Report: Pilot error caused crash - Pt. Mugu Air Show 4/20/2002

Pilot error caused the fiery crash of a Phantom jet that killed both crew members during Point Mugu's air show last year, a Navy investigation has found.

After nine months of painstaking examination of charred wreckage and videos taken by spectators, Navy investigators have ruled out mechanical failure, birds caught in the engine, and faulty maintenance as causes of the crash that killed the pilot, Navy Cmdr. Michael Norman, and radar intercept officer Marine Corps Capt. Andrew Muhs.

The 800-page report on the April 20 crash pins the blame on Norman's handling of the Vietnam-era jet during an air show maneuver and the veteran pilot's relative inexperience with the QF-4 aircraft. Although Norman had racked up more than 3,300 hours of flying time in military jets during his 16-year career, he had logged just 79 hours flying QF-4s, an experience level that is considered "below average," according to the report, based on the work of a team of investigators from the Naval Weapons Test Squadron at Naval Base Ventura County.

Several squadron pilots characterized Norman as a "careful, meticulous pilot ... (but) his skills in the QF-4 were described as below average compared to other, more experienced QF-4 pilots."

Others in the squadron told investigators Norman, 39, was heavy-handed at times with flight controls, and one flight officer expressed concern about flying with him.

"He believed Cmdr. Norman had come close to stalling the aircraft and nearly had a midair collision during an opening day flyby at Dodger Stadium (a month earlier)," according to the investigator's summary.

Capt. Mike Rabens, commander of the Naval Test Wing Pacific, disputed that account in his statement to investigators. Rabens also flew in the Dodger Stadium flyby and said at no time did Norman lose control of his jet.

Rabens said that although Norman had less experience with the QF-4 than average, he was fully qualified to perform a flyby at the air show.

The investigation report, obtained by The Star through a Freedom of Information Act request, details how Norman yanked the control stick as the QF-4S Phantom II peeled off from a diamond formation 675 feet above ground.

The "hard pull" pushed the nose up at nearly twice the recommended angle, causing the plane to nearly stall and lose speed rapidly, the investigation determined.

To recover, flight manuals call for the pilot to lower the nose to regain speed and lift. But Norman pulled hard again on the control stick, pushing the nose up.

"The initial hard pull on the control stick was above the 'G' (force) level that had been briefed for the practice and air-show flyby," Rabens wrote in his endorsement of the investigation findings.

"The reason for the second hard pull is unknown, although it may have been an attempt to 'square the corner' of the turn to give the appearance of a sharp break."

After the second pull on the control stick, the engine compressors stalled, causing two short flashes of flame from the left engine. The blasts prompted initial speculation that the 34-year-old plane had suffered a mechanical malfunction or that a bird had flown into the engine.

Now in a stall, the jet began to wobble, then rolled to the right 120 degrees to a nearly inverted position. Norman was able to pull the wing back up to 90 degrees and get the nose down, but the plane was plummeting fast toward the ground.

It took five seconds from the moment the plane began to veer off course to impact.

In that small window of time, both crew members had little opportunity to safely eject, investigators found. Muhs, 31, ejected at 150 feet, followed by Norman at nearly ground level. The ejection mechanisms were in working order, investigators found.

A video shot by a spectator shows Muhs, who was in the back of the two-seater jet, got clear briefly from the jet seconds before it hit the ground in front of 25,000 spectators. But his parachute never opened and he plunged through a huge orange fireball into the ground. Both men died of blunt-force trauma from striking the ground, autopsies showed.

The plane dug a deep crater in the fallow field east of Casper Road in Oxnard, where it crashed about 12:15 p.m. Wreckage was strewn over a swath 350 yards long and 100 yards wide. No one on the ground was hurt.

Investigators concluded that Norman did not account for the weight of 8,000 pounds of fuel on board, which was about 4,000 pounds more than the plane was carrying during a practice run three days earlier. The fuel shifted during the sharp break maneuver and changed the Phantom's center of gravity.

The report found there was no discussion of the heavier weight among the pilots before they broke formation -- something that should have occurred, investigators found.

Although "an experienced aviator would normally recognize (the different fuel) condition and adjust as needed to fly the aircraft ... more awareness about the inexperience of the pilot (Norman) with regard to the heavy landing condition should have resulted in calls before the break such as, 'QF-4s, you're/we're heavy, watch the pull,' " the report states.

Rabens said the Navy investigation was exceptionally thorough and "determined to get to the truth."

"We sent the engines and parts to technical experts who took a lot of time going over (the wreckage)," Rabens said. "These guys are like the CSI team of forensic experts for airplanes. We wanted to make sure that there was nothing wrong with that airplane that could endanger someone else's life."

The investigative team included an aviation safety officer, flight surgeon, operations representative, maintenance representative and the squadron's senior officer, said Teri Reid, spokeswoman for Naval Base Ventura County. A member of the Naval Safety Center in Norfolk also assisted with the investigation.

After the crash, former civilian employees -- some with pending wrongful-termination lawsuits against the Navy -- came forward with complaints about management, record-keeping and high turnover at the base. Investigators discovered a history of "significant discrepancies" in paperwork on the QF-4S that crashed, but "no evidence of any kind could be found which showed any maintenance-related activity contributed to this mishap," according to the report.

The Phantom that crashed, valued at $1.66 million, was a recent arrival from the Naval Aviation Depot Cherry Point in North Carolina, where it was converted into a drone. Before it was shipped in January, the maintenance crew at Cherry Point performed a complete overhaul of the airplane, documentation obtained under the Freedom of Information Act shows.

The NAVAIR Point Mugu squadron has 22 QF-4s, of which eight to 10 are bagged and preserved for future use. The drones can be flown by pilots or controlled as targets by remote control from the ground.

The investigation's findings have prompted Navy officials to raise standards for pilots in Point Mugu's QF-4 program. Under the new standards, Norman would not have been allowed to fly in the air show.

Only pilots with a minimum of 200 flight hours on F-4s of all types and 600 to 800 hours of tactical jet experience such as flying in formation will now be assigned to fly QF-4s.

As a result of the crash, the F-14 Tomcats and QF-4s in the squadron Norman flew in, nicknamed the Bloodhounds, will no longer participate in Point Mugu air shows, Reid said. Whether a show will be held this year remains uncertain, largely because of difficulty booking a military jet precision flying team such as the Navy's Blue Angels.

Norman lived in Camarillo with his wife and two young daughters. Muhs lived with his wife on the Point Mugu base.

Norman was born in Mount Airy, N.C., became a naval aviator in 1987 and flew for American Airlines for several years. He later returned to military life and served as a flight instructor at the naval air station in Kingsville, Texas. In 2001, he became the director of F-4 operations at the base.

Originally from Maryland, Muhs obtained his aerospace engineering degree in 1994 from the University of Maryland's A.J. Clark School of Engineering.

What's the difference between a regular F4 & a QF4?

I thought Q designated a target drone, but I must be wrong since it had a pilot

5 posted on 03/13/2003 6:22:57 PM PST by jaz.357 (When Jessica Lange marries one of the dads of her children,, she can start talking about morality.)

I downloaded that video and watched it again yesterday. It may have been pilot error, but I would like an explanation for the black puffs which started coming from the engines just before the stall occured. It appeared that one of the engines was burping and sputtering.

Both the Air Force & Marines still have a few in service (not many, but a few)

As late as 2000 McDonnell Douglas Phantom Works rebuilt several F4 Wild Weasels for the Air Force

If they were smart they would sell them instead of using them as drones, I would buy one

I know a guy that spent around $500,000 on a Saab Draken, I bet a F4 would go for a lot more

As the article explains, the extreme angle of attack change resulting from excessive stick input stalled the compressor on the engine.

He was straight & level when the white puffs started. He was at an extreme angle when the backfire with sprouts of flame started. I would like to know what caused the white puffs.

This one's in private hands and I bet you're right, there's got to be more than a half million wrapped up in this one.

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