Crash Date: July 21, 2004

January 31, 2005

Answers in fatal midair collision
Report: Pilot ‘lost situational awareness;’ lax safety culture cited

By Christian Lowe
Marine Corps Times staff writer

Marine investigators determined that an experienced Reserve F/A-18 Hornet pilot lost situational awareness during a training flight, leading to a midair collision that killed two and injured another.

During the July 21 training flight near Arlington, Ore., Maj. Gary R. Fullerton, safety officer for the Marine Corps Air Station Miramar, Calif.-based Marine Fighter Attack Squadron 134, pulled his two-seat F/A-18B Hornet into a right-hand turn and crashed into the tail end of another, single-seat Hornet piloted by Maj. Craig Barden, also with VMFA-134. Both Fullerton and his back-seat passenger, Capt. Jeffrey L. Ross, were killed; Barden ejected safely.

The collision was the fifth accident involving Marine Hornets in fiscal 2004 and contributed to one of the worst years of Marine aviation safety in more than a decade. Just one month earlier, two Hornets crashed in separate incidents, killing both pilots.

According to the Judge Advocate Manual Investigation report obtained by Marine Corps Times through the Freedom of Information Act, Fullerton “lost situational awareness” when he banked his plane to follow Barden’s aircraft, which was leading the flight of two.

“Many factors were looked at to determine the cause of this mishap, yet none stood out as causal,” wrote Brig. Gen. Harold Fruchtnicht, 4th Marine Aircraft Wing commander, in a Nov. 7 letter accompanying the report. “The only conclusion that I can make is that some factor caused Maj. Fullerton, a very experienced Marine Corps aviator and commercial pilot, to lose situational awareness as he maneuvered his aircraft near his flight lead, which resulted in the mid-air collision.

“Ultimately, only Maj. Fullerton truly knew what was happening in his cockpit moments before he impacted with his flight lead,” Fruchtnicht added.

While the investigation did not find wrongdoing on the part of the aviators, Fruchtnicht took issue with a seemingly lax safety culture in the pilots’ squadron. He noted that procedures to make sure the pilots were qualified to fly were not followed and that the Marine in the back seat of Fullerton’s Hornet was not qualified to be aboard the flight.

“While these deficiencies cannot be definitively identified as causal factors contributing to the instant mishap, they must be addressed in order to ensure the safety of future flight operations within the squadron,” Fruchtnicht wrote.

Fruchtnicht ordered a team of 4th MAW safety experts to assess the squadron’s adherence to proper standards by May 2005 and called for a formal Naval Safety Center survey and “cultural workshop” to be held with VMFA-134 “as soon as possible.”

Additional opinions and recommendations were deleted from the copy of the investigation report provided to Marine Corps Times.

The findings dovetail with recent statements by senior Marine officials who are cracking down fleetwide to avoid another deadly year. Last summer, Lt. Gen. Mike Hough, deputy commandant for aviation, vowed to hold squadron commanders and staff accountable for accidents — particularly because most of the Corps’ crashes occurred during routine portions of flights, reflecting a lack of discipline and attention to detail.

In October, five senior leathernecks with Marine Light Attack Helicopter Squadron 367 — including the commander and executive officer — were fired or reassigned after a rash of accidents during the first few weeks of their deployment to Iraq caused Maj. Gen. Keith Stalder, 3rd MAW chief, to lose confidence in the squadron’s leadership. The move marked the first time Hough’s push for leadership accountability was put into action.

It is unclear whether VMFA-134 will face similar sanctions.

The investigation report brought to light several inconsistencies in the way the squadron kept Fullerton and Barden qualified to fly — including incomplete flight training and instrument ratings — and noted that Ross, who was not a qualified naval aviator, should not have been allowed to fly in the back seat of the Hornet the day of the accident. Ross was the squadron’s maintenance officer.

The two aircraft flew out of Portland International Airport at 2:20 p.m. July 21 in support of a training sortie with the Oregon Air National Guard, the report stated. Ross accompanied Fullerton for unknown reasons because squadron officials assumed he was authorized to fly.

According to the investigation report, naval flight regulations state fighter aircraft may not be used for “point-to-point” transport, and Ross was not on a special flight for VIPs.

During the flight, Barden — who was in the lead — was told to steer clear of a nearby training range since Air Force jets were operating there. He told air-traffic control operators that he would descend and turn around for a return to Portland’s airport.

As Barden turned his aircraft to the right, Fullerton’s Hornet impacted the right-rear of his aircraft, causing both planes to break apart. Barden ejected safely, sustaining injuries to his shoulders and a broken tailbone.