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(b)(3), (b)(6)

(b)(5)

(b)(5)

(b)(5)

(b)(5)

3D MARINE AIRCRAFT WING MARINE CORPS AIR STATION MIRAMAR

PoOo BOX 452038 SAN DIEGO, CA 92145-2038

MEMORANDUM FOR THE RECORD

From: To:

Commanding General, Third Marine Aircraft Wing Files

:N RF.P;,Y REfER TO:

5830 SJA

2 1

Subj: MODIFICATION TO FINAL ACTION ON COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE F/A-IS AIRC~~FT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEHBER 2008 IN UNIVERSITY CITY, SAN DIEGO, CA

Ref: (a) of 1 Mar 09 wI end

1. Per the reference I in action on the subject investigation, I previously approved the following recommendations:

discussions, to include with the model manager, have developed the consensus that such changes are unnecessary and in fact may have the undesired effect of creating confusion by inserting more variables into the decision-making process.

3. Accordingly, after much discussIon and deliberation, Recommendations 7 and 8 of the reference are disapproved and will not be pursued.

Copy to: D/C, Aviation DOSS SJA

. <-::::---r T. G. ROBLING V

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C) (b)(6), (b)(7)(C)

(b)(6), (b)(7)(C) (b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

LJr.lITED STATES MARINE CORPS 3D MARINE AIRCRAFr WING

MARINE CORPS AIR STATION MIRAMAR P.O. BOX 452038

SAN DIEGO, CALIFORNIA 92145·2038

IN REP!,Y REn:R TO:

5830 SJA

MAR 0 22009

FIRST ENDORSEMENT on ltr 5830 SJA of 1 Mar 09

From: To:

Subj:

Commanding General, Third Marine Aircraft Wing Files

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 fail ures: 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 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:

a. relieved for cause the following personnel from Commanding Officer;

Aircraft

57

(b)(5)

(b)(5)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

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

Training and Operations Procedures Standardization Officer and Operations Duty Officer at the time of the mishap.

b. The following individuals have received administrative measures 1 of refer~n~~

4. In addition to the corrective actions listed above and contained in Recommendations 6 - 13, the following additional information and recommendations are provided:

a. 3d Marine Aircraft Wing (3d MAW) has forma l ly requested that the Commander, Naval Air Forces/Naval Air Systems Command improve Maintenance Status Panel (MSP) code policy through a three-phased approach:

(a) Short-term: provide interim guidance to clarify MSP code management at the Group/Squadron level;

(b) Mid-term: provide an F/A-18A-D Critical MSP Code List; and

b. On 22 January 2009, the Commanding Officer, Marine Aircraft Group (MAG) 11 issued interim MSP management guidance, which provided to all MAG-11 F/A-18 squadrons enhanced pol i cy on critical fuel-system-related MSP codes, standardizat ion of trend analysis programs, and hot-pit and refueling procedures.

58

(b)(5)

(b)(5)

(b)(5)

(b)(5)(b)(5)


c. The Assistant Chief of Staff, Aviation Logistics Division, is directed to conduct a comprehensive review of MAG and squadron "safe-for-flight" certification syllabi and procedures to ensure standardization within 3d MAW and to ensure compliance with governing directives.

d . The Assistant Chief of Staff, Aviation Logistics Division, shall review by-squadron compliance status for Maintenance Control Management Courses, take steps to attain full compliance where deficiencies exist, and coordinate with Headquarters, Marine Corps to improve the quality, effectiveness, and availability of these courses.

e. The Assistant Chief of Staff, G-3, is directed to ensure that all squadrons are conducting drills and training geared toward improving ready room procedures, particularly during in-flight emergencies.

5. Recommendation 10 is submitted to the Commanding General, Marine Corps Installations West for his consideration. Whi le the overall post-mishap response was well-coordinated and wellexecuted, I concur that providing Air Station Aircraft ' Rescue Fire Fighters with communications equipment compatible with local fire departments would enhance their ability to

59

(b)(6)

SUbj: COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE F/A- 18 AIRCRAFT MISHAP INVOLVING BUNO 1 640 17 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DIEGO, CA

6. Per reference (a), the Office of the Staff Judge Advocate will retain the original o f this investigation for a period of two years.

7. Our deepest sympathies are with the families and with all those affected.

Copy to: OJAG (Code 15) D/ C, Aviation CMC (JAD) AC/S, ALD AC/S, G-1 DOSS CO, MAG-ll CG, MCI-W SJA

-, . A3.?~ T. G. ROBLING (f

60

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

S u b j : COMMAND I NV E S TI G A TI O N I N T O THETHE F / A - 1 8 A I RCRA FT MI S HA P I NV O L V I NGOCCURRED O N 0 8 DECEMBER 2 0 0 8 I NDIEGO, C A

(1 0 ) E x c e r p t s f r o m MP P i l o t L o g b o o k(1 1 ) R A C P e r f o r m a n c e R e v i e w B o a r d(1 2 ) E x c e r p t s f r o m MP A i r c r e w(1 3 ) M S RP RB O r d e r 5 4 2 0 . 2

CIRCUMSTANCES SURROUNDINGBUNO 1 6 4 0 1 7 T HA T

UNIVERSITY C I T Y , S A N

(RPRB) r e p o r tP e r f o rma n c e R e c o r d

(1 4 ) Summary o f I n t e r v i e w w i t h (b)(6), (b)(7)(C) d t d 1 9Dec 0 8

(1 5 ) Summary o f I n t e r v i e w w i t h (b)(6), (b)(7)(C) d t d16 D e c 0 8

(1 6 ) S a f e f o r CQ l e t t e r d t d 1 D e c 0 8(1 7 ) E x c e r p t s f r o m NATOPS L a n d i n g S i g n a l O f fi c e r M a n u a l(1 8 ) S t a t e me n t o f ( b ) ( 6 ) , (b)(7)(C) t d 9 D e c 0 8(1 9 ) CQ G r a d e S u mma ry(2 0 ) USS L I NCO L N A i r p l a n , 8 D e c 0 8(2 1 ) P h o t o o f MS R e a d y Ro o m (US S L I NCO L N) F l i g h t S t a t u s

B o a rd(2 2 ) E x c e r p t s f r o m MAC A i r f r a m e L o g b o o k a n d P h a s e p a c k e t(2 3 ) E x c e r p t s f r o m MAC A i r c r a f t D i s c r e p a n c y B o o k (A D B )(2 4 ) E x c e r p t s f r o m MAC E n g i n e L o g b o o k(2 5 ) F i n a l E n g i n e e r i n • I n v e s t i g a t i o n R e p o r t s(2 6 ) S t a t e me n t o f (b ) (6 ) , (b)(7)(C) d 2 3 J a n 0 9(2 7 ) S t a t e me n t o f ( b ) ( 6 ) , (b)(7)(C) d t d 5 J a n 0 9(2 8 ) F / A -1 8 C / D MSP C o d e s P o c k e t G u i d e 2 0 X(2 9 ) Summary o f i n t e r v i e w w i t h (b)(6), (b)(7)(C) d t d

26 J a n 0 9(3 0 ) S t a t e me n t o f ( b ) ( 6 ) , (b)(7)(C) d t d 2 9 D e c 0 8(3 1 ) (b)(6), (b)(7)(C)E - m a i l f r o m d t d 5 F e b 0 9(3 2 ) Summary o f i n t e r v i e w w i t h (b)(6), (b)(7)(C) d t d 5 J a n 0 9(3 3 ) E x c e r p t o f P o w e r p l a n t s 1 1 0 P a s s Do wn L o g b o o k(3 4 ) O r g a n i z a t i o n M a i n t e n a n c e T e s t i n g a n d

T r o u b l e s h o o t i n g , F u e l S y s t e m , W o r k P a c k a g e ( A l -F l 8 A E -4 6 0 -2 1 0 )

(3 5 ) Summary o f I n t e r v i e w w i t h (b)(6), (b)(7)(C) d t d22 J a n 0 9

(3 6 ) E x c e r p t s o f C r a s h S u r v i v a b l e F l i g h t I n c i d e n tR e c o r d e r S y s t e m (C S F I R S ) F i n d i n g s

(3 7 ) 5 0 2 / 5 9 0 / 5 9 1 3 0 - d a y H i s t o r i c a l fi n d i n g s f r o m SAMEDa t a

(3 8 ) E x c e r p t s f r o m NATOPS F l i g h t M a n u a l N a v y M o d e l F A -1 8 A / B / C / D

(3 9 ) O v e r v i e w o f M a i n t e n a n c e R e c o r d s F a c t - F i n d i n g f o rM i s h a p , MA L S -1 1

(4 0 ) F / A -1 8 A / B / C / D M i s s i o n E s s e n t i a l S u b s y s t e m M a t r i x(MESM) a n d m o d i fi c a t i o n s t h e r e t o

2

(4 1 ) US MC F / A - 1 8 I n i t i a l T r a i n i n g P o w e r P o i n t p r e s e n t a t i o n(4 2 ) V MF A T -1 0 1 AMSRR, 8 D e c 0 8

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

S u b j : CO MMA ND I NV E S TI G A TI O N I N T O THE CIRCUMSTANCES SURROUNDINGTHE F / A - 1 8 A I RCRA FT MI S HA P I NV O L V I NG BUNO 1 6 4 0 1 7 T HA TOCCURRED O N 0 8 DECEMBER 2 0 0 8 I N UNI V E RS I TY C I T Y , S A NDIEGO, C A

(4 3 ) C o m b i n e d AMSRR f o r MA G -1 1 R E I N(4 4 ) C i v i l i a n C o n t r a c t o r P e r s o n n e l S u mma ry(4 5 ) S t a t e m e n t o f ( b ) ( 6 ) , (b)(7)(C) d t d 2 7 J a n 0 9(4 6 ) S t a t e m e n t o f ( 6 ) , ( 7 ) ) d t d 1 3 J a n 0 9(4 7 ) S u m m a r y o f I n t e r v i e w w i t h ( b ) ( 6 ) , (b)(7)(C) d t d

3 F e b 0 9(4 8 ) V MF A T -1 0 1 C a t e g o r y I F RS S y l l a b u s S u mma ry(4 9 ) N A S N o r t h I s l a n d A i r fi e l d I n f o r m a t i o n , A I R N A V . c o m(5 0 ) E x c e r p t s f r o m S o u t h w e s t Do D H i g h A l t i t u d e A p p r o a c h

P l a t e(5 1 ) I F R E n r o u t e S(5 2 ) E - m a i l f r o m(5 3 ) S t a t e m e n t o f

l e me n td t d 2 6 J a n 0 9

d t d 1 7 D e c 0 8(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(5 4 ) S u m m a r o f f o l l o w o n i n t e r v i e w w i t ht d 1 7 D e c 0 8(5 5 ) E x c e r p t s f r o m NATOPS I n s t r u m e n t F l i g h t M a n u a l(5 6 ) F A A SOCAL A p p r o a c h A u d i o T r a n s c r i p t(5 7 ) MCA S M i r a m a r A i r fi e l d I n f o r m a t i o n , A I R N A V . c o m(5 8 ) S t a t e m e n t s o f ( b ) ( 6 ) , (b)(7)(C) d t d 2 2 D e c 0 8 a n d9 J a n 0 9(5 9 ) S t a t e m e n t o f(6 0 ) E - m a i l f r o m(6 1 ) S t a t e m e n t o f(6 2 ) S t a t e m e n t o f(6 3 ) S t a t e m e n t o f( 6 4 ) S t a t e m e n t o f ( b ) ( 6 ) , (b)(7)(C)(6 5 ) N o t i c e t o A i r m e n (NO TA Ms) p o s t e d a t S q u a d r o n R e a d y

Room D e s k f o r NA S NI a n d M i r a m a r(66 ) U S S L I NCO L N ( C V N - 7 2 ) CA TCC A u d i o T r a n s c r i p t(6 7 ) E x c e r p t s f r o m NATOPS P o c k e t C h e c k l i s t ( P C L )(6 8 ) E x c e r p t s f r o m CV NATOPS M a n u a l(6 9 ) MA G -1 1 L o c a l A d d e n d u m t o SOP f o r USMC F / A - 1 8 F l i g h t

O p e r a t i o n s(7 0 ) S t a n d a r d O p e r a t i n g P r o c e d u r e s (S O P ) f o r USMC F / A - 1 8

F l i g h t O p e r a t i o n s(7 1 ) V MF A T -1 0 1 L o c a l A d d e n d u m t o USMC F / A - 1 8 S OP a n d MA G -

I ' A d d e n d u m(7 2 ) E x c e r p t s f r o m OPNAVINST 3 7 1 0 . 7 T(7 3 ) RA DE S d a t a p r i n t o u t(7 4 ) S t a t e m e n t o f (b )(6 ), (b)(7)(C) d t d 3 1 D e c 0 8(7 5 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t h

23 J a n 0 9(7 6 ) S t a t e m e n t o f(77 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t h (0 ) (6 ) , (0) (7) ( C ) d t d

23 J a n 0 9

(b)(6), (b)(7)(C)

3

(b)(6), (b)(7)(C)

d t d 1 7 D e c 0 8d t d 5 F e b 0 9

d t d 1 3 J a n 0 9d t d 5 J a n 0 9

d t d 2 3 D e c 0 8(USN) d t d 2 2 J a n 0 9

(b)(6), (b)(7)(C) d t d

d t d 1 6 D e c 0 8

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6)

(b)(6)

(b)(6)(b)(6)

(b)(6)

(b)(6)

(b)(6)


S t a t e me n t o f (b)(6), (b)(7)(C) d t d 8 Dec 0 8S t a t e me n t o f (b)(6), (b)(7)(C) d t d 8 D e c 0 8S t a t e me n t o f (b)(6), (b)(7)(C) d t d 31 D e c 08

(7 8 ) P h o t o o f MS E m e r g e n c y I n f o r m a t i o n B o a r d a n d MS R e a d yRoom ( M i r a m a r ) F l i g h t S t a t u s B o a r d

(7 9 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t hd t d 2 2 D e c 0 8

(8 0 )(8 1 )(8 2 )(8 3 ) P r i n t o u t o f s i m u l a t o r B I NG O d e s c e n t p r o fi l e a n d

su mma ry o f F u e l d i s c r e p a n c y o b s e r v e d i n s i m u l a t o r(8 4 ) W e a t h e r O b s e r v a t i o n R e p o r t s (A DDS ME TA R)(8 5 ) MCA S M i r a m a r T o w e r A u d i o T r a n s c r i p t(8 6 ) S u m m a r y o f i n t e r v i e w w i t h NA V A I R e n g i n e e r s d t d

2 F e b 0 9(8 7 ) P h o t o o f t r e e e a s t o(88 ) S t a t e m e n t o f(8 9 ) P h o t o s o f s k i d m a r k v i c o f(9 0 ) P h o t o s o f f u s e l a g e i m p a c t m a r k s(9 1 ) P h o t o o f s t o r a g e t r a i l e r a t(92 ) P h o t o o f r i g h t w i n g i m p a c t a t(9 3 ) S a n D i e g o C o u n t y M e d i c a l E x a m i n e r R e p o r t s(94 ) S a n D i e g o P o l i c e D e a r t m e n t Me mo ra n d u m d t d 3 1 D e c 0 8(95 ) P h o t o g r a p h o f(96 ) M i s h a p s i t e d i a g r a m(9 7 ) M i s h a p s i t e n o t e s d t d 0 8 D e c e m b e r 2 0 0 8(98 ) S u m m a r y o f m i s h a p s i t e n o t e s a n d p h o t o s d t d 9 D e c 0 8(99 ) M a p s o f d e b r i s l o c a t i o n s(1 0 0 ) S u m m a r y N o t e s f r o m (b ) (6 ) , (b)(7)(C) d t d 6 J a n 0 9

b ) (6) ,( Wg )( c )

(1 0 1 ) S u m m a r y o f i n t e r v i e w w i t h ( d t d(1 0 2 ) P h o t o g r a p h o f v e h i c l e s a t ( b ) ( 6 )(1 0 3 ) P h o t o g r a p h o f v e h i c l e a t ( b ) ( 6 )(1 0 4 ) S u m m a r y o f i n t e r v i e w w i t h d t d 1 4( b ) (

6) ,( b )( 7 )( c )

Ja n 0 9(1 0 5 ) S u m m a r y o f i n t e r v i e w w i t h

09(1 0 6 ) C i t y o f S a n D i e g o F i r e I n c i d e n t R e p o r t(1 0 7 ) E - m a i l f r o m (b)(6), (b)(7)(C) d t d 9 F e b 0 9(1 0 8 ) N T S B r e p o r t o f 1 9 9 9 A m e r i c a n A i r l i n e s MD -8 2 D i v e r t

i n t o MCAS M i r a m a r(1 0 9 ) NA V A L A V I A T I O N GENUSE HAZREP, 0 1 - 0 9 , 1 2 J A N 2 0 0 9 -

° 1 -3 0(1 1 0 ) C O , MA G -1 1 1 t r 3 5 0 0 A S O o f 2 2 J a n 0 9(1 1 1 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t h

d t d 1 9 F e b 0 9

(b)(6), (b)(7)(C)(b)(6)

(b)(6)

4

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

d t d 2 3 J a n 0 9

d t d 2 2 J a n

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6)

(b)(6)

S u b j : CO MMA ND I NV E S TI G A TI O N I N T O THE CIRCUMSTANCES SURROUNDINGTHE F / A - 1 8 A I RCRA FT MI S HA P I NV O L V I NG BUNO 1 6 4 0 1 7 THA TOCCURRED O N 0 8 DECEMBER 2 0 0 8 I N UNI V E RS I TY C I T Y , S A NDIEGO, C A

3. L e g a l a s s i s t a n c e w a s p r o v i d e d b yUSMC, 3 d M a r i n e A i r c r a f t W i n g ( 3 d MAW)

(b)(6)

(1 1 2 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t hd t d 1 8 F e b 0 9

(1 1 3 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t h18 F e b 0 9

(1 1 4 ) S u m m a r y o f f o l l o w u p i n t e r v i e w w i t hDt d 1 8 F e b 0 9

(b)(6), (b)(7)(C)

P r e l i m i n a r y S t a t e m e n t

5

(b)(6), (b )( 7 )( C )(b)(6), (b)(7)(C)

2. A l l r e a s o n a b l y a v a i l a b l e e v i d e n c e w a s c o l l e c t e d f o r t h i si n v e s t i g a t i o n , e a c h d i r e c t i v e o f t h e C o n v e n i n g A u t h o r i t y w a sme t , a n d a l l g o v e r n i n g r e g u l a t i o n s c o n t a i n e d w i t h i n t h er e f e r e n c e s w e r e a d h e r e d t o . E n c l o s u r e s ( 3 ) t h r o u g h ( 1 1 0 )c o n t a i n f a c t u a l m a t e r i a l e v i d e n c e p e r t i n e n t t o t h i si n v e s t i g a t i o n .

d t d

(b)(6), (b)(7)(C)

1. T h e p u r p o s e o f t h i s r e p o r t i s t o p r o v i d e a c o m p r e h e n s i v esu mma ry o f t h e i n v e s t i g a t i o n i n t o t h e c i r c u m s t a n c e s s u r r o u n d i n gt h e c r a s h o f M a r i n e F i g h t e r A t t a c k T r a i n i n g S q u a d r o n O n e - Z e r o -One (V MF A T -1 0 1 ) F / A - 1 8 D a i r c r a f t b u r e a u n u m b e r (B UNO ) 1 6 4 0 1 7 o nt h e m o r n i n g o f 0 8 D e c e m b e r 2 0 0 8 i n U n i v e r s i t y C i t y , i n t h ev i c i n i t y o f M a r i n e C o r p s A i r S t a t i o n (MCA S ) M i r a m a r , S a n D i e g o ,C a l i f o r n i a .

(b)(6), (b )( 7 )( C )

(b)(6)

4. E y e w i t n e s s e s w e r e i n t e r v i e w e d a t MCAS M i r a m a r , C a l i f o r n i a i np e rs o n a n d b y t e l e p h o n e , a t N a v a l A i r S t a t i o n ( N A S ) L e m o o r e ,C a l i f o r n i a i n p e r s o n , a n d a t N a v a l A i r S t a t i o n P a t u x t e n t R i v e rand N a v a l B a s e B r e m e r t o n , W a s h i n g t o n b y t e l e p h o n e . N od i f fi c u l t i e s w e r e e n c o u n t e r e d w h i l e i n t e r v i e w i n g w i t n e s s e s .

5. A l l s o c i a l s e c u r i t y n u mb e rs w e r e o b t a i n e d f r o ma d m i n i s t r a t i v e s o u r c e s . P r i o r t o q u e s t i o n i n g w i t n e s s e s , t h e ywe re a d v i s e d o f t h e i r r i g h t s u n d e r t h e p r i v a c y a c t i n a c c o r d a n c ew i t h P a r a g r a p h 0 5 2 3 , r e f e r e n c e ( a ) , a n d c o n s e n t e d t o a n s w e rq u e s t i o n s .

6. F l i g h t d a t a f r o m t h e a i r c r a f t w a s r e c o n s t r u c t e d f r o m t h eCra s h S u r v i v a b l e F l i g h t I n c i d e n t R e c o r d i n g S y s t e m ( C S F I R S ) ,w h i c h w a s r e c o v e r e d f r o m t h e a i r c r a f t w r e c k a g e .

7. A l l t i m e s i n t h i s r e p o r t a r e l o c a l P a c i fi c S t a n d a r d T i m e(PST) u n l e s s o t h e r w i s e a n n o t a t e d .

(b)(6) (b)(6)

(b)(6), (b)(7)(C)(b)(6)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)


8. O r i g i n a l i t e m s o f e v i d e n c e a r e i n t h e c u s t o d y o f t h e V MFA T-101 A i r c r a f t M i s h a • B o a r d (A MB ) . T h e s e n i o r me mb e r o f t h e AMBi s ( W M U S M C , D S N

9. T h i s i n v e s t i g a t i o n c o m p l i e s w i t h U . S . C o d e T i t l e 1 0 ,s u b t i t l e A , P a r t I V , C h a p t e r 1 3 4 , s u b c h a p t e r I I , § 2 2 5 5 ( A i r c r a f tA c c i d e n t I n v e s t i g a t i o n B o a r d s ) . T h e i n v e s t i g a t i n g o f fi c e r ( 1 0 ) ,

i s a d e s i g n a t e d N a v a lA v i a t o r , t h e ( b ) ( 6 ) o f 1s t M a r i n eE x p e d i t i o n a r y F o r c e ( 3 d MAW h i g h e r h e a d q u a r t e r s ) , a n d p o s s e s s e se x t e n s i v e i n v e s t i g a t i v e e x p e r i e n c e a n d t r a i n i n g . T h e T Oc o n s u l t e d w i t h a n d w a s a s s i s t e d i n t h i s i n v e s t i g a t i o n b y

(b)(6), (b)(7)(C)

(b)(6)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)f r o m M a r i n e A i r c r a f t G r o u p 1 1 a n d

f r o m 4t h M a ri n e A ir cr af t Wing as F/A-18 subject matter

e x p e r t s . B o t h a s s i s t a n t s a r e a l s o d e s i g n a t e d N a v a l A v i a t o r s a n dh a ve p r i o r e x p e r i e n c e i n v e s t i g a t i n g a i r c r a f t m i s h a p s .

(b)(6), (b)(7)(C)

10 . T h e MAC M a i n t e n a n c e S t a t u s P a n e l (MS P ) c o d e s a n d CS FI RSd a t a w e r e d o w n l o a d e d a n d d e c o d e d b y

(b)(6), (b)(7)(C) N A V A I R , F / A - 1 8 F l e e t S u p p o r t(b)(6), (b)(7)(C)Team. p r o v i d e d e n g i n e e r i n g i n v e s t i g a t i o n a n a l y s i s a n d

a i r c r a f t s y s t e m t e c h n i c a l e x p e r t i s e .

(b)(6), (b)(7)(C)

11 . A n e x t e n s i o n t o t h i s i n v e s t i g a t i o n ' s d u e d a t e o f 8 J a n u a r y2009 w a s r e q u e s t e d o n 3 0 D e c e mb e r 2 0 0 8 a n d g r a n t e d o n 5 J a n u a r y2009 d u e t o d e l a y s i n a c q u i r i n g p h y s i c a l e v i d e n c e a n d t h e v o l u m eo f e v i d e n c e a n d d a t a a n a l y s i s r e q u i r e d f o r t h i s i n v e s t i g a t i o n .A s e c o n d e x t e n s i o n w a s r e q u e s t e d o n 6 F e b r u a r y 2 0 0 9 a n d g r a n t e don 8 F e b r u a r y 2 0 0 9 f o r a n e w d u e d a t e o f 1 1 F e b r u a r y 2 0 0 9 .A f t e r 1 1 F e b r u a r y 2 0 0 9 a fi n a l e x t e n s i o n w a s g r a n t e d t o 0 1 M a r c ht o c o n d u c t f o l l o w - o n i n t e r v i e w s . E n c l o s u r e ( 1 ) c o n t a i n s t h eo r i g i n a l a p p o i n t m e n t a n d s u b s e q u e n t e x t e n s i o n s . N o o t h e r d e l a y so r d i f fi c u l t i e s w e r e e n c o u n t e r e d i n c o n d u c t i n g t h i si n v e s t i g a t i o n .

6

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6)

(b)(6)

(b)(6)

(b)(6) (b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

ubj: COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE F 18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 0 DECEMBER 200 IN UNIVERSITY ITY, SAN D EGO, CA

MP a current " chit" th an ration te cf 31 r 2009 certi h s clearance

aV'ation [encl 6J

MP a r for 05 ober 200 [encl 8]

1 MP's water survival tra was current val il 1 December 200. [encl 6]

14. he MP's r 2009.

iology train [encl 6]

was current and valid until 31

's ejection seat/egress t unti 28 February 009. [encl 6J

was current and

16. The MP's standard strument rat was current and val 1 2009. [encl 6]

MP leted annual rati (CRM) trai l Resource

[encl 6

The MP Ie which was valid th

19. MP 17 p ior to the

rs In the 180

monthly eme 15 De r 008.

and .0 79.7

prior to the

(ORM) 2 08.

res exam, [encl 9J

rs 30 56.3 s lator

[encl 10]

20. MP had flown 3 4.2 hours n military aircraft with 107.6 hours the F 18. [encl 10]

Boa si

In the MS, a (RPRB) 1

lacement

e se of training.

rcrew (RAC) for an RAC

[encl 13J

8

ew SODs in

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

(b)(6)

Sub..;: COMMAND INVESTIGATI INTO THE CI S THE F 18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DIEGO, CA

4 The [ nIl J

an 20 October 2008.

2C, In pr

the MS, conven

a Human Factors Board (HFB) will be RPRB enc 13J

rI';'-"e MS [encl

111

30. The:'1S

3=--. MP e,1 12J

The MP w n VT 21.

ously flown out of NASNI i [encls 10,1 J

T 45 wh Ie

Two weeks prior to the MF, MP had flown an uneventful ~ua Sl e ne approach and 1

800 foot ceiling with the I p ssure caution. [encl 14 J

ramar at ni ne shut down for an

34 of

the time of the mi ,the MP was in the f F 1 RP t , with anI carr r qualif

r we remain [encl 12

:3 The MP ,cO imula tor s

roa s int NASNI

carrier lification ( imul normal and emergency

cls ,14,15]

9

s

(b)(6)

(b)(6)

J: COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE F 18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DISGO, CA

3 . MP Practice (FCLP) fli

leted all r ired Field Carrier s. [encl 12]

MP was certified "safe for " MS Of i [encl 16

RPs ire arrested 1 and six ro C' ~O d 1 18 initial [encl

The MP had leted e of ten ired la and six of six required n arres 07 December 2008. [encls 10, 2]

n 17]

as of

C The MP had flown two sorties in the MAC on 07 December 08 in wh he eted one and ni arrested

:-:dings. [encls 10,18,1 J

4 The MF was on the carrier air p an on 08 December 2008 11:00 Ie t [encl 0]

4" L .

cJ. si mhe MS re room ( rd

aircraft #253 (the MAC) fl board

r the 11:00 the MP

Ie t [encl 21]

B

41. The MAC, a Lot 12 MS on 30 i1 990.

1 0, entered or [encl 22

for

1 se ce th

MAC flown ,47 .3 hours s it ente service. rene 22]

6. The last scheduled in ction performed the MAC was a 30 ~o~r inspection focuses on the s, Accessory Drives (AMADs) and oil system, was aboard. the sh on 07 December 2008. [encl 23]

47. ~he last se inspection was a se "AU completed on 21 ust 2008. [encl 22]

tl. The MAC had no external o at t f MF

10

tanks, external stores, [encl 23]

r

Referred to COMNAVAIRSYSCOM






49. T h e M A C ' s l e f t e n g i n e :

a . W a s r e c e i v e d r e a d y f o r i n s p e c t i o n ( R F T ) a f t e r r e w o r kf r o m M a r i n e A i r c r a f t L o g i s t i c s S q u a d r o n E l e v e n ( M A L S - 1 1 ) o n 2 7No ve mb e r 2 0 0 7 ;

b . H a d n o o u t s t a n d i n g M a i n t e n a n c e A c t i o n F o r m s ( M A F s ) .[end l 2 4 ]

[ e n d s 2 5 , 2 6 ]

Referred to COMNAVAIRSYSCOM50.



[ e n d s 2 5 , 2 6 ]


[ e n d s 2 5 , 2 6

54 . T h e M A C ' s r i g h t e n g i n e :

a . W a s r e c e i v e d R F I f r o m A i r c r a f t I n t e r m e d i a t e M a i n t e n a n c eDe p a r t me n t ( A I M D ) O c e a n a , V A o n 0 9 J u n e 2 0 0 6 ;

b . H a d n o o u t s t a n d i n g MA F s .[e n cl. 2 4 ]


56. T h e MA C d i d n o t h a v e a n y o r d n a n c e o r c h a f f / fl a r ee x p e n d a b le s o n b o a r d . [ e n d ] . 2 3 ]

57 . T h e MAC h a d t w o o u t s t a n d i n g MA Fs a t t h e t i m e o f t h e m i s h a p .[ e n c l 2 3 ]

11


(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

S u b j : CO MMA ND I NV E S TI G A TI O N I N T O THE CIRCUMSTANCES SURROUNDINGTHE F / A - 1 8 A I RCRA FT MI S HA P I NV O L V I NG B U N ° 1 6 4 0 1 7 T HA TOCCURRED O N 0 8 DECEMBER 2 0 0 8 I N UNI V E RS I TY C I T Y , S A NDIEGO, C A

58. O n e o f t h e t w o o u t s t a n d i n g MA Fs w a s f o r i n o p e r a t i v e f u e ldump s y s t e m ( a i r c r a f t s y s t e m t h a t r e m o v e s e x c e s s f u e l b y" d u mp in g " o v e r b o a r d v i a p r e s s u r i z e d fl o w t o a d j u s t g r o s s w e i g h tt o a l o w e r w e i g h t ) t h a t r e a d " A i r c r a f t w i l l n o t d u mp f u e l w h e ndump i s s e l e c t e d , " a n d w a s i n i t i a t e d o n 0 6 D e c e m b e r 2 0 0 8 .[end l 2 3 , 2 7 ]

59 . N o c o r r e c t i v e a c t i o n w a s i n d i c a t e d o n t h e MA F a n d t h ei n d i v i d u a l e x e r c i s i n g s a f e - f o r - fl i g h t a u t h o r i t y r e q u e s t e da i r c r e w c h e c k t h e f u e l d u mp s y s t e m o n t h e n e x t fl i g h t . [ e n d s2 3 , 2 7 ]

60. O n t h e n e x t fl i g h t o n 0 7 D e c e m b e r 2 0 0 8 , a i r c r e w r e p o r t e dt h a t t h e f u e l d u mp e d , b u t w a s d u m p i n g " v e r y s l o w l y . "Ma i n t e n a n c e c o n t r o l c o n s u l t e d w i t h P o w e r P l a n t s o n t h e s h i p a n dd e c i d e d t h i s w a s n o t a d o w n i n g d i s c r e p a n c y . [ e n d l 2 7 ]

61. T h e MA C fl e w t w o fl i g h t s o n 0 7 D e c e m b e r 2 0 0 8 a f t e r t h ei n i t i a t i o n o f t h e f u e l d u m p i n g MA F, a n d o n e ( t h e MF ) o n 0 8 D e c2 0 0 8 . [ e n d s 1 0 , 2 3 ]

62. T h e s e c o n d o f t h e t w o o u t s t a n d i n g MA Fs w a s f o r i m p r o p e rl e f t w i n g f u e l t a n k t r a n s f e r a n d w a s i n i t i a t e d o n 1 4 J u l y 2 0 0 8 .[end l 2 3 ]

63. T h e f u e l _ t r a n s f e r MA F s t a t e d " L i n t e r n a l w i n g t a n k w o u l dn o t t r a n s f e r b e l o w 3 0 0 # u n t i l t o t a l f u e l s t a t e w a s 4 5 0 0 # .E x t e n d i n g p r o b e a n d c y c l i n g b l e e d s d i d n o t a i d i n t r a n s f e r .[ R i g h t ] i n t e r n a l w i n g t a n k w a s a t 2 0 # . U n a b l e t o c o n d u c t O CF[ o u t o f c o n t r o l fl i g h t ] w i t h f u e l s p l i t [ w i n g f u e l t a n k st r a n s f e r r i n g u n e v e n l y ] . M S P s [ M a i n t e n a n c e S t a t u s P a n e l( c o d e s ) ] : 5 1 0 , 8 4 3 , 5 9 1 , 5 0 0 , 4 6 9 , 9 9 8 , 4 9 9 , 5 0 3 , 1 1 0 . " [ e n d l23]

65 .and

MSP c o d e 5 9 1 i n d i c a t e s

MSP c o d e 5 0 0 i n d i c a t e sMSP c o d e 4 6 9 i n d i c a t e sMSP c o d e 4 9 9 i n d i c a t e sMSP c o d e 5 0 3 i n d i c a t e s

[end l 2 8 ]

64. M S P c o d e s r e l a t e d t o t h e w i n , f u e l t r a n s f e r MA E a r e :


(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)MS A i r c r a f t M a i n t e n a n c e O f fi c e r ( A M O ) ,

12

(b)(6), (b)(7)(C)


(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6)

(b)(6)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)(b)(6), (b)(7)(C)


(b)(6), (b)(7)(C) s t a t e d t h e r e p r e v i o u s l y w a s a N a v a l A i r S y s t e m sCommand (N A V A I R ) p r o g r a m t h a t p u b l i s h e d a m o n t h l y s u m m a r ya n a l y s i s o f MSP c o d e s . T h e p r o g r a m w a s c a n c e l l e d a b o u t s i xmo n t h s a g o . [ e n d s 2 9 , 3 0 1

66. T h e r e i s n o a p p r o v e d NA V A I R l i s t o f d o w n i n g MSP c o d e s o rs e r i e s o f c o d e s p u b l i s h e d o r i n u s e f o r t h e F / A - 1 8 A - D . [ e n d s2 9 , 3 1 ]

67 . A l t h o u g h t h e r e i s n o c u r r e n t g u i d a n c e o n u s i n g MS P c o d e si n d i v i d u a l l y o r i n s e q u e n c e s t o d i c t a t e s p e c i fi c m a i n t e n a n c ea c t i o n , B o e i n g a n d NA V A I R e n g i n e e r s s t a t e d i n i n t e r v i e w s t h a t :


[end l 3 1 ]

(b)(6), (b)(7)(C)68. O n 2 5 S e p t e m b e r 2 0 0 8w o r k i n • i n t h e (10 ) ( 6 ) r e c om m e nd e d to

o f ( b ) ( 6 ) t o r e m o v e a n d r e p l a c e t h e l e f t m o t i v efl o w b o o s t p u mp a n d t h e l e f t b o o s t i n l e t p r e s s u r e t r a n s d u c e r .A c c o r d i n g t o ( b ) ( 6 ) , (b)(7)(C) a l t h o u g h t h e w o r k p a c k a g e p u b l i c a t i o n swe re v a g u e a n d d i d n o t p r e s e n t a c l e a r d i a g n o s i s o r s o l u t i o n ,t h e i n c r e m e n t a l r e p l a c e m e n t o f t h e s e t w o p a r t s w o u l d h a v ea l l o w e d f o r a s s e s s m e n t a n d p o s s i b l e i s o l a t i o n o f t h e c a u s e .[end l 3 2 , 3 3 ]

( b)( 6) , (b)(7)(C)

13

69. B a s e d o n t h e f a c t t h a t t h e r e w a s n o c l e a r o r d e fi n i t i v eg u id a n c e f r o m m a i n t e n a n c e p u b l i c a t i o n s , ( b ) ( 6 ) , (b)(7)(C) d e c l i n e d t oh a ve t h e a i r c r a f t p l a c e d i n a " d o w n " c o n d i t i o n t o p e r f o r m t h ere co mme n d e d w o r k a t t h a t t i m e a n d i n s t e a d d i r e c t e d t h a t i t b en o t e d a n d p e r f o r m e d a t a l a t e r t i m e . ( b ) (6) , ( b ) (7) ( c ) b e l i e v e s t h i s

t y p e o f i s s u e w o u l d l i k e l y h a v e n o t b e e n b r o u g h t t o t h ea t t e n t i o n . Q u a l i t y A s s u r a n c e D i v i s i o n w a s n e v e r c o n s u l t e d .[ e n d s 3 2 , 4 7 , 1 1 1 ]

b)(6), (b)(7)(C

(b)(6)





70 . T h e P o w e r P l a n t s d i v i s i o n m a i n t e n a n c e p a s s d o w n l o g d a t e d 2 5S e p t e mb e r 2 0 0 8 r e a d s " M / C ( m a i n t e n a n c e c o n t r o l ) w a n t e d u s t ot r o u b l e s h o o t L i n t e r n a l w i n g s l o w t o t r a n s f e r . L o w p o w e r e d A / C( a i r c r a f t ) a n d f o u n d l e f t m o t i v e fl o w s y s t e m h a s l o w p r e s s u r e i nt a n k s 1 , L w i n g , a n d L f e e d p r e s s u r e . W e t r o u b l e s h o t d o w n t oR/ R ( r e m o v e a n d r e p l a c e ) L MFBP ( m o t i v e fl o w b o o s t p u mp ) a n d LMFBP p r e s s u r e s w i t c h . A l s o , t h e e l e c t r i c s h o p n e e d s t o R / R Lf e e d p r e s s u r e t r a n s d u c e r d u e t o i n c o r r e c t r e a d i n g a n d MMP [ MS P ]591 . O n c e w e [ n o t i fi e d ] M / C t h e y t o l d u s n o t t o w o r k o n i t .Wh e n e ve r M / C l e t s u s w o r k o n i t , w e n e e d t o c u t a MA F t oe l e c t r i c s h o p t o R / R L f e e d p r e s s [ u r e ] t r a n s d u c e r . L w i n gt r a n s f e r t e s t [ c h e c k s ] 5 . 0 . N e e d t o c h a n g e t h o s e p a r t [ s ]wh e n e ve r c o n t r o l i s r e a d y . " [ e n d l 3 3 ]

71 . T h e ( b ) ( 6 ) s t a t e d t h e y w o u l d t y p i c a l l y w a n t t o k n o wa b o u t a q u e s t i o n s u c h a s t h i s w h e r e t h e m a i n t e n a n c e p u b l i c a t i o n sdo n o t p r o v i d e d e fi n i t i v e g u i d a n c e a n d w o u l d w a n t t o w e i g h i n o nt h i s t y p e o f d e c i s i o n o n w h e t h e r t o c o n t i n u e t h e m a i n t e n a n c e .[ e n d s 2 9 , 3 0 ]

72 . T h e r e i s n o d e fi n e d p r e s s u r e r a n g e o r l o w e r l i m i ta s s o c i a t e d w i t h t h e m a i n t e n a n c e w o r k p a c k a g e t r o u b l e s h o o t i n g MSPcode 5 9 1 ( L m o t i v e L m o t i v e b o o s t p u mp o r b o o s t p r e s s s w f a i l ) .Th e re i s n o l i m i t a t i o n l i s t e d t h a t d i c t a t e s a p a s s / f a i l t e s t o rt h a t d e fi n e s a n u p o r d o wn s t a t u s a s a r e s u l t o f t r o u b l e s h o o t i n gs t e p s . [ e n d s 3 3 , 3 4 ]


74. Referred to COMNAVAIRSYSCOM

e n c •

75 . T h e MS P c o d e s f r o m t h e fl i g h t p r e v i o u s t o t h e M F i n c l u d e d :

a . 5 0 2 :

591 :

[end l 2 8 , 3 6 ]


14

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(b)(3) 10 U.S.C. 130

(b)(3) 10 U.S.C 130

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Referred to National GeoSpatial

Referred to National GeoSpatial

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SUD COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE F 18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED DIEGO, CA

08 DECEMBER 2008 IN UNIVERSITY CITY, SAN

E ramar

116. NASNI has a maximum available runway (RWY) 1 feet, and short and long f ld, bi-directional arrest gear ava able on RWYs 36/18, and 29/ 0 [encls 4 ,50,51 ]

17. NASNI has a Tactical r ion a (TACAN) th di tance measur (DME). [encls 50,51

118. ar on RWY 36 is i ly de-l

ope::-ations.

eld arrest when NASNI is

[encls 49,52J pr ry rt eld for er

119. 11

1 O. NASNI lenc '" 9,50J

pr ar were ri

rec s

rt ai rt on 08 De r 2 0 in battery. [encl 52]

cis ion app s to RWY 36.

121. ere was no MS LSO support at NASNI for divert aircraft this riod. [encls 53,54J

at 150 KTS 20 e radius of turn of San Diego

International Airport is 2.0 from the of from the end of RWY 36. Downtown

Diego is 2.5 from NASNI. [encls 49,55

5. ~he weather at NASNI at the t of rt was 2,500' scattered, winds 100/08 (scattered cloud deck at 2,500 feet, winds _rom 100 s at 8 KTS). [encl 5 ]

. The t he yIP

/. :VIiramar has a et, short and 1 L, 06R, 24L

was available and offered to [encl 56]

1 1 o 12,000 field rectional arrest ar on RWYs

24R. [encls 50,51,57J

9

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(b)(6)

(b)(6) (b)(6), (b)(7)(C)

(b)(6), (b)(7)(C) (b)(6)

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(b)(6), (b)(7)(C)

(b)(6)

(b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6) (b)(6), (b)(7)(C)

(b)(6) (b)(6), (b)(7)(C)

(b)(6), (b)(7)(C)

(b)(6)




(b)(6)

Referred to COMNAVAIRFOR


(b)(6)

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(b)(6)

S~bl: COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING

1 O.

THE 1 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN

IEGO, CA

MP I rn after off, flew a ten to

necessary amount of 1. Ie arc from

[encl 18J

1 1. When the MP dete he was close to maximum arrested 1 wel he entered the overhead re to es ish s interval ~n carr r 1 tern. [encl 18J

n the MP entered the 1 rece an "oil pressure low" caution for [c~c s 18,36J

(R OIL PR).

MP power on the affected in acco communicated the em to the

~o ak to a s sentat , and [e s 19,61,63,66,67J

pres [encl

1

the MP indi

18,62,66J

nitiall told

rted to MS hat 35 psi with the throttl

s r at

the t1P to keep the affected id e power while f the tern, and when turn

oil

inal

r.

at to

the throttles fly a normal roach to an arrested 1 [encls 1 , 66 J

Th

an

~encls

Tit 1 5 the at litary power and start

ately over-rode the 1 ng recovery

22

that". [encls

conferred, rt

and Wl MP to shore.

the MP to t s left , leave his gear down,

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(b)(6)

J. COMMAND INVE TIGATION INTO THE C RCUMSTANCES SURROUNDING THE F/A- 8 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DIEGO, CA

en 1 94J

total loss of structure [ Is 92,94

contents at

of was into the house at [encls 4,95,96J

loss of structure and content at [encls 95,96J

was not occupi at time f

remained in the structure ly 120 t from ial

322. The left came to rest rt rm s Street, app ly 150 feet

f om initial [encls 96,97,9 J

323. Sf s, riz to

s Street between 200 feet from

horizontal s i ator came to rest on

of

south side f ins Street, tween [encls 96,97,98]

in the 96,97,98J

on the cement

. The aft coc ejection seat s from the fuselage and 1 be the site, in at

atitu N 32.8614, longi W 117.1971. [encls 98,99]

2 ~ The nose radome section and other ed under a truck par near the

st fire. [encls 9

8. The se at smoke and along its west

9 Two vehicles in the dr of were dest fire. [encls 96,100,101]

39

rene

1e

f orn iIlitia

1

R, 'T'II at

ION 11'T'0 THE

f

I

II P INV() I

- - - -.. - ,.. . ~ ,~< '--! -='=

o fee

f

101]

at

ive ,1 0.1

s at

f

ke

lage

t

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(b)(6)(b)(6)

(b)(6)

l: COMMAND INVESTIGATION INTO THE CIRCUMSTANCES THE F 18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRE ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DIEGO, CA

5~. Smoke blowi from west to east ni site. encl 01J

355 There was ini al difficul account s. [encl 88J

356. Several rs after there be

5 . MFD 60 and 62 were re ieved t s At this int three

1 10

ired visibility at the

for res s f

ly four hours after been recovered.

3 8. ARFF does not possess 00 rtz os to cate with the c lian firefi rs, but MFD does and rout ly uses t in San ego erne ses. s 88,1 4J

All post-mi fires were ext ished on 08 December 008 [enc1s 94,106J

360. MCAS ramar Office cont an envi onmenta1 ass ssment and c

ssessment on 09 December 2008. i i ial site [enc1 107J

361 ~he AMB released Environmental on 0800 12

site to MCAS ramar r 2008 [enc 94,107]

3 . Air monitor at the December 2008. Results were

site was ical of structural

encl 107J

until 14 re and no

onnal thresho

36 . San Police Post the site 0900 12 De r 2008. [enel 107]

4. Miramar PMO Post remained on site until 1200, 23 r 2008. [encl 10 J

65. An American t ke off from San

sse gers and crew at ~iramar June

H. scellaneou

rlines MD-82 had a loss of thrust on Lindbe International with 141

onboard and successfull rted to RWY 06L 5, 1999. [encl 108J

42

(b)(6)

J. COMMAND INVESTIGATION INTO THE CIRCUMSTANCES SURROUNDING THE 18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 200 IN UNIVERSITY CITY, SAN DIEGO, CA

6. The s lators used the MS to t RPs not cura:ely 1 cate t fuel transfer tween n when crossb e rative ne. [encl 83]

36/. The s la rs used the MS to train RPs did not visually di ay RWY 36 at NASNI until of November To there is abilit to re rd ters or s late a f ld arrestment on RWY 6. [encl 83]

368 Marine Forces Pacific ncern F 18 MSP codes

rno~-_ ve

s response to pos 109

69. on 2 January 2009

-related MSP s

ished a General Use Hazard groups cat poss

on 12 January 2009. This from AMB. [encl

a rect of

tiate an ana is to monitor their occurrence. It rects that an

ircraft will placed down status for occurrences o s gle fuel-reI in the last ten fl Sf or a single MSP code occurrence conjunction th any

s [encl 110]

3

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(b)(6)

(b)(6)

(b)(6)

(b)(6)


(b)(6) (b)(6)

~he MP, a recently p at VMFAT-101,

:nissior1.

3. d

t would

syllabus and was 43, 4-9 ,135,141 1 3]

The MP was aware the pr December 2008 evolution. NASNI once in the train

A. MP

rent 1-6,8 2

ified, current, lose to fini

or se.

rt was NASNI he only

all of is s rts were into NASNI. This

wi rt to NASNI, v u21 does not support full RWY 36

,35,15, 143,366,36 ]

and

ems

assi the

[FOF

MP

5. the f the mi , the MP's conduct around the and dur the initial l -I -L

f the vert was professional and res and regulations. FOF

28J

6. The MP should have landed at NASN but allowed If to be 1 .fluenced the

i t ca had

OPNAV 3

weather as Miramar, ree rcra

was briefed as the primary divert, st re over the wee

(b)(6)


(b)(6)


(b)(6)

(b)(6)

(b)(6)




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

B. The MAC

14. Clearer, more definitive guidance in maintenance publications and more aggressive maintenance troubleshooting could have identified and corrected the MAC's internal wing fuel transfer problem prior to the mishap. MSP codes are diagnostic tools designed to assist in identifying particular system or component faults or failures. MSP codes related to the left motive flow boost system were persistent for several months, but there were no governing maintenance documents that specifically identified these codes as up or down discrepancies. The left wing slow to transfer MAF was written and put into work several months prior to the mishap, but was not corrected because of the lack of guidance on MSP code significance and the lack of definitive troubleshooting steps in the maintenance publications. The aircraft was flown safely 146 times over the next several months. Unfortunately, there was an actual degradation of left Motive Flow Boost system pressure that slowly worsened over time, the symptoms of which were masked to the aircrew by the built-in fuel system redundancies. With the right engine shut down, the redundancy was eliminated and the fuel transfer problem became paramount. Unrecognized by the MP and the ready room personnel, the fuel transfer problem contributed to the mishap. [FOF 50-53,59-80,100-115,368,369]

15. The MESM is not intended to be the sole source document for determining up or down status of an aircraft. The MESM lists systems that dictate an aircraft be categorized not-missioncapable for any system failures/discrepancies that negatively effect safety of flight, to include the fuel system. The MESM does not specify which MAFs or MSP codes define the aircraft as not safe for flight and practitioners state it is too "vague." The sentiment that the MESM is vague coupled with the history of the outstanding MAFs contributed to the decision to defer maintenance on the left internal wing transfer MAF. [FOF 81-83J

16. Other than the two outstanding MAFs, the ADB was unremarkable. [FOF 44-49,54-56J

17. The MAC right engine experienced an actual oil pressure loss on the MF. The right engine was shut down in accordance with NATOPS. Post-flight engineering investigations revealed an oil leak likely caused by a degraded seal. The precautionary shutdown of the right engine was in accordance with NATOPS.

47


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COMMAND INVESTIGATION INTO THE CI TANCES SURROUNDING THE A-18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRE ON 08 DECEMBER 2 08 IN UNIVERSITY CITY, SAN DIEGO, CA

1 NATOPS S roach conflicts th OPNAV 3710.7T. The NATOPS p re

a ti qravity f simulation S ngle 1 ilit t air:'r:g.

rect the pilot

F. S

18 simu ator Is to licate the fuel stem 1 si the feed tank rconnect valve and s

crossbleed operation This lack of tern function that is a caution in the and re leads to an

realistic fli procedure 4,95,1 9,110, 283,366,367]

G. Local res

local arr 1 procedures are and were not a rect s, the fa

MP him

r in

Miramar,

NATOPS and OPNAV

comrnerc a rcra is turning rfie an emergency

g ve the Command the rand respons li to ia as necessary from established course ru s in the

1 st of the safe conduct f the fl In this cas the MP ad declared an erne and was be vectored approach

control under instrument fli rules a sol cloud ck , order to te is return to ramar. FOF 186,213,214

65'

H.

9 The mi site was contalned to a relatively smal area, and a i visible aircraft wre that ' t burn in the

rm in the back rd of ss of s momentum

likely to more houses. [FOF 311-339]

53


40. MCAS Miramar FD, ARFF, PMO, San Diego FD, and San Diego PD responded within a reasonable amount of time and worked in concert to fight the fires and secure the area according to established procedures. ARFF provided valuable information unique to military aircraft hazards but relied on MCAS FD communication assets to communicate with San Diego FD due to their lack of 800 megahertz radios. [FOF 340-364J

41. The impact of the aircraft directly caused the four fatalities. [FOF 311-329,340-342,349-357J

54

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, (b)(5)

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Subj: COMMAND INV~STIGATION INTO THE CIRCUMS,ANCES SURROUNDING THE F/A-18 AIRCRAFT MISHAP INVOLVING BUNO 164017 THAT OCCURRED ON 08 DECEMBER 2008 IN UNIVERSITY CITY, SAN DIEGO , CA

Recommendations

(A) Personnel

2. That the MS CO be relieved of command for cause .

3. That the MS OPSO be relieved of his duties as squadron Operations Off i cer and reassigned within the MAG .

5.

6.

(B) Operations

3d MAW submits a NATOPS change to review file data for the F/A- 18A- D aircraft to

9 . That 3d MAW submits a request to upgrade the F/A-18 simulator ' s programming to properly duplicate the aircraft fuel system' s closing of the feed tank fuel interconnect valve when crossbleeding an engine, and to allow the interconnect valve to open when the fire light is depressed .

55

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(b)(6), (b)(7)(C)

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