Lejeune AAV investigation details missteps, chaos

A command investigation into a serious nearly fatal Marine amphibious assault vehicle training accident year at in North Carolina last fall Camp Lejeune recounts a series perfect storm of missed opportunities to avoid the mishap, and paints a picture of a chaotic and uncoordinated medical evacuation in its immediate aftermathbut stops short of finding negligence.

The Oct. 10, 2014, accident incident aboard Camp Lejeune, North Carolina, during a nighttime predeployment certification exercise for the 24th Marine Expeditionary Unit sent 15 Marines and one sailor to the hospital. Their with injuries rangeding from knee sprains to shattered backs and traumatic brain injury after an AAV crew from Battalion Landing Team, 3rd Battalion, 6th Marines, unwittingly drove into a 30-foot-wide by 8-foot-deep chasm, according to a redacted version of the command investigation obtained by Marine Corps Times via a Freedom of Information Act request.

The unnamed investigating officer also concludes that report goes on to say that in the wake of the accident, the unorganized response in calling in and directing disorganized effort to call for and direct medical response could have cost Marines their lives.

It took about two hours for from the time of the accident to the time the most severely injured person to leave left base airspace aboard civilian aircraft from piloted by first responders in jurisdictions near adjoining Camp Lejeune the base.

"This investigation uncovered where we can collectively improve our ability to respond when mishaps occur," the investigating officer wrote investigation reads. "Sixteen personnel were injured in this incident, with some of the injuries severe. The multiple aircraft dispatched to transport the injured were not effectively coordinated, deconflicted and utilized in order to provide the urgent medical care required in this situation. We were fortunate in that none of our Marines or sailors were killed because we could not respond in a timely fashion."

The investigation found the AAV crew, led lead by an experience vehicle commander with more than 16 years in the Marine Corps — including a dozen 12 in the AAV, was traveling at just about 15 mph and following standard operating procedures at the time of the accident.

Driving into the gaping holed was a result of a limited view while the vehicle was in a tactical configuration, leaving only "very small windows for the driver to look through." The Marines' at they drove into a gaping hole was due to a limited field of view from the vehicle while in its "tactical configuration" and their night vision devices were not able inability to highlight the gap in a washed out tank road, according to the investigation.

"The failure of Range Control to adequately identify, assess, and then communicate a known hazard …plus a lack of a physical route reconnaissance , plus the embarked AAV crew's familiarity with the route (perception bias)…plus the visual illusion created by overarching vegetation during low-light set conditions for the mishap," the investigating officer wrote.

The accident occurred after 12 AAVs with 3/6 hit the beach at about 7 p.m. The AAV platoon began heading towards a combat training townown, a military operations on urban terrain trainer, where they would conduct a mock raid in conjunction with dismounted forces.

Operation planners selected had chosen a familiar route for the AAVs along a tank road that the lead vehicle commander had driven on months prior that July during another training exercise. Since then, however, a culvert along the road had washed out.

Range control marked the road as closed in August with a small sign and temporary plastic road barriers, but failed to communicate to units using the range that the path road was washed out since because it was neither the only nor primary route to the combat town, the investigation states.

As the crew approached the washout, their vehicle hit the barrier, which the Marines crew did not see in low-light conditions between after sunset and but before moonrise.

One crew member asked "What was that?" after striking the barrier, according to the investigation, and another replied, "I think it was a boulder." The vehicle commander got on the radio to advise other AAV crews of rock or debris on the road, saying, "All victors be advised of rock or debris on the road," the investigation states.

During later interviews with the investigating officer, Marines crew described vegetation along the trail as "creating a tunnel effect" or a "canopy" that was like "walking into a dark closet and shutting the door" as they approached the washed out culvert.

When During a recreating the events, on investigators found that the crew would have been unable to see the signs or barriers marking the road closed, closing the road and that the washout could have easily appeared as a shadow or shallow standing water through their night vision goggles NVGs. Potentially contributing to the accident was also tThe vehicle commander's familiarity with the route could have also contributed to the accident as that he believed it to be was smooth and clear based upon his experience on the same road months earlier s in July.

At 7:45 p.m., the vehicle hit the washed out culvert and chaos ensued. Marines were flung though the vehicle, several knocked onunconscious, according to the investigation. One crew member and one had his face "busted open," a platoon commander who was present later told investigators.

Within eight minutes, By 7:53p.m. a crew member was using his personal cell phone to call for a corpsman, the investigation states. Ambulances quickly began headed started towards the site.

Several actions could have prevented the accident, according to an investigating team that investigators who have now recommended changes to range policy and the way that units using ranges plan operations.

Chief among their recommendations, iIn the report, investigators suggest that range officials devise written guidance to identify potential range safety hazards and clearly communicate those to all using units prior to exercises. The washed out culvert was identified on Aug. 4, 2014, more than two months before the accident. But it Aug. 4, was classified as a non-essential maintenance issue and handed to base maintenance, which was taking months to repair the road, the investigation states.

Another range official identified the potential need for better ways to close ordon off hazards, including signage that would be more visible through night vision goggles.

Investigators also recommend that range officials implement internal training "of casualty procedures aboard [Camp Lejeune] to include communication procedures with civilian responders" to prevent a repeat of the confusion that occurred between base officials and when working with outside agencies.

While the accident was ultimately the result of chalked up to poorly established procedures and night-time conditions, administrative action was recommended against one range control official "for his failure to execute his assigned duties in regards to the communication of the hazard in the training area." All additional details about the reprimand Exact details were redacted, however.