The Ministry of Defence and the Defence Safety Authority have released the findings of the Service Inquiry into the loss of the F-35B Lightning ZM152 (BK-18) of 617 Squadron.

The aircraft, which was stationed on the HMS QUEEN ELIZABETH, crashed into the Mediterranean around 11:00 hrs local time on 17th November 2021.

The final report provides insights into the reasons behind the tragic incident and offers recommendations to enhance defence safety. Thankfully, the pilot was able to eject in time and was safely returned to the HMS Queen Elizabeth.

Key Findings from the Inquiry:

  1. Causal Factor: The leading cause for the accident, as determined by the panel, was the positioning of the left intake blank at the engine compressor’s front face during the aircraft’s launch.
  2. Contributory Factors: The inquiry has identified multiple contributing factors, including:
    • The absence of security discussions in crucial engineering planning meetings.
    • Peripheral tasks distracting the engineers, hindering effective management of Red Gear.
    • A lack of detailed handover procedures, leading to missed removal steps.
    • Inadequate lighting during servicing which restricted visibility.
    • An inherent perception within the Lightning program that Red Gear posed no significant threat to the aircraft’s airworthiness.
    • A lack of awareness and procedures regarding specific parts like the pip pin.
    • Windy conditions dislodging intake blanks.
    • Fatigue among the limited workforce, potentially leading to errors.

The carrier was on its way back to the UK after a seven-month maiden voyage to the Far East when the incident took place.

The complete findings, spanning 148 pages, are available on the Ministry of Defence’s official website for those who wish to explore the report in detail.

You can read the report here.

George Allison
George Allison
George has a degree in Cyber Security from Glasgow Caledonian University and has a keen interest in naval and cyber security matters and has appeared on national radio and television to discuss current events. George is on Twitter at @geoallison
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154 COMMENTS

  1. Aircraft carrier flight decks are dangerous and demanding work environments. Mistakes happen. It isn’t the first loss and probably won’t be the last. The Americans have been operating large deck carriers for decades and incidents and aircraft losses still happen. We want large carrier’s with more aircraft, we have to accept the risks increase. Lessons will have been learnt, and we carry on. Its what we do. 👍🇬🇧

    • Lighting 2, one lost at sea.

      English Electric Lightning, over 30 ‘submarined’, with enough crashed into the med of RAF Akrotiri alone to make an artificial island!

      It’s no competition as far as I’m concerned, Lighting 2 has to go some to catch up…..

    • Hmmmme

      In the slightly nutty culture we have in the UK where there is no such thing as an accident……I think you and I accept there are risks and rewards……I’m not sure that the cost and stifling effect of a zero incident though process has fully sunk in.

      • The problem we have today. And it’s a very good problem to have. We are not used to aircraft crashing, because it’s such a very rare event these day’s. Yes, we have fewer aircraft in service, but the flight safety record today is second to none.

        • I fully agree we don’t want any crashes or incidents: however rare.

          In a sense thought, the problem with not having incidents, or their being infrequent, is that there is an air of unreality when discussing them…..because they never happen…..

          I do recall Tonkas and Harriers being periodically lost: that wasn’t a good look either. Standards and aircraft reliability have moved on.

          • They sure have. The RAF lost 3/4 Tornados during the build up to the Gulf war during training back In the UK before they even deployed to the Gulf. I don’t think the RAF have lost a single Typhoon in what you would call training incidents. And it’s been a very long time since we lost any aircrew. Think it was 2009 when a Tornado F3 crashed in the Highlands was the last loss of fast jets crews.

      • because aviation has the culture- and properly so- of finding all the contributing causes.
        In this case primary cause was the intake protection cover left in
        Just saying its an ‘accident’ is the nutty approach.

  2. Windy conditions, who would of thought? Fatigue among the workforce, let’s hope they can stay awake in a real war. Pathetic inquiry, pathetic excuses, pathetic failings, but wholly typical of the UK military.

  3. Perfect example of a human factors chain of events leading to a serious incident. This will be taught in air safety classrooms for decades to come.

  4. It maybe that the lean crew needs a small increase in some areas on long deployments. Hopefully the lessons learned can be put into practice.
    Sounds like more lights needed, aircraft check around by pilot or someone just before takeoff etc.

    • “aircraft check around by pilot or someone just before takeoff etc.”

      I though that was a standard practice anyway by pilots.

        • Pilot walkaround was done and found a separate issue

          “1.3.72. Each pilot’s walkaround31 included an inspection of both engine intakes, the exhaust, and a general visual inspection of the aircraft. Due to the noise on the flight deck, the pilots wore their helmets throughout the walkaround. BK-18’s pilot noticed the undercarriage pins were still installed, removed them and handed them to the see-off team. “

          There was a major issue with the ‘red blanks’ not stored properly or accounted for after servicing.
          Its like engineering tools ( or doctors/nurses operating room equipment) proper accounting of all the equipment used on plane etc is made when servicing is complete. A single tool or even bolt left inside a plane does have consequences

          • This matter is not easy. I think the task of runing an aircraft carrier is daunting.
            We heard that acquiring competencies again was no joke fur UK. Good luck for your crew’s!
            Looking foward to see your 2 carriers at sea with French CDG and Spanish or Italian carriers. It would start to look powerfull! And create peace where needed.

          • Agree our NATO allies combined do bring some capable assets to bear. European NATO alone could likely defeat the Ruskfascist navy.

          • Why didn’t the pilot notice he had an engine compressor cover still fitted on his walkaround?

          • That was what I thought straight away, even with my limited carrier ops knowledge? Surely all pilots have an SOP of a visible walkaround?

  5. I think the fact the carrier was worked so hard to show it off must have contributed. It was almost worked on a war footing to generate the highest mission rates. When you do that you increase the chances of accidents. The RN must have known this and took the risk.

  6. One of my first trade bosses, when he was a young JT left the intake blanks in the port intakes of a Vulcan. Result 2 RR Olympus engines needs major strip down and rebuilds.
    It happens.

  7. Definitely worth reading the report. It shows that QNZL (or rather her people) was barely ready for CSG21 (Op FORTIS), still too many inexperienced personnel and immature procedures (including security and safety related). E.g. It was only in Oct 2020 (Ex STRIKE WARRIOR 02-20) that the carrier first practiced live weapon carriage on deck! Also, the required manning levels when on an operational deployment had been underestimated, not helped by Covid. By the time of accident key personnel staff had been working flat out for over a year and were both “fatigued” and had become a bit complacent as risky events were increasingly being just accepted. It’s not as though they got many decent runs ashore either! Reading between the lines, the whole show was very marginal and risky, but cancelling the CSG21 deployment would have been a huge political and PR disaster for the RN. Finally, the redacting seems excessive. E.g. all mentions of the embarked USN/USMC contingent and VFMA-211 have deleted – there is so much in the public domain (including news reports of the Queen meeting them in May ’21!) that it’s a bit ludicrous.

    • Covid had a massive effect on the deployment. That was clear from the TV documentary. Working at sea is always tiring and demanding. But I’m sure if a similar deployment took place this year, they would be much better prepared for it. That’s why we train so rigorously.

      • Agreed. The report gives examples of experienced personnel with or exposed to Covid having to be replaced by less experienced personnel. But it also gives an example of an aircraft maintenance activity expected to need just two people actually requiring five. That extra effort might be tolerable on a one-week exercise, but not on a seven-month deployment. I’ve suggested in the past that the promised ultra leaning manning of the QEC seemed unrealistic and got edited out. However I’m [sadly] being proven right as their complement keeps increasing from the 600 crew estimated by the ACA in September 2003 – much to the dismay of the RN. Finding an extra c.200 personal for just one carrier’s crew is effectively a T23 frigate laid up. And the number of air group personnel is growing as well – the F35B is far more maintenance heavy than LM promised 20 years ago.

        • Aircraft engineers arent really cross crewed with frigates normal crew
          But its a good point you make about the extra numbers now required

    • Long tradition of British carriers getting sent sea when they are “not ready” indeed almost every British carrier from Victorious to Invincible were sent out too early. COVID was a major factor but we can’t always allow events to dictate military preparation. We need the ability to go in a hurry some times. If we wait for every box to be ticked nothing will ever happen.

      We should be more willing to accept risk in such instances.

  8. Consequences of carrier aircraft hiatus in Royal Navy?

    • The absence of security discussions in crucial engineering planning meetings.
    • A lack of detailed handover procedures, leading to missed removal steps.
    • Inadequate lighting during servicing which restricted visibility.
    • An inherent perception within the Lightning program that Red Gear posed no significant threat to the aircraft’s airworthiness.
    • A lack of awareness and procedures regarding specific parts like the pip pin.

    If Harrier remained until F35 arrival would this accident happened?
    Because for me it seems an accident from a “green” team.

    • It’s a green team that managed to operate two squadrons of the latest generation aircraft on a 7 month cruise round the planet participating in numerous exercises.

      No one has done that in the Royal Navy since the 70’s.

      Better to learn from f**k up like this in peace time, only so much you can learn from manuals and experienced hands.

      • The Marines did not have had a mishap like this. They have went from Harrier to F35 directly, they did not stopped carrier operations for years like RN.

        Italians too went from Harrier to F-35 without hiatus, but those have much less aircraft than RN.

        • Unfortunately accidents can happen to anyone, thankfully the pilot survived and was okay afterwards. It is a shame that the CSG21 which was an important show of force for the RN had this incident but as Jim said better that it happens in peace time, if anything it was a good test of how to retrieve the jet before potential enemies could extract it, that in itself would be a crucial task during awar scenario.

  9. The limited workforce comment is concerning depending how limited, but the fact it was stated means it wasnt zero impact. We know these were designed to be operated with lower crewing but we also know a number of incidents with foreign navies have occured due to lack of crew, especially around lookouts etc. Is there a risk the RN has cut it too far to save money. Especially when combined with this being a training op and not a war situation where thing would be way more stretched.

  10. I worked on aircraft maintenance years ago. Technicians used shadow boards to make sure all tools were back in place before the plane was released. Is there a similar approach/board used for ‘red gear’ (assuming this is the term used for intake blanks, pitot ribbons, undercarriage pins etc)?

  11. So in plain english, someone left an intake cover over the engine intake and this choked the airflow so as to prevent a successful take-off. I find that reassuring because it suggests no actual design or build quality issues. Obvious solution would be to label and account for the blanks individually- much the same approach surgeons take to avoid leaving instruments in their patients.

    • More likely the intake blank went into the engine and caused as a minimum an engine surge/stall if not a mechanical failure of the engine – a fan failure. Hence loss of thrust.
      On small aircraft – its common for the intake blanks to be tied together – literally with a length of harness strop. When fitted the strop material hangs down under the aircraft. That way if you take 1 intake blank out, makes it just about impossible not to realise the 2nd intake blank is still fitted

  12. Very obviously the intake cover should have been removed before flight – but if the maintainers missed this flight safety critical task then should not the pilot also have indenfied the problem during his pre-flight inspection of the aircraft?

    That is a ‘thing’ is it not?

  13. Makes you wonder why the intake blanks aren’t tied together – literally. Its what we used to do on various RAF squadrons for smaller aircraft. That ways its virtually impossible to leave 1 blank fitted while the other is removed and NOT to realise.

    • Yo jj. Paint chaffing by whatever the connecting material may be. Surface medium is expensive to upkeep. I suppose items could be lashed to the deck bolt.
      👍 😊.

      • That makes very little sense. The aircraft paint doesn’t get chaffed, the connecting strop hangs below the aircraft, if that is what you are saying

        • Hi jj, yes, on an airfield wind speeds are nominal. On a carrier deck “muchos” variable direction /speed occurs, except streaming for flight. I seem to remember some edit about F35b paint and or corrosion. I do remember a sqdn grubber getting his balls handed to him for tethering intake Blanks together,by the sqdn Sup. Fltdecks are very very dangerous. Flight safety is Everyone’s concern. 👍😊🛫.

  14. Personnel fatigue is an interesting point. Could the QE classes lean manning have contributed or was the fatigue because of the duration of deployment?
    US carriers get away with this as they have +5000 crew for circa 60 aircraft. QE class has 1600 for circa 40 aircraft.

  15. If anyone would actually take the time to read the report which virtually no one here has. It is much more scathing than the superficial roundup here. Basically it amounts to even deploying the one small squadron at anything remotely close to real world intensity was a tremendous overreach.

      • Oh you two are so sad and easy to spot, your getting your arse kicked all about this site and the other sad US fanboy pops up and posts at exactly the same time, same threads with the same chuff. You need to get a grip and make more of an effort, both of your jealousy and seething anger at not being from the UK is now showing in every post.

    • Oh what a surprise, old Frosty troll is getting his knickers in a twist, getting gripped and getting everything wrong and how lucky, the other sad troll just happens to “turn up” on the same threads and gives a little sad backup!

  16. 617 squadron was not ready for prime time… The whole operation was rushed. They were not ready. It is in the report. Aviation week was not impressed.

        • Try to be a little impartial, and reduce your anti UK rhetoric to just an angry foaming session, then people may take note of your random posts.

          • it says so in the report

            The report also questions whether 617 Sqdn., the UK’s frontline F-35 unit, was fully ready for the deployment, noting that it “faced a higher operating tempo than it was prepared for, as the Carrier Strike Group aspired to a baseline flying rate associated with so-called surge operations.”

            Personnel had not received the necessary levels of training for operations at sea, the report finds, noting there were high levels of fatigue.

            Rates of flying, it says, resulted in decreased opportunities for fresh air and recreation for those personnel without routine access to outside spaces, contributing to fatigue. The report noted that some witnesses described the Queen Elizabeth carrier as “the largest submarine in the Navy.”

            Aviationweek.

          • Yes aviation week highlights that, and as most reports highlight, it needs to be learned from for future reference, however Esteban does not report that as a statement which can be learned from, he states it as an anti UK, anti UK military and general anti UK post and loves the opportunity to degenerate the UK, the EU and European NATO allies in general. Do make an effort at researching his history and try not to support troll behaviour. Thanks.

  17. I am surprised there is no monitoring of the engine air flow to alert the plane/pilot to a problem. The airflow must have been vastly reduced but the pilot was not aware there was a issue.

  19. Aircraft failures are quite commom, USMC losses on the Harrier are quite shocking.

    but failure by a entire crew and the pilot to miss a big red thing, hope we dont go to war against Clifford the big red dog

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