Word Count: 489
Pairing/Focus: Zak, Kara, Cain
Summary: Military review of Zak's death Written as a Memo
MEMORADUM FOR COMMANDER, COLONIAL FLEET BASIC FLIGHT SCHOOL, PICON TRAINING COMMAND.
FROM: CPT. JILL A. CAIN, OIC, INCIDENT REVIEW BOARD: CASE A-52-03, PICON TRAINING COMMAND
SUBJECT: EXECUTIVE SUMMARY AND RECOMMENDATION; TRAINING VIPER MISHAP, CASE A-52-03
The Picon Fleet investigation team has determined that poor situational awareness was the likely cause of a Mark VII crash in the Briel Aerial Training Range, Picon Colony.
Lieutenant (jg) Zachary R. Adama, of flight class 2013-02, CF BASIC FLIGHT SCHOOL, PICON FLEET was killed from injuries when the Viper Mark VII he was flying crashed into Grand Lake located within the Briel Aerial Training Range.
Neither Lieutenant (jg) Zachary R. Adama nor Lieutenant Kara Thrace, an instructor pilot flying another Viper Mark VII, gained enough situational awareness of a low-altitude condition early enough to prevent the crash, according to the investigation team.
Lieutenant (jg) Adama was flying lead in a two-ship training formation over Grand Lake when the mishap occurred. On the final check mission of the day he unknowingly set-up and began an engagement 1000 feet above the briefed “floor” altitude limit of 5,000 feet.
Immediately after Lieutenant Thrace made the “execution” call, Lieutenant (jg) Adama began a series of maneuvers resulting in the Viper descending below the altitude limit. When he realized his altitude he immediately called “terminate” and began recovery. Three seconds later he ejected and the viper hit the water one second later.
Search-and-Rescue recovered Lieutenant Adama’s body after about 45 minutes. The base coroner found that he had broken his neck during ejection and was killed instantly.
Investigators determined Lieutenant (jg) Adama failed to crosscheck his aircraft’s altitude during the mission engagement and did not know his altitude or proximity to the water until he reached about 1500 feet above the lake level.
Investigators also determined Lieutenant Thrace failed to recognize the non-standard set up before the start of the mission. Lieutenant Thrace was not aware of either aircraft’s proximity to the floor or the water until the mishap aircraft hit the water, at which time she recovered her own Viper 250 feet above the water.
Conclusion of the board is that there is clear and convincing evidence that pilot error was the cause for the crash. Lieutenant (jg) Adama, who had recently flight qualified, was inexperienced and lacked situational awareness, that led to the crash. Also it is the conclusion of board that Lieutenant Thrace, the supervising instructor pilot, failed to properly brief the student on the aerial range’s safety guidelines, and also lacked situational awareness until it was too late.
It is the Incident Review Board’s recommendation that Lieutenant Thrace be suspended from flight status, and relieved of her instructor’s billet with Picon Training Command, and that her promotion points be rescinded. Lieutenant Thrace had been notified of the investigation team’s findings and had waiver her rights to contest the points of fact.
Signed Jill A. Cain Captain, Colonial Fleet Flight Safety Officer Picon Training Command