4. SEQUENCE OF EVENTS a. Mission On 30 June 2020, the mishap flight (MF) was a 4-ship of F-16CMs, and consisted of call sign Meat 41 as the Mishap Flight Lead (MFL), Meat 42 as the Mishap Wingman (MWG), Meat 43 as the Mishap Element Lead (MEL), and Meat 44 as the MP (Tab K-3 and K-6). The mission was an MQT sortie planned to take off from Shaw AFB, fly to the Bulldog Military Operating Area (MOA) approximately 110 nautical miles (nm) southwest of Shaw AFB, execute air-to-air refueling (AAR) with a KC-135 Stratotanker, conduct Suppression of Enemy Air Defenses (SEAD) training, and return to Shaw AFB (Tabs K-3, Z-8, and FF-6). Due to the MP’s inability to AAR, he was unable to perform SEAD training, which was the primary training focus of the mission (Tab AA-29 and AA-31). Figure 1: Mishap Flight Operating Area (Tab Z-8) b. Planning The mission was the MP’s first SEAD training sortie and first attempt to conduct AAR (Tabs G1046 and T-6). Prior to the pre-flight brief, the MFL reviewed various tactics, techniques, and procedures with the MP (Tab R-48). At approximately 1825L, the MFL conducted the flight brief in accordance with 20 OG Standards, Air Force Manual (AFMAN) 11-2F-16, Volume 3, F-16 Operations Procedures, dated 4 February 2020, and Air Force Instruction (AFI) 11-202, Volume 3, General Flight Rules, dated 19 March 2020 (Tabs K-6, K-9 to K-23, R-48 to R-49, BB-23 to BB-24, BB-26 and BB-95). The MFL discussed mission objectives, ORM measures, current and forecasted weather, notices to airmen (NOTAMs), emergency procedures (EPs), special interest items, and the mission materials (Tabs K-6, K-9 to K-23, R-48 to R-49, BB-23 to BB-24, BB-26, and BB-95 to BB-96). The weather forecast included thunderstorms, rain, and a layer of broken clouds from 13,000 to 17,000 feet mean sea level (MSL) (Tab F-2 to F-14). Due to the forecasted weather conditions, the MFL F-16CM, T/N 94-0043, 30 June 2020 6 directed the MF to use a Bingo, or predetermined recovery fuel state, which would allow aircraft to divert to Robins AFB, Georgia if required (Tabs R-60 and V-7.6). During the flight brief, the MFL emphasized techniques for keeping situational awareness and how to AAR at night. The flight brief lasted approximately fifteen minutes longer than planned due to sortie complexity and the amount of instruction required (Tab R-45). The Air Force’s risk management (RM) system is a decision-making process to systematically evaluate possible courses of action, identify risks and benefits, and determine the best courses of action for a given situation (Tab BB-74). All commanders are expected to identify and clearly establish specific risk acceptance authority levels and thresholds for elevating risk acceptance decisions for operations and activities (Tab BB-75). These levels can vary depending upon specific operations or activities, units, personnel involved, etc. (Tab BB-75). The intent is to ensure that as risk levels increase, risk acceptance and associated Go or No-Go decisions are elevated to obtain appropriate commander or supervisory oversight and approval (Tab BB-75). The MFL used the 20 OG RM worksheet to assess the overall risk of the mission, and determined the risk to be in the moderate range due to a number of factors, including night AAR, thunderstorms in the area, a wet runway, and it being the first time for the MWG and MP to fly a SEAD mission (Tab K-5). The 77 FS/DO approved the flight’s RM level, and the morning Top 3 authorized the flight (Tabs K-5, T-2, and V-15.8). The MFL miscalculated the level of risk for the mission, neglecting to include the risk values for "Landing After 2200L", "Instrument Meteorological Conditions Enroute/in the Working Area", and "Greater than 5 Days Since the Last Flight" for both the MP and MWG (Tabs F-8, G-1045, G-1065, and K-5 to K-6). Additionally, two risk categories (Upgrade/MQT and Never Flown Mission Type) were included in the total score, but actually applied to both the MP and MWG separately, and their individual contributions to the total score should have been doubled based on guidance at the bottom of the form (Tab K-5). These changes would have increased the Risk Management score from 30 to 51, and would have required approval from the Operations Group Commander or his designee (Tab K-5). c. Preflight During ground operations, the MFL was impressed with the MP’s preparedness and timeliness despite the intricacy of the required setup procedures for the weapons and systems (Tab R-49 to R-50). The MF took off on time (Tab R-46). d. Summary of Flight At 2101L, the MF departed Shaw AFB and joined with a KC-135, call sign Turbo 27, for AAR in the Bulldog MOA (Tabs AA-7 to AA-10 and FF-6). Refueling was delayed while Turbo 27 exited a dense layer of clouds and relocated to a different altitude block. The MFL and MEL refueled without incident, and the MWG, on his second-ever AAR attempt and first at night, was able to receive fuel, but bobbled somewhat, required approximately ten minutes (twice the time of the MP and MEL) and was not able to completely fill his tanks, ending the AAR approximately 1,000 pounds below the planned offload (Tabs V-7.16, V-11.3, and AA-18 to AA-22). The MP’s AAR attempt, however, ended after being unable to meet the intense formation requirements to receive fuel (Tabs V-11.3 and AA-29). Following his unsuccessful AAR attempt, the MP is heard expressing frustration over the cockpit voice recorder (Tab AA-17 to AA-29). After being unable to receive fuel, the MEL and MP were required to return to Shaw AFB (Tab AA-29). During the return to Shaw AFB, the MP is heard once again expressing frustration at having to return to base early, and struggles to maintain proper formation spacing and airspeed while trailing the MEL (Tabs AA-40 and FF-2). Approximately 16 nm from Shaw AFB, the MEL communicated, in a lighthearted tone, "that was not the way to start your tanking experience," and then follows more sincerely with "that was really challenging". In response, the MP exhaled and said, "no excuse" (Tab AA-41). e. Summary of Accident Shaw AFB is equipped with an Instrument Landing System (ILS) approach to runways 22R and 04L (Tab AA-72). An ILS consists of two electronic beams which work together to steer approaching aircraft to the runway through clouds and other weather (Tabs BB-130 to BB-131 and CC-15). The localizer beam guides aircraft laterally along the runway extended centerline, and the glideslope beam guides aircraft vertically to a point approximately 1,000 feet beyond the runway threshold (Tabs AA-72, BB-131, and CC-15). The localizer also broadcasts a specific Morse code signal which aircraft can listen to in order to confirm the system is functioning and they are receiving the signal properly (Tabs AA-72, BB-130, and CC-15). On the night of the mishap, the runway 22R ILS components were operating normally with no faults detected, reported, or logged, and the MP successfully tuned, identified, and monitored the ILS signal (Tabs V-2.2 and FF-3). The final approach portion of the ILS to runway 22R begins 4.3 nm from the end of the runway (Tab AA-72). At that point, the procedure directs a 2.82-degree descent until transitioning to the runway visual environment for landing or arriving at the Decision Altitude (DA) of 440 feet MSL (Tab AA-72). F-16CM, T/N 94-0043, 30 June 2020 7 F-16CM, T/N 94-0043, 30 June 2020 8 At 2224L, the MP was trailing the MEL by 2.5 nm and established on the localizer’s lateral guidance (Tab FF-2). At that time, the MP was at 2,000 feet MSL, and below the clouds (Tab FF2). He did not reenter the clouds throughout the remainder of the approach (Tabs AA-72 and FF2). Eighteen seconds after intercepting and descending on the glideslope, the MP radioed that his gear were down, and the Air Traffic Control (ATC) tower acknowledged and issued the MP a clearance to land (Tabs N-4 and FF-2). Prior to transitioning to visual landing cues, the MP executed an ILS approach to runway 22R with minor deviations and corrections (Tab FF-2). Two minutes after lowering the landing gear, at an altitude of 620 feet above and 1.8 nm from the runway, the MP transitioned from ILS electronic guidance to the visual cues of the runway environment for a visual landing (Tab FF-3). Runway 22R at Shaw AFB is equipped with a precision approach path indicator (PAPI) and an approach lighting system (ALS) with sequenced flashing lights 1 (ALSF-1) (Tab AA-72). Along with other lighting elements, this system includes a line of green lights along the threshold of the runway (Threshold Lights) and a line of white lights oriented the same direction, approximately Figure 2: ILS Y 22R procedure (Tab AA-72) F-16CM, T/N 94-0043, 30 June 2020 9 1,000 feet prior to the threshold (1000 FT Light Bar), see figure 3 (Tab Z-4). On runway 22R, there is an array of localizer antennas approximately 82 inches tall located 76 feet in front of the 1000 FT Light Bar (1,076 feet before the runway threshold) (Tabs V-2.3, Z-5, and FF-5). All runway lights were in good working order on the night of the mishap, they were inspected one hour prior to the mishap, and there were no pilot requests to change ALS intensity settings.