Marines: Mechanical, human errors led to jet crash - East Valley Tribune: Nation / World

Marines: Mechanical, human errors led to jet crash

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Posted: Wednesday, March 4, 2009 12:12 am | Updated: 12:53 am, Sat Oct 8, 2011.

SAN DIEGO - A military jet crash that killed four people and incinerated two homes was caused by mechanical failure and a string of bad decisions that led the pilot to bypass a potentially safe landing at a coastal Navy base, the Marines said Tuesday.

The military disciplined 13 members of the Marines and the Navy for a series of errors that led to the crash. Low oil pressure killed the jet's first engine, and the second died when fuel stopped flowing from the tank.

Recordings of conversations between federal air controllers and the pilot of the F/A-18D Hornet show the pilot, Lt. Dan Neubauer, was repeatedly 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 pilot decided to fly the jet, which had lost one engine and was showing signs of trouble with the second, to Marine Corps Air Station Miramar, which is about 10 miles north of Coronado, the Federal Aviation Administration tapes disclose.

Col. John Rupp, operations officer for the 3rd Marine Aircraft Wing at Miramar, said there was "collectively bad decision-making" by officers in San Diego who told the pilot to land at the inland base. He faulted the pilot for neglecting to consult a checklist of emergency procedures and for failing to grasp the severity of his problems.

The first engine indicated low oil pressure 10 minutes into the 47-minute training flight, which began from the carrier USS Abraham Lincoln off the San Diego coast, Rupp said. The pilot shut off the engine seven minutes later.

A squadron representative on the aircraft carrier told the pilot to land at North Island, which was a "conservative and prudent decision," Rupp said.

A low-fuel warning occurred 25 minutes into the flight, when the plane was 61 miles off the coast from North Island, he said.

Officers at Miramar, including the squadron's commanding officer, cleared the pilot to go to the inland base, favoring Miramar's longer runway and assuming the pilot was closer to the base than he actually was, Rupp said.

The plane had about 340 gallons of fuel when the pilot safely ejected, crashing two miles from the runway in a residential neighborhood, the Marines said. Two homes were destroyed and three others were damaged.

Potential problems with the plane's fuel transfer surfaced in July, but the Marines sent the aircraft on 146 more flights before it crashed.

The dozens of successful flights after the warning "lured the maintenance personnel into a state of complacency," Rupp said. "More effective maintenance practices and stronger supervision in the maintenance department could have directed further troubleshooting prior to this flight."

Col. Kurt Brubaker, staff judge advocate of the 3rd Marine Aircraft Wing, said no one person shouldered the brunt of the blame.

"Collectively, there were a number of judgment errors," he said.

Four officers in Miramar-based Marine Fighter Attack Training Squadron 101, including the commanding officer, have been relieved of duty for failing to follow safety procedures and allowing the Hornet to fly over the residential area. Nine other Marine and Navy personnel received lesser reprimands.

The pilot has not been disciplined but his actions are under review by Marine Corps headquarters.

The findings drew quick reaction from members of Congress.

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

"This plane should not have even been in use," Rep. Susan Davis, a San Diego Democrat, 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.

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.

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