Consolidated Disposition Authority Review Board Report on 2016 and 2018 Aviation Mishaps
2 Jul 2020

On 18 June 2020, the Assistant Commandant of the Marine Corps provided the institution’s review and position on the Consolidated Disposition Authority Review Board’s report that looked into two separate aviation mishaps. On 6 December 2018, a midair collision between an F/A-18D Hornet aircraft from Marine All-Weather Fighter Attack Squadron 242 and a KC-130J Super Hercules aircraft from Marine Aerial Refueler Transport Squadron 152 occurred off the coast of Japan shortly after aerial refueling. Six Marines died in this incident and two aircraft were lost. On 28 April 2016, a less severe mishap with no injuries or aircraft loss occurred after aerial refueling between the same two squadrons.  Both squadrons are assigned to 1st Marine Aircraft Wing, the aviation combat element of III Marine Expeditionary Force. The Marine Corps subjected the command investigations into these mishaps to further review.

 The Consolidated Disposition Authority, as an independent commander, appointed a review board on 3 October 2019. The CDA was authorized to order a range of actions to include further investigation and/or administrative or disciplinary action in accordance with the Uniform Code of Military Justice. Where the previous command investigations were conducted by a single individual, the appointed review board was comprised of twelve experts from the F/A-18, MV-22, C-130, maintenance, medical, and legal communities. The CDA-RB’s intent was to enumerate every contributory and casual factor, allowing the institution to hold accountable those who should be held accountable, and provide appropriate, workable, and implementable recommendations for the institution to consider going forward.

 The CDA-RB’s report determined four interconnected causal factors led to the 6 December 2018 mishap. First, the flight lead (F/A-18 call sign, Profane 11) requested, and received approval for, an un-briefed, non-standard departure from the C-130 tanker (call sign, Sumo 41). This departure placed the mishap pilot (F/A-18 call sign, Profane 12) on the left side of the tanker. A standard departure would have placed both F/A-18s on the right side of the tanker. Second, Profane 11 chose an authorized, but not optimized, lighting configuration. After tanking, Profane 11 placed his external lights in a brightly lit overt setting, while the C-130’s lights remained in a dimly lit covert setting. These circumstances set the conditions for Profane 12 to focus on the overtly lit Profane 11 aircraft, instead of the dimly lit tanker. Third, Profane 12 lost sight of the C-130 and lost situational awareness of his position relative to the tanker resulting in a drift over the top of the C-130 from left to right. Fourth, Profane 12 was unable to overcome these difficult and compounding challenges created by the first three factors. As a result, when Profane 12 maneuvered his aircraft away from Profane 11, he moved from right to left and impacted the right side of the tanker’s tail section. It must be noted, this specific set of circumstances would have been incredibly difficult for any pilot, let alone a junior, or less proficient pilot to overcome.

 The CDA-RB determined the previous 2018 mishap command investigation did not capture a completely accurate picture of the event. The CDA-RB determined portions of the investigation contained a number of inaccuracies. Specifically, the 2018 command investigation incorrectly concluded medication may have been a causal factor in the mishap, the mishap pilot was not qualified to fly the mission, AN/AVS-11 night vision devices contributed to the mishap, and the previously mentioned mishap in 2016 had not been properly investigated. These conclusions are not supported by the evidence, and are addressed in detail in the CDA-RB report. While the 2018 CI contains a few inaccuracies, the CDA-RB does confirm the command investigation’s conclusions related to organizational culture and command climate as contributing factors to the mishap.

 The CDA-RB made 42 recommendations to address institutional and organizational contributing factors. As a result, the Assistant Commandant directed 11 actions to address manpower management, training, operations, and medical policies. The Director of the Marine Corps Staff will lead the coordination of all required actions to ensure proper tracking and accomplishment.

 Our Marines are our most precious resource and the loss of these six aircrew continues to be felt across our Corps. It is our sincere hope the directed actions will go a long way in mitigating future risk. The six Marines who perished in this mishap made the ultimate sacrifice while serving their fellow Marines and our great Nation. They will never be forgotten.

Communication Directorate

Headquarters Marine Corps