2008 San Diego F/A-18 Crash - Investigation

Investigation

On March 3, 2009, an investigation by the Marine Corps concluded that the accident was preventable. The report was generally scathing in its criticism of the conduct of the participants including: the pilot, the commander of the squadron involved, its top maintenance officer, operations officer, and operations duty officer, all of whom were relieved of duty as a result of the investigation. Nine other Marines have received other disciplinary action.

From the report, it appeared that the jet in question had a known track record of trouble in its left engine for several months. Maintenance was deferred after mechanics detected problems in the fuel flow system, a practice that was allowed at the time under established maintenance rules and procedures (since altered to forbid this practice); the aircraft had flown 146 times since the problem was identified. When the right engine was shut down due to low oil-pressure, the left engine did not receive enough fuel for flight, leading to the crash. Forty similar aircraft throughout the fleet have been grounded to investigate similar fuel issues.

Following the pilot's report of the failure of the jet's right engine, controllers aboard the Abraham Lincoln, as well as a civilian air traffic controller, directed the pilot to land at NAS North Island – the closest divert field. Squadron officials, however, ordered the pilot to land at MCAS Miramar after a brief discussion, which the investigation deemed "collectively bad decision-making by the duty officer, by the operations officer and by the squadron's commanding officer." The pilot also failed to consult his emergency procedures checklist during the emergency, as well as unnecessarily lengthening his approach to Miramar by making a 270-degree left turn after bypassing North Island, rather than a shorter 90-degree right turn. Specifically, the report criticized Neubauer for not questioning the order to divert to Miramar more forcefully, which he had briefly questioned. The squadron operations officials had underestimated the urgency of the situation, and placed undue emphasis on returning the pilot to his home field, having in mind the pilot's familiarity with that base, the longer runway, and better repair resources.

Despite criticism, Neubauer was returned to a probationary flight status and allowed to resume training in late April 2009, in a decision made by Lieutenant General George J. Trautman, III, the Deputy Commandant for Aviation.