WASHINGTON: A Marine Corps investigation confirms that, as Breaking Defense reported July 9, the pilot at the controls of an MV-22B Osprey that crashed April 11 in Morocco, killing two crew chiefs aboard, violated flight manual procedures and committed other errors that contributed to the accident.

Breaking Defense has obtained a redacted summary of a Judge Advocate General Manual (JAGMAN) report on the accident — a document that stands at the center of a major effort by the United States government to convince the Japanese people and their government that the Osprey is both safe and highly effective. A redacted copy of the report was provided Wednesday to Japan’s vice minister of defense as part of a bilateral government effort to defuse Japanese protests of plans to deploy 24 Ospreys to Okinawa.

A small group of protesters in boats greeted the V-22′s arrival in July at Marine Corps Air Station Iwakuni on mainland Japan and Okinawa’s local governments have passed resolutions protesting the plane’s deployment.

Marine Commandant Gen. James Amos upped the ante today by issuing an extraordinary personal statement on that issue:

As the senior pilot on active duty today in the United States military, I personally attest that there is no more definitive way to strengthen the aviation capability of our allied forces than to forward deploy these remarkably capable aircraft to the Asia-Pacific region as soon as possible.

The JAGMAN report summary obtained by Breaking Defense recommends that “no administrative or disciplinary action” be taken against either of the two pilots but attributes the crash to “a series of imprecise decisions and actions in the cockpit,” as one officer’s written endorsement of the findings puts it.

The Marine Corps is expected to release the full but redacted JAGMAN report Friday in conjunction with a Pentagon news conference where the deputy commandant for aviation, Lt. Gen. Robert Schmidle, will take questions on the accident.

Amos added that he had just returned Tuesday from an Asia-Pacific trip that included a visit to Okinawa, where he flew one of the CH-46 Sea Knight helicopters the Ospreys will replace at Marine Corps Air Station Futenma. Citing Japanese worries about the Osprey’s safety record, Amos said he would work with the Japanese to “allay those concerns.” But he added that, “The deployment of the MV-22B to Japan, and its eventual location on Okinawa, is critical to the United States’ fulfillment of its responsibilities under our mutual security treaty.”

The Osprey takes off like a helicopter, swivels two wingtip rotors housed in pods called “nacelles” forward to fly like an airplane, then turns it nacelles upward again to land. The JAGMAN report confirms that after delivering a dozen Marines to a coastal landing zone during a military exercise in Morocco, the pilot lifted the Osprey into a hover of about 20 feet, made an immediate 180 degree turn to the right, let the nose of the aircraft pitch down five degrees while climbing to 46 feet, and lowered the nacelles farther than is permissible at low forward speed. He also failed to take into account a tailwind. Those factors combined sent the Osprey plunging nose first into the ground.

The report says that, “Failure to follow NATOPS procedures for VTOL Mode Hover and Low Speed Flight were a significant factor in this mishap.” NATOPS — Naval Air Training and Operating Procedures Standardization – is a generic name for Navy and Marine Corps flight manuals. VTOL means vertical takeoff and landing. “By conducting a 180 degree hover turn, the mishap aircraft co-pilot placed the aircraft directly into a tailwind of 15-27 knots,” the report said, adding that this also violated NATOPS instructions.

The mishap pilot “states that the moment he started to transition was the moment he lost control of the aircraft,” the report said. One of the pilots — the redacted report left unclear which one — “felt an overwhelming force that pushed the nose of the aircraft down.”

The names and other identifying information about the two pilots were redacted from the copy of the report obtained by Breaking Defense, but the censor failed to black out the fact that the co-pilot – who was at the controls during the crash – had a total of 160.1 hours in the Osprey, a relatively modest amount of experience but more than enough to be considered fully trained.

The crash occurred at 3:53 p.m. local time in daylight and good weather, the JAGMAN report said, on a day when “all required maintenance action was complete on the mishap aircraft (and it) was considered safe for flight.”

The mishap aircraft, which belonged to Marine Medium Tiltrotor Squadron 261 (VMM-261) of Marine Corps Air Station New River, N.C., was participating as part of the 24th Marine Expeditionary Unit in a joint military exercise with Morocco called “African Lion.” Based on the amphibious assault ship USS Iwo Jima (LHD-7), the Osprey had begun the day by flying to a Moroccan airfield called Plage Blanche, near the town of Tan Tan. The crash occurred midway through three round trip flights the Osprey was supposed to make to ferry 12 Marines at a time from Plage Blanche north to Cap Drâa, a flat area on the Atlantic coast.

The landing zone, designated “LZ North,” was a 408-by-492-foot rectangle of flat land which was graded, filled in with small rocks, and located 662 feet from a line of cliffs rising up from the Atlantic. On the first trip to the landing zone, the mission commander was at the controls and “landed at LZ North with the nose heading into the wind at 330 degrees,” the report said. Seeing “significant numbers of personnel, tents and vehicles around the LZ,” the mission commander decided to depart for the return trip to Plage Blanche by hovering, turning back in the direction he’d arrived from, then flying away. At takeoff, the mission commander lifted the aircraft into a hover, executed a 180 degree pedal turn to the right and departed with no problems. “Nothing unusual was noted with the aircraft and no concern was noted by either pilot once this maneuver was completed,” the report said.

During the return trip to Plage Blanche, the mission commander passed the controls to the more junior co-pilot, who remained at the controls through the crash. After they picked up their second load of 12 Marines at Plage Blanche and delivered them to LZ North, the mishap pilot told the commander he was going to depart the same way the commander had on their first visit to the zone. The commander “concurred with the decision,” the report said.

“When the mishap aircraft was approximately 20 feet off the ground, [the pilot] began turning the aircraft 180 degrees in a rightward direction, (‘nose right, tail left’ maneuver),” the report said. Ten seconds into the flight, the aircraft was pointed in the direction the pilots wanted but had climbed to about 46 feet above ground and had its nose pitched downward five degrees – and at one point, 10 degrees, one of the pilots told investigators. At that moment, the co-pilot began lowering the angle of the MV-22B’s nacelles – a task pilots accomplish by turning a small thumbwheel on the Osprey’s Thrust Control Lever. Within three seconds, the mishap aircraft’s nacelles had moved from 87 to 71 degrees – below the allowable level.

The MV-22B NATOPS, the report noted, instructs that “when normal hover altitude is reached,” the pilot should “adjust nacelle angle to achieve a level nose attitude.” The NATOPS also says, the report noted, that “as the nacelles are tilted forward, the aircraft nose attitude will tend to pitch down. The pilot must counter with aft cyclic to maintain a level fuselage attitude.” To “counter with aft cyclic” means pulling back on the control stick to pitch the nose upward.

As Breaking Defense has previously reported, the Osprey’s NATOPS also includes a “Warning” – a term used to highlight risks that can lead to injury or death – that “severe pitch down and altitude loss can occur if nacelles are rotated too far forward too quickly at takeoff.” The MV-22B NATOPS also instructs pilots to keep the nacelles above 75 degrees at speeds less than 40 knots, in part so the rotors can provide sufficient lift to keep the machine airborne.

As the mishap pilot felt the Osprey’s nose begin to plunge forward, he made a “significant leftward jerk on the cyclic control stick, followed by pulling the cyclic control stick all the way to the rear.” The mission commander, realizing the co-pilot had lost control, tried to pull the control stick back himself but quickly saw it was “all the way to the rear,” the report said. The Osprey’s nose turned down and plunged into the ground at a 45- to 60 degree angle about 15 seconds into the flight, the report continued.

“Immediately upon impact,” the report said, Marines from Battalion Landing Team 1 / 2 and Combat Logistics Battalion 24 “rushed toward the aircraft and started searching the wreckage for survivors.” Some of them quickly pulled the pilots, both of whom were injured, away from the aircraft, where Navy corpsmen began giving them medical attention.

Neither of the crew chiefs was strapped into a seat when the crash occurred, a clear factor in their deaths.

Cpl. Robby A. Reyes, 25, of San Bernardino, Cal., who as forward crew chief had been standing behind the cockpit at the front of the large back cabin, suffered “multiple severe injuries to the head and torso,” the report said. Reyes couldn’t be pulled from the wreckage. One of the Marines who tried to rescue him, however, quickly determined that he was already dead.

Other Marines pulled the aft crew chief, Cpl. Derek A. Kerns, 21, of Salem, N.J., out of the back of the cabin “coherent and talking.” Kerns, however, who had been standing near the rear ramp, strapped to the aircraft only by a thick “gunner’s belt,” failed to respond to treatment by the time a Moroccan Puma helicopter got him to a forward medical facility only three miles away. He died at 5:30 p.m. local time, just over 90 minutes after the crash.

“Trauma caused by the impact of the gunner’s belt worn by Corporal Kerns on his abdominal region ultimately was the cause of death, but there is no guarantee that he would have survived the accident if he were wearing a different harness or strapped into the aircraft in any other way,” the JAGMAN report said.

The way Reyes and Kerns died led the chief investigating officer to recommend that the Marine Corps study what circumstances really require crew chiefs to stand or walk about the cabin in flight, a common practice in both Ospreys and large helicopters. “At all other times, crew members should be required to remain seated with a four point seat belt fastened,” the report said, urging the Corps to pay particular attention to whether moving around in the cabin is necessary in a “non hostile environment.”

The investigating officer also urged the Marine Corps to “look into ‘gunner’s belt’ designs that spread out the impact of violent cessation of movement,” reasoning that “a ‘gunner’s belt’ design that spreads the force impact across the body may have resulted in significantly less injuries to Corporal Kerns.”

In his official endorsement of the report, Maj. Gen. Glenn M. “Bluto” Walters, a highly experienced Osprey pilot who commands the 2nd Marine Air Wing at Cherry Point, N.C., said he wanted to emphasize the recommendation on crew movements. “A major push must be made in the rotary wing community for all crew members to be strapped to their seats when not performing some critical function,” Walters wrote. “This is especially true for non-hostile and training environments.”

Other key findings in an “Opinions” section of the JAGMAN report include:

  • “The mishap aircraft co-pilot did not have a clear understanding of the true wind speed when taking off from LZ North just prior to the accident.”
  • “Failure to correct for a nose down attitude during the hover turn exacerbated the situation and compounded the severity of the other factors that led to the mishap.”
  • “The mishap aircraft had the nacelles moved too far forward for an aircraft at hover with a tailwind of 15-27 knots.”

2nd MAW commander Walters recommended that the opinions section also include this statement: “The mishap aircraft co-pilot failed to adjust nacelles aft during the pedal turn, preventing him from having enough aft cyclic stick control margin to overcome the effects of a nose down attitude and transitioning to aircraft mode with a significant tailwind.”

The 24th MEU commander, Col. Frank Donovan, wrote in his endorsement of the report that he was “hopeful for a recovery of the injured pilots and I would look forward to the opportunity to serve with them in the future.” Donovan also said that, “The loss of Corporal Reyes and Corporal Kerns significantly impacted the 24th MEU. Both were highly respected as superior Marines and contributing members to our mission and community.”

Japan’s vice defense minister, Hideo Jimpu, was given a copy of the report as a team of Japanese experts visited Washington and Marine Corps Air Station New River, N.C., this week for briefings on the Osprey and the Morocco accident. The protests in Japan against Marine Corps plans to base two squadrons of Ospreys on Okinawa have led the U.S. to promise that a dozen MV-22Bs shipped to Japan last month won’t fly until Japanese experts have examine the causes of the Morocco accident and the June 13 crash of an Air Force CV-22B Osprey in Florida.

During an Aug. 3 meeting at the Pentagon to discuss the Osprey, Defense Secretary Leon Panetta promised Japan’s defense minister, Satoshi Morimoto, that the U.S. would share the findings of the Air Force crash investigation by the end of August.

The JAGMAN report said the MV-22B lost in Morocco cost $73 million at delivery but could be replaced “similarly equipped” for $64 million, the price of a Marine Corps Osprey under a current contract with 50-50 partner manufacturers Bell Helicopter Textron Inc. and Boeing Co.