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Safety Report Urges Aviators to Show ‘Moral Courage’ and Recognize Shortcomings



More than five years after a helicopter crash off the coast of Oahu claimed the lives of 12 Marines, the Navy has released a “lessons learned” document on the incident that urges pilots to be realistic about their training and their proficiency at flying.

A routine night training flight on Jan. 14, 2016, ended in tragedy when two CH-53E Super Stallions attached to Marine Heavy Helicopter Squadron 463 out of Hawaii collided in midair.

Four officers and eight enlisted crew members were killed.

A command investigation released later that year blamed pilot error, but noted that exhaustion and low pilot and aircrew practice time also contributed to the crash.

The squadron was short on functional helicopters and under pressure to get more choppers and pilots ready to fly, while pilots were not getting the flight hours needed to maintain their skills, the new safety document found. Several months before the collision, the squadron failed a maintenance inspection. Plus, the squadron’s commanding officer was relieved days before the crash. His bosses said there was a loss of confidence in his abilities stemming from inadequate improvement in the squadron between the failed inspection and the first days of the new year.

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Now, the Naval Safety Center says that a cultural shift is necessary to prevent future casualties.

The safety document emphasizes that “current does not equal proficient,” noting that simply being up to date on training is not the same as being comfortable with a particular situation or conditions.

The Marines in the crash caught up on their flight requirements with a training flight immediately before the one that ended in tragedy.

“Naval aviators (particularly Marines) tend to be hardwired to accomplish the mission,” the document adds — with the emphasis included. “It takes moral courage for us to admit when — in real-time — we are not proficient in executing a training or operational mission as it was designed.”

However, safety experts argue that the myriad challenges and changes the squadron experienced leading up to the deadly flight should have set off more alarms.

“Failed inspections, the relief of the CO [commanding officer], and the arrival of a new CO days later should have been enough to hit pause,” the document adds.

Ultimately, the report urges aviators to “remember that a training flight is just that: a training flight” — and should have lower risk.

“Have the assertiveness to make the call, and live to fly and fight another day,” the document said.

Military.com reached out to the Marine Corps for a reaction to the report but did not immediately get a response.

Maj. Jorge Hernandez, a spokesman for the Marine Corps, explained that the branch is part of the Naval safety center and “contributed to the development of this publication.” Hernandez said that the safety document “is the posture/reaction of the Marine Corps” and that the branch is “adapting and implementing mitigating factors to prevent tragedies like this from happening again.”

The report comes after another investigation that found Marine leadership is not doing enough to prevent training accidents and deaths.

Last month, a Government Accountability Office report found that 123 U.S. soldiers and Marines died in non-combat tactical vehicle accidents in the last decade, most of them in the United States, because the services didn’t do enough to enact their own safety measures.

That report was mandated by Congress following the 2019 death of a 24-year-old Marine platoon commander when his 12-ton vehicle rolled during a training exercise at Camp Pendleton, California. After the incident the Marine’s father, his mother, and the Marine’s fiancée lobbied members of Congress to dig into the troubling trend of military rollover deaths.

— Konstantin Toropin can be reached at konstantin.toropin@military.com. Follow him on Twitter @ktoropin.

Related: Army and Marines Aren’t Doing Enough to Prevent Deadly Vehicle Accidents, Watchdog Say

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