On December 8, 2008 a Marine Corps jet crashed near my house, killing four civilians. The USMC did a thorough investigation and held a press conference about the results, complete with powerpoints. However, I was not able to find the actual report anywhere. I eventually filed a FOIA request, and got a redacted version of the report and all its attachments.
The crash fit a common pattern: a lot of small mistakes, by a variety of people, added up to a disaster. It was not just the pilot at fault, although he was certainly involved.
Because these reports were hard to get, and will be of interest to others, I’m putting them up on this site. If I can find a better (more relevant) repository, I’ll also post it there.
There is a lot of bureaucratic material in the reports. I will gradually post all of it. Questions are welcome – use the Comments section.
From: Commanding General, Third Marine Aircraft Wing
Subj: COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE F/A-18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DIEGO, CA
1. Having carefully reviewed the subject investigation, the findings of facts, opinions, and recommendations of the investigating officer are approved except Opinions 26 and 27 and Recommendations 4 and 5, which are disapproved.
2. This tragic accident was the result of mechanical failures: first with the right engine, necessitating its precautionary shutdown, then with the fuel transfer system, ultimately causing the left engine to run out of useable fuel despite the presence of ample quantities of fuel in other tanks. Nevertheless, as borne out in the investigation, this tragedy was avoidable; any one of the following could have prevented this incident: more aggressive maintenance procedures; clearer guidance in maintenance publications; improved integration and supervisory oversight within the squadron Maintenance Division; increased training, situational awareness, and better decision-making by the pilot and squadron personnel directing the aircraft from the ground.
3. By all measureable [sic] standards, Marine Fighter Attack Training Squadron 101 (VMFAT-101) was performing its mission both safely and satisfactorily prior to this mishap. However, the squadron’s leadership failed in a number of areas leading up to and during this incident. Accordingly, I have taken the following steps regarding personnel accountability: [end of excerpt]