The Marine Corps upgraded its entire fleet of MV-22 Ospreys received an upgrade early this year after a crew member was killed when a tiltrotor plummeted off a ship in October due to while suffering form a software design flaw that limited engine power in flight.
The flaw incident, which resulted in more than $1 million a million dollars in aircraft damage and caused the first U.S. death during Operation Inherent Resolve against the Islamic State group and $1 million in aircraft damage, according to recently released documents. An Investigations. It ultimately resulted in prompted administrative action against the crew, but also speedy changes to software — made within four months — to prevent a similar future tragedy.
The Osprey had just taken off from the assault ship Makin Island on Oct. 1, 2014, but was mistakenly in "maintenance mode", which robbed the aircraft of much of its power and sent it plunging into Persian Gulf waters. the water. Crew chief Cpl. Jordan L. Spears, 21, was , died Oct. 1, 2014 when the Osprey he was aboard with Marine Medium Tiltrotor Squadron 163 and died in the accident. took off from the assault ship Makin Island in "maintenance mode." The maintenance mode setting was mistakenly , inadvertently set by a sergeant who started the aircraft, robbed the engines of much of their power, according to documents obtained by UT San Diego through a Freedom of Information Act request.
"It is inexplicable that an aircraft systems design would allow a crew to take an aircraft flying with a potential degredation in engine power of 20 percent without providing a caution or warning alerting them of the situation," said the 11th Marine Expeditionary Unit's commanding officer Col. Matthew Trollinger, in the investigation.
He went on to say he did not "believe the crew was willfully negligent in executing their duties" but that adherence to established procedures and checklists would have prevented the accident. The sergeant who set the aircraft's mode referred to a checklist, but may have been fatigued or complacent as he performed a task he had done many times before, using his peripheral vision to punching in pre-flight settings while reading a checklist.
The Moments after departing the deck, the aircraft flying from the Persian Gulf plummeted and struck the water, as reported in October by Marine Corps Times.
Pilots were able to maintain control of the Osprey even as it took on water by pushing the engines to keep the aircraft from fully sinking. Believing they were in imminent danger, however, they ordered their two crew chiefs to ditch.
"The engines were still somewhat working and I wasn't ready to give the aircraft up yet," the major flying the aircraft is quoted as saying in the documents obtained by UT San Diego. "We had ensured the safety of the aircrew, but I wanted to see if we could still save it."
One crew chief was quickly recovered by a Navy helicopter and rescue swimmer, but Spears, weighed down by his body armor, sank and drowned after his life vest failed to inflate. His body was never found.
While the investigation spreads blame citing a number of factors, the report also says the danger was known but had not been effectively communicated to the fleet. About seven months earlier, the problem was discovered by the Quantico-based Marine Helicopter Squadron One. HMX-1 issued an advisory about the flaw, but the Osprey's crew had neither been briefed by their squadron on the issue nor had flight manuals been updated to include mention of the potential danger.
In fact, there were subtle indicators that day that something was amiss prior to takeoff, but nothing so significant that the pilots or crew thought of foregoing their mission, according to the investigation. When engines started there was a slight hangup of about 15 seconds, but they eventually then began turning normally. Pilots also realized exhaust deflectors, which rob the engines of power, were indicated as set to "on" rather than "auto" but after discussing with the crew assumed it was the product of a non-critical software glitch.
When the aircraft lifted off, however, it became immediately clear something was horribly amiss. When the aircraft slammed into the water, the crew chiefs piled out the back. The pilots, however, continued to fight to save the aircraft in washout conditions with sea spray totally limiting visibility.
They cut the aircraft's weight by dumping fuel and were able to get enough altitude to make it back onto the ship's deck, but not before dipping in and out of the water about 5 times.
In the meantime, the crew chiefs had piled out of the back of the aircraft without a life raft. Spears and the other crew chief thought there was not enough time to launch one. When Spear's hit the water and pulled the beads on his life vest, it failed to it did not inflate. The other crew chief worked to keep Spear's head above water, but each time Spears tried to manually inflate his vest by blowing into it, his head sank. Exhausted, the weight of his body armor eventually pulled him under, never to be seen again despite a two week search.
By January, all Ospreys were given a software update that would still provide them full power during flight even if one took off in maintenance mode.