SAN DIEGO — The F/A-18 crash that killed four family members in a San Diego neighborhood on Dec. 8 was caused by poor maintenance on the plane and a series of critical errors by the pilot and officers trying to guide him to an emergency landing, a Marine investigation report released Tuesday concluded.
Among the worst of the mistakes was the pilot's decision, made with his squadron bosses, to bypass a runway on Coronado and attempt to land at Miramar Marine Corps Air Station, 11 miles farther away. The pilot could easily have landed his jet at the closer North Island Naval Air Station, the investigation concluded.
Four top squadron officers at Miramar have been relieved of duty.
The investigation found that the commanding officer, operations officer, aviation maintenance officer and operations duty officer violated emergency procedures, gave incorrect instructions to the pilot, did not adequately check on the plane's location and failed to note the pilot's warning that his plane's only functioning engine had fuel problems.
Eight other Marines and a sailor have also been punished. The pilot, Lt. Dan Neubauer, who was still in training, has been grounded. The deputy commandant for aviation will decide whether he is allowed to resume flying.
"While we did not find any evidence of criminal wrongdoing, the responsible parties are being held accountable for their part in this tragic accident," said Maj. Gen. Randolph Alles, an F/A-18 pilot and assistant commander of the Miramar-based 3rd Marine Aircraft Wing.
Also on Tuesday, Marine brass briefed politicians in Washington and San Diego, as well as Dong Yun Yoon, whose wife, two young daughters and mother-in-law were killed when the plane smashed into their home.
As a result of the crash, the Marines have upgraded their maintenance standards and changed their emergency training. Flight simulators will now include a scenario like the one the F/A-18 pilot faced, officials said.
Minutes after taking off from the carrier Abraham Lincoln, which was a little more than 100 miles southwest of North Island, Neubauer reported low oil pressure in the plane's right engine. As a safety precaution, he shut down the engine.
The F/A-18, nicknamed the Hornet, is designed to fly on one engine in cases where the fighter jet might be damaged by enemy fire and need to return to a carrier or land base.
After he turned off the engine, Neubauer did not scan lists pilots are supposed to check when mechanical problems occur in the air. Ground personnel at Miramar read him parts of those lists but omitted key parts, the investigation found.
The pilot was instructed by the carrier captain and "air-boss" to land at North Island, which can be approached over the ocean. Instead, Neubauer and his squadron bosses decided to attempt an emergency landing at Miramar, where the squadron is based. That meant the jet would have to fly over the densely populated University City neighborhood.
The flight officers at Miramar also failed to take note when the pilot reported that a light indicated he was low on fuel for the left engine, a "critical mistake," according to the investigation.
As Neubauer prepared to land at Miramar, the left engine "flamed out" and lost power for lack of fuel. The pilot attempted to crash in a canyon, but the 30,000-pound plane, traveling an estimated 150 mph, was out of his control. If the plane had stayed aloft just two more seconds, it would have slammed into the canyon behind the homes.
The investigation found that, for months, maintenance personnel had ignored problems with the fuel flow to the left engine and had certified the plane as fit to fly. The problem was not listed on F/A-18 regulations as requiring immediate attention.
Still, allowing the plane to fly "was collectively poor judgment on the part of the squadron's maintenance department," said Col. John Rupp, operations officer for the 3rd Marine Aircraft Wing.
Tactics used by the pilot, and suggested by the ground personnel, exacerbated those fuel-flow problems and led the left engine to be deprived of fuel, even though the plane's tanks had thousands of pounds of fuel.
The pilot's final error was to make a left-turning loop to line up his approach to Miramar because he thought, incorrectly, that he could not turn toward the inoperative right engine. The turn took 90 seconds to accomplish and, for mechanical reasons, deprived the left engine of fuel.
At the point the left engine conked out for lack of fuel, the plane was just seconds from landing at Miramar. When it crashed, it spread jet fuel and metal parts throughout the neighborhood.
From engine flameout to crash took just 21 seconds.
Neubauer held on for 17 of those seconds and then ejected at approximately 400 feet; if he had waited a second or two longer, he probably would have been killed, the investigation concluded. The plane clipped a tree and skidded along Cather Avenue before smashing into the Yoon home. Two homes were destroyed and three others damaged.
After the crash, Marine Corps officials sent a bulletin to squadrons around the world telling them of the engine and fuel problems. The Navy and Marine Corps found 40 F/A-18s with the same problems, Alles said, but none have crashed.