WPR15FA125

The pilot’s initiation of an early rotation during takeoff, which led to an aerodynamic stall and loss of airplane control. Contributing to the accident were the pilot's use of noseup pitch trim and the operator's policy to use nose-up pitch trim during takeoff and the lack of oversight of the operator by the US Air Force. Contributing to the severity of the accident were US Marine Corps airport policies that allowed construction activities immediately adjacent to an active runway, which resulted in the airplane's collision with a truck.

The swept-wing advanced trainer/light attack airplane was privately owned and contracted to provide support to the US Air Force (USAF) under public aircraft provisions. It was equipped with wing-mounted external fuel tanks and bomb rack/dispensers loaded with practice ordinance. During takeoff, the airline transport pilot was unable to maintain airplane control following rotation. The airplane did not climb, departed the left side of the runway, and struck a pickup truck, which was involved in construction activities and parked about 150 ft from the runway edge. The occupant of the truck was killed, the pilot and his passenger (who was flying as a "ride along") were not injured, and the airplane sustained substantial damage. The entire accident sequence was captured by an onboard video camera, which was positioned inside the canopy at the rear of the cockpit. The camera recorded some engine instruments, the primary flight instruments, the back of the pilot's head, and the runway and horizon. Analysis of the recording revealed that the pilot initiated rotation about 8 knots before reaching the correct indicated airspeed and that the airplane lifted off the ground about 10 knots early, about the same time as it reached its target pitch attitude. The video image, which up until this point had been smooth, then began to shudder in a manner consistent with the airplane experiencing the buffet of an aerodynamic stall. The airplane immediately rolled aggressively left, and the main landing gear struck the ground hard. The airplane then pitched up aggressively and began a series of roll-and-pitch oscillations, bouncing from left to right with the outboard bomb dispensers and landing gear alternately striking the ground as the pilot attempted to establish control. The airplane passed beyond the runway edge and reached its target takeoff speed just before striking the truck, but by this time, it had departed controlled flight, was in a steep right bank at almost twice its target pitch attitude, indicating that it had likely aerodynamically stalled. The pilot reported that he felt the airplane's nose become light as the airplane approached rotation speed, and the video revealed that the nose was oscillating lightly up and down a few seconds before rotation, consistent with his statement. The pilot stated that, before takeoff, he set the pitch trim to 3 degrees nose up, which was consistent with the operator's policy for takeoff with external stores. The policy was in place to relieve stick pressure on rotation; however, the airplane's flight manual specified that 0 degrees pitch trim should be used for takeoff in all configurations. During the postaccident examination, the airplane's pitch trim was found at almost full nose up for reasons that could not be determined. It is likely that the pilot initiated an early rotation instinctively as the airplane's nose became light due to the excessive nose-up pitch trim. The operator stated that the company policy for nose-up trim on takeoff was intended to give the airplane control stick pressures on rotation comparable to other U.S. fighter aircraft, such as the FA-18 and F-16. Although the operator had used this technique without incident on many prior missions, it was in direct contrast with the manufacturer's takeoff recommendations and likely increased the risk of early rotation. Postaccident examination of the airframe and flight control systems did not reveal any anomalies that would have precluded normal operation. The primary engine components were undamaged, and the video revealed that the engine appeared to operate uninterrupted and at high power levels throughout the accident sequence. The external fuel tanks were partially filled with fuel, which was allowed per the airplane's flight manual, (assuming the airplane was flown at the correct airspeeds). The bomb dispensers were not on the airplane manufacturer's list of approved weapons; therefore, the operator had commissioned an Federal Aviation Administration (FAA)-designated engineering representative to prepare a structural comparison report to assess the viability of installing the alternate dispensers. Although the report concluded that the use of the alternate dispensers was structurally satisfactory, it did not take into account the aerodynamic effects of using the alternate dispensers. It is possible that the airplane's stall margin was eroded further by the use of the alternate dispensers, along with a shift in the center of gravity due to the partially filled fuel tanks. The majority of the airport was operated and governed by the Department of Defense (DoD), specifically the US Marine Corps (USMC). It was operated as a "shared use" airport concurrently supporting both military and civilian operations, although the accident runway was used almost exclusively for military flights. A USMC construction crew was preparing the area immediately adjacent to the runway for the installation of an arresting gear system. The operation was composed of about 20 people, along with support vehicles and construction equipment, and the group occupied the space from the runway edge outward about 150 ft. The truck that was struck was located on the outer edge of the space, farthest from the runway, and was occupied by a Marine Lance Corporal who was providing operational escort and safety support for the construction crew. USMC airport-specific station orders did not prohibit construction activities in this area, and no notice to airmen relating to construction was issued at the time of the accident nor was one required. If the airport had been under operating under Part 139 regulations and full FAA oversight, no such construction activities would have been permitted while the runway was active, and the ground fatality would have been avoided. About 21 months before the accident, the DoD issued a directive that all aircraft owned, leased, operated, used, designed, or modified by DoD must have undergone an airworthiness assessment in accordance with the applicable military department policy and that management authorities within the military departments should be established to provide ongoing oversight. The directive allowed the use of DoD or FAA airworthiness certification standards. Under the auspices of this directive, the operator had undergone a series of oversight inspections from the Naval Air Systems Command and interim flight clearance was granted to perform missions for the USMC. Although the accident flight departed from a USMC base, it was operating in support of the USAF, and the USAF chose to place the responsibility of certification and ongoing oversight with the FAA. However, because the airplane's missions were flown under the umbrella of "public aircraft," the FAA was not providing, nor was it required to provide, any oversight beyond issuance of the airplane's initial airworthiness certificate. As such, the operator was effectively operating without oversight at the time of the accident. This lack of oversight likely enabled the continued operating philosophy, which resulted in the difference in takeoff procedure between the operator and the manufacturer and the use of inadequately evaluated weapons system components.

Previous Accident On October 18, 2014, an Air USA Hawk, N509XX, was involved in an accident after it departed the runway during the ground roll, just prior to takeoff (NTSB accident number CEN15TA019). The pilot reported that having reached about 90 knots, the airplane turned hard left, and he was unable to regain directional control. Subsequent examination did not reveal any mechanical anomalies to account for the turn, and the NTSB issued the probable cause, "Loss of directional control during the takeoff roll for reasons that could not be determined during postaccident examinations and testing." DoD Airworthiness Policy Air USA was established in 1994, and during the period from 1999 through 2010, operated exclusively as a DoD military contractor, specifically for the Navy, in "threat presentation" missions. In the summer of 2010 Air USA took part in a "fly-off" competition supporting live close air support training for the USMC JTAC's. Following the competition, they were awarded a contract with the USMC, and for the first time the USAF Special Operations Command (AFSOC). The close air support missions involved delivery of practice munitions during day and night operations, as part of JTAC training support. Air USA's fleet consisted primarily of Alpha Jets, with according to Air USA, oversight provided by the FAA until May 2013, when the DoD issued Directive 5030.61 (subsequently updated in June 2015) to the U.S. military service branches. The directive established policy and assigned responsibilities for DoD airworthiness, specifically: "All aircraft and air systems owned, leased, operated, used, designed, or modified by DoD must have completed an airworthiness assessment in accordance with Military Department policy. The airworthiness assessment provides DoD personnel (to include Service members and DoD civilians) and DoD contractors the appropriate level of safety of flight and risk management adapted to DoD-unique mission requirements. DoD airworthiness authorities, within their respective airworthiness guidance, will provide commanders the ability to conduct missions while employing prudent risk mitigation measures in cases where a timely airworthiness assessment is not feasible." The directive required the military departments to designate within their organizations both technical and airworthiness management authorities for initial airworthiness approval, along with continued airworthiness. The directive allowed the military departments the option of adopting DoD or FAA airworthiness certification standards. With regard to FAA standards, the directive current at the time of the accident specifically stated: "Utilization of FAA airworthiness certification by a DoD airworthiness authority as a basis of certification is permissible provided the flight profile, operating environment, and continued airworthiness program as certified for that aircraft and the air system is similar to the intended usage of DoD. The DoD airworthiness authority will assess and certify the airworthiness of any existing gaps between the intended usage of the FAA certification and the intended usage of DoD. Where required, interface with the FAA for aircraft and air systems certification issues will be coordinated through the FAA Military Certification Office. Interface with the FAA regarding DoD operations will be coordinated as described in DoDI 4540.01 and DoD Directive 5030.19." Following the directive, the U.S. Naval Air Systems Command (NAVAIR) chose to adopt DoD airworthiness certification standards. As such, contractors were required to demonstrate a series of more stringent standards including the utilization of a NAVAIR approved aircraft inspection program (FAA approved inspection programs and clearances were unacceptable, including the DER approval for the SUU-20 bomb dispenser), engineering "reach back" support for airframe and engine components, and original equipment manufacturer support (or parts supplied from a source with NAVAIR approved engineering substantiation data). NAVAIR allowed a grace period of continued operations with the Alpha Jets based on the past history of the aircraft and Air USA, but advised that the Alpha Jets must be replaced, or flight operations must cease beyond the grace period unless OEM parts support was achieved. The Hawk was still being manufactured by BAe, and therefore, Air USA presumed that OEM support would be available, allowing them to more readily meet the NAVAIR requirements. The Hawk fleet was then purchased, and after undergoing a series of inspections by NAVAIR, Air USA was granted a series of interim flight clearances for the Hawk from NAVAIR valid through January 31, 2016, with the understanding that beyond that period OEM support had to be achieved, along with reach back support. In October 2014, Air USA submitted a formal proposal requesting OEM support from BAe; however, according to Air USA, no formal response was received. BAe reported that they initially received a request for support from Air USA on September 2, 2014, and replied stating that they did not support the continued operation of the Hawk by Air USA, but would be willing to attend a meeting with Air USA to discuss the matter further. The October request from Air USA was then received, but BAe did not respond in part because the first Air USA Hawk accident had just occurred and BAe wanted to understand its circumstances before providing a reply. BAe provided technical assistance to the NTSB during that accident investigation, and at the time of publication of this report, their decision to not provide support to Air USA remained in effect. At the time of the accident maintenance was being performed utilizing OEM replacement components, which were acquired from the ROKAF during the initial sale of the airplanes. According to Air USA, the USAF opted to utilize FAA certification standards for continued airworthiness, and operations for the USAF continued largely unchanged. The contract in place with the USAF at the time of the accident included a core requirement stating that the USAF or its designated representatives may perform an annual inspection of aircraft operations, flight crew certification/currency and qualifications and aircraft maintenance procedures, and that this inspection can commence within 6 months after award of contract. The accident occurred about 5 months after the contract was awarded, and therefore, no inspection had occurred. Air USA stated that they had never undergone any type of inspection from the USAF since being awarded their first contract in 2010, with the exception of an ordinance inspection in 2011. Unlike NAVAIR, the USAF contract allowed for the use of alternate bomb dispensers, as long as approval had been granted by a DER. Air USA voluntarily ceased Hawk operations immediately following the accident, instead supporting the current USAF contract with their fleet of L-39 airplanes. Following completion of the initial phase of the investigation, Air USA restarted Hawk operations on April 20, as part of a live CAS support mission for the USAF. The USAF continued to utilize Air USA for close air support missions until the contract expired in September 2015. NAVAIR immediately withdrew Air USA's flight clearance following the accident, a decision which remained in effect at the time of this report's publication. On November 9, 2015, the USAF issued a memorandum directing that all Major Commands immediately cease conducting live contracted close air support (CCAS) missions. The memorandum stated that the prohibition would stay in effect pending a review of contract, airworthiness, and aircrew training related to the missions, and that the goal was to ensure that the relevant contracts adequately protected public interests. This prohibition remained in effect at the time of this reports publication. FAA Oversight Responsibilities Air USA's headquarters were ba