Miramar crash update

[+Typhoid 231]

a very sad, tragic and preventable crash.

 

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13 Disciplined in Fatal Hornet Crash

March 04, 2009

 

Associated Press

 

SAN DIEGO - A pilot struggling to control a crippled Marine Corps jet bypassed a chance to land at a coastal Navy base and instead flew toward an inland base, where minutes later the fighter crashed into a San Diego neighborhood and killed four people, recordings released Tuesday revealed.

 

Meanwhile, military officials say that four officers at Marine Corps Air Station Miramar have been relieved of duty in connection with the fatal crash and nine other military personnel received lesser reprimands. Officials said the 13 were disciplined for a series of avoidable mechanical and human errors that led to the crash, which killed four members of the same family, including two children.

 

"It was collectively bad decision-making," said Col. John Rupp, operations officer for the 3rd Marine Aircraft Wing at Marine Corps Air Station Miramar.

 

Hear the entire audio transmission.

 

Recordings of conversations between federal air controllers and the pilot of the F/A-18D Hornet show the pilot repeatedly was offered a chance to land the plane at the Naval Air Station North Island in Coronado. The base sits at the tip of a peninsula with a flight path over water.

 

Instead, the Federal Aviation Administration tapes disclose, the pilot decided to fly the jet, which had lost one engine and was showing signs of trouble with the second, to the inland Miramar base, which is about 10 miles north of Coronado.

 

That route took him over the University City neighborhood, where the Dec. 8 crash incinerated two homes and damaged three others.

 

"This was a tragic incident that could have been prevented," Rep. Duncan Hunter, R-Calif., who was among the lawmakers who received a closed-door briefing Tuesday on the results of the Marine Corps' investigation into the crash, said in a statement.

 

The pilot and senior officers "did not consult their checklists and follow appropriate procedure," Hunter said. Had those rules been followed, "the crash would not have occurred."

 

Four officers at Miramar have been relieved of duty for failing to follow safety procedures and allowing the Hornet to fly over the residential area, while nine other military personnel received lesser reprimands.

 

According to the military, the jet's right engine went out due to an oil leak shortly after the fighter left the deck of the Navy aircraft carrier Abraham Lincoln on a training flight. The aircraft can fly on one engine, so losing power in one of the General Electric turbofan engines was not cause for extreme concern.

 

At the same time, the plane was having trouble moving fuel from its tanks to the engines. Marine Corps aviation rules dictate that a plane with such a combination of mechanical failures should land immediately. The investigation determined the best and safest option was to bring the aircraft down at Coronado, not Miramar.

 

As the jet approached Miramar, the left engine failed because it was getting too little fuel, leaving the plane without power. Seventeen seconds later, the pilot ejected.

 

"This plane should not have even been in use," Rep. Susan Davis, D-Calif., said in a statement. "There was ambiguity as to whether this particular aircraft should have been grounded due to the mechanical concerns."

 

It's difficult to determine the pilot's precise location from the tapes, but he reported his position as 20 miles south of Coronado, flying at 13,000 feet with 20 to 30 minutes of fuel remaining, less than a minute before he was asked by controllers if he wanted to land at Coronado, according to the recordings.

 

When air controllers told him a runway was available at Coronado, the pilot said, "I'm actually going to try to take it to Miramar if possible."

 

According to the tapes, air controllers gave the pilot instructions that would allow for a landing at Coronado or Miramar. At one point he was given a heading to follow but indicated he was having trouble with the jet.

 

"I'm trying, sir, but single engine," the pilot said.

 

The pilot said he wanted to land at Miramar and told controllers to have emergency crews ready on the ground.

 

The pilot told the air controllers at one point he was within sight of Miramar, but about two minutes later, according to the tapes, an unidentified pilot reported seeing smoke on the ground near Miramar.

 

The pilot ejected safely. The Marine Corps has not decided whether to discipline him, Hunter told The Associated Press.

 

Four members of a Korean family were killed in their home - Young Mi Yoon, 36; her daughters Grace, 15 months, and Rachel, 2 months; and her mother Suk Im Kim, 60. Kim was visiting from South Korea to help her daughter move across town and adjust to the arrival of her second child.

 

Marine generals initially defended the choice to send the Hornet to Miramar. Since the crash, a lingering question has been why the pilot didn't attempt a landing at Coronado over open water.

 

The tapes indicate that the ailing jet was closer to Coronado when the pilot reported a possible problem with the second engine. Miramar is ringed by freeways and bordered on its western end by residential areas that include a high school.

 

Miramar dates to 1917, when the site was used to train troops headed to World War I. As late as the 1950s, it was still miles beyond San Diego's urban fringe, but homes have since been built right up to the edge of the base, where the Navy established its "Top Gun" fighter training school in 1969.

[FastCargo 412]

Thanks for the update. I'd be curious as to why the pilot was set on Miramar. I've always been taught that if I'm single engine, to land ASAP at the nearest suitable field.

 

However, it is always easy to second guess while at zero airspeed and altitude.

 

FC

[+Typhoid 231]

some more details in this report

 

http://www3.signonsandiego.com/stories/200...c/?zIndex=61668

 

I am appalled at some of the stuff reported in here by the accident investigation board.

[+GrinchWSLG 24]

Thanks for the update. I'd be curious as to why the pilot was set on Miramar. I've always been taught that if I'm single engine, to land ASAP at the nearest suitable field.

 

However, it is always easy to second guess while at zero airspeed and altitude.

 

FC

 

I'd hazard a guess that it was stress induced fixation. He was set on Miramar and just couldn't see any other alternative properly.

 

Interesting series of events, you can see the typical chain of mistakes that lead to just about any aviation accident. Really surprised to see a professional pilot disregard his checklist, but he isn't the first and won't be the last. I wonder though if the way the military punishes their officers and enlisted men whether that leads to covering up of possible problems. I know this is why you cannot be charged criminally for an accident, to keep people open and willing to cooperate. Granted, even in the civilian field you'd be fired for having the responsibility that lead to the accident, but it seems losing a military career would affect a person a bit more.

[serverandenforcer 33]

Holy S! I definately did not expect the situation was that jacked up. The pilot could've easily brought it in to North Island. I think it's guranteed that his career is over and will possibly face criminal charges. All I can see here is incompetence and laziness of the extreme order.

[+GrinchWSLG 24]

Holy S! I definately did not expect the situation was that jacked up. The pilot could've easily brought it in to North Island. I think it's guranteed that his career is over and will possibly face criminal charges. All I can see here is incompetence and laziness of the extreme order.

 

No, I highly doubt he will face criminal charges. It was an accident caused by bad maintenance, poor management, and bad decision making. The only way he would face criminal charges is if he purposely crashed the aircraft into that house, which he obviously did not.

 

At least that's the way it works in the civil field, but I'd be surprised if the military would be any different.

[FastCargo 412]

Actually, it depends.

 

The problem here is it looks like he let the folks on the ground 'fly' his aircraft for him. This isn't the first time this sort of thing has happened...usually to someone inexperienced in the aircraft.

 

A similiar situation happened WAY back while I was going through pilot training. An IP in our flight, relatively new in the aircraft, was in the air with one of my classmates, when they got an asymmetric flap indication.

 

Instead of fully following the checklist, he got on the horn with the SOF, who got on the phone with Stan/Eval and Northrop. They tried all sort of troubleshooting, pulling CBs, Aux Flap, etc, all based on guidance from the 'experts' on the ground.

 

They basically ended up getting him into a FULLY asymmetric flap condition instead of his original slight asymmetric flap.

 

He was able to land the aircraft, with great difficulty. He and the student had to keep switching off who was flying because they were getting fatigued holding the stick at near full deflection.

 

After landing, they find out that until that point...a full asymmetric flap condition had not been considered landable.

 

So much for the ground experts.

 

Ultimately, it's still your ass in that seat, therefore, like I teach my students, take charge. Don't let the guy sitting in his comfy chair on the ground cause you to make bad decisions. Make sure he gets you the info you need, but then you make the decision.

 

FC

[+Jug 99]

Actually, it depends.

 

The problem here is it looks like he let the folks on the ground 'fly' his aircraft for him. This isn't the first time this sort of thing has happened...usually to someone inexperienced in the aircraft.

 

A similiar situation happened WAY back while I was going through pilot training. An IP in our flight, relatively new in the aircraft, was in the air with one of my classmates, when they got an asymmetric flap indication.

 

Instead of fully following the checklist, he got on the horn with the SOF, who got on the phone with Stan/Eval and Northrop. They tried all sort of troubleshooting, pulling CBs, Aux Flap, etc, all based on guidance from the 'experts' on the ground.

 

They basically ended up getting him into a FULLY asymmetric flap condition instead of his original slight asymmetric flap.

 

He was able to land the aircraft, with great difficulty. He and the student had to keep switching off who was flying because they were getting fatigued holding the stick at near full deflection.

 

After landing, they find out that until that point...a full asymmetric flap condition had not been considered landable.

 

So much for the ground experts.

 

Ultimately, it's still your ass in that seat, therefore, like I teach my students, take charge. Don't let the guy sitting in his comfy chair on the ground cause you to make bad decisions. Make sure he gets you the info you need, but then you make the decision.

 

FC

Never, repeat never, pass up a good airpatch with a bad jet. Rule of thumb that most aviators learn early. This one didn't get the message.

[firehawkordy 34]

Coming from the Maintenance side of Naval Aviation I have to say that I am appalled at what has been reported. I had it hammered into my head that we were to ALWAYS use our check lists. Now you know why it's been said "checklists are written in blood". I want to know what was going on in that units Maintenance Control office, who the hell thought it was good to allow an aircraft to fly with a known engine gripe? If I had my way the senior enlisted maintenance staff should be sacked and gone. Safety is never tobe sacrificed for operational commitments, I heard that for 20 years, right out of the Naval Safety Office, the same office that tells the Marines the same thing.

 

Four relived and nine others disciplined? Good, I hope the pilot faces some form of punishment also, if only for not going to the first field available.

 

I'm going stop ranting before I say something about nugget pilots that I shouldn't.

Edited March 5, 2009 by firehawkordy

[gbnavy61 1]

The problem here is it looks like he let the folks on the ground 'fly' his aircraft for him. This isn't the first time this sort of thing has happened...usually to someone inexperienced in the aircraft.

 

Exactly what I was thinking. More than likely, this was a less experienced pilot since: 1) Miramar is the home of the F/A-18C FRS, and 2) the Lincoln and the Reagan were both out there doing CQ related activities.

 

Just as FC said, it seemed like he left too much decision-making up to the guys on the ground and they put him in a tight spot. I don't know what exactly the "checklist" was that was not followed, but if the compounding factors (bird was questionable on the ground, potential difficulties with the remaining engine, fuel not feeding properly) were really present then, North Island would have been the better choice. It's closer, better weather, has the same crash-fire-rescue resources, arresting gear, etc. Seems like poor headwork all the way around.

 

But, with that said, I wasn't the one in the hot seat.

[fallenphoenix1986 603]

If it is accurate that the pilots on the squadron were aware of the maintenance condition of this jet yet continued to fly it anyway then he may be liable for criminal negligence, ie. a potentially catostrophic fuel system problem was left uncorected for months. 146 flights in an aircraft that is known to have a crippling flaw is utterly unforgivable.

 

As to not looking at checklists maybey we can put this down to being a highly stressed rookie however, SOP in the event of an engine failure is land as soon as possible and that is drummed into you before you are allowed in the jet. So there isn't really any excuse that I can see for passing up North Island, even more so for the fact that it is an overwater approach.

 

Craig

Edited March 5, 2009 by fallenphoenix1986

[+CrimsonRoamer 1]

Looks like charlielima was right in the first topic, micromanaged until he had two bad decisions left.

 

That said, not every pilot who gets into trouble can be a master aviator.

[+Typhoid 231]

Looks like charlielima was right in the first topic, micromanaged until he had two bad decisions left.

 

That said, not every pilot who gets into trouble can be a master aviator.

 

 

that appears to be absolutely what happened here. He was talking to his squadron CO and Ops officer at Miramar who wanted to bring him home for maintenance rather than have him park it someplace else. And in coaching him over the radio (standard practice by the way) they failed to open the relevant checklists (NOT standard practice!!), and led this young student pilot down the primrose path to disaster.

 

As in almost every accident that I've read of, its a chain of events each of which by itself would not have caused the accident and any one of which could have prevented it had that chain been broken. Such was the case here. In each part of the sequence of events, the opportunity to prevent the accident was there, but in each part they all continued and contributed to the eventual disaster.

 

My take on this is based on my being an NFO, a squadron maintenance officer working under the same Naval Aviation Maintenance Program this squadron did, having been an NFO instructor at a RAG at Miramar, having flown in the same airspace, in the same training environment both as a student as an instructor and then as an Evaluator (Stan Eval to our Air Force brothers) and having also been in a twin engined with one fan not fanning, in the same airspace. (We went to San Clemente that day.)

 

When I was the Maintenance Officer in a squadron, I had at one point maintenance dets spread out across the Western Pacific on four different islands retrieving broken planes that had been safely landed at divert fields rather than pressed on to home plate. When I was at Miramar in the RAG - we had planes diverted to North Island, San Clemente and even El Centro that had problems in flight. The closest piece of concrete was where anyone went in an emergency (and E-2's certainly had their share of emergencies). It is completely inexplicable that two perfectly good airfields were passed up for this guy to press on - at the specific direction of his squadron CO over the radio.

 

He again passed up the chance to avoid an accident when he did his loop out over the Pacific. Listening to the controller audio (before I looked at the chart with his track on it) I heard the controller give him a right vector for a final straight in - and the pilot replied that he was in a left turn. You can hear the controllers surprise and I was too - no reason for that left turn. That left turn caused him to loose his fuel pressure and lost him the time and distance that could have made the field for him. The stated reason was their misconception that a right turn would aggravate his fuel pressure problem - in fact it contributed to that and was probably a direct contributory factor in the disaster.

 

and why in God's name would he LAUNCH from the ship a hundred miles out to sea and check in with an emergency almost immediately with only 20 minutes of fuel?!!!!!!

 

the term is cluster ............

[+Dave 2,322]

You know being a C2 controller, we live and die by our checklists. Since reading this report I am just shaking my head. YOU ALWAYS USE THE CHECKLIST FIRST. ALWAYS ALWAYS ALWAYS! Its beat into our heads, and that is what should of been done.

[charlielima 328]

Bravo Zulu Typhoid

"The closest piece of concrete was where anyone went in an emergency"

For us on the SH-3H it was usually a mall parking lot because of a transmission chip light on a thursday or friday night between cruises when the aircrew, maintenance guys, Skipper and XO had plans after the bird was back to North Island that early evening or even afternoon.

 

Oh Yah, Back to my first question:

Why didn't he land at North Island, San Clemente Island, or even Imperial Beech?

The good sticks I flew with had thier own personnall checklists that seemed to work for them, me, and anybody that has a healthy aversion to large pieces of aluminum falling from the sky.

:ph34r: CL