Investigation: Fatal collision was preventable - Navy News | News from Afghanistan & Iraq - Navy Times

Investigation: Fatal collision was preventable

SAN DIEGO — A fatal midair collision last fall involving Marine Corps and Coast Guard aircraft was “entirely preventable,” according to a Navy report released Tuesday, with investigators faulting both aircrews and the air traffic controllers guiding them.

A Coast Guard report, also released Tuesday, does not directly blame anyone for the accident off the California coast that killed seven Coast Guardsmen and two Marines, but it too criticizes Navy air controllers and questions whether the Marines’ use of night-vision lighting contributed to the mishap.

The crew of a Coast Guard HC-130H was searching for a missing boater around 7 p.m. Oct. 29 and simply did not see the Marine Corps AH-1W Super Cobra before the two collided about 1,000 feet above the Pacific Ocean, according to the Coast Guard’s investigation. The Marine Corps conducted an investigation into the collision as well, but a copy of that report has not yet been made public.

At the time of the accident, the HC-130, based in Sacramento, Calif., was nearly three hours into the search-and-rescue mission, flying in and out of military air ranges and at times guided by Navy air traffic control out of North Island Naval Air Station in Coronado. The AH-1W was the lead escort for a four-helicopter flight — two AH-1Ws from Camp Pendleton, Calif., and two CH-53E Super Stallions from Marine Corps Air Station Miramar in San Diego — headed through the nearby W-291 range en route to a Navy range on San Clemente Island.

The sky was clear that evening, with seven miles of visibility. Marines operating the helicopters wore night-vision goggles for the flight, the Coast Guard report states. The four-helicopter flight, flying in a diamond formation, operated as a “single aircraft,” meaning that for an NVG flight, some but not all of the helicopters would turn on their transponders and navigation lights.

The lead helicopter, a CH-53E, activated its “identification friend or foe,” making it visible on radar to other air traffic. The rear helicopter, an AH-1W, had its flashing anti-collision light on, the Coast Guard report states.

The HC-130 was not night-vision compatible, the report states.

Coast Guard investigators concluded that “no single factor or individual act or omission caused this mishap,” calling it “the product of a tragic confluence of events, missed opportunities and procedure/policy issues in an airspace where most aircraft fly under a ‘see-and-avoid’ regime.” But they questioned whether either aircrew had sufficient information about where the other was located — and whether night-vision lighting used by the Marine helos made it too difficult for the HC-130 to maintain visual contact.

Coast Guard and Navy investigators criticized the Navy’s Fleet Air Control and Surveillance Facility in San Diego, with the former saying personnel there never provided “operational priority” to the search-and-rescue mission. Guidance given by air traffic controllers would have reinforced the HC-130 crew’s expectation that they would be protected from live fire areas and other aircraft operating in W-291 training area, the Coast Guard report states.

The air controller and the watch supervisor did not notify the HC-130 crew about the Marine helos, impose altitude or aircraft restrictions, or preempt training while the search-and-rescue mission was still underway, the report states.

“This mishap and the tragic loss of life that resulted was entirely preventable,” the Navy report, signed by U.S. Pacific Fleet Commander Adm. Patrick M. Walsh, states. “… This incident was caused by a series [of] actions taken by both aircrews and air traffic controllers; all of which were compounded by a lack of communication between the parties.”

Additionally, while the helicopter formation was within regulation, Coast Guard Vice Commandant Adm. Sally Brice-O’hara, who approved the Coast Guard’s report, wrote that its size and lighting afforded the HC-130’s crew “little opportunity to see and avoid the mishap aircraft and were contributing factors” to the accident. Moreover, at the time of the collision the lead and rear helicopters in that formation were separated by almost 1½ miles, far longer than what the crews had briefed.

The Coast Guard has since ordered a number of changes in procedures and policies, including broad reviews of safety program management, prioritizing search-and-rescue missions and improving liaison with civilian and military air traffic control centers.

“We are using what we found in these investigations to improve aviation safety,” Rear Adm. Joseph Castillo, who commands the 11th Coast Guard District in Alameda, Calif., said in a statement. “We are committed to preventing a recurrence of this terrible tragedy. We owe nothing less to the memories of the dedicated men and woman lost in the crash, their families, their shipmates, and the public.”

Crash victims

• Maj. Samuel Leigh, 35, of Belgrade, Maine.

• 1st Lt. Thomas Claiborne, 26, of Parker, Colo.

• Lt. Cmdr. Che Barnes, 35, of Capay, Calif.

• Lt. Adam Bryant, 28, of Crewe, Va.

• Chief Aviation Maintenance Technician John F. Seidman, 43, of Carmichael, Calif.

• Aviation Electronics Technician 2nd Class Carl P. Grigonis, 35, of Mayfield Heights, Ohio.

• AET2 Monica L. Beacham, 29, of Decaturville, Tenn.

• AMT2 Jason S. Moletzsky, 26, of Norristown, Pa.

• AMT3 Danny R. Kreder II, 22, of Elm Mott, Texas.