An Osprey crash in Australia that killed three Marines last August was caused by multiple pilot errors during a near mid-air collision, a military investigation has found.
It also found that squadron leadership had permitted “a culture that disregarded safety of flight.”
Two Marines were killed by the Aug. 27 crash, pilots Capt. Eleanor V. LeBeau, 29, and Maj. Tobin J. Lewis, 37.
A third Marine, crew chief Cpl. Spencer R. Collart, 21, was killed as he “heroically re-entered the burning cockpit of the aircraft in an attempt to rescue the trapped pilots,” the investigators said in a report released late Friday.
The crash was one of four fatal accidents in the past two years that have drawn renewed congressional scrutiny of the V-22 Osprey, which is able to fly both as an airplane and helicopter.
The Osprey has been a vital asset in special operations and combat missions, but it is considered one of the most complex aircraft to fly and maintain, and it has a troubled accident history.
The Osprey is now subject to a number of reviews looking at whether it is the right fit for the military moving forward.
The Australia accident exposed significant safety issues within the squadron. Investigators recommended punitive actions, including potential court martial charges for one senior squadron member and potential administrative actions against the squadron’s former commanding officer, Lt. Col. Joe Whitefield, who they said “permitted a culture that disregarded safety of flight procedures.”
A senior maintenance officer, who was unnamed, was found to be in violation of the Uniform Code of Military Justice for dereliction of duty and for falsely generating and signing a form detailing the aircraft’s weight and loads after the crash.
Lewis, the aircraft commander for the downed Osprey, was required to have reviewed that information prior to the flight.
Investigators recommended the maintenance officer face administrative or judicial procedures.
Given the seriousness of the safety violations, investigators also recommended all Marine Corps Osprey squadrons schedule a temporary pause in flight operations, known as a standdown, to review this accident.
It is the second recent Marine Corps Osprey accident where critical flight data and voice data were lost because the recorder was destroyed by the post-crash fire.
After a 2022 Osprey crash in California that killed five Marines, investigators recommended that all Marine Corps MV-22B Osprey flight data recorders be replaced with a version that was resistant to high-temperature and fire and would survive a crash.
A query to the Marine Corps on whether those replacements were being done was not immediately answered.
The Hawaii-based squadron had been on a high pace of operations on its overseas Australia deployment and may have been overloaded.
In the three weeks before the fatal crash the squadron experienced two lesser accidents, including one that was another near-miss that also was tied to weight and load issues, which should have been warning signs, investigators found.
That the two preceding accidents did not prompt Whitefield, the former commanding officer, from conducting a standdown to look for larger safety issues “is gravely concerning and directly contributed to the failure to execute required safety of flight and weight and power procedures” on Aug. 27, the investigators found.
On the day of the crash, Lewis was responsible for serving simultaneously as the in-flight instructor for the pilot flying the lead aircraft and also as the aircraft commander on his own Osprey during a complex, multinational exercise.
But investigators found that Lewis did not attend mission planning briefs detailing the flight and did not review the aircrafts’ loads, maintenance history or risk assessment before taking off, leaving him with a lack of awareness of the flight, investigators found.
Investigators found both Ospreys had taken on 2,000 pounds more fuel than they had planned for and had only used estimates on how much each of the troops in the back would weigh.
The weight of an aircraft plays a critical role in how pilots can safely operate it.
The Osprey that crashed also had incomplete maintenance, but none of the squadron’s leaders held up the aircraft from taking off.
While the outstanding maintenance tasks were not identified as factors in the crash, “ultimately, the aircraft should not have been certified as safe-for-flight,” the investigators found.
A fourth crew member was seriously injured in the crash, which occurred as the two Ospreys were flying low on a final landing approach during the multinational training exercise.
In the final minutes of the flight, the lead Osprey reduced power without informing the trailing Osprey, and the trailing Osprey did not sense the quickly closing gap between the two aircraft in time, investigators found.
The trailing Osprey reacted with a steep bank to avoid a mid-air collision, then quickly entered two additional steep banks that put the aircraft in a position where it was subject to a 20-knot tailwind.
The aircraft commander did not assess the seriousness of the situation and take the flight controls until it was too late, and by that point the trailing Osprey did not have its tilted rotors or its power settings in a position to handle the maneuvers with the aircraft’s weight.
It quickly stalled, became unrecoverable, and crashed nose down.
There were a total of 23 Marines on board the crashed aircraft.
The 19 troops in the back, who were being flown to a drop-off point for the military exercise, all survived.