Los Angeles Times
March 4, 2009

Poor Maintenance, Errors Caused Crash
Marine investigation finds that squadron bosses gave a pilot
incorrect
instruction in a crash that killed 4.

By Tony Perry

SAN DIEGO -- The F/A-18 crash that killed four family members in a
San
Diego neighborhood on Dec. 8 was caused by poor maintenance on the
plane
and a series of critical errors by the pilot and officers trying to
guide
him to an emergency landing, a Marine investigation report released
Tuesday
concluded.

Among the worst of the mistakes was the pilot's decision, made with
his
squadron bosses, to bypass a runway on Coronado and attempt to land at
Miramar Marine Corps Air Station, 11 miles farther away. The pilot
could
easily have landed his jet at the closer North Island Naval Air
Station,
the investigation concluded.

Four top squadron officers at Miramar have been relieved of duty.
The investigation found that the commanding officer, operations
officer, aviation maintenance officer and operations duty officer
violated emergency procedures, gave incorrect instructions to the
pilot,
did not adequately check on the plane's location and failed to note
the
pilot's warning that his plane's only functioning engine had fuel
problems.

Eight other Marines and a sailor have also been punished. The pilot,
Lt. Dan Neubauer, who was still in training, has been grounded. The
deputy commandant for aviation will decide whether he is allowed to
resume
flying.
"While we did not find any evidence of criminal wrongdoing, the
responsibleparties are being held accountable for their part in this
tragic accident,"said Maj. Gen. Randolph Alles, an F/A-18 pilot and
assistant commander of the Miramar-based 3rd Marine Aircraft Wing.
Also on Tuesday, Marine brass briefed politicians in Washington and
San
Diego, as well as Dong Yun Yoon, whose wife, two young daughters and
mother-in-law were killed when the plane smashed into their home.

As a result of the crash, the Marines have upgraded their
maintenance
standards and changed their emergency training. Flight simulators will
now
include a scenario like the one the F/A-18 pilot faced, officials
said.

Minutes after taking off from the carrier Abraham Lincoln, which was
a
little more than 100 miles southwest of North Island, Neubauer
reported low oil pressure in the plane's right engine. As a safety
precaution, he shut down the engine.

The F/A-18, nicknamed the Hornet, is designed to fly on one engine
in
cases where the fighter jet might be damaged by enemy fire and need to
return to a carrier or land base.
After he turned off the engine, Neubauer did not scan lists pilots
are
supposed to check when mechanical problems occur in the air. Ground
personnel at Miramar read him parts of those lists but omitted key
parts,
the investigation found.

The pilot was instructed by the carrier captain and "air-boss" to
land
at North Island, which can be approached over the ocean. Instead,
Neubauer and his squadron bosses decided to attempt an emergency
landing at Miramar, where the squadron is based. That meant the jet
would
have to fly over the densely populated University City neighborhood.

The flight officers at Miramar also failed to take note when the
pilot
reported that a light indicated he was low on fuel for the left
engine, a "critical mistake," according to the investigation.

As Neubauer prepared to land at Miramar, the left engine "flamed
out"
and lost power for lack of fuel. The pilot attempted to crash in a
canyon,
but the 30,000-pound plane, traveling an estimated 150 mph, was out of
his
control. If the plane had stayed aloft just two more seconds, it would
have
slammed into the canyon behind the homes.

The investigation found that, for months, maintenance personnel had
ignored problems with the fuel flow to the left engine and had
certified
the plane as fit to fly. The problem was not listed on F/A-18
regulations
as requiring immediate attention.

Still, allowing the plane to fly "was collectively poor judgment on
the part of the squadron's maintenance department," said Col. John
Rupp, operations officer for the 3rd Marine Aircraft Wing.
Tactics used by the pilot, and suggested by the ground personnel,
exacerbated those fuel-flow problems and led the left engine to be
deprived of fuel, even though the plane's tanks had thousands of
pounds
of fuel. The pilot's final error was to make a left-turning loop to
line up
his approach to Miramar because he thought, incorrectly, that he could
not
turn toward the inoperative right engine. The turn took 90 seconds to
accomplish and, for mechanical reasons, deprived the left engine of
fuel.

At the point the left engine conked out for lack of fuel, the plane
was just seconds from landing at Miramar. When it crashed, it spread
jet fuel and metal parts throughout the neighborhood.
From engine flameout to crash took just 21 seconds.
Neubauer held on for 17 of those seconds and then ejected at
approximately 400 feet; if he had waited a second or two longer, he
probably would have been killed, the investigation concluded.

The plane clipped a tree and skidded along Cather Avenue before
smashing into the Yoon home. Two homes were destroyed and three
others
damaged.

After the crash, Marine Corps officials sent a bulletin to
squadrons
around the world telling them of the engine and fuel problems. The
Navy
and Marine Corps found 40 F/A-18s with the same problems, Alles said,
but
none have crashed.