R 242208Z AUG 10
ALCOAST 429/10
COMDTNOTE 3750
SUBJ: RELEASE OF THE FINAL ACTION MEMO (FAM) ON THE ADMINISTRATIVE
INVESTIGATION INTO THE MIDAIR COLLISION OF HC-130 CGNR 1705 THAT
OCCURRED ON 29 OCTOBER 2009
1. PURPOSE: THE COAST GUARD HAS COMPLETED AN ADMINISTRATIVE
INVESTIGATION OF THE FATAL MISHAP LAST YEAR THAT CLAIMED THE LIVES OF
7 COAST GUARD AND 2 MARINE CORPS AVIATORS. THE FINDINGS ARE DESCRIBED
BELOW AND PUBLISHED IN DETAIL ONLINE TO EXPLAIN THE FACTORS THAT
CONTRIBUTED TO THE MISHAP. THE FAM IS A STAND ALONE DOCUMENT THAT
PRESENTS FINDINGS, DETERMINATIONS, AND INFORMATION UPON WHICH TO BASE
DECISIONS AND FUTURE ACTION. IT ALSO TASKS VARIOUS COAST GUARD
PROGRAMS WITH REQUIRED ACTIONS TO MITIGATE FUTURE RISK.
2. SYNOPSIS: ON THE EVENING OF 29 OCTOBER 2009, COAST GUARD AIR
STATION SACRAMENTO C-130 (CG 1705), WITH A CREW OF SEVEN, DEPARTED
SACRAMENTO AT APPROXIMATELY 1530 LOCAL EN ROUTE TO A PLANNED SEARCH
FOR AN OVERDUE SKIFF. THE SKIFF WAS REPORTED OVERDUE SINCE 27 OCTOBER
2009 AND REPORTEDLY HAD ONE PERSON ON BOARD. CG 1705 COMMENCED ITS
SEARCH PATTERN AT APPROXIMATELY 1640 LOCAL IN THE VICINITY OF SAN
CLEMENTE ISLAND, CA. THE SEARCH PATTERN INCLUDED FLIGHT IN AND NEAR
AIRSPACE WARNING AREA (W-291) AND SUNSET WAS AT 1800 LOCAL. AT
APPROXIMATELY 1846 LOCAL, TWO AH-1W COBRAS, V38 (THE MISHAP COBRA)
AND V39, EACH WITH A TWO PERSON CREW, LAUNCHED FROM MARINE CORPS
BASE, CAMP PENDLETON (MCB CP) EN ROUTE TO W-291. THE TWO COBRAS
TRAVELED SOUTH TOWARD OCEANSIDE, CA AND RENDEZVOUSED WITH TWO HEAVY
LIFT TRANSPORT HELICOPTERS (CH-53ES), WARHORSE 53 (WH53) AND WARHORSE
50 (WH50), THAT HAD LAUNCHED FROM MARINE CORPS AIR STATION MIRAMAR
(MCAS MIRAMAR). ALL USMC PILOTS AND AIRCREW, WITH THE EXCEPTION OF
ONE OFF-DUTY PILOT IN THE CABIN OF WH50, WORE NIGHT VISION GOGGLES
(NVGS). THE MC HELICOPTERS FORMED A FLIGHT OF FOUR FORMATION, WITH
WH53 AS FLIGHT LEAD, AT 500 FEET ALTITUDE AND WH50 AS THE TRAIL
FLYING STEPPED-UP SLIGHTLY AT THE 5 OR 7 O CLOCK POSITION FROM WH53.
THE TWO ESCORT COBRAS, V38 AND V39, WERE BRIEFED TO FLY AT 300 FEET
OF STEP-UP (I.E. 800 FEET ALTITUDE) AT THE 5 AND 7 O CLOCK POSITIONS
OF THE TWO CH-53ES. V38 WAS THE LEAD COBRA, FOLLOWED BY V39, WHICH
WAS ALSO THE TRAIL AIRCRAFT IN THE FLIGHT OF FOUR. AFTER FORMING, THE
FLIGHT PROCEEDED WESTBOUND TOWARD W-291 TO CONDUCT AN ESCORT/ASSAULT
TRAINING MISSION. WHEN MULTIPLE AIRCRAFT FORM A FLIGHT, THEY CAN
OPERATE AS A SINGLE AIRCRAFT WITH RESPECT TO NAVIGATION AND POSITION
REPORTING. THE FLIGHT OF FOUR OPERATED IN THIS MANNER, WITH ONLY THE
LEAD AIRCRAFT (WH53) HAVING ITS IDENTIFICATION FRIEND OR FOE (IFF)
TRANSPONDER ACTIVATED, AND ONLY THE REAR AIRCRAFT (V39), DISPLAYING
ITS FLASHING ANTI-COLLISION LIGHT. THE MISHAP COBRA, V38, HAD ITS
ANTI-COLLISION LIGHT AND IFF TRANSPONDER IN THE OFF POSITION. OTHER
AIRCRAFT WERE ALSO OPERATING WITHIN W-291, INCLUDING SIX U.S. NAVY
F/A 18 HORNET FIGHTER JETS AND ONE NAVY SH-60 MARITIME HELICOPTER
(LONEWOLF 55). FLEET AREA CONTROL AND SURVEILLANCE FACILITY SAN DIEGO
PROVIDED OFF-SHORE AIR TRAFFIC CONTROL WITHIN W-291. THE FLIGHT OF
FOUR ENTERED W-291 AT APPROXIMATELY 1854 LOCAL AND CONTINUED
WEST-SOUTHWEST TOWARDS THE SHORE BOMBARDMENT AREA ON THE SOUTHERN END
OF SAN CLEMENTE ISLAND. HAVING COMPLETED A LEG OF ITS SEARCH PATTERN
THAT TOOK IT OUT OF W-291, CG-1705 RE-ENTERED W-291 AT 1906 LOCAL ON
A SOUTHWESTERLY COURSE, WHERE IT CONTINUED SEARCHING FOR THE OVERDUE
SKIFF FROM AN ALTITUDE OF APPROXIMATELY 1000 FT ABOVE GROUND LEVEL
(AGL). AT 1908 LOCAL, WH53 LED THE USMC FLIGHT OF FOUR ON A
WEST-SOUTHWEST HEADING AND INITIATED A RIGHT-HAND TURN TO A WESTERLY
HEADING WHILE CLIMBING TO APPROXIMATELY 1000 FT AGL TO INCREASE
SEPARATION WITH LONEWOLF 55, WHICH WAS OPERATING AT APPROXIMATELY 2.5
MILES IN FRONT OF AND BELOW WH53. THE THREE TRAILING HELICOPTERS IN
THE FLIGHT OF FOUR FOLLOWED WH53 LEAD AND EXECUTED A RIGHT TURN AND
CLIMB, WHICH BROUGHT THE MISHAP COBRA INTO CONTACT WITH CG 1705. THE
COLLISION OCCURRED AT 1909:37 LOCAL AT 1000 FT AGL IN VISUAL
METEOROLOGICAL CONDITIONS OF 7 MILES VISIBILITY. AS A RESULT OF THE
COLLISION, BOTH AIRCRAFT WERE DESTROYED AND ALL SEVEN COAST GUARD
CREWMEMBERS AND BOTH MARINE CREWMEMBERS WERE KILLED. NO SINGLE FACTOR
OR INDIVIDUAL ACT OR OMISSION CAUSED THIS MISHAP. IT WAS THE PRODUCT
OF A TRAGIC CONFLUENCE OF EVENTS, MISSED OPPORTUNITIES, AND
PROCEDURE/POLICY ISSUES IN AN AIRSPACE WHERE MOST AIRCRAFT FLY UNDER
A SEE-AND-AVOID REGIME (I.E. WHERE INDIVIDUAL AIRCRAFT DE-CONFLICT
THEMSELVES).
3. THE RELEASE OF THE FAM SIGNALS THE COMPLETION OF A RIGOROUS
ADMINISTRATIVE INVESTIGATION, ANALYSIS AND HIGH LEVEL REVIEW OF THE
CIRCUMSTANCES WHICH LED TO THE LOSS OF CG 1705 AND CREW ON 29 OCT
2009. THE PRIMARY PURPOSE OF THE ADMINISTRATIVE INVESTIGATION WAS TO
MAKE FINDINGS AND PROVIDE INFORMATION UPON WHICH TO BASE POLICY,
DOCTRINE, AND TRAINING DECISIONS AND TAKE IMPROVEMENT ACTION. THE FAM
TASKS VARIOUS COAST GUARD PROGRAMS WITH REQUIRED ACTIONS TO MITIGATE
FUTURE RISK. ALL MEMBERS OF THE COAST GUARD ARE HIGHLY ENCOURAGED TO
READ THE FAM POSTED IN THE FOIA READING ROOM
AT:(HTTP://WWW.USCG.MIL/FOIA/READING-ROOM.ASP).
4. LCDR CHE BARNES, LT ADAM BRYANT, AMTC JOHN SEIDMAN, AET2 CARL
GRIGONIS, AET2 MONICA BEACHAM, AMT2 JASON MOLETZSKY, AND AMT3 DANNY
KREDER II AS WELL AS THE CREW OF V38 MADE THE ULTIMATE SACRIFICE
WHILE SERVING OUR NATION. THIS ACCIDENT IS A REMINDER THAT WE
ROUTINELY CONDUCT INHERENTLY DANGEROUS OPERATIONS AND THAT COAST
GUARD MEN AND WOMEN GO INTO HARMS WAY EACH DAY. THE AIRCREW OF CG
1705 EPITOMIZED SELFLESS SERVICE AND THE NATION IS GRATEFUL.
5. I AM ALSO GRATEFUL FOR THE SERVICE OF THE TWO MARINE CORPS PILOTS,
MAJ SAMUEL LEIGH AND 1ST LT THOMAS CLAIBORNE, WHO LOST THEIR LIVES IN
THIS ACCIDENT. EACH DAY, THE EXTRAORDINARY PERSONNEL OF THE MARINE
CORPS SELFLESSLY PUT THEMSELVES IN HARMS WAY TO TRAIN AND EXECUTE
THEIR MISSIONS.
6. I COMMEND THE EXTRAORDINARY PERFORMANCE BY THE COAST GUARD AND
DEPARTMENT OF DEFENSE PERSONNEL WHO RESPONDED THROUGHOUT THIS TRAGIC
MISHAP. SPECIAL RECOGNITION IS DUE TO THOSE WHO MET THE NEEDS OF
GRIEVING FAMILIES, FRIENDS AND SHIPMATES IMPACTED BY THIS TRAGIC
LOSS.
7. RELEASED BY VICE ADMIRAL SALLY BRICE O HARA, VICE COMMANDANT.
8. INTERNET RELEASE IS AUTHORIZED.
