Something was not right with the Marine flier at the stick of Blue Angels jet No. 6 on June 2, the day he split off for a routine maneuver and crashed into a field during an air show practice. Shortly after takeoff Capt. Jeff Kuss, the opposing solo pilot, initiated a Split-S maneuver. But he was flying too fast and too low, according to a new Navy report. He called in over the radio that he’d turned off his afterburners, but he hadn’t. At the time, rumors flew on social media and blogs that Kuss must have gone unconscious because he hit the ground at such a high speed. Others were sure he had sacrificed himself and stuck with the jet to make sure he didn’t fly it into a populated area. The truth is, by the time he realized what was happening and tried to eject, it was too late. A cloudy day, tactical errors and — investigators concluded -— fatigue were to blame for the accident that claimed the 32-year-old pilot’s life in Smyrna, Tennessee, according to the Navy investigation released Thursday. “Capt. Kuss represented the best and brightest of Naval Aviation,” Vice Adm. Mike Shoemaker, head of Naval Air Forces, said in a statement. “His professionalism, expertise and love of flying made him a valued member of the Blue Angels. His loss is devastating and felt across the Naval Aviation community. It is our duty as leaders and aviators to stress vigilance and operational risk management to avoid future tragedies.”

Kuss made an error by starting the Split-S maneuver at a higher speed and below the required altitude, and investigators believe his other mistakes and oversights were likely due to tiredness. Officials are ordering changes that allow Blues pilots to more readily opt out of flying when they're not feeling ready, are reviewing all air show maneuvers and are reworking future air show schedules to give fliers more rest time.

After the crash, investigators noted that he hadn't signed off on his aircraft discrepancy book that day, giving the jet the good-to-go for the practice. His F/A-18C Hornet was fine, but it was uncharacteristic for Kuss to forget to do something like that. It was also odd that he forgot to enter his radar squawk code and turn on his transponder, according to the report, and then later told air traffic control that he had turned off his afterburner, though he hadn't.

Those mistakes, coupled with some cloud cover at 3,000 feet were to blame for the accident, concluded the Chief of Naval Air Training report, which Navy Times obtained via an open records request. The team discussed the weather that day, AIRFOR spokeswoman Cmdr. Jeannie Groeneveld told Navy Times on Thursday, but Kuss and his fellow solo pilot didn't make formalize any adjustments to avoid it.

"Clouds at about 3,000 did not impact the solos' ability to fly, but that weather was likely a contributing factor to Capt. Kuss' decision to initiate the 'Split S' maneuver below the normal altitude," Shoemaker said.

After his initial climb, Kuss attempted to half-roll the jet while inverted, then go into a descending half-loop, so that he would end up in the opposite direction at a lower altitude. But because his afterburners were still on, Kuss went into the split at 184 knots, where it should have been 125 to 135. He was also flying at 3,200 feet — 300 feet below the required altitude for the maneuver.

"When you combine that with afterburners, it resulted in rate of descent that he didn’t recognize," as he started the descending half-loop, Groeneveld said.

It's possible that Kuss was too exhausted to fly that day, but also felt too much pressure to let anyone know, Shoemaker wrote in a letter closing the investigation.

"Every other squadron in the fleet has the ability to find a substitute pilot to complete the mission or execute an alternative mission," he wrote. "However, if one of the Blue Angels pilots is not ready, there are no other pilots who can readily cover their position for a show."

The Navy Flight Demonstration Squadron is unique that way, because there are only six pilots with very specific roles in the show. To prevent future tragedies will require a culture change, he added.

"Fundamentally, we will create an environment for NFDS where each pilot feels empowered to speak up before or during a brief if they feel they are not physically or mentally prepared for a flight."

Their shipmates will also have to look out for them, he wrote. There are well-established procedures in the fleet for pilots to "take a knee" if necessary, the Blues should follow them as well, he added.

Devastating loss

Kuss' death sent shock waves throughout the Navy and Marine Corps and devastated aviation and air show enthusiasts.

He was mourned publicly in his hometown of Durango, Colorado, back at Naval Air Station Pensacola, Florida, and in Smyra, where the Blues' canceled their appearance in the Great Tennessee Air Show.

They canceled several more appearances after that, returning to the sky in July as a five-some and a month later adding a new No. 6 pilot.

In the meantime, the team also made changes to the way it operates. A dozen immediate action items were identified in the investigation and are already completed. Five long-term initiatives are also underway.

"The Split-S maneuver is no longer to be performed in the show until further notice," Groeneveld added.

Shoemaker, the Navy's air boss, also ordered an altitude buffer during shows, a review of airspeed requirements for maneuvers and that weather flying decisions be made by the squadron boss and carried out by the whole team, rather than the previous policy of the four diamond pilots and the solos making decisions separately.

Long-term changes include an annual review of squadron training, maintenance and culture to be done by an F/A-18 expert in the off season, an assessment of all maneuvers and their prescribed altitudes, an adjustment to season schedules to allow more rest, selection of new commanding officers earlier in the year to give new leaders more time to get familiar with standard operating procedures and codifying winter training and standardization in the squadron's SOPs, to be signed off at the beginning of each season.

The Blues have eight more shows scheduled this year before their homecoming on Nov. 11 in Pensacola. One of those shows, to be determined, will be canceled, Groeneveld said, to give the team a break as the season comes to an end.

Meghann Myers is the Pentagon bureau chief at Military Times. She covers operations, policy, personnel, leadership and other issues affecting service members.

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