thedrifter
08-22-06, 01:25 PM
August 28, 2006
Fatal flaws
‘Stifling command climate,’ as well as pilots, blamed in 2-helo crash off Africa that killed 10
By Christian Lowe
Staff writer
Crew m ember Sgt. Donnie Leo F. Levens, 25, of Long Beach, Miss.
It was exactly the kind of situation Marine aviation brass had been trying to reverse for the last two years. And it was completely avoidable.
The original flight plan had been scrubbed at the last minute and a new one ginned up on the flight line — then changed again in midair. It had been a boring deployment anyway, and the overbearing commander and his top pilots were putting the squeeze on the new officers, coming down on them so hard that some questioned their chosen path as Marine aviators.
It was a “stifling command climate” and a lack of attention to detail that extended all the way to the squadron commander back in North Carolina, officials claim.
In the end, two CH-53E Super Stallion transport helicopters from Marine Heavy Helicopter Squadron 464 were destroyed and 10 service members killed in a collision investigators say could have been avoided. Further, the Feb. 17 incident off the coast of Djibouti was a major blow to an aviation community on the upswing after years of dismal safety records.
When it was all done, a squadron commander lost his job, a detachment commander and an up-and-coming pilot faced disciplinary action and an entire helicopter community was put on notice that past practices would not be tolerated.
“The mishap … was the result of a cascading chain of events that began with failures by the leadership of HMH-464 and HMH-464 Detachment Bravo to instill, inculcate and emphasize at all levels of the command the need for proper operational risk management and sound general aviation safety practices,” wrote Lt. Gen. John Sattler, then-commander of Marine Forces Central Command in his May 4 endorsement of the Judge Advocate Manual Investigation report.
The JAGMAN report, obtained Aug. 16 by Marine Corps Times through a Freedom of Information Act request, said the two helicopters from the detachment collided during a poorly planned daytime flight in which the aircrews failed to adhere to basic flight safety procedures. Investigators found that both helicopters’ pilots exhibited poor leadership and failed to maintain situational awareness during the last few moments of the flight.
Marines killed in the crash were pilot of the lead aircraft Capt. Bryan D. Willard, 33, of Hummelstown, Pa., and co-pilot, 1st Lt. Brandon R. Dronet, 33, of Erath, La., along with the crews of both aircraft and two Air Force communications specialists assigned to the flight.
The pilot and co-pilot of the second aircraft, dubbed “Condor 11,” were the only survivors. The mishap report faults Condor 11 pilot Capt. Susan Craig, 28, for a failure to stand up to Willard — “Condor 10” pilot and section leader for the mission — during the flight’s planning.
“She clearly recognized that Capt. Willard’s preflight and in-flight change of mission and plan was ambiguous and created unnecessary operational risk,” according to the mishap report.
Sattler recommended Craig lose her wings and called for action against Detachment Bravo’s commander, Maj. Bart Ludlow, and HMH-464’s commanding officer at the time, Lt. Col. Jeffrey Martinez.
“The failures by the commander of HMH-464 are directly related to this mishap,” Sattler wrote. “Despite the geographical separation of the squadron and its detachment, the squadron commander cannot abdicate this responsibility.
“Appropriate administrative and/or disciplinary action should be taken.”
A 2nd Marine Aircraft Wing spokesperson said Martinez was relieved of his command May 5 and “appropriate administrative actions” were taken against Craig and Ludlow but could not elaborate on what those actions were.
Sattler disapproved of the investigators’ call to pull the wings of Condor 11 co-pilot 1st Lt. Heath Ruppert, saying he “has future potential as a Naval aviator.”
Craig and Ludlow declined to comment on the investigation. Martinez now works at wing headquarters at Marine Corps Air Station Cherry Point, N.C., with the operations department. He, too, declined comment for this article.
An unexpected turn
It was to be a routine training mission — like so many others Craig had flown on this, her second deployment to Djibouti as part of Combined Joint Task Force Horn of Africa.
The two Super Stallions from Marine Corps Air Station New River, N.C., were to fly from the airfield at Camp Lemonier around 3:45 p.m. local time and link up with an Air Force refueling plane, take on some gas, then split up for another hour or so to practice landings in the rugged terrain abutting the base.
But about 20 minutes before the Stallions were due to depart, the Air Force canceled its refueling flight, throwing mission leader Willard’s plan out the window. So, on the flight line, Willard concocted a new plan to fly reconnaissance of two desert landing areas and execute practice landings as a pair, pointing to a map of the new route for Craig, the pilot of the second aircraft, but never establishing any navigation points or procedures for the other crew members, the investigation says.
“The new plan was, pretty much, ‘Follow those guys,’” said Ruppert, Craig’s co-pilot in the second aircraft. “She was telling us what we were doing when she was putting on her flight gear.”
About 10 minutes into the impromptu mission, Willard radioed that he was changing the plan once again to “check out” an airfield north of the base. It was unclear to the Condor 11 pilots flying behind Willard if they were to land at the field or just fly by, and Willard never shared any information on how the new mission should proceed.
“We were going to go up there and land and that’s completely what I thought,” Craig told investigators, “but he did not use those words.”
“I just made that assumption,” she added.
The two Super Stallions flew up the Djiboutian coast for another 10 minutes. Around 4:05 p.m., as both aircraft were turning west toward land, Willard suddenly banked right into Condor 11’s flight path. Craig tried to avoid Willard’s helicopter, passing slightly above and to the right of the oncoming helo, but not before Willard’s rotors sliced through Condor 11’s tail, sending both aircraft out of control and into the Gulf of Aden below.
The two pilots in the second helo — Ruppert and Craig — struggled to the surface and swam to shore about 100 yards away. None of the other crew made it out of their helicopters. Craig and Ruppert were spotted around 6:20 p.m. by Djiboutian troops who were responding to the crash.
The Marines were later picked up by fellow HMH-464 pilots and flown back to base.
Command climate
Investigators found no mechanical defects with the Super Stallions that would have contributed to the crash. The report puts most of the blame squarely on the shoulders of detachment commander Ludlow, saying his overbearing leadership style discouraged junior pilots from questioning procedures and forced them into responsibilities that distracted them from safely doing their job.
“Detachment Bravo’s command climate was not conducive to professional aviation operations because it did not foster critical thinking among captains and first lieutenants [nor] free and open discussion of flight safety-related issues,” the investigation said. “The detachment [commander] habitually berated rather than mentored Capt. Willard and first lieutenants as opposed to constructively contributing to their professional development.”
As detachment commander, Ludlow was responsible for making sure all of his pilots were qualified for their jobs.
The report suggests that it was a bad call by Ludlow to let Willard fly as a section leader and that sloppy leadership and crew management on his part contributed to the mishap.
Ruppert told investigators that when his detachment assumed the Djibouti mission in October 2005, Ludlow told the junior pilots not to question the senior pilots’ actions in flight.
“Co-pilots are ‘not allowed to question [helicopter aircraft commanders]’ but rather to sit there and keep quiet,” the report said. “Ludlow … informed the lieutenants that questioning HACs ‘was the quickest way back to the states and getting kicked off the Det.’ ”
The report also questioned the wisdom of putting Willard in command of a section. Since July 2005, Willard had been involved in four in-flight mishaps, one of which caused him to be taken off flight status for more than one month at the beginning of the Djibouti deployment.
And just one month after getting back into the cockpit, Willard damaged one of the Super Stallions during a hard landing on a pile of jagged rocks, punching holes in the helicopter’s floor. Ten days later, Willard — with Ruppert as co-pilot — dropped a Humvee during sling-load training, injuring three soldiers and causing more than $30,000 in damage to the vehicle.
Additionally, Willard was assigned five jobs, including director of safety and standardization and aviation safety officer, on top of his flight duties, a workload that investigators found was too much for one of only nine pilots in the detachment.
Willard’s instructions to the crews during the pre-mission planning and in flight were vague and did not adhere to standards of conduct for such flights, investigators said.
“Captain Willard, the section leader and aircraft commander for Condor 10, failed to effectively lead the flight by ensuring uniform expectations for the conduct of the flight,” the report states.
In his endorsement of the investigation, Sattler further recommended squadron commander Martinez’s removal, but there’s no specific evidence in the report of any wrongdoing on his part other than Sattler’s opinion that he “failed to ensure operational risk management and safety of flight policies were practiced by HMH-464 Det-B.”
Cracking down
The harsh recommendations against HMH-464’s surviving pilots, detachment staff and commander come after a major crackdown on aviation safety launched in 2004 by then-Marine Corps aviation chief Lt. Gen. Mike Hough. Following a series of fatal accidents over several years during non-combat, routine training and transport flights, and a dismal overall safety record, aviation officials vowed to stem the tide by cracking down on leaders across the fleet.
In short, if you had too many mishaps in your squadron, you were gone, Hough demanded.
In October 2004, then-3rd Marine Aircraft Wing commander Maj. Gen. Keith Stalder relieved five top aviators with Marine Light Attack Helicopter Squadron 367 while they were deployed to Iraq due to a poor safety record — the first major move in the Corps-wide aviation safety crackdown.
Now, the Corps is on track to log its second best year in terms of aviation safety, based on major mishaps per flight hours.
Since the HMH-464 mishap, aviation officials with 2nd MAW have implemented a variety of changes to help prevent another such incident, said wing spokeswoman Maj. Shawn Haney.
New reporting procedures, leadership responsibilities and increased supervision have been implemented for the CJTF-HOA detachments coming from Marine Aircraft Group 29 helicopter squadrons.
The group will also require squadron commanders to visit the detachments at least once during their six-month deployment, Haney said.
“Squadrons fleetwide were required to brief and discuss the safety investigation report, focusing on detachment and flight leadership issues, cockpit resource management and operational risk management responsibilities of all involved in flight duties,” she added.
“This was a terrible tragedy,” Haney said. “We recognize that, and we take this very seriously.”
The victims
The Feb. 17 collision of two CH-53E Super Stallion helicopters off the coast of Djibouti in east Africa killed eight Marines and two airmen.
The Marines killed
Pilot Capt. Bryan D. Willard, 33, of Hummelstown, Pa.
Co-pilot 1st Lt. Brandon R. Dronet, 33, of Erath, La.
Crew member Sgt. James F. Fordyce, 22, of Newton Square, Pa.
Crew member Lance Cpl. Samuel W. Large Jr., 21, of Villa Rica, Ga.
Crew m ember Sgt. Donnie Leo F. Levens, 25, of Long Beach, Miss.
Crew member Cpl Matthieu Marcellus, 31, of Gainesville, Fla.
Crew member Sgt. Jonathan E. McColley, 23, of Gettysburg, Pa.
Crew member Lance Cpl. Nicholas J. Sovie, 20, of Ogdensburg, N.Y.
The airmen killed
Communications specialist Staff Sgt. Luis M. Melendez Sanchez, 33, of Bayamon, Puerto Rico.
Communications specialist Senior Airman Alecia S. Good, 23, of Broadview Heights.
Safe year
The Marine Corps’ Class A mishap rate — accidents that cause $1 million or more in damage or loss of life — through Aug. 16 stood at 1.8 per 100,000 flight hours with six mishaps and involving three helicopters.
At this rate, the Corps will have the second-best aviation safety record in its history.
Marine Class A aviation mishaps
Fiscal ’01 — 5
Fiscal ’02 — 15
Fiscal ’03 — 11
Fiscal ’04 — 18
Fiscal ’05 — 9
Fiscal ’06 — 6 (to date)
Source: Naval Safety Center
Ellie
Fatal flaws
‘Stifling command climate,’ as well as pilots, blamed in 2-helo crash off Africa that killed 10
By Christian Lowe
Staff writer
Crew m ember Sgt. Donnie Leo F. Levens, 25, of Long Beach, Miss.
It was exactly the kind of situation Marine aviation brass had been trying to reverse for the last two years. And it was completely avoidable.
The original flight plan had been scrubbed at the last minute and a new one ginned up on the flight line — then changed again in midair. It had been a boring deployment anyway, and the overbearing commander and his top pilots were putting the squeeze on the new officers, coming down on them so hard that some questioned their chosen path as Marine aviators.
It was a “stifling command climate” and a lack of attention to detail that extended all the way to the squadron commander back in North Carolina, officials claim.
In the end, two CH-53E Super Stallion transport helicopters from Marine Heavy Helicopter Squadron 464 were destroyed and 10 service members killed in a collision investigators say could have been avoided. Further, the Feb. 17 incident off the coast of Djibouti was a major blow to an aviation community on the upswing after years of dismal safety records.
When it was all done, a squadron commander lost his job, a detachment commander and an up-and-coming pilot faced disciplinary action and an entire helicopter community was put on notice that past practices would not be tolerated.
“The mishap … was the result of a cascading chain of events that began with failures by the leadership of HMH-464 and HMH-464 Detachment Bravo to instill, inculcate and emphasize at all levels of the command the need for proper operational risk management and sound general aviation safety practices,” wrote Lt. Gen. John Sattler, then-commander of Marine Forces Central Command in his May 4 endorsement of the Judge Advocate Manual Investigation report.
The JAGMAN report, obtained Aug. 16 by Marine Corps Times through a Freedom of Information Act request, said the two helicopters from the detachment collided during a poorly planned daytime flight in which the aircrews failed to adhere to basic flight safety procedures. Investigators found that both helicopters’ pilots exhibited poor leadership and failed to maintain situational awareness during the last few moments of the flight.
Marines killed in the crash were pilot of the lead aircraft Capt. Bryan D. Willard, 33, of Hummelstown, Pa., and co-pilot, 1st Lt. Brandon R. Dronet, 33, of Erath, La., along with the crews of both aircraft and two Air Force communications specialists assigned to the flight.
The pilot and co-pilot of the second aircraft, dubbed “Condor 11,” were the only survivors. The mishap report faults Condor 11 pilot Capt. Susan Craig, 28, for a failure to stand up to Willard — “Condor 10” pilot and section leader for the mission — during the flight’s planning.
“She clearly recognized that Capt. Willard’s preflight and in-flight change of mission and plan was ambiguous and created unnecessary operational risk,” according to the mishap report.
Sattler recommended Craig lose her wings and called for action against Detachment Bravo’s commander, Maj. Bart Ludlow, and HMH-464’s commanding officer at the time, Lt. Col. Jeffrey Martinez.
“The failures by the commander of HMH-464 are directly related to this mishap,” Sattler wrote. “Despite the geographical separation of the squadron and its detachment, the squadron commander cannot abdicate this responsibility.
“Appropriate administrative and/or disciplinary action should be taken.”
A 2nd Marine Aircraft Wing spokesperson said Martinez was relieved of his command May 5 and “appropriate administrative actions” were taken against Craig and Ludlow but could not elaborate on what those actions were.
Sattler disapproved of the investigators’ call to pull the wings of Condor 11 co-pilot 1st Lt. Heath Ruppert, saying he “has future potential as a Naval aviator.”
Craig and Ludlow declined to comment on the investigation. Martinez now works at wing headquarters at Marine Corps Air Station Cherry Point, N.C., with the operations department. He, too, declined comment for this article.
An unexpected turn
It was to be a routine training mission — like so many others Craig had flown on this, her second deployment to Djibouti as part of Combined Joint Task Force Horn of Africa.
The two Super Stallions from Marine Corps Air Station New River, N.C., were to fly from the airfield at Camp Lemonier around 3:45 p.m. local time and link up with an Air Force refueling plane, take on some gas, then split up for another hour or so to practice landings in the rugged terrain abutting the base.
But about 20 minutes before the Stallions were due to depart, the Air Force canceled its refueling flight, throwing mission leader Willard’s plan out the window. So, on the flight line, Willard concocted a new plan to fly reconnaissance of two desert landing areas and execute practice landings as a pair, pointing to a map of the new route for Craig, the pilot of the second aircraft, but never establishing any navigation points or procedures for the other crew members, the investigation says.
“The new plan was, pretty much, ‘Follow those guys,’” said Ruppert, Craig’s co-pilot in the second aircraft. “She was telling us what we were doing when she was putting on her flight gear.”
About 10 minutes into the impromptu mission, Willard radioed that he was changing the plan once again to “check out” an airfield north of the base. It was unclear to the Condor 11 pilots flying behind Willard if they were to land at the field or just fly by, and Willard never shared any information on how the new mission should proceed.
“We were going to go up there and land and that’s completely what I thought,” Craig told investigators, “but he did not use those words.”
“I just made that assumption,” she added.
The two Super Stallions flew up the Djiboutian coast for another 10 minutes. Around 4:05 p.m., as both aircraft were turning west toward land, Willard suddenly banked right into Condor 11’s flight path. Craig tried to avoid Willard’s helicopter, passing slightly above and to the right of the oncoming helo, but not before Willard’s rotors sliced through Condor 11’s tail, sending both aircraft out of control and into the Gulf of Aden below.
The two pilots in the second helo — Ruppert and Craig — struggled to the surface and swam to shore about 100 yards away. None of the other crew made it out of their helicopters. Craig and Ruppert were spotted around 6:20 p.m. by Djiboutian troops who were responding to the crash.
The Marines were later picked up by fellow HMH-464 pilots and flown back to base.
Command climate
Investigators found no mechanical defects with the Super Stallions that would have contributed to the crash. The report puts most of the blame squarely on the shoulders of detachment commander Ludlow, saying his overbearing leadership style discouraged junior pilots from questioning procedures and forced them into responsibilities that distracted them from safely doing their job.
“Detachment Bravo’s command climate was not conducive to professional aviation operations because it did not foster critical thinking among captains and first lieutenants [nor] free and open discussion of flight safety-related issues,” the investigation said. “The detachment [commander] habitually berated rather than mentored Capt. Willard and first lieutenants as opposed to constructively contributing to their professional development.”
As detachment commander, Ludlow was responsible for making sure all of his pilots were qualified for their jobs.
The report suggests that it was a bad call by Ludlow to let Willard fly as a section leader and that sloppy leadership and crew management on his part contributed to the mishap.
Ruppert told investigators that when his detachment assumed the Djibouti mission in October 2005, Ludlow told the junior pilots not to question the senior pilots’ actions in flight.
“Co-pilots are ‘not allowed to question [helicopter aircraft commanders]’ but rather to sit there and keep quiet,” the report said. “Ludlow … informed the lieutenants that questioning HACs ‘was the quickest way back to the states and getting kicked off the Det.’ ”
The report also questioned the wisdom of putting Willard in command of a section. Since July 2005, Willard had been involved in four in-flight mishaps, one of which caused him to be taken off flight status for more than one month at the beginning of the Djibouti deployment.
And just one month after getting back into the cockpit, Willard damaged one of the Super Stallions during a hard landing on a pile of jagged rocks, punching holes in the helicopter’s floor. Ten days later, Willard — with Ruppert as co-pilot — dropped a Humvee during sling-load training, injuring three soldiers and causing more than $30,000 in damage to the vehicle.
Additionally, Willard was assigned five jobs, including director of safety and standardization and aviation safety officer, on top of his flight duties, a workload that investigators found was too much for one of only nine pilots in the detachment.
Willard’s instructions to the crews during the pre-mission planning and in flight were vague and did not adhere to standards of conduct for such flights, investigators said.
“Captain Willard, the section leader and aircraft commander for Condor 10, failed to effectively lead the flight by ensuring uniform expectations for the conduct of the flight,” the report states.
In his endorsement of the investigation, Sattler further recommended squadron commander Martinez’s removal, but there’s no specific evidence in the report of any wrongdoing on his part other than Sattler’s opinion that he “failed to ensure operational risk management and safety of flight policies were practiced by HMH-464 Det-B.”
Cracking down
The harsh recommendations against HMH-464’s surviving pilots, detachment staff and commander come after a major crackdown on aviation safety launched in 2004 by then-Marine Corps aviation chief Lt. Gen. Mike Hough. Following a series of fatal accidents over several years during non-combat, routine training and transport flights, and a dismal overall safety record, aviation officials vowed to stem the tide by cracking down on leaders across the fleet.
In short, if you had too many mishaps in your squadron, you were gone, Hough demanded.
In October 2004, then-3rd Marine Aircraft Wing commander Maj. Gen. Keith Stalder relieved five top aviators with Marine Light Attack Helicopter Squadron 367 while they were deployed to Iraq due to a poor safety record — the first major move in the Corps-wide aviation safety crackdown.
Now, the Corps is on track to log its second best year in terms of aviation safety, based on major mishaps per flight hours.
Since the HMH-464 mishap, aviation officials with 2nd MAW have implemented a variety of changes to help prevent another such incident, said wing spokeswoman Maj. Shawn Haney.
New reporting procedures, leadership responsibilities and increased supervision have been implemented for the CJTF-HOA detachments coming from Marine Aircraft Group 29 helicopter squadrons.
The group will also require squadron commanders to visit the detachments at least once during their six-month deployment, Haney said.
“Squadrons fleetwide were required to brief and discuss the safety investigation report, focusing on detachment and flight leadership issues, cockpit resource management and operational risk management responsibilities of all involved in flight duties,” she added.
“This was a terrible tragedy,” Haney said. “We recognize that, and we take this very seriously.”
The victims
The Feb. 17 collision of two CH-53E Super Stallion helicopters off the coast of Djibouti in east Africa killed eight Marines and two airmen.
The Marines killed
Pilot Capt. Bryan D. Willard, 33, of Hummelstown, Pa.
Co-pilot 1st Lt. Brandon R. Dronet, 33, of Erath, La.
Crew member Sgt. James F. Fordyce, 22, of Newton Square, Pa.
Crew member Lance Cpl. Samuel W. Large Jr., 21, of Villa Rica, Ga.
Crew m ember Sgt. Donnie Leo F. Levens, 25, of Long Beach, Miss.
Crew member Cpl Matthieu Marcellus, 31, of Gainesville, Fla.
Crew member Sgt. Jonathan E. McColley, 23, of Gettysburg, Pa.
Crew member Lance Cpl. Nicholas J. Sovie, 20, of Ogdensburg, N.Y.
The airmen killed
Communications specialist Staff Sgt. Luis M. Melendez Sanchez, 33, of Bayamon, Puerto Rico.
Communications specialist Senior Airman Alecia S. Good, 23, of Broadview Heights.
Safe year
The Marine Corps’ Class A mishap rate — accidents that cause $1 million or more in damage or loss of life — through Aug. 16 stood at 1.8 per 100,000 flight hours with six mishaps and involving three helicopters.
At this rate, the Corps will have the second-best aviation safety record in its history.
Marine Class A aviation mishaps
Fiscal ’01 — 5
Fiscal ’02 — 15
Fiscal ’03 — 11
Fiscal ’04 — 18
Fiscal ’05 — 9
Fiscal ’06 — 6 (to date)
Source: Naval Safety Center
Ellie