A Marine Corps review board has found several flaws in the investigation of a December 2018 midair collision off the coast of Japan that killed six Marines.

The review has led to administrative reprimands for two senior Marines, several recommendations for fixing systemic Marine aviation problems and vindication for the pilot involved.

The new report claims the initial investigation was flawed and came to incorrect conclusions, while providing 37 recommendations to help prevent future similar incidents.

“The 2018 Mishap CI (command investigation) was not impartial in its focus, thorough in its scope or accurate in its findings,” read the report, first reported by Military.com and then posted publicly on Thursday. “Because of this, we lost trust with the American people, the families of those who perished, and the young men and women who fly our aircraft.”

In the early morning of Dec. 6, 2018, two F/A-18s assigned to Marine All-Weather Fighter Attack Squadron 242, based in Iwakuni, Japan, met off the coast with a KC-130J bearing the call sign Sumo 41 from Marine Aerial Refueler Transport Squadron 152.

During an attempt to refuel the jets in the dark, one of the F/A-18s crashed into refueling aircraft, which led to the death of six Marines.

The Corps’ initial investigation laid the blame for the crash on the inexperience of the F/A-18 pilot, Capt. Jahmar F. Resilard, 28, the trace amounts of Ambien in the weapon systems officer, along with a complacent command that allowed for an overall disregard for regulations and policy.

Lt. Col. James R. Compton, the commander of VMFA-242, along with his executive officer, operations officer and the aviation safety officer were all fired from their positions in April 2019 because of the accident, Marine Corps Times previously reported.

The review board found that the original investigating officer was concerned about what his chain of command would think about the investigation and allowed his “personal aspirations” to outweigh his “professional duties.”

The report called into question claims that Resilard was not qualified for the procedure along with the implication that the Ambien found in the weapon systems officer system played any role in the accident.

“I am so glad though, that Jahmar’s reputation and name was clear because he loved what he did,” Joni Resilard, the late Marine’s mother, told Marine Corps Times Thursday.

“He was experienced, he did the best that he could with what was given to him.”

A rare occurrence

The review, started October 3, 2019, was created by a board of 12 Marine Corps experts in aviation, medical and legal, headed by Lt. Gen. Robert Hedelund, a designated Naval aviator since 1985 and the Corps longest serving active pilot.

The new report found four causes on the fateful morning of Dec. 6, 2018, that directly led to accident.

Resilard’s Hornet call sign Profane 12 attempted to fly the Hornet to the left of the tanker after it completed its refueling ― a rare occurrence, Marine Corps Times previously reported.

When jets refuel, under normal procedures, they move from the left to the right of the aircraft. Moving to the left is not necessarily more dangerous, just not the usual procedure, Capt. Christopher Harrison, a Marine spokesman told Marine Corps Times when the initial investigation was released in September 2019.

After moving to the left of the tanker the Hornet attempted to join the other Hornet, call sign Profane 11, on the right of the refueling aircraft. At some point in this maneuver the Hornet piloted by Resilard drifted left and slammed into the KC-130J.

Resilard and his weapon systems officer both ejected from the jet into the ocean below, while the KC-130J caught fire and dove into the clouds, the pilot of the second of the Hornet, Profane 11, later reported.

All the crew members of the KC-130J were killed in tragic accident, along with Resilard: Lt. Col. Kevin R. Herrmann, 38, Maj. James M. Brophy, 36, Staff Sgt. Maximo Alexander Flores, 27, Cpl. William C. Ross, 21, and Cpl. Daniel E. Baker, 21

The Hornet’s weapon system officer was the only survivor of the accident.

‘Not optimized’

The new review board confirmed that the command climate and culture were contributing factors, despite inaccuracies of the initial report.

The first causal factor, the new report found, was the permission to conduct the refueling in a way other than what was considered normal procedure.

After the unusual move, Profane 11 turned its external lights onto the overt setting, which was “authorized, but not optimized.”

The overt setting brightly lit up the second Hornet, making it harder for Resilard to see the dimly lit KC-130J, the report said.

“Profane 12 lost sight of the C-130 and lost situational awareness of his position relative to the tanker resulting in a drift over the top of the C-130 from left to right,” the report says.

The factors compounded to create a situation that even an experienced pilot would have had difficulty with, the report read, resulting in the crash.

“It must be noted, this specific set of circumstances would have been incredibly difficult for any pilot, let alone a junior, or less proficient pilot to overcome,” Assistant Marine Commandant Gen. Gary Thomas wrote in a letter summarizing the board’s findings.

In addition, the report found more than 20 institutional or organizational factors that increased the probability of a fatal event occurring.

The initial investigation claimed that Resilard was not qualified to conduct a night refueling operation. The latest report, however, found that he was indeed qualified, suggesting that “cumbersome” and sometimes contradictory training and readiness manuals led to the idea that the pilot was not qualified for the flight.

“When they told me my son was very qualified and even a very experienced person would have very difficult time making those maneuvers, I just broke down and cried,” Joni Resilard told Marine Corps Times Thursday.

Flight readiness

After the accident the weapon systems officer on Resilard’s Hornet was found to have Ambien in his system. The original investigation cited the unauthorized use of the sleeping drug as contributing factor in the accident.

The new report dismissed the idea that the drug directly played a factor in the events of that fateful night.

Instead, the report focuses on the drugs use as a sign that the operational tempo Marine Corps pilots keep forces “unit commanders and individuals to invent their own coping mechanisms for ensuring flight readiness.”

The report also called into question the Marine Corps’ reliance on Japanese search and rescue for their pilots in the area. From the time Profane 11 reported the crash, it took 2 hours and 19 minutes for Japanese search and rescue aircraft to take off, the report said.

The take-off time for a Coast Guard search and rescue aircraft off the coast of the U.S. is roughly 30 minutes.

Profane 12′s weapon system officer was safely pulled out of the water nearly four hours after he ejected and was the sole survivor of the crash.

Resilard, though injured from the impact and ejection, survived in the cold ocean roughly 200 miles from the Japanese coast for nearly nine hours. It took 10 hours and 35 minutes for Japanese search and rescue to pull him out of the water.

Despite the creation of multinational working groups and increased training between U.S. and Japanese personnel, the report found that search and rescue capabilities in Japan are the same as they were the morning of Dec. 6, 2018.

The report laid out several short- and long-term solutions to help mitigate search and rescue issues, including adding beacons that automatically transmit the location of an injured pilot and working with the Japanese to have search and rescue assets on a 15 minute standby during large U.S. operations.

Flight hours

The review board found the Marine Corps squadron, based in Iwakuni, Japan, to be one of the least prepared in the fleet.

The squadron had only 160 average monthly flight hours, with a particular dip in monthly flight hours preceding the December 2018 accident.

Over the past four years, only one other squadron had fewer average monthly flight hours: Marine Fighter Attack Squadron 251 based in Beaufort, South Carolina.

The report also found that a high proportion of young and relatively inexperienced pilots get stationed at Iwakuni, Japan’s VMFA(AW)-242, considered by the board the most “challenging flight environment in peacetime.”

The lack of experienced pilots was mirrored on the enlisted maintenance side, with the report finding that the squadron had 8 percent and 12 percent more junior Marines in key maintenance billets than other F/A-18 squadrons.

The lack of qualified and experienced maintenance Marines was a common complaint from the squadron commander, the report found, but reduced readiness of VMFA(AW)-242 was simply accepted by 1st Marine Air Wing, the report found.

“Accepting low readiness from VMFA(AW)-242 had become common practice for many years, and in this case, (1st Marine Air Wing) made no effort to mitigate” risk, the review board said.

The readiness issue also was overlooked by Marine Air Group 12, “to a greater degree and with greater ramifications,” the report said.

“MAG-12 failed to effectively understand or advocate for the barriers VMFA(AW)-242 faced in readiness generation, and did not fully understand the compounding effects of VMFA(AW)-242′s low aircraft availability and low flight hours over the past 90 days,” the report said.

Maj. Gen. Thomas Weidley, the former head of 1st MAW and Col. Mark Palmer, former commanding officer of MAG 12 received administrative action as a result of the review, a Marine Corps spokesman said.

“Upon review of the CDA-RB results, appropriate level of administrative action was taken regarding the 1st Marine Aircraft Wing commanding general and Marine Aircraft Group 12 commanding officer,” Capt. Joseph Butterfield told Marine Corps Times in a Thursday email.

“The administrative action taken is protected under the Privacy Act and therefore not releasable,” he added.

The report found Compton, the squadron’s former commander “did not commit any misconduct, and that his level of performance was not substandard so as to warrant disciplinary action,” though found his relief to be warranted because of the lack of trust in his leadership the accident instilled.

Compton retired from the Marine Corps on Dec. 1, 2019.

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