The Most Scathing AIB Report Yet - B-1B Mishap at Ellsworth

On 4 January 2024, a B-1B from Ellsworth AFB, SD crashed on landing with low visibility. All four crew members ejected safely. Reviewing the AIB Report that was recently released.
*The appearance of U.S. Department of Defense (DoD) visual information does not imply or constitute DoD endorsement.*
*Views presented are my own and do not represent the views of DoD or its Components.*

Chapters
0:00 Intro
1:36 Executive Summary
4:37 Background Information
9:41 Sequence of Events
16:36 Summary of Accident
36:49 Crew Qualifications
38:23 Board Opinion
44:32 Mover's Opinion And Conclusion

[B-Eric]

Mover, as a former B-1 IP/OGV EP stationed at Ellsworth, I can fill in some details.

1 - The SOF Callsign is FOXTROT. It looks like the FOX-3 name is a combination of FOXTROT and TOP-3 (Ops Sup). When I was there, when only one squadron was flying (Ellsworth as two operational flying squadrons), a single sortie (e.g., OCF, divert RTB), the SOF was not required, but the Top 3 had to have the SOF truck to assume SOF duties. The SOF could only be in the tower or the SOF truck. My guess is manning issues have allowed this combination of duties to occur more liberally than previously allowed.

2 - No HUD in the B-1

3 - While the B-1 had the ability to fly a coupled approach, there is/was a WARNING in the Dash 1 that stated "Do not engage ILS automatic approach mode due to oscillations below 500 feet AGL that may result in ground impact." Furthermore, there is another WARNING that states before entering the traffic pattern "Failure to ensure Auto Throttle disengagement can result in loss of throttle control and an unsafe landing condition." Every approach is hand flown.

4 - Per the Dash 1, pilots are told to use the AOA indicator and indexer to maintain an on-speed 7 degrees AOA indication throughout the approach. This represents the optimum approach AOA. Turbulence, gusty wind, or wind shear conditions may induce variations in AOA or airspeed and may cause excessive sink rates to develop on final approach. In this case, the pilot should increase final approach and touchdown airspeed by a maximum of 10 knots in such cases to improve aircraft handling characteristics. The aircraft should be landed at higher airspeeds. The -1 also warns: Maintain AOA throughout the approach and landing. Do not allow an excessive sink rate to develop since recovery may not be possible.

5 - The B-1 has recently received a glass cockpit mod, but previously, the checklist had you bug an altitude in the radar altimeter and once you flew below that altitude the Min Decision Height Caution light would come on and your steering cross would flash. That could be different now, but I could probably assume there is something on there display to alert them they are below the index altitude. Also, I think the checklist used to direct you set approach minimums on your altimeter.


6 - WITHHOLD deals with weapons employment. Anyone on the crew can call WITHHOLD due to things like exceeding heading tolerances, timing tolerances, threats, Safe Escape, Safe Separation etc. ABORT is in the context of a takeoff / rejected takeoff.

7 - The 28BW used to have a section in it on Cold Weather Altimeter Corrections. (I also used to teach this during my IRC classes.) Not sure what happened to this knowledge.

I don't want to point fingers as no one is infallible and we all screw up, it really is just the magnitude and time that it happens. These guys got painted into a corner both self-induced and by outside influences. I would almost guarantee that if they knew about the NOTAM, applied it correctly, and diverted to Tinker, they would have landed safely. But, yes, a poor instrument approach was flown. Finally, I knew the Board President when he was a Lt / Capt at Ellsworth. Stand-up guy when we were stationed together and I think he presented the facts and opinions well and highlighted some big deficiencies.

[goose]

Former USAF guy now 121 guy - excellent breakdown. You are 1, 000% correct about the sad state of NOTAM code. That accident is textbook complacency combined with queep getting in the way of flying training. Outstanding video.

[danielroncaioli]

In the Army, I’ve scrubbed missions. I was a Crew Chief/Door Gunner. We were just out burning gas, and weather was coming in. I spoke out that I was uncomfortable because clouds were dropping and we would run the risk of having to fly IFR. Pilots immediately aborted the operations. There were no questions asked. We had a fantastic “all go or no go” safety policy.

[brianrmc]

I think you nailed it: Poor basic airmanship, further worsened by degraded leadership.

[rockydabull]

I am currently assigned to one of the pilot training wings…. this attitude is being bred into our new pilots from the ground up. Disregard of regulations and guidance is commonplace. The current syllabus is not being executed as written… syllabus deviations are routine…without documentation. Syllabus events are routinely pencil whipped….with tacit approval of leadership. Crew rest is a recommendation only. I could go on and on…
Students leave here thinking that this is a normal way of executing the mission….do whatever it takes to get the X.

[Medic]

I've got a crazy B-1B crash story. I was director of a small Kentucky county (Crittenden County) emergency medical services, and the counties primary first out paramedic. We received a 911 dispatch for a possible aircraft accident about 7 miles from the city out in the county. I was driving the ambulance to the scene. I had responded to 5-7 various aircraft incidents over my, at the time, 20+ years. I reassured my partner it was probably another small experimental single occupant light craft. About a half mile from the scene I saw a large amount of smoke and a tall oak tree on fire with flames reaching to the top of the tree. I thought to myself maybe this aircraft was somewhat larger lol. On arrival, I noted it was on the farm of the lead singer of the current weekend band I was in. Eddie was at work but another local farmer arrived to the scene at the same time as the ambulance. We requested fire and rescue to respond. The debris field was enormous. The farmer offered to drive my partner and myself through the initial impact mud into the debris field with his 4x4. I grabbed medic bags, and pitched them in the truck. About 100 yards in we were clear of the mud. We got off the truck. I told them to look for aircraft seats as that historically had been where I located crash victims. Started trudging through this incredible mass of parts. I saw some papers blowing in the wind with "SECRET" then saw an intact helmet bag with tour patches and unit emblems. Got on the radio and advised dispatch supect aircraft was military and to call Fort Campbell, our nearest military base. A few more yards in, and there are the enormous landing gear but still no seats or chutes. The whole scene was so surreal, smells, fires, smoking parts etc., still no seats or victims. The very last parts we found were the hugh engines, finally stopped, when they encountered the woods at the end of the debris field. The jet engines were still smoking emitting an acrid smell. I advised dispatch no victim contact and we were at the end of the debris. Dispatch advised me that Fort Campbell is notified, but it's not their aircraft. Dispatch then gave us a new 911 call to a location about 15-20 miles from this scene. "injured man hanging from parachute in tree". We cleared the crash site and responded to last dispatch. The fire department was arriving. I thanked the farmer for the assist, and headed to new dispatch coordinates Long story short a second ambulance was dispatched to assist us. We eneded up locating and transporting the four crew members of the B-1 to our small county hospital. Found out they were flying out of their Texas base. Injuries were minor or non existent for three of the crew. The wizzo had a manageable head injury. From the scuttlebutt that got back to me: 1.This B1 had undergone recent updates to the electronics. 2. A sudden fire was noted in the main cabin probably related to the recent updates. (Never herard exact cause). The pilot, that noted the fire, apparently punches out the whole crew when ejection is required. 3. The pilot told the crew of imminent ejection intent. 4. The wizzo did not have enough time to don and/or secure his helmet before being ejected from the aircraft. He was the airman that ended up hanging by his chute from the tree with a head injury. Apparently military aircraft accident word travels fast. On our arrival to Crittenden County Hospital we noted Blackhawks. One landing on our hospital pad. Others landing on the parking lots and grassy areas. We were being invaded by the US ARMY from Fort Campbell! One cigar chomping Colonel appeared to be in charge. Well folks, we were having a Dustoff Medevac operation right before our eyes. We gladly turned our 4 patients over to the mighty colonel his, Blackhawks, and his medics! With their hotloads onto the aircraft, we barely had time to give patient reports on our airmen. Our assumption was that the military powers that be, had worked out a plan to take care of their own and bypass our little county hospital. I was amazed Fort Campbell and the Texas airbase formed and implemented a plan between the time Fort Campbell was notified, and their arrival at the county hosp. I guess loosing a nuclear weapon capable aircraft has extra urgency eh? BTW, we were told later, the B-1 was unarmed. Yeah, we didn't observe any ordinance on our journey through the crash site. Not sure how our lil facemask and rubber gloves would've saved us from a nuclear holocaust anyway. Lol

[demmertp]

As a former weather puke, I agree that the fact that the weather sensor on runway 13 was down for 2 months should have been elevated and corrected within the weather and OSS channels. While the NOTAM correctly identified the visibility sensor outage and limitations, that sensor should have been replaced at an active northern tier base with known poor flying weather in the winter. However I think the wind shear element is a red herring. A change from 340/11 to 190/05 is an indication of light and variable winds, typical during a winter fog condition. Note that the report said the wind data came from the onboard tactical display, so wasn't this information was available to the crew in real time? I also question how a change from a quartering tailwind to a crosswind condition, at these low wind speeds, is responsible for a 12 kt increase in airspeed in 25 seconds. Bottom line is that if the aircrews had known about the NOTAM visibility restrictions, they would have diverted to Tinker. A hard lesson but everyone lived to tell the tale.

[stephenhenley]

Flight Training in USAF has been consistently subpar at the Aircraft Specialization level. Rocky is correct, syllabus deviations continue to be routine and have been for ~2 decades.

I remember repeatedly being told by an instructor to do X which was explicitly prohibited by CJCS regulations. As an O-5, he had rank and told me to do it or he'd mark it as an unsatisfactory flight. I did X as there was only a VERY minor actual risk at the time. 5 flights later I did the same thing under his tutelage and he wrote me up. That's not training. That's just flexing and being cruel. The students escalated it, but he retired before anything could be done about it.

Every student in the schoolhouse knew he was trouble and avoided him. We came up with our own checklist just to comply with his demands instead of focusing on learning.

[Gadget]

I was asked in a promotional interview what I felt the biggest problem in law enforcement. I said easy, it is complacency. That applies to everything. 99% of things that go wrong can easily be traced back to complacency. Every member of the board raised their eyebrows like a light went on. Fight complacency with high expectations and discipline, inspections, adherence to standards, and promote self responsibility and ensure your subordinates are properly trained you are taking big steps in fighting complacency which prevents mishaps.

[HowardSteiner-vv]

I witnessed the B1 taking off at on Rwy 31 at 1630 into a fog back. They were below mins to takeoff. I was at the departure end of rwy 13 at the time. The visibility when they landed was about 100 feet. I am a retired Navy pilot with 700 hours in prowlers and 2200 hours in C9Bs. CAP worked with 28th BW to provide photos via drone and aircraft of the mishap area

[pollylewis]

WOW, scathing is right C.W. this report was after heads for sure. I appreciate how you go through this report and explain to us the verbage of what things mean and especially your opinion of what mistakes were probably made, just so many things lined up for such mishap to happen. Thank you again.

[aquariusdrakeblood]

I was on hot pit on that day and launched out 129, scary thing sitting out there in the fog and seeing 129 go by on the runway then hearing 3 distinct explosions. Glad to finally see this investigation concluded.

[stevelaue]

I was an instructor navigator on EC-135 aircraft out of the 28th BMW at Ellsworth in the early 1970's. My first lesson to any new navigator assigned to the aircraft was that on the approach or in the traffic pattern, his ONLY job was to keep the two idiots in the front seats from killing the rest of the crew. Fortunately, I took my own advice. I'm still here, though we did have a couple of close calls over the years. The reason you have a crew on a crew aircraft is that one person can't do it all. If the crew works together, mistakes are caught and problems are prevented.

[johnv.]

Definitely some changes since I was there. Say SOF in the Ellsworth tower. Your take on briefings is spot on even in the bomber world. Shame but the AIB lead is a good guy and I have flown with him in the past so, so trust his review of the incident.

[michaellingg]

I wanted to just say in general, not specifically directed at this video, thank you CW Lemoine for sharing your experience with the rest of the world. Hearing and understanding the view point of someone with your experiences on specific topics, and in general, is invaluable history!

[yankeetango]

I was stationed at Ellsworth in the early 90s when a B-1 crew botched a disengagement from a tanker and ripped a huge gash in the tanker fuselage with the tail of the B-1. Luckily, both damaged aircraft were able to safely land.

[danlowe]

Weight limit for ejection seat is 245lbs. MIP's weight at last medical check was 245. At hospital, after crash, MIP's weight was 260lbs.

[joecarpenter]

Thank you Mover for calling a spade a spade. At the end of the day, we had 4 airman ejecting and a wrecked airplane because the pilot flying failed to do the stick n rudder thing. It really is that simple.

[capnhardway]

When I was stationed at Hahn AB in the 80's I was a fire team leader and we saw an F-16 burst into flames from right behind the cockpit to the tail! It became transparent you could see the framework! The pilot cut the engine ejected, he was full AB braking when it ignited. The SOF was in a truck and met the pilot seconds after he landed on his feet and the SOF was slapping him on the back saying you did the right thing! I was with Security Police. In the cold war days.. I enjoy your reports, I subbed thank you sir.

[stephenpage-murray]

Lack of discipline, professionalism and basic airmanship. A clusterfuck of immense proportions!