Sunday, June 2, 2019


It was a brilliant springtime day in Southern California. The sun was bright and hot and the air was mostly clear, although a typical SoCal haze persisted, making the hills to the north and east look fuzzy and doubtless making the horizon less than distinct. On the other side of the hills the air was pristine and viz was clear and a million. Interesting how a couple of bumps on the ground can make such a difference.

My friends and I, each of us active duty U.S. Navy Squadron Corpsmen, had come to Marine Corps Air Station El Toro to attend the annual spring air show, and in particular, to watch the Blue Angels perform in their shiny new F/A-18 Hornets.

There was more to the air show than the Blues, though. One particular event was a demonstration of the Hornet's power and agility performed by a seasoned and highly experienced Marine Aviator in a single F/A-18A. He flew a very dynamic routine, rolling, looping, yanking and banking, all of it within the confines of the Air Station boundary (IIRC). At one point he pulled up into a low-speed Immelmann, showing off the new jet's ability to sustain maneuverability at high alpha (angle of attack). A funny thing happened at the top though. Instead of rolling upright, the jet seemed to pause for a moment. Still inverted, the nose dipped up and down, seemingly sniffing for the true location of the horizon. Surely he wasn't going to complete a loop -- he was much too low... 

Nevertheless, the nose came down and the jet streaked toward the ground. The nose pulled through and came back above the horizon, and the F-404 motors roared in full dry thrust, then snarled into afterburner. Everything looked precisely like the bottom of a well-executed airshow loop, except the jet was descending at a very high rate (circa 10,000ft/min) and the ground was much too close. In those fleeting seconds I hoped mightily for a miraculous intervention, but to paraphrase Admiral Tom Connolly's testimony regarding Bobby Strange's pet F-111B, there wasn't enough thrust in all of Christiandom to arrest that sink rate before the jet matched the world low altitude record. At about 50 feet a mass of flames erupted from the back of the jet, then it slammed onto the runway in a cloud of smoke, dust, debris, and fire.


Human memory is a funny thing. I don't think a lot of people realize how much memory can diverge from the way past events actually played out. We can think back and see pictures of the past in our mind's eye which are sharp, fine grained, and realistic. How closely do those images match the reality of previous events though?

I've mentioned before that I had formal training in a number of naval medical sub-specialties. My basic rate was Hospital Corpsman, or HM-0000. Each time I completed specialized training through one or another navy "C" schools, a clever four-digit code was appended to the "HM" in my personnel record. The code that mattered most of all when it came to assignments was 8406, or Naval Aerospace Medical Technician The Aerospace Medical Technician was (is) also known as an AVT (I don't really know why), or more colloquially as a squadron corpsman. As that last implies, squadron corpsmen were assigned to aviation squadrons, one per squadron. AVT/8406 was my primary NEC and the most "in demand" of my specialties so I was always assigned as an AVT either ashore or afloat.

A big part of AVT training was aircraft mishap investigation. I found the training fascinating and I believe some of my best work was done when I was part of a mishap investigation. Finding out what caused a given mishap and then passing those findings and lessons along to the fleet was an excellent and satisfying way to support my aviation brethren and sistren.

One aspect of mishap investigation which was both surprising and very interesting was eyewitness accounts. I learned in training that every witness will see an event differently. At one point we were told that three people standing together and witnessing the same event will offer up three different accounts, often differing substantially.

At the time I thought our instructors were laying it on a bit thick but after working a couple of mishaps I realized that they'd been completely correct.

This led me to believe that untrained eyewitness were all a bunch of morons. Trained eyewitnesses, such as myself, were probably the only people capable of giving an accurate account of an event.

Then a funny thing happened while I was en route to collecting my prize at the Best Trained Witness Of All Time Awards Ceremony.

I found out that while I was trained in aircraft mishap investigations and understood some of the theory of memory and eyewitness accounts, I was not, in fact, a reliable witness.

By the time I discovered irrefutable proof of my shortcomings in perfect recall I had nearly a decade of experience in Naval Aviation. I'd been hands-on in about 20 mishap investigations, about half of which involved loss of life and/or total loss of aircraft. I'd also been on the other side three times in Sea King mishaps, flying as crew when we put one in the water, rolled one up in a ball at Dare County, and broke one in an out-of-envelope autorotation/hard landing on the boat. I'd been there, done that, and got the tee-shirt. I was a Naval Aviation Mishap Investigation God.

Yeah, right.

In April, 1988 the airwing was deep into the workup cycle preparing for a major deployment to the Sixth Fleet in the Mediterranean Sea. I was on a weapons detachment to MCAS Yuma, one of my favorite places of all time. When we were on Det there I was always welcomed by the Station SAR guys and could fly with them as much as I wanted, which was pretty much every day. They flew the UH-1N Huey.
In the foreground, an MCAS Yuma SAR helo on display at the station air park. This example is an HH-1N, a dedicated Search and Rescue platform. In my day, station SAR still flew the UH-1N, a regular utility model configured for the SAR mission. In the background on the stick is an A-4L Skyhawk painted in the colors of VMA-214 -- the famous Black Sheep of WWII and Pappy Boyington fame. The Lima model Skyhawk was a Charlie model (including the J-65 motor) with Fox model avionics. The Black Sheep never flew Limas, and this example is emulating, to some extent, the Mike/Skyhawk II variant produced for the Marines.

Compared to the War Winnebago SAR configured Sea King, the November was a sports car.

In the way such things sometimes happened back in the good ol' days the Yuma SAR guys allowed me to to collect a nice bit of bootleg stick time. That last bit is why Yuma was one of my favorite places. But I digress.

At the midpoint of the det came a weekend, and that weekend featured the annual MCAS El Toro Air Show. The Blues would be there and this would be my first opportunity to see them flying the Bug. Therefore a couple of fellow squadron corpsmen and I checked out a gray navy Suburban and set off toward the big city.

On arrival we took in an amazing sprawl of humanity, reportedly 300,000 strong, and we took in the airshow. It was all soda pop and sunshine until the crash.

Being hard-charging AVT/Accident Investigators at the scene of a mishap, my friends and I sought out our El Toro Aeromedical peers and pitched in to help. There wasn't much for us to do other than run and fetch, but we ran and fetched with a will. By the time we had to head back to Yuma, we had a good idea of the main causal factors. A combination of indistinct horizon and an "expedite" call from the tower had likely contributed to the pilot's decision to continue a loop at too low an altitude. And something broke on the airplane, but that was probably just bitter icing on the cake. At the end of the day the cause was essentially running into the planet, an interesting but far from unheard of type of Controlled Flight Into Terrain. Fortunately the pilot, MAG-11 Commander Colonel Jerry Cadick, survived the crash, though he was badly injured.

Flash forward several months and a new Flight Surgeon joins our team on USS Boat. He's the replacement for the Flight Surgeon assigned to the Marine F/A-18 squadron on board, and he's come from El Toro. In a somewhat ironic twist, he remembers me from the crash investigation -- though I was only present for about six hours -- while I remember him not at all. Says a lot about my arrogant hubris. At some point we're having a discussion about the mishap and I ask him what broke on the aircraft. What, in other words, caused the aft end of the jet to burst into flames before it hit the ground? Fuel leak? Compressor or turbine failure?

"Nothing broke before the jet hit the ground."

"What about the fireball at 50' AGL?"

"There wasn't any fireball."

He just happened to have a rough copy of the tape which was part of the MIR. Note the lack of pre-impact ahem, and note the tower pestering Colonel Cadick in the second part of the video. Interesting stuff.

Yeah, no shit. No fireball. Well firetruck me. Who ya gonna believe, reality or memory?

It was a jarring but wholly appropriate learning experience. Took me down a peg or two. Perhaps I wasn't a mishap investigation god. A minor deity, surely, but I was no god.


Flash even morward forward, and I'm watching parts of a 20th anniversary investigation into the death of Princess Diana. The investigator spends a lot of time questioning witnesses. Well, actually, he spends a lot of time explaining to witnesses what they surely must remember, given his comprehensive study of the events. It's remarkable how readily they change their tunes. I don't think they had a clue what was happening in their own minds.

Worth keeping things like this in mind when it comes to our flawed and limited ability to recall events "just as they happened."