify) liad.y_ant
t.P CI hr C_47 I`
ft Observer.
10 MEDICAL OFFICER'S RATIONALE, COMMENTS
This section is to include comment
causation. Injuries should be correlated
through 9 should be commented upon.
See attached Flight
? 25X1A
an medical, personal, social, family, industrial hygiene and allied factors in incident causation, and a description and analysis of the factors in injury
with the operations of personal equipment, malfunctions and failures of structures, systems, etc. Pertinent contributing factors in Items 3
Include X.ray and laboratory findings. Pertinent recommendations are encouraged.
Surgeon's Comments.
USE ONLY
SECRET FOR OFFICIALI3andIIrs I:IrAd pp AFP 12741
Date
' 7 Jan 67
*711.4
PAGE 2
Approved For Release 2001/08/29: CIA-RDP71600590R000100010001-4
ftsio
?tiord
USAF ACCIDENT INCIDENT INDEX ,
TAB
A ? AF FORM 711 ? USAF Accident/Incident Report
B ? AF FORM 711a ? Ground Accident Report (Not applicable for Acft Accidents)
C ? AF FORM 711b ? Aircraft Accident/Incident Report
0 ? AF FORM 711c ? Aircraft Maintenance Materiel Report
E ? AF FORM 711d ? Missile Accident/Incident Report
F ? AF FORM 711e ? Explosives Accident/Incident Report
G ? AF FORM 711f ? Nuclear Accident/Incident Report
H ? AF FORM 711g ? Life Sciences Report of an Individual
I ? Unsatisfactory Report
J ? Teardown Deficiency Report
K ? List of Technical Orders Not Complied With
L ? AFTO Forms 781 Series
M ? AF FORM 5
N ? Statements
0 ? Rebuttals
P ? Orders Appointing lnves Board
Q ? Board Proceedings
R ?.DD FORM 175 or DD FORM 1080
S ? DD FORM 365 (Wgt-Balance)
T ? Private Property Damage
U ? Damage to Aircraft
V ? Communication ? Transcripts
W ? Additional Data
X ? Other Forms
Y ? Diagram
Z ? Photos
Approved For Release 2001/08/29 : CIA-RDP71600590R000100010001-4
Approved For %Rase 2001/08/29: CIA-RDP711300590Raftb100010001-4
A-12 SERVICE BULLETIN/S.A.M. STATUS
Bulletin
Number Title
285 OUTBD ELEVON DOWN SPRING
890 LOWER FILLETS
974 REDUCED TVL PITCH TRIM ACT
976 AFT BYPASS DOOR WIRESHIELD
987A SPIKE ACTUATOR SWITCH
987D FLEX LINES
987F TERMINAL STRIPS
1006 IFR INTERPHONE
1025 NOSE TRANSPONDER INSTALL
1035 ALTITUDE RECORDING MOD
1041-4 SAS HARNESS REPL
1052 HYD SWIVEL PLUMBING
1061 RELOCATE FUEL SHUT-OFF VALVES
SAM 115 COMP INLET PRESS IND WIRE
SAM 150 DIODE SUPPORT COVER
SAM 153 ALTERNATOR CHANGE
SAM 162 SEALING Q-BAY HELIUM LEAKS
SAM 165 SLIP INDICATOR
SAM 167 ACCESS HOLE - STUB FIN
SAM 171 ATTACHMENTS GEAR BOX ACCESS DOOR
SECRET
Date
30 Mar 66
7 Mar 66
18 Jan 66
16 Aug 65
31 May 66
31 May 66
31 May 66
24 Jun 66
24 Mar 66
19 Apr 66
24 May 66
19 Aug 66
13 Sep 66
8 Mar 66
16 Aug
66
21 Sep
66
2 Nov
66
8 Nov
66
15 Nov
66
14 Dec 66
FOR OFFICIAL USE ONLY
ecial Handling Required. See AFR 127-4)
Approved For Release 2001/08/29: CIA-RDP71600590R000100010001-4
Approved For Release 2001/08/29 : CIA-RDP711EW0R000100010001-4
A
USAF ACCIDENT INCIDENT INDEX ,
TAB
A ? AF FORM 711 ? USAF Accident/Incident Report
? AF FORM 711a ? Ground Accident Report (Not applicable for Acft Accidents)
C ? AF FORM 711b ? Aircraft Accident/Incident Report
0 ? AF FORM 711c ? Aircraft Maintenance Materiel Report
E ? AF FORM 711d ? Missile Accident/Incident Report
F ? AF FORM 711e ? Explosives Accident/Incident Report
G ? AF FORM 711f ? Nuclear Accident/Incident Report
H ? AF FORM 711g ? Life Sciences Report of an Individual
I ? Unsatisfactory Report
J ? Teardown Deficiency Report
K ? List of Technical Orders Not Complied With
L ? AFTO Forms 781 Series
M ? AF FORM 5
N ? Statements
0 ? Rebuttals
P ? Orders Appointing lnves Board
Q ? Board Proceedings
R ? DD FORM 175 or DD FORM 1080
S ? DD FORM 365 (Wgt-Balance)
T ? Private Property Damage
U ? Damage to Aircraft
V ? Communication ? Transcripts
W ? Additional Data
X ? Other Forms
Y ? Diagram
? Photos
Approved For Release 2001/08/29 : CIA-RDP71600590R000100010001-4
J
_ J-.1....314LLIEBEEMEA3333 ono. ?
Pll OT INDIVIDUAL-HT RECORD
3E 3?111113?Enomm ? ?
7. BASE .
D
2. WING. GROUP, AND SOUADRAPPROVeC IITY17-1"---
e ease 0C31/08129cfrIA-RDP71EMONetod
OCT-N7-T--LiC 6.-..,
70
13.
first middle
INSTRUMENT CERTIFICATE
25X1A
8. SERVICE NUMBER
'CATION
8. BIRTH (Day, weft* year)
29 DOC 33
9. DUTY AFSC
14. GRADE AND COMPONENT
WHITE
rI
I ;REM' t
----i
NONE
O. ORIGINAL TIN6 AND DATE
H. PRESENT RATING AND DATE
12. n; ^r PH Y SI 0 L OG I C A L TRAINING f ERTIF-
IC, i. r ., P I R E S
1 Mar i.)?
DATE OF EXPIRATION
AF I 29 Dec Y/
SECTION 1
DATE
Tirria 5
ttiebtti-
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,i
MISSION
SYMBOL
LAND.
IN GS
INSTRUCTOR
PILOT TIME
CLASSIFICATION OF INSTRUCTOR AND FIRST PI LOT
COMMAND
PILOT
TIME
L
CLASSIFICATION OF COMMAND AND/OR CO-PILOT
FIRST
DAY
NIGHT
HOOD
K
CO.P1 LOT
TIME
M
DAY
RIGHT
PILOT TIME
F
VFR
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WEATHER
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WEATHER
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