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Crash Details from the F-18 crash that killed 4 in San Diego

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Nikki Stone1 Donating Member (1000+ posts) Send PM | Profile | Ignore Tue Mar-03-09 07:12 PM
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Crash Details from the F-18 crash that killed 4 in San Diego
Crash Details from the F-18 crash that killed 4 in San Diego

These are my notes. I thought you might be interested. I just watched the briefing on the ABC affiliate. I've taken some notes and I hope they're sufficient. I probably missed a few things, but you'll get the general jist.


Overall problem: The F-18 crash was a combination of a maintenance issue, mechanical failures and some very faulty decision making by both the pilot and a couple of squadron on the ground at Miramar, leading to the shutting down of one engine and the flameout of the other. (The right engine had a low oil pressure condition and the left engine had a case of fuel starvation leading to the flameout.) At the time of pilot ejection (an impact) the F-18 had lost both of its engines and its electricity, and the plane was in freefall over the San Diego neighborhood it crashed into. The F-18 was two seconds away from a canyon (where it could have crashed without killing anyone.) The accident could have been avoided at a number of points, and there is a lot of fault to go around. Eight people have been relieved of their positions and the pilot has been grounded.

Flight Details

1. F-18 had a Deferred fuel transfer discrepancy. There was a maintenance request on this F-18 on July 14 for “slow degradation of motive flow.” This aircraft had a history of maintenance status codes, but the squadron elected to use the aircraft. They were allowed to do this—it’s a judgement call—and the F-18 had 166 successful flight hours between July and December 8, when it crashed. The investigator, Col. Rupp (?), said that the maintenance department was lured into a sense of complacency. The questionable decision to fly the F-18 with its degraded fuel system was the first mechanical cause of the crash, and it affected the left engine (the one that eventually flamed out at the end).

2. 10 minutes after taking off from the aircraft carrier, the pilot noticed an oil caution from the right engine. He asked to speak to the squadron’s tower rep who told the pilot to divert to North Island, which was close by. According to Col. Rupp, this was the correct decision and was also normal operating procedure.

3. The pilot began to divert to North Island, and with a failing oil system, had to shut down the right engine. The tower rep read the pilot the procedures during the attempted diversion, assuming that the pilot was reading his own emergency checklist along with the tower rep. The pilot was not; he had not taken out the emergency checklist, although he led the tower rep to think he had by saying, “Yes. Ok.” Because the pilot was not reading the checklist and because the Tower rep assumed he was, the Tower rep did not read all of the cautions that came along with the procedures. One of these cautions concerned fuel (“Trapping Fuel” caution).

4. At 13,000 ft., the pilot, flying only on the left engine, gets a “fuel low” caution. (This is related to the initial maintenance issue.) The pilot tried to relay his condition to the ship, but communications were garbled and unreadable. No one on the ship heard what was happening to him. The pilot also did not read his emergency card which would have said “Land as soon as possible,” guiding him to continue his diversion to North Island. So you have a pilot with a single engine emergency and a low fuel emergency who was not reading his procedures and did not correctly analyze the situation. He did not realize that the fuel for the left engine was in a critically low state. The left engine’s feeding tank, Tank 2, was only receiving gravity transfer of fuel. The motive fuel system was not working at all. Had the pilot landed at North Island even at this point, he could have made a safe landing. He is 15 nautical miles from North Island at this point.

5. Pilot contacts Miramar and checks in with his squadron. He told them about his situation. Col Rupp said that the pilot was “not assertive enough” in his reporting because he didn’t understand the low fuel issue and had not read the “low fuel caution.”

The squadron duty officer received the call and got backup from the squadron operations officer, who told the pilot to land at Miramar. At Miramar there was a landing signals officer and a familiar, longer runway. (The pilot has not been able to see the ground all this time because of the San Diego marine layer. He has been relying exclusively on his instrument panel.) The Commanding officer (of the squadron) OKs the Miramar landing. The duty officer has not relayed the “Fuel Low” caution to the Commanding officer and no one obtained the pilot’s position relative to Miramar. No one understood where the pilot was or how critical his situation was. Col. Rupp calls this “collective bad decision making.”

6. Pilot gets a left AMAD caution. The left engine is getting hot because of the lack of cooling due to improper fuel flow. (Degraded motive flow.) According to Col. Rupp, this should have been an indicator of the severity of the situation. The pilot told the Operations officer at Miramar about the AMAD caution but the Operations officer does not read the emergency procedure to the pilot and the pilot does not read it in flight either.

7. The pilot is given a short cut to Miramar by the FAA approach control. This short cut apparently went right by North Island, where the pilot still could have landed safely had someone guided him there. The pilot heads to Miramar.

8. The “Boost Low” caution comes on. At this point, no one has read procedures and the Operations officer, thinking it is important to minimize communications at this point, does not read the pilot anything about the Boost Low caution. No one in the squad room realized all the cautions that were coming on and that tank 2 was running out of fuel.

9. Pilot called Miramar and confirmed settings for the landing. The operations officer led the pilot to believe that he had to remain at 85% RPM on a descent. Therefore, the descent was prolonged and used more fuel. The pilot knowing he is too close to Miramar and not wanting to make turns into an inoperative engine, declines the offer of descent. returning to the original idea of North Island.

10. The operations officer tells the pilot to “crank the right engine”. The idea was to allow air to spin in the non operative engine. (The right engine has been off since early on in the flight). No one having read the procedures, the pilot tries to restart the right engine; this action ends up causing the unintended consequence of stopping gravity transfer to the left engine. Apparently, this could have been mitigated by pressing a particular light (I didn’t get the name of it) but, again, nobody had read the procedures.

11. Although the pilot was trying to go for a landing at North Island, the Controller offered a right turn into Miramar. Because the right engine was inoperative, the pilot asks for a left turn, and ends up with a left turn of 270 degrees, which took 1 ½ minutes and used extra fuel and time. By the time the pilot emerges beneath the marine layer and can see the ground, he could see the Miramar runway which was 6 nautical miles away. He was cleared for landing by the LSO. Less than a minute later, the pilot, slowing down, realizes he is losing his left engine too. “I just lost my motor” he transmits. His left engine had just flamed out. The pilot is 992 feet above the ground and saw houses and a canyon. Trying to save lives, he moves the F-18 toward the canyon, but then he loses all electrical power. The pilot had no control.

The pilot ejects at the last possible minute, 400 ft above the ground, 1-1.5 seconds prior to being outside the safe ejection envelope.

The F-18 is in freefall, clips a tree, left nose and wing down. The wheel and left wing make impact into the two homes, destroying them.

The aircraft was 250-300 ft and 2 seconds away from the canyon.


Col Rupp stated:

1. A Jan 9th Fleet Wide Hazard Report of F-18s was issued.
2. At Miramar, a policy memorandum concerning Maintenance Status Codes was issued.
3. Commander of Naval Air Systems Command: overseeing a review of maintenance and clarity on maintenance codes.
4. F-18 simulator was found deficient in regard to simulations of engine failure and is being corrected.
5. There are conflicts and deficiencies in published procedures that have to be worked out.

Relieved for Cause: The Squadron’s

Commanding officer
Operations Commander
Operations duty officer

and 5 other administrators who were not named.

The pilot has been grounded. Marine headquarters will determine his future flight status.
No criminal wrongdoing was found.
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