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.
Multiple factors contributed to the F-35B loss, including missed security discussions, engineer distractions, and a lack of proper handovers. Windy conditions & workforce fatigue also played roles.
— George Allison (@geoallison) August 10, 2023
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:
- 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.
- 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.
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…..
I believe back in the early 80s, the F16 had the unenviable nickname ‘the Lawnmower ‘.Due to the very high crash rate.
Wasnt sure on that but the data makes it sound even worse
But lots of planes in service
https://aviation-safety.net/wikibase/type/F16
Not as bad as the F104 Starfighter though Robert! I believe the F14 has a bad record too.
The flying coffin as I think it was affectionately known as.
One of the better known incidents involving Harrier, but at least the pilot was OK and we got our plane back.
https://theaviationgeekclub.com/that-time-a-royal-navy-sea-harrier-did-an-emergency-landing-on-a-spanish-cargo-ship-the-alraigo-incident/
Shows some ingenuity in my book.
I’ve also heard, “The Widow Maker” – but maybe that was for those planes in the West German Air Force?
Yes, that one rings a bell as well.
In Germany at the time, the joke was; if you want a Starfighter, buy a hectare of land and wait.
Actually, the F-16 was referred to as the ‘Lawn Dart’. It was named after the kids toy, popular in the USA, which is thrown up into the air and plummets back down into the ground nose first, like a Dart.
I thought it was something like that. Thanks. 👍
Huge over exaggeration
Records show 7 Lightning crashes from planes based at Akotiri
https://en.wikipedia.org/wiki/List_of_accidents_and_incidents_involving_the_English_Electric_Lightning
3 alone in 1971 from fire which indicates there was a particular problem at that base
Only 7, oh that’s fine then…. It’s called humour, look it up in a dictionary mate. The English Electric Lightning is my favourite aircraft, particularly the wonderful F2A’s of RAF Germany 19 and 92 Squadrons. Loved them ever since seeing the old LTF F3 punch a blue sky hole clean through a low overcast, filled by the roar and heat from two Avon’s on full tilt during a typical zoom climb as a young cadet. Just wonderful, made the hairs on the back of your neck stand up and your ears ring for an hour afterwards….. As much as I… Read more »
Its not humour when plane nuts are laughing at you
Emm ok, lost in translation that one, another troll from the farm perhaps??.
Nobody is laughing at John.
I bet the EE lightning wasn’t as insanely expensive or limited in number in UK service as the F35B though. Aircraft in the old days were almost ten a penny in comparison.
Well the Lightning wasn’t cheap in its day, but it’s like comparing chalk with cheese, one was a simple point defence interceptor, the other an all things to all men everything!
That never comes cheap!
With a very high power, and quite good, brute force radar for its time.
A true thing of cold war brute force British beauty SB, the sound of those Avon’s in full reheat was the very sound of freedom….
The sound of a Lightning going past you on the runway in full chat just about to rotate, back in the good old days when you could litteraly stand at the runways edge watching aircraft movements was something to behold, it made your eyeballs and teeth shake!
Indeed, I remember them from air shows when I was a kid.
Have you seen some of Ian Black’s books about the Lightning?
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.
The only RAF Typhoon loss I’m aware of is the Wheels Up Landing incident in the US.
👍
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.
A700 log would be interesting to see. 😎. Thank god no one drafted DD. 👌👍
I notice that the Police now refer to a RTC not a Road Traffic Accident.
As the SME on this site, there is not much else to say.
👍🇬🇧
👍.
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.
Pathetic comment.
And how many carriers does your ‘country’ operate then nobber?
It’s a nice round number Jacko….
None.
Is this your country the Faroe islands by any chance? Or the mighty dumping hole in the ground that is Ruskfascist land?
Carriers not balls!
It’s not a pathetic enquiry as all the things u listed would be unknown without it.
It’s how things are done and from what has been learnt new procedures can be put in place to stop it happening again.
Most countries wouldn’t release such enquiries into the public domain. We take a lot for granted.
Yes they do. Ive read/skimmed them many many times
Check the MoD download many sensitive parts are blacked out if that was your concern
Heres the last one for the US navy for an F-35C carrier crash
https://news.usni.org/2023/02/21/pilot-error-after-sierra-hotel-break-resulted-in-south-china-sea-f-35c-crash-investigation-says
With over 960 F35’s in service now. The aircraft has an excellent safety record so far.
yes . It seems it human factors around operations are at the core of the issue. I see it as poor supervision of the maintenance staff to see the ‘tidy up’ is completed properly
Our armed forces are not for ornament. We work them hard and this accident is part and parcel of that.
I am sure had they been able to, the R.N. would have saved those lads on the Kursk.
The reasons in the report say the accident was preventable. To be honest I dont think the Navy is worked hard at all, too many ships spend too much time alongside the wharf, often thats for maintenance/overhaul reasons or more common now ‘too many’ dont want sea time which is called crew shortages. Ive looked at the RN manpower numbers by specialisation- last published in 2017 but now considered a secret – and it seems they should have plenty of the specialities for crewing but everyone wants to stay at home! Numbers by Branch specialisation and rank for RM and… Read more »
That is a particularly silly comment, from someone who has never worked on a flight deck, it’s not known as the most dangerous working environment for nothing. The point of an enquiry is to find cause and then act on it. I suggest you read all 148 pages and then post your analysis.
He is just another sad toll mate, read his previous sad and rather jealous posts.
Sad sad troll. Jealousy and anger rears its head with you almost constantly. But don’t worry, you have never served and therefore you have no clue about the subject matter in hand. Ta ta little troll.
In summary: lack of discipline lead to the loss of the F35B.
Yaaaaaaawn still a weak effort at trolling!
Anger and jealousy are not emotions I feel often, certainly not about the UK. You on the other hand seem angry when you come across a different opinion to your own…you don’t seem like Officer material.
Oh dear denying your jealousy and obvious online anger will make you feel much worse! Deep breath…..good troll.
I think he is stating he has no emotions, definitely a chat bot 😀
Congratulations on your promotion Lance Corporal!
Many thanks, it has only took me 37 years…..
😂
I’m not sure he is even real, I think he is the kremlin’s latest AI chat bot troll. All the real trolls got set to the front.
It’s no wonder there military is so starved for equipment when they can afford to pay army’s of people to troll the comments section on a UK defence website.
Agreed, rather pathetic and he can’t even stay focused on trolling in a subtle way, he gets vexed and goes off on a rant. At least it’s amusing mate 👍
What’s the point in commenting if your not advancing the conversation topic?
Ask Airborn.
I respond to your nonsense, don’t post nonsense I won’t reply! You post garbage, it gets challenged, but it is obvious to all you are unable to have a serious, knowledgeable debate, as you have no subject matter experience. That is your fault, don’t try to blame others.
He’s such a poor imitation of his predecessor, I suggest we get a petition to get John in MK back, at least he had technical knowledge as opposed to just blah, blah BS.
No he didn’t John in MK was useless too. Although very very very funny.
RFS Moskva sailing back to Sevastapool. That one made me laugh when she was sunk and down at 150 foot depth.
Agreed, he is the cheaper version of said previous trolls!
I think this versions just out of shorts, he knows F all about F all.
He does show a remarkable lack of both subject and general knowledge.
I miss JohninMagnetogorsk … sad b@stard that I am.
Was it up to having a TV crew on board crew wanting their few seconds of fame. Mind of the job, glad nobody seriously hurt.
Yawn. Get back in your box Ruskfascist
👍
💼
Fuck you Born. Old codger. Is that English enough
Hilarious, every reply verifies my assertions you are getting angrier and angrier, jealous of others achievements and heritage, and unable to formulate a decent conversation. Your PC screen must be awash with spittle and froth. Get some wet wipes, give it a clean or it may stain.
One of the possible contributing factors that may have lead to fatigue is the RN’s practice of working 4 on 4 off. We’re they working this shift pattern?
If you’re not used to it, you very tired very quickly. It takes time to adapt. However, the mitigation is that this was on the ship’s return leg. So the ground crew and deck handlers should have adapted by then.
But even so, not only to the tie down team, but also the maintainers are supposed to do a quick walk round, specifically looking for aircraft blanks/pins that have been missed.
It was lack of discipline. It will be cause issues in combat.
What would you know about such matters? Nil.
And you would know any better? Troll magnet
I’ve reeled you in my little angry, yet sad troll. Don’t like getting gripped do you.
Maybe the Russians need to learn a thing or two about discipline. Or they wouldn’t be getting there arses handed to them by the Ukrainians.
8 on/off was the norm for the air wing. But due to covid infections, that could well have changed.
Glad it’s changed.
about is brutal to star with
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.
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.
The one who never failed throw the first stone…
It is annoying. Fire the guy and create new one…
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… Read more »
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.
Bravo, Math.
Bravo. EU, we can beat anybody
Oh dear, how sad never mind.
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?
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.
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.
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… Read more »
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 –… Read more »
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.
Inexperienced people and immature procedures because we had a 10-year hiatus on operating carriers.
Consequences of carrier aircraft hiatus in Royal Navy?
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.
It is strange the Inquiry don’t make reference to Marines and Italians procedures.
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.
Hi West Midlands? Nice place.
Yeah nice place. What region you from ?
He is a troll, don’t bother with his nonsense.
👍, it does appear to be that case, it’s all a bit pathetic.
Not all accidents are equal in their quality. Some are avoidable, some are very avoidable.
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.
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)?
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
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?
Yes I would say so – an oversight that could have resulted in dire consequencies for him as well.
You would have thought his own safety would have been sufficient driver to ensure all was checked – so complacency all round methinks.
Also why would a pilot wear his helmet when undertaking a visual saftey check – seems madness to me.
Flight deck noise apparently was the reason for that
Everyone on the flight deck has to wear head protection. For pretty obvious reasons.
Is the cover visible from a pilots walk round inspection?
I believe so yes.
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. 👍😊🛫.
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.
Fatigue was because the crew are too busy pissing about on social media in their spare time. What an absolutely pointless comment you made.
I can’t recall any post of yours ever having any relevance, fact or point to it.
Likewise
Your anger and jealousy are still very visible, its vey sad to see.
Hi warrior. How is “wetherspoons”, enjoy your ale in the house of the fallen, my old tosspot.
Your anger continues it seems, now name calling! A simple sign of your seething frustration and jealousy.
Coming from the guy pissing about on social media……That’s a good one
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.
Exactly, the shit show Royal Navy are based on former glory. Without the US they are pigeon feed.
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.
Yeah everyone wants to be from the UK…. Not.
No, you want to be from the US, dreaming of getting over the fence and becoming top fan boy.
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!
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.
Yaaaaaaaaaaawn…….
Try to read the actual report. If you can read which is extremely doubtful at this juncture. It’s not pretty..
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.… Read more »
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.
Aviation week wasn’t impressed…..🤣😄 That’s a good one.
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.
The War Zone has commented on the crash. A good summary. See: https://www.thedrive.com/the-war-zone/f-35-crash-report-includes-sonar-image-of-it-on-seafloor
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