B-1B 85-0085

The Pilot Flying (PF) was the MP, a qualified B-1B Pilot who began flying the B-1B on 29 November 2021 and has accumulated 257.8 flight hours, 63 sorties, and 151.1 simulator hours.

	Hours	Sorties
Last 30 Days	13.9	3
Last 60 Days	24.5	6
Last 90 Days	36.4	8

Source: AIB, pp. 29 - 30

The Pilot Monitoring (PM) was the MIP, a fully qualified Command Pilot. He began flying the B-1B on 6 October 2006, and has accumulated 2,087.6 flight hours, 450 sorties, and 305.2 simulator hours. Of the 2,087.6 hours, 693.1 were combat hours, and 85.3 were combat support hours.

	Hours	Sorties
Last 30 Days	5.6	2
Last 60 Days	5.6	2
Last 90 Days	11.7	4

SFOX3 conducted the pre-flight step brief for the MC, utilizing the approved 34 BS Step Brief. The step brief is a formal process for ensuring aircrew currency and qualifications; reviewing current and forecast weather conditions, assigned aircraft, airfield status, hazards, and NOTAMs, and verification of aircrew’s mission ORM.

Source: AIB, p. 35

On 18 December 2023, Airfield Operations issued a NOTAM (M0766), which increased the minimum visibility requirement for an approach to Rwy 13 from 1/2 Statute Miles (SM) to 3/4 SM. This NOTAM was not explicitly highlighted on the 34 BS “Step Brief.” As of 4 January 2024, a previously applicable “Ops Note” slide addressing reduced reflectivity for Rwy 13 and Rwy 31 centerline markings was hidden, which meant the step brief contained no information regarding increased visibility minimums for Rwy 13.

Source: AIB, p. 4

On 4 January 2024, at approximately 17:47 local time (L), FELON 02, a U.S. Air Force (USAF) B-1B aircraft, Tail Number (T/N) 85-0085, was returning from a routine training sortie to Runway (Rwy) 13 at Ellsworth AFB, SD. At 17:26L, the mishap aircraft (MA) returned early from its planned mission as the weather at Ellsworth AFB worsened, with a dense fog rolling across the airfield. The MA was crewed by two members of the 34th Bomb Squadron (34 BS), including the Mishap Pilot (MP) and Mishap Defensive Systems Operator (MDSO), one member of the 28th Operations Support Squadron (28 OSS), the Mishap Offensive Systems Operator (MOSO), and one member of the 28th Operations Group (28 OG), the Mishap Instructor Pilot (MIP). As the mishap crew (MC) attempted to conduct an instrument landing, the MA made initial ground contact short of the runway overrun, and all four members of the MC ejected as the MA skidded across the runway before coming to a rest on the infield between two of the airfield’s taxiways. The MC survived their ejections with varying injuries, but the resulting fire destroyed the MA. The total cost of the MA was $450,800,000.00, and the total cost of the mishap, including damaged airfield structures and cleanup, was $456,248,485.00.

Source: AIB, p. 1

FELON 02’s mission on 4 January 2024 was to execute a training mission in Powder River Training Complex Area 2 (PR2). The tactical mission focused on large-scale Stand Off Weapon (SOW) employment. FELON 02 was number two of a two-ship formation identified as FELON Flight.

After check-in with Approach Control with information MIKE, FELON flight requested an approach to Rwy 13 due to the increased ceiling reported by MFOX3 on Rwy 13. Based on the 5/8 SM visibility relayed by MFOX3 being more recent and restrictive than information MIKE’s reported 7/8 SM visibility, the MIP relied upon it to commence FELON 02’s approach. At 17:26L, Approach Control passed an updated information OSCAR, which neither FELON crew acknowledged. Neither FELON crew referenced the NOTAM M0766, which stated that ALS inoperative weather minimums were in effect, and therefore, the minimum visibility required had increased from 1/2 SM to 3/4 SM for Rwy 13.

FELON flight requested a flight split and the instrument landing system (ILS) approach to Rwy 13 with radar approach control (RAPCON), and both aircraft subsequently commenced the approach. Neither FELON crew applied cold weather corrections to the Decision Altitude (DA). Information MIKE reported the temperature at -5 degrees Celsius, and cold weather altimeter corrections are required below 0 degrees Celsius according to Air Force Manual 11-202, Volume 3, Air Force Global Strike Command Supplement, Flight Operations (Tabs F-4 and BB- 7.6). This would have increased the DA for the ILS approach to Rwy 13 from 3,476ft Mean Sea Level (MSL) to 3,496ft MSL, 20ft higher. Based on their testimony, none of the eight FELON crew members recognized that cold weather altitude corrections were required.

Radar Approach and Tower controllers approved FELON’s approach to Rwy 13 as an “opposite direction approach” rather than switching the active runway. The Tower Watch Supervisor (ATC1) then switched the runway approach lights from Rwy 31 to Rwy 13, automatically changing the reporting weather sensor to the Rwy 13 sensor. This caused an update to the METAR, which now read “visibility missing”. The duty weather forecaster (WF1) was not notified of the opposite direction approach by Tower. However, WF1 believed the active runway had changed to Rwy 13 as soon as WF1 noticed the METAR update with missing visibility data. WF1 stepped outside with the Weather Flight observation binder to manually augment and verify the 5/8 SM visibility data reported by the Rwy 31 sensor.

The only weather data the crews received was for Rwy 31, and they did not request any weather information for Rwy 13 beyond the vertical visibility provided by MFOX3.

FELON 01 landed on Rwy 13 without incident, approximately 7.71 miles ahead of FELON 02. The FELON 01 crew exercised appropriate crosschecks, with LCP calling out corrections to airspeed as the aircraft descended. The LCP saw the runway lights before what they understood to be the DA and the runway markings before 100ft AGL. The crew subsequently described the conditions as the “minnest of mins,” but did not communicate these difficult conditions to the MC. Personnel in the tower could not see FELON 01 or its landing/taxi lights. ATC1 noted the tower was completely in the fog, unable to see the runway 5/8 mile away. ATC1 never relayed these visibility observations to Weather Flight, MFOX3, or the MC.

When the MC discussed the approach, the MP stated he was going to fly the approach, and the MIP agreed. The MP, backed up by the MOSO, correctly calculated the approach speed at 164 knots (kts) indicated airspeed (KIAS). During the approach brief, the MP never briefed the required vertical velocity for the approach and never set the radar altimeter to an altitude that would assist with the approach. Specifically, setting the altimeter at 200ft AGL for the approach would have provided the crew with a visual warning when descending below the DA to continue the approach. Once established on the final course and up to the last 55 seconds of the flight, the MP was properly managing speed, altitude, and glideslope.

During the last 55 seconds while descending, the winds rapidly shifted from a 340-cardinal direction at 11 kts to a 190-cardinal direction at 5 kts within 25 seconds. This is “performance enhancing” directional wind shear. Flight data shows the MA’s airspeed increased by approximately 12 kts during this wind shear event from 164 KIAS to 176 KIAS. Performance enhancing wind shear was evidenced by increased airspeed as the MA was now flying faster through the airmass around it. Throttle reductions are commonly required with performance-enhancing wind shear to mitigate the increasing airspeed, and this reduction in the MA’s throttles is reflected in the Military Flight Operations Quality Assurance (MFOQA) collected data. The wind data was collected from onboard tactical displays showing the wind velocity and direction readout. Flight data and engine data are derived from the MA’s MFOQA data. The MP reduced power three notable times throughout this period. However, once the wind stabilized at 5 kts crosswind, the MP did not increase the core rpm as the airspeed decreased toward the approach speed to “catch” the approach speed of 164 KIAS. This power input never occurred, resulting in a thrust deficient condition.

The MC did not use standard low visibility Crew Resource Management (CRM) communication as defined by Air Force Manual 11-2B-1, Vol. 3, Ellsworth AFB Supplement, B-1 Operating Procedures. Communication such as “Continue,” “Runway in Sight,” and “Visual” alert aircrew that required landing environment visual cues are present and allow for the continuation of the approach. The MP testified that he transitioned visually when the MIP called “Lights”. The MIP believed he called “continue” at 200ft, and the MOSO believed the “continue” call occurred; however, no “continue” call is audible on the cockpit voice audio recording. Even had a “continue” call been made, the MP should not have transitioned to a visual approach until after the MIP called “Runway in Sight,” which never happened. Only the “runway in sight” call communicates that enough visual cues would allow the MP to fly the remainder of the approach visually. Had the MC adhered to the B-1B manual regarding low visibility approach communication, then the MIP would have called “runway in sight,” and that would have been the correct point for the MP to transition to a visual approach. Instead, the MP failed to remain on instruments until the “runway in sight” call, which never occurred. This would have extended the time his instrument crosscheck was in place – and increased the likelihood of recognizing the decreasing airspeed and increasing VVI. Additionally, if the MC adhered to the B-1B manual regarding low visibility approach communication, the MC would have called a “go-around” once they were at or below the DA without a “Continue” call

Over the final 14 seconds of flight while on final approach, the MA's airspeed was allowed to decrease to 12 kts below the calculated approach speed, and the aircraft began to sink. The VVI for a precision approach should be minus 750ft per minute, according to the B-1B flight manual. The MA's VVI was recorded at minus 1,800ft per minute just before impact. The MIP called "climb, climb, climb" four seconds before impact, and again called out "climb" two seconds before impact.

After the final “climb” call, the MP selected MAX (afterburner) on the throttles and pulled the control stick aft at 17:47:44L. Due to the excessive sink rate and late recognition, the MA was unrecoverable and out of control.

The MP decided to eject due to the MA hitting the ground and losing power, and he pulled the ejection handles shortly after impact. Within seconds, the MP heard bangs, which were the MOSO, MDSO, and MIP hatches jettisoning and the seats firing in the automatic ejection sequence. Finally, the MP’s hatch and ejection seat departed the aircraft similarly.

Source: AIB, pp. 4 - 18

I find by a preponderance of the evidence that the lack of a composite crosscheck by the MC caused this mishap. During an instrument approach, the pilot flying incorporates flight instruments into a composite crosscheck to continuously monitor the aircraft’s overall performance. Pilots use that information to determine appropriate throttle and control stick movement to achieve desired performance. The MP did not effectively crosscheck the airspeed, descent rate, and projected aircraft flight path leading up to the mishap. By failing to crosscheck using his instruments effectively, the MP did not recognize the MA’s deviations from the desired airspeed, descent rate, and aircraft flight path. Additionally, rather than maintaining his instrument crosscheck until hearing “runway in sight” from the MIP, the MP deviated from AFMAN 11-202, Vol. 3, procedures when he prematurely transitioned his eyes from the MA instruments to looking outside when hearing the MIP verbalize “lights” rather than waiting until the authorized words “runway in sight.” The rest of the MC also failed to conduct an effective crosscheck by not recognizing and calling attention to the MA’s decreasing airspeed, accelerating descent rate, and deficient flight path. Moreover, the MIP was ineffective in his crosscheck and supervision responsibilities by not recognizing and intervening when the MA entered an unsafe state, which resulted in deteriorating flight parameters. Because the MC did not follow established procedures for maintaining an effective crosscheck, the MA progressed to a state where it could not recover before ground impact. The MC succumbed to complacency and fixation, while the MIP was ineffective in his crew leadership and instructor supervision duties.

Source: AIB, pp. 43 - 44

I find by a preponderance of the evidence that an ineffective flying operations supervision program substantially contributed to the mishap. Although the aircrew retains responsibility for adhering to all flight rules and restrictions, the Step FOX-3 (SFOX3) failed to highlight the airfield’s status and hazards to the MC. The Mishap FOX-3 (MFOX3) lacked awareness and understanding that the current prevailing visibility values provided by the Weather Flight applied to Rwy 31 alone and not Rwy 13. Lacking awareness of the incomplete prevailing visibility conditions, the MFOX3 recommended an approach to Rwy 13, for which there was no valid weather observation. Using the Rwy 13 visibility observation, he mistakenly recommended an approach to a runway not authorized due to the Notice to Airmen (NOTAM)-directed increased visibility restrictions. The MFOX3 lacked awareness of the NOTAM due to an insufficient shift changeover and individual failure to review applicable airfield hazards and restrictions at the beginning of the shift. Additionally, the discretionary decision to conduct flying operations without a Supervisor of Flying (SOF) in the tower removed a critical layer of flying supervision. Undisciplined procedures by the SFOX3 and MFOX3 and the resulting lack of airfield hazard and restriction awareness, a misunderstanding of the observed weather conditions, and task saturation enabled a flawed recommendation to the FELON crews to attempt an unauthorized approach to a runway void of the required minimum visibility.

I find by a preponderance of the evidence that a lack of awareness of airfield conditions substantially contributed to the mishap. A significant degradation to the Rwy 13 weather sensing equipment went largely unnoticed across the 28th Bomb Wing for approximately two months preceding the mishap. Additionally, because of the lack of communication, there was a lost opportunity to publish a related NOTAM or update to Flight Information Publications. The FELON crews and both the SFOX3 and MFOX3 all stated they were unaware of any airfield weather sensor degradations. Even without being briefed on the degradation of weather sensors, there were missed opportunities to recognize it. The MC had access to Electronic Flight Bag data, which indicated no visibility observations for Rwy 13. Additionally, the MFOX3 had access to current Weather Flight visibility observations via the online Joint Environmental Toolkit, which also reflected missing sensor data. Collectively, the lack of degraded sensor awareness contributed to the FELON crews’ decision to commence their approaches without valid weather observations for Rwy 13. Compounding the lack of awareness, the Tower Watch Supervisor did not execute cooperative weather watch procedures. The mishap Air Traffic Control Watch Supervisor noted that he had no visibility of the runway environment. He should have contacted the Weather Flight or MFOX3 to note that his observation appeared worse than the reported 5/8 statute miles (SM) visibility, which the MC used when making their approach decision. Automated Terminal Information Service (ATIS) publishing was also delayed immediately preceding the mishap, which further reinforced the FELON crews’ distorted weather mental model. Finally, while the policy does not require it, the Tower did not notify the Weather Flight when switching the approach lighting for the opposite direction approach. Switching the approach lighting also switched the weather equipment to the degraded Rwy 13 sensor, which required a manual visibility observation. Because the Weather Flight was not notified of the opposite direction approach, they did not perform the necessary manual visibility observation until after the FELON crews commenced their approaches and were still conducting their observation at the time of the mishap.

Source: AIB, p. 45

This investigation has shown that many failures leading to this mishap were not a one-time occurrence or an aberration. I have noted that the mishap occurred due to numerous factors, including a culture of noncompliance, widespread deviation from established policy and procedure, and several organizational influences and preconditions. The inability of the MC to conduct effective crosschecks and utilize proper CRM, along with the 34 BS’s lack of effective flying operations supervision and the 28 OSS’s failure to communicate airfield and weather capabilities and conditions, all speak to culture and leadership issues. After the Board’s extensive investigation, I conclude the human factors causing and contributing to the 4 January 2024 mishap were not an aberration. Instead, they reflected broader trends within the 34 BS and 28 OSS. The 34 BS and 28 OSS lacked proper supervision, which set the conditions for individual causal acts and the overall mishap circumstances and events. I find by a preponderance of the evidence that these leadership and climate issues directly contributed to the mishap.

Source: AIB, p. 46