‘A dereliction of duty’ — Why the amphibious vehicle disaster that killed 9 servicemen was entirely preventable
“What ought one to say then as each hardship comes? I was practicing for this, I was training for this.” —Epictetus
The findings of the Marine Corps investigation of the July 30, 2020 sinking of an Amphibious Assault Vehicle (AAV) that resulted in the deaths of eight Marines and a Navy corpsman are gut-wrenching. On the first page of the 63-page report, it states that “a confluence of human and mechanical failures caused the sinking of the mishap AAV, and contributed to a delayed rescue effort, resulting in the deaths of eight Marines and one Sailor.” While that assessment is supported by overwhelming evidence contained in the 1,700 additional pages of witness statements and evidentiary material, the Marine Corps failed to look beyond the actions of the personnel of the 15th Marine Expeditionary Unit (MEU) to identify the primary reason for the loss of life: lack of training.
I have some basis of experience on which to base that assertion. Before retiring from the Marine Corps in 2018, I was assigned as the acquisition program manager for training systems at Marine Corps Systems Command, which oversees the development, procurement, fielding, sustainment and disposition of operational and training systems. In August 2017, three Marines died after an MV-22B Osprey tiltrotor aircraft assigned to 31st MEU crashed at sea and sank. The subsequent investigation identified the same failures in the chain of command to ensure that Marines received and successfully completed underwater egress training (UET) before buckling into an aircraft flying over water or an AAV moving through open ocean. Yet the Marine Corps failed to learn and take corrective actions that could have saved the lives of all onboard the AAV last summer.
Regardless of the sum total of human and mechanical failures that contributed to last year’s sinking of AAV 523519, I believe that every Marine and Sailor could have evacuated to safety. The decisive factor between limiting the loss to merely the AAV and embarked equipment versus the loss of nine lives was the failure to ensure that all personnel successfully completed UET.
There is an old Marine Corps saying about the importance of training: “Let the ghost of no Marine cry from beyond the grave, ‘If only I had been trained.’“ In an interview with Marine Corps Times, the mother of one of the Marines who died in the mishap relates that she was told by a survivor who was aboard AAV 523519 that her son and another Marine, a classmate from boot camp, “were praying together, because…that’s all they had in the darkness.” In addition to their prayers, they should have been equipped with skills developed from UET. Of all the tools and weapons with which the Marine Corps can equip Marines, skill is the only thing that is truly weightless and available at all times. This is why providing quality training and training support is the first duty of the Corps to its Marines.
The investigation found that only two of the 13 passengers on AAV 523519 had completed UET. Even so, it appears they had only received the Shallow Water Egress Trainer (SWET), also called the “dunker chair,” according to the witness statement of the rear crewman aboard the AAV. The below 27-second video depicts what a SWET device looks like and how it is used.
Notably, the SWET component of UET does not provide training to egress from an armored vehicle or aircraft compartment with other passengers. It is only individual training that shows Marines how to release seat belt harnesses and escape from a passenger seat after a vehicle has flipped over in water. It does not explain how to exit from the passenger compartment of an AAV or the fuselage of an aircraft.
The Submersible Vehicle Egress Trainer (SVET), however, was specifically designed to provide team-collective training to egress from an AAV. This is a photograph of the SVET, which combines the aft compartment of an AAV with the cab of a Humvee to provide training for egressing from both types of vehicles.
The videos below show the training that the Marines from Bravo 1/4 should have completed but did not.
SVET training instructs passengers embarked on an AAV that when water rises to deck plate level inside the AAV, that is the signal to “prepare to transfer personnel.” And when water rises to ankle level above the deck plates it is time to “transfer personnel,” an order that was never issued by the vehicle commander who was faulted in the investigation. But if only the Marines on board had been trained, they would have known to take action without an explicit order.
The report of investigation describes a period of time lasting 15 to 20 minutes from when the water inside the AAV reached the deck plates and the moment that the AAV sunk beneath the surface. Had the Marines received the comprehensive training they should have received, they would have been shedding their body armor, helmets, rifles, and preparing to egress the vehicle. Instead, all of the deceased were recovered still wearing their body armor, seven were wearing their helmets, and two still had their rifles slung across their body. Eight of the deceased managed to escape from the interior of the AAV after it sank rapidly beneath the surface but only one made it to the surface and was later pronounced dead.
It didn’t have to be this way. Just three years prior to the sinking of AAV 523519, another mishap investigation into the loss of an MV-22B Osprey off the coast of Australia identified the same failures to establish a comprehensive and coherent policy for personnel to successfully complete egress training and noted that the operating forces had inadequate access to these critical training systems and instructors.
On Aug. 5, 2017, an MV-22B Osprey tiltrotor aircraft assigned to 31st MEU crashed into the side of the USS Green Bay while attempting to land and fell into the ocean off the coast of Queensland, Australia with 26 Marines on board. Two members of the aircrew and one embarked Marine died with the cause of death found to be drowning.
In that incident, the investigation found that none of the 21 Marines embarked as passengers had been identified as “frequent flyers” and therefore had not been required to complete UET. Only 13 had attended the training and only 11 had passed the UET with satisfactory performance. And yet, two of those who failed UET remained assigned to fly in the MV-22B Osprey over water.
The excerpt below is from the findings of fact in that investigation:
The following excerpts are from the investigator’s interview with the commanding officer of the squadron. His comments on the lack of training capacity to provide underwater egress training for ground combat element Marines assigned to the MEU are both surprising and illuminating.
One would think that in light of such direct evidence of a flawed policy for requiring completion of UET and the apparent lack of training capacity, the Marine Corps would institute meaningful reforms. The record indicates that no such meaningful policy reform or re-prioritization of budgetary resources resulted from the recommendations made in the report of investigation of the 2017 mishap. On the contrary, in May 2018, shortly after a heavily-redacted version of the investigation was released to the public, the Marine Corps published a policy directive titled MARADMIN 293/18 Establishment of Interim Service Level Underwater Egress Training Requirements. Not only is it stated that the Marine Corps will assign untrained personnel to ride in AAVs in water or to fly in helicopters over water, but the directive also contains the following statements:
4.A. Personnel unable to complete UET prior to participating in rotary wing/tilt-rotor aircraft flight operations over water shall be briefed on the use of the supplemental emergency breathing device and procedures for underwater egress. Aircraft commanders are responsible for ensuring all untrained personnel are fully briefed prior to flight.
4.B. Personnel that are unable to complete UET prior to conducting AAV waterborne operations shall be briefed on the procedures for underwater egress. AAV commanders are responsible for ensuring all untrained personnel are fully briefed prior to splash.
This interim policy directive remains in effect three years later but surprisingly, it is not listed as a reference or mentioned even once in the investigation of the sinking of the AAV from the 15th MEU.
More than a year after the publication of the investigation report on the MV-22B mishap, I submitted a complaint to the Inspector General of the Marine Corps concerning the failure to incorporate the recommendations from that report into the training policy directives covering UET. I stated in the complaint that the relevant Marine Corps Orders had not been updated and the issue of insufficient training capacity for UET had not been addressed in the annual budget request submitted by Training and Education Command (TECOM). Eleven months later in March 2020 the investigation of that complaint was closed with the following statement: “As a result of the inquiry, IGMC determined that the issues that you raised were appropriately addressed by the respective commands or agencies. IGMC also determined that your complaint contained inaccuracies as to whether or not certain recommendations had been appropriately acted on.”
Indeed, five months after the IGMC complaint had been submitted, the Marine Corps published a revision to the order in September 2019 titled Marine Expeditionary Unit Pre-deployment Training Program (MEU PTP) that ostensibly implemented corrective actions in line with the recommendations. But the changes were not substantive and amounted to renaming terms and leaving open wiggle-room for commanders to allow Marines who were training failures in the SVET or MAET dunkers to be considered “trained” by remediating them in the SWET. It is not merely my opinion that the Marine Corps failed to address the issues raised in the 2017 mishap investigation. It is the opinion of the investigating officer for last summer’s 15th MEU AAV mishap that is stated on page 59 of the report:
The looming unasked and unanswered question hanging in front of Congress and the Marine Corps leadership is, “Why?” Why were the Marines of Bravo 1/4 not trained? The comprehensive answer to that question goes above the echelon of the MEU Commander. The availability and capacity to provide UET to the units assigned to the MEU are outside the authority and responsibility of not only the MEU Commander but also his boss, the commander of 1st Marine Expeditionary Force. It is also outside the authority of the Commanding General of 1st Marine Division and the Marine Corps Base Commander at Camp Pendleton. Neither operating forces, force-provider commands, nor Marine Corps Installation Command makes these decisions.
The endorsement on the report of investigation by the Commanding General of the 1st Marine Expeditionary Force contained the following comment on the recommendation of the investigating officer:
“I assess the general operation of ground vehicles and associated training and safety standards to be inadequate. There should be a concerted Marine Corps effort to ensure ground vehicle safety procedures and checks are conducted in a manner more akin to the vigorous aviation procedures and checks. In short, there can be no laxity with regard to the safety checklists of any kind.”
The senior leaders who have escaped the attention of this mishap investigation are those with the authority and responsibility for establishing training policy requirements, training systems requirements, and budgetary resources for training. Specifically, the Commanding General of TECOM is the “requirement sponsor” and “resource sponsor” for training capabilities. The Deputy Commandant for Capability Development & Integration is the “advocate” for budgetary resources for all capabilities including training. The Deputy Commandant for Programs and Resources is the central authority and coordinator for the fiscal Planning, Programming, Budgeting, and Execution (PPBE) process that consolidates and transmits the Marine Corps’ budget request via the Secretary of Defense to the Office of Management and Budget and ultimately to the Congress.
It is the actions, and more specifically the inaction, to provide comprehensive training requirements and training capacity for which there must be additional investigation and accountability. As Capt. Samuel B. Griffith observed in 1937, “Wars and battles are not lost by private soldiers. They win them, but don’t lose them. They are lost by commanders, staffs, and troop leaders, and they are often lost long before they start.” His words have been enshrined for over 80 years in the Marine Corps Manual and the Marine Corps Doctrinal Publication 6-11 Leading Marines. It seems plausible if not likely that the lives of these Marines and Corpsman may have been lost in the PPBE process several fiscal years before the sinking of the AAV.
Additionally, the manner in which the Marine Corps conducts mishap investigations deserves Congressional scrutiny because investigating officers may suffer professional consequences for the opinions and recommendations of their reports. That is not merely my opinion but the finding of a review of a mishap investigation of an air to air collision between a KC-130J and an F/A-18D completed just 10 months ago at the direction of the Assistant Commandant of the Marine Corps, which said the “investigation was not impartial in its focus, thorough in its scope or accurate in its findings.” Two senior officers received reprimands for their role in the 2018 aviation mishap, including the major general commanding the 1st Marine Air Wing who appointed the investigating officer and endorsed the original investigation. That same commander appointed the investigating officer in the August 2017 MV-22 mishap.
The truth is that a colonel assigned to conduct an investigation usually does not dare to glance upward to consider what actions or inaction and decisions by the higher chain of command may have contributed to the mishap. Such is the scoping statement in the appointment of the investigating officer that focuses the investigation to look downward. But the standard playbook of limiting the assignment of responsibility to the lieutenant colonel and colonel in the chain of command should not be allowed to continue. Investigations and accountability must extend to the level of the general officers who draft and endorse requirement documents and budget requests. The routine practice of budgeting for procurement of new weapons systems and vehicles without a proportional investment in training capacity for those systems must stop.
The infamous debacle of the 1980 mission to rescue the U.S. hostages held by Iran, Operation Eagle Claw, resulted in the deaths of eight military personnel and was followed by energetic Congressional inquiry and hearings into the planning and execution of that mission. The result of that inquiry was a major reorganization of the Department of Defense that established the U.S. Special Operations Command.
The Marine Corps lost eight Marines and one Sailor in the 15th MEU AAV mishap. Less than three years prior, the 31st MEU MV-22 mishap that killed three Marines was found to be the result of the same leadership failures to provide adequate training capacity. And yet it hasn’t resulted in a change to a single budget line addressing the deficiencies so that future tragedies can be avoided. It hasn’t even prompted TECOM to request funding to operate the four SVET and MAET training sites at Campe Lejeune, Camp Pendleton, Marine Corps Base Kaneohe Bay, and Camp Hansen Okinawa on double shifts and on weekends to address the backlog of Marines in desperate need of UET.
The gaping holes in directives for UET must be closed to ensure that all Marines assigned to travel through the water in amphibious vehicles and over the water in helicopters or tiltrotor aircraft receive the full course of training that includes swim qualification, SWET, use of supplemental oxygen devices, and dunker training (SVET/MAET). Additionally, the Marine Corps headquarters cannot be allowed to simply publish a requirement for training without allocating the budget, time, and manpower resources to deliver that training. UET cannot be relegated to the status of an “unfunded requirement” that is below the cut-line for the budget request submitted to Congress.
Failure to implement recommended corrective measures to prevent loss of life isn’t benign neglect. It is a dereliction of duty and it is far beneath the aspirations of the Marine Corps motto, Semper Fidelis. Always Faithful goes along with what Marine officers are taught from the earliest days of Officer Candidates School — that commanders are accountable for “all that their unit does or fails to do.” The Marine Corps has not demonstrated the ability to hold its senior leaders in the supporting establishment accountable for failure to take action. Congress must exercise its oversight authority to determine why the Marine Corps headquarters did not act despite the recommendations of the investigations into the 2017 mishap and hold senior leaders accountable.
Those Marines who have paid the price and their families deserve to know the full story and to be assured that no other Marines will die for lack of proper training.
Walt Yates retired from the Marine Corps in 2018 after 27 years of active duty at the rank of Colonel. He was assigned to Marine Corps Systems Command as the Program Manager for Training Systems from 2014 to 2018.
‘Fire the generals’ — Who is to blame for the Marine Corps’ deadliest training accident in decades