Accident involving F-35B ZM152 on HMS Queen Elizabeth on 17 November 2021
The inquiry determined that a plastic engine intake cover ("blank") was accidentally left in place, causing a sudden loss of thrust that forced the pilot to eject as the £82m stealth jet rolled off the carrier’s ramp into the Mediterranean.
On 17 November 2021, during the maiden operational deployment of HMS Queen Elizabeth (Operation FORTIS), a British F-35B Lightning II—serial number ZM152—failed to launch successfully. As the aircraft accelerated down the "ski jump" ramp, the pilot noticed a significant power deficit. Despite selecting maximum afterburner, the jet reached the end of the ramp with insufficient speed to achieve flight. The pilot ejected just as the aircraft cleared the deck, landing safely on the carrier via parachute, while the jet plunged into the sea.
The subsequent Service Inquiry, conducted by the Defence Safety Authority (DSA), was exhaustive, involving the recovery of the wreckage from a depth of over 2,000 metres to prevent sensitive technology from falling into hostile hands. The physical evidence confirmed the "causal factor": a reinforced plastic intake blank (part of the "red gear" used to protect the engine from debris) had been sucked into the left-hand engine intake. This obstruction restricted airflow so severely that the engine could only produce roughly 74% of the required thrust.
The report delved deeply into the human and organisational factors that allowed this "simple" mistake to occur. It highlighted a "perfect storm" of contributory issues. Firstly, the design of the intake blanks was criticised; they were not tethered to the aircraft, making them harder to account for. Secondly, the inquiry noted significant personnel fatigue; the crew had been operating at a high tempo for months, and the engineering team was understaffed. Crucially, a "red gear" check was missed because the engineering supervisor was distracted by other tasks, and there was no formalised system to verify that all covers had been removed before flight.
Furthermore, the inquiry found that security protocols—designed to protect the F-35's secret technology—had inadvertently hindered safety. Some maintenance discussions were held in restricted areas where not all relevant personnel could attend, leading to "siloed" information. By January 2026, this incident remains a landmark case study in "Human Factors Integration," illustrating how even the most advanced military technology in the world can be defeated by a single piece of plastic and a lapse in basic procedural discipline.
Key numbers at a glance
46
Recommendations
Months to complete
Cost in millions (if known)
0
Deaths (direct)
Recommendations
Recommendation Category | Summary of Advice | Current Implementation Status |
Equipment Design | Redesign of engine "red gear" to include tethers and high-visibility markers. | Implemented (Modified gear issued to all UK F-35 squadrons). |
Personnel & Fatigue | Review of manning levels for Carrier Strike Group deployments to reduce burnout. | In Progress (Revised rest-period mandates implemented in 2025). |
Operational Procedure | Introduction of a "second-set-of-eyes" protocol for intake inspections. | Implemented (Standardised across RAF/Royal Navy Lightning Force). |
Security vs Safety | Re-evaluation of "Siloed" working environments to ensure safety info is shared. | Implemented (New multi-disciplinary briefing structures adopted). |
Resource Management | Enhanced tracking systems for all loose equipment on the flight deck. | In Progress (Digital tool-tracking trials ongoing as of 2026). |
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