Marine Corps leaders have issued recommendations to protect against lapses in standard operating procedures and are rewriting training handbooks to make sure, they said, another accident like the July 30 sinking of an amphibious assault vehicle in which nine men died, never happens again.
On Thursday, March 25, a 2,000-page report with the findings of the first of two investigations was released on what happened last summer off Southern California’s San Clemente Island during the pre-deployment training exercise for Battalion Landing Team 1/4, which was attached to the Camp Pendleton-based 15th Marine Expeditionary Unit.
The Marine Corps took responsibility for the tragedy in the report, which officials said was caused by a mix of mechanical problems in the decades-old amphibious assault vehicles, leadership failures, a lack of training and the demands of a schedule to keep up with plans for a September deployment amid the coronavirus pandemic.
The report’s senior officer in charge, Lt. Gen. Steven R. Rudder, commander of Marine Corps Forces Pacific, in his final review of the investigation, said it was “a confluence of human and mechanical failures” that led to the sinking of the AAV and the men’s deaths, and it all could have been prevented.
Before the report’s public release this week, senior Marine Corps leaders who reviewed the report spoke in depth about the accident and about new recommendations to be undertaken. The roundtable was arranged to give background and understanding for a handful of invited reporters. The four provided experts — all with backgrounds in amphibious operations — spoke anonymously, per Marine Corps direction, so they could candidly weigh in on the investigation’s findings.
They discussed the series of preventable events, gave context and comment on decisions made and explained the need for improvements to the Marine Corps’ amphibious elements. Two years ago, Marine Corps Commandant Gen. David Berger outlined a new vision for the Marines to be a more nimble force that supports Naval warfare as the United States faces evolving future threats.
“So, we have to get good at this and we will,” said one of the experts, a former commander of a Marine Expeditionary Unit, traditionally just called an MEU.
He also emphasized that decisions made in the July accident were made by people who weren’t properly trained and didn’t follow procedures they should have been trained on.
“There’s an aspect of judgment in all of this,” he said. “There is also an aspect of adherence to orders, policies and procedures.”
In the AAV when it sank were Pfc. Bryan J. Baltierra, 18, of Corona, a rifleman; Lance Cpl. Marco A. Barranco, 21, of Montebello, a rifleman; Pfc. Evan A. Bath, 19, of Oak Creek, Wisconsin, a rifleman; U.S. Navy Hospitalman Christopher Gnem, 22, of Stockton, a hospital corpsman; Pfc. Jack Ryan Ostrovsky, 20, of Bend, Oregon, a rifleman; Cpl. Wesley A. Rodd, 22, of Harris, Texas, a rifleman; Lance Cpl. Chase D. Sweetwood, 18, of Portland, Oregon, a rifleman; and Cpl. Cesar A. Villanueva, 21, of Riverside, a rifleman.
Lance Cpl. Guillermo S. Perez, 19, of New Braunfels, Texas, was found unconscious in the water on the scene and later pronounced dead.
Not what right looks like
The AAV platoon, part of the Battalion Landing Team 1/4, and its 13 vehicles left the USS Somerset for a training raid on the island off the Southern California coast around 7:45 a.m. on July 30. A 14th AAV had to remain onboard for maintenance issues, the report says.
They arrived on the island’s west cove around 8:30 a.m. and pushed inland through the rough terrain in a mock attack scenario. The plan was for them to return to the beaches around noon and launch shortly thereafter back to the ship.
But the timing was pushed off by four hours after another AAV broke down and couldn’t move. The platoon commander decided four vehicles would have to remain on the island and wait for the Navy to send tools and equipment, the report says.
Around the same time, the driver of AAV#5 noticed a leak from his vehicle’s transmission. The engine had begun smoking. He worked on it, tightening bolts and adding about six gallons of transmission fluid to the 23-gallon reservoir.
At about 4:30 p.m., AAV#5 and eight others lined up on the beach to return to the USS Somerset, but two more couldn’t go into swim mode after heading out into the surf and had to be towed back to the sand.
Per standard operating procedures, a platoon-wide safety briefing should have been held on the beach. The investigation found no evidence of the checklist to prove it was done. Pre-water checks were also not done to standard. Investigators said the changing circumstances throughout the raid seem to have confused who was doing what.
With little communication between the platoon and the Navy ship three miles off shore, the seven AAVs dipped into the ocean and left the cove. Once out of the harbor, the water became choppy and the swells and surf grew larger.
About 25 minutes later and a half-mile out to sea, water began seeping into AAV#5 from multiple places, the report says. Not long after, the transmission seized so the bilge pumps couldn’t push the incoming water out fast enough.
Over the next 45 minutes — the time it took for the armored vehicle to sink — the crew fought for their lives. As water raised over their boots, the vehicle’s commander climbed on top of the AAV and signaled for help, waiving what is known as a “November flag.”
It took about 20 minutes for two other AAVs to arrive to assist.
There were no safety boats in the water because of an earlier miscommunication with the ship, the investigation found. The Marines believed the Navy had boats out and the Navy thought the Marines were using one of their AAVs as a safety boat, investigators said.
Per protocol, when there are six AAVs in the water, two safety boats are required.
A rescue AAV collided with the sinking vehicle, causing it to turn broadside to a swell and tumbling around the men who remained inside, the report says. Another large wave swept over the vehicle pouring more water in the open hatch, finally overwhelming it and sending it to the bottom of the ocean 385 feet below.
Seven Marines made it out of the vehicle, two had to be flown to hospitals and Perez died on scene.
Investigators and military leaders said the call to evacuate the troops happened much later than standard operating procedures would dictate.
Part of preparing to evacuate the troops inside the tight compartment would have included having them remove their armor and leaving their rifles behind. But, when the men’s bodies were recovered, all still wore their armor and two had rifles slung around them. All but one had on life vests.
The investigators said some of the men appear to have attempted to remove their body armor by quick release, but the life preserver worn over their gear likely impeded them.
The investigation found the life vests — which provide 65 pounds of buoyancy when at the surface — are sufficient to keep a Marine in all their combat gear above water, but their buoyancy decreases progressively with depth.
As part of the new recommendations, Rudder has requested that Marines review the utility of the life preservers used on AAVs. He also asked there be a review of the use of safety boats and if an AAV is suitable for that role.
“This is not what right looks like,” the former MEU commander said in the roundtable, commenting that the problems with the accident extend beyond the crippled vehicle and into the training received. “We need to focus on what right looks like compared to what wrong looks like.”
Over the course of the investigation, the Marine Corps has removed the 15th Marine Expeditionary Unit’s entire chain of command.
Including on Tuesday, March 23, Col. Christopher J. Bronzi, commanding officer of the 15th MEU, who was relieved of command while the unit is still on deployment in the Middle East. In October, Lt. Col. Michael J. Regner, commander of the BLT 1/4, was relieved, as was his company commander.
More disciplinary decisions are expected, the investigation report says.
As part of the recommendations released Thursday, Marine Corps leaders said they will make sure this training accident — the deadliest in the decades the AAVs have been used to carry troops — will stand prominent in the minds of all service members, but especially for those who are training to operate and fight in these vehicles.
The troops who deploy with MEUs are expected to receive a high level of training and evaluation as part of one of the Marine’s most elite forces.
“Had the training requirements been met, the AAV crew and embarked Marines may have been better prepared and responded more quickly,” Rudder said in the investigation’s final report.
A combat readiness evaluation should have exposed some of this AAV platoon’s deficiencies in training had it been performed, Rudder said. The platoon had no prior experience as a unit in water training. The first time this unit was in the ocean together was during the San Clemente Island raid.
“The confidence of both commanders that proficiency on land would translate to success in waterborne operations was misguided,” the report says.
Investigators also said there was a lack of underwater egress training — that of the nine men who died, eight had only completed the training for shallow water, which doesn’t translate to getting out of a submerged vehicle.
The problems weren’t only found in the troops’ training, but also in the condition of the failed AAV#5 — manufactured in 1984 and retrofitted four times since.
After the AAV was recovered from the ocean floor, the investigation found a series of causes for the water intrusion, including an incorrectly installed headlight on the port side and faulty seals on a plenum grill at the front of the AAV, which controls airflow into the vehicle.
No fluid was found in the transmission. A water pump belt was not at the correct tension and the cooling tower was missing all its mounting hardware, the report says. The power take-off marine drive clutch was seized so the propulsion shafts couldn’t turn, limiting the vehicle’s ability to push forward in the ocean.
Following the accident, Berger suspended all water operations for the Marine Corps’ fleet of more than 800 AAVs. Most of the vehicles have been in service since the early 1970s and have been repaired and restored many times.
Though Marines at Camp Pendleton are testing their replacement, the Amphibious Combat Vehicle, the aging AAVs will still be used for training and deployments through at least 2028.
As part of the recommendations, the Marine Corps ordered fleet-wide inspections with a focus on water integrity and found more vehicles that wouldn’t be considered ready for use.
Physical, instead of just visual, inspections will be required for every vehicle annually, including pouring water to check for leaks.
Tip of the spear
Among the most alarming to the senior military leaders was that the AAVs provided to the 15th MEU were among the worst in condition, having been parked in a lot with little use for almost a year.
What should have been the “best of the best,” were deemed “operationally inoperable” and required weeks of repair before they could even be used on land. Only in the weeks before the island raid had they been declared fit for water operations.
An MEU, which includes infantry troops, aviation squadrons and teams of engineers that help move the troops around, is considered among the Marine Corps greatest assets. While on deployment, they are the 9-1-1 responders to any crisis and are often called upon to provide humanitarian aid.
“It’s an all-star team,” the prior division commander said in the roundtable. “It’s the pointy edge of the spear; you don’t have a shortage of people putting their hand up. You get the best vehicles, the most currently capable vehicle. People have a qualification they have to have. It does not appear from this investigation that this occurred with this platoon.”
Marine Corps officials have now given the commanders of the 1st Marine Expeditionary Force, based at Camp Pendleton, and the Third Marine Expeditionary Force, based in Okinawa, Japan, 90 days to review all safety procedures and procedures associated with water operations.
“The Marine Corps is a learning organization,” the former MEU commander said in the roundtable. “We have learned from this mishap and we will apply things that will save future lives or prevent other mishaps.”
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