Cadena de decisiones equivocadas, accidente F18 en SAN mp3

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'A chain of wrong decisions'
Shoddy maintenance, human error led to crash that killed 4, Marines say
By Steve Liewer (Contact) Union-Tribune Staff Writer, Rick Rogers (Contact) Union-Tribune Staff Writer
2:00 a.m. March 4, 2009



EXCERPTS
Portions of the recording released yesterday by the Federal Aviation Administration:

FAA air traffic controller: Nature of emergency?

Lt. Dan Neubauer: Yes, sir. One fellow on board. I'm down to a single engine (and) possibly a problem with the other engine

Controller: Straight into Runway 36 (at North Island)?

Neubauer: I'm actually going to try to take it to Miramar, if possible.

Controller: OK, just let me know what you want to do.

Neubauer: Thank you. I'm coordinating with people on the ground to figure out what we're doing.

Controller: Just let me know if you want to change to North Island. I'm going to keep you on a heading that will run you right by North Island and it's going to be a shortcut to Miramar.

Neubauer: Roger.

Military air traffic controller: (Neubauer) has crashed, actually.

FAA supervisor: You're kidding me.

Online: To hear a recording between the pilot and an air traffic controller, view a photo gallery and see video of yesterday's news conference at Miramar Marine Corps Air Station, go to uniontrib.com/more/marinecrash

A military jet's deadly December crash in University City could have been averted if the pilot and ground crew had followed emergency rules for landing at North Island Naval Air Station, and if the plane had been removed from service when mechanics found a fuel problem, Marine officials said in strikingly candid remarks yesterday.

Lt. Dan Neubauer's decision to bypass North Island and head toward Miramar Marine Corps Air Station over populated areas has been criticized by many, including residents near the crash site.

The Dec. 8 crash killed a woman, her two young daughters and her mother.

Half an hour before the crash, Neubauer shut down one of the jet's two engines because of low oil pressure. (Editor's note: earlier version incorrectly said fuel wasn't flowing.) Marine officials defended the decision at first, saying no one could have expected the second engine to fail.

They reversed their stance yesterday.

“Landing at North Island was the prudent and correct decision to make,” said Col. John Rupp, operations officer for the Miramar-based 3rd Marine Aircraft Wing. “Unfortunately, that decision was never made.”

No criminal charges are pending, but four officers from the Marine Fighter Attack Training Squadron 101 – the squadron commander, squadron operations officer, standardization officer and maintenance officer – were relieved of their duties in the past two weeks. The move basically ends their military careers.

“That is all the senior leadership of the command. They're gone,” said retired Navy Capt. Charles Nesby of Mira Mesa, a former aircraft-wing commander who flew 17 years out of Miramar.

Eight other Marines and one sailor have been reprimanded.

Marine officials have grounded Neubauer while they review his flight status. The pilot, new to the F/A-18D Hornet, was practicing his first rounds of takeoffs and landings on the aircraft carrier Abraham Lincoln on the day of the crash.

Aviation tradition assigns full responsibility for safe operation of an aircraft to the pilot. But Maj. Gen. Randolph Alles, assistant wing commander for the 3rd Marine Aircraft Wing, attributed the crash to “supervisory error and a chain of wrong decisions.”

The F/A-18D suffered engine trouble shortly after Neubauer's 11:11 a.m. takeoff from the carrier about 60 miles southwest of San Diego. He was told to open his safety checklist but didn't do so, Rupp said, and instead relied on guidance from Marines at Miramar who had incomplete knowledge of his situation.

Steve Diamond, a former naval aviator who witnessed the crash and spoke with Neubauer moments after the crash, was stunned to learn that the pilot – as well as his superiors – had neglected to use the checklist.

“Checklists are the most essential things,” Diamond said. “It's almost like a doctor going into surgery and forgetting to wash. It's that basic.”

Even though Neubauer shut down his right engine about 17 minutes into the flight, the fuel transfer problem persisted and activated a low-fuel warning light.

A civilian air traffic controller offered to direct Neubauer's jet – with the call sign SHUTR25 – toward Runway 36 at North Island, according to an audio recording released yesterday by the Federal Aviation Administration. That approach would have kept the aircraft over water until it touched down.

“I'm actually going to try to make it to Miramar if possible,” Neubauer replied as he flew at an altitude of about 13,000 feet nearly 20 miles south of North Island.

By 11:49, Neubauer again turned down the civilian controller's suggestions to land at North Island.

About two minutes later, Neubauer asked the controller to route him toward Miramar's Runway 6, an approach over La Jolla and University City that is rarely used.

Because his right engine had been shut off, he made a 270-degree turn to the left instead of a shorter turn to the right. That maneuver wasted precious time and fuel, Rupp said.

The controller asked whether the pilot would need emergency-response units at the airfield.

“Affirm,” Neubauer replied.

In his last transmission, Neubauer told the controller that he had the Miramar runway in sight.

He emerged from the cloud cover, Rupp said, and moments later slowed to landing speed. At 11:57, Neubauer radioed that he had lost his second engine, which flamed out because fuel was still not flowing correctly.

At less than 1,000 feet and nearly three miles short of the runway, the jet's electrical systems died.

Rupp said Neubauer tried to aim the faltering jet toward a canyon. The pilot ejected 17 seconds later near the Genesee Avenue and Governor Drive.

“He stayed with the aircraft until the last possible moment,” Rupp said.

The jet clipped a tree and plunged into Cather Avenue near Huggins Street west of Interstate 805. Nose down, its wheels and left wing hit the ground first at 11:58 a.m. The Hornet plowed through two homes and damaged three others.

A few minutes later, a military air traffic controller at the Miramar tower contacted the FAA traffic-control supervisor, who also is at Miramar.

“SHUTR25 has crashed, actually,” the military controller said.

“You're kidding me,” the FAA supervisor responded.

The post-crash investigations showed that mechanics had noted the jet's faulty fuel system in July. But Marine pilots flew 146 more sorties – 166 flight hours – without repairs being made, Rupp said. Neubauer and those in his squadron knew of the problem when he climbed into the cockpit.

Rupp said ambiguous maintenance requirements allowed the squadron to keep using the plane without fixing it. The practice is no longer tolerated.

After the crash, the Marine Corps issued a fleetwide hazard report about the potential fuel problem. Forty F/A-18s, including some in Iraq, were grounded after being identified as needing a closer look.

The Marine Corps has paid 11 families affected by the crash a total of $147,000, and it's working with those households on further claims, said Joe Kasper, spokesman for Rep. Duncan D. Hunter, R-Lakeside. Kasper attended a Marine Corps briefing yesterday morning with Hunter and other lawmakers.

“It is of great concern that I learned the outcome of the report,” said Rep. Susan Davis, D-San Diego. “Not only could this tragedy have been avoided had proper procedures been followed, but this plane should not have even been in use.”

The four crash victims – Youngmi Lee, 36, a nurse; her daughters Grace, 15 months, and Rachel, 2 months; and her mother, Seokim Kim, 60 – were part of a family of Korean immigrants.

The plight of grocer Don Yoon, Lee's husband, touched many people in San Diego and elsewhere. Yoon publicly forgave Neubauer during a news conference the day after the tragedy.

“I don't have any hard feelings,” Yoon said at the time. “I know he did everything he could.”

Yesterday, Yoon's family members referred inquiries to their attorney, Raymond Feldman in Santa Monica.

Feldman said the victims' family was briefed on the findings. “The Yoon and Lee families appreciate the candor and sensitivity shown to them as they continue to mourn for their loved ones,” Feldman said in a statement.

Tina Neubauer of Yorba Linda, the pilot's mother, sounded close to tears when asked how her son was coping in the aftermath of the crash.

“This is a tough time,” she said.

Residents were startled that the Marine Corps readily took responsibility for the crash.

“The Marines aren't trying to hide from it or duck it. They took it on the chin,” said Bob Johnson, who lived behind the Yoons and barely escaped the crash with his wife, daughter and 2-year-old grandson.

Ron Belanger, a retired Navy transport pilot who lives less than a block from the crash site, said he was surprised to learn the safety violations were more serious than the Marine Corps first revealed.

Belanger and other neighbors formed a group called Citizens Advocating Safe Aviation to push the Marines into investigating thoroughly and limiting future flights over University City. He, too, was impressed by the Marines' honesty.

“After the general's briefing today,” he said, “I think we're out of business.”

Staff writer Tony Manolatos and The Associated Press contributed to this report.
http://www3.signonsandiego.com/stor...y-maintenance-human-error-led-c/?zIndex=61668


http://www.signonsandiego.com/news/military/audiovideo/090303jetcrash_goingtomiramar.mp3
 
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