Pilots, military aviation experts and family members are voicing concerns about a recently released investigation report into a CV-22 Osprey crash off the coast of Japan last year that killed eight service members, saying the Air Force‘s findings that the crew were partially to blame for the incident isn’t fair.
Findings released publicly last week by Air Force Special Operations Command, or AFSOC, probing a 2023 crash off the southern coast of Japan that led to the deaths of the eight airmen pointed to their “decision-making” and “ineffective crew resource management” as contributing factors to the crash, as well as a mechanical failure in the gearbox that lead to the deadliest CV-22 crash in the service’s history.
But crash documents obtained by Military.com, including some that were marked as “Controlled Unclassified Information,” along with interviews with a half dozen family members briefed on the findings and pilots who have flown the Osprey, reveal that the crew was doing exactly what they were trained to do and what was expected of them, with pilots saying that the warnings cited by Air Force investigators are commonplace and not often cause for immediate concern. In addition, data about developing problems on the aircraft wasn’t relayed to the crew.
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“I think the report probably went a little far in criticizing them for what they did,” an Air Force CV-22 pilot who spoke with Military.com said, describing having seen “a fair share” of the type of system warnings that popped up before the Osprey crashed in November. “I don’t see a lot of people doing anything that drastically different in that scenario.”
The Osprey, flying under call sign Gundam 22, was on an AFSOC training mission near Yakushima Island, Japan, on Nov. 29. The gearbox components started to chip and shed debris that wedged in, causing the left proprotor to stop spinning and the aircraft to fall out of the sky. The crew had decided to land the aircraft, but didn’t deem the situation an emergency and were following normal landing procedures.
Killed in the crash were Maj. Jeffrey T. Hoernemann; Maj. Eric V. Spendlove; Maj. Luke A. Unrath; Capt. Terrell K. Brayman; Tech. Sgt. Zachary E. Lavoy; Staff Sgt. Jake M. Turnage; Senior Airman Brian K. Johnson; and Staff Sgt. Jake Galliher.
Gailliher’s mother, Kim Krautter, has tried to process her grief in the months since her son’s passing, but the findings in the accident investigation report, namely that the crew was partially to blame, have made it harder to get closure.
“That’s what I can’t process, that this blame has been put on the crew — when the V-22s have a history of problems, and there was a problem that day,” Krautter said.
In the minutes before the crash, the pilots discussed several warnings that sensors had flashed about metal flakes and chips in the oil of the gearbox, according to logs of the voice recorder from the crashed Osprey reviewed by Military.com.
When metal chips are detected by the sensors, a small electrical current is used to dissipate them, and a “chip burn” warning flashes for the pilots.
One of the Gundam 22 pilots in the minutes leading up to the crash recalled his experience of getting “100 and some chip burns in a space of like 15 minutes” but without any other detectable issues on a flight earlier in his career.
Another crew member mentioned in the log that he’d encountered the issue “on training sorties at Cannon” Air Force Base in New Mexico.
The warnings are sufficiently common that pilots often don’t view them as critical, according to the pilots who spoke to Military.com.
Air Force policy says that after three “chip burn” lights, Osprey crews should “land as soon as practical” — the first and least serious of three landing conditions — but the policy also gives pilots the opportunity to press on.
According to the logs of the flight voice recorder, the crew not only discussed the warnings for several minutes after a series of alarms, but also talked about whether they were experiencing any sort of “secondaries” — additional signs or symptoms like vibration, noise or leaking that would corroborate a potential issue.
That’s exactly what they should have been doing, according to the pilots who spoke to Military.com and those who spoke to investigators after the crash.
“I’d be flipping through the status layers just to ensure that everything is still kind of working as it should be for that,” one pilot told investigators.
Another pilot said that they would be “looking at gauges to look for fluctuating pressures, temperatures within the gearbox and then possibly a gearbox oil pressure and temp trending in a certain direction,” before adding that “with chips, I expect the gearbox to start tearing itself up, so I would expect erratic indications within those gauges.”
Air Force investigators confirmed that the crew of the fatal Osprey flight in November never saw any further indications of problems.
Retired Marine Corps Lt. Gen. Steven Rudder, a former helicopter pilot and prior commanding general of United States Marine Corps Forces, Pacific, told Military.com in an interview that examining a crew’s actions in the wake of a tragedy is difficult, complicated further by hindsight.
“As far as I know, this crew did all the right things. I would offer, for a Marine crew, I can’t say whether they would have done anything different,” Rudder said, adding that, in his experience in the Pacific, it is a paramount concern for crews to know where an aircraft should land in case of an emergency when operating over water.
But Rudder also pointed out that that’s a call that the pilot is allowed to make on his own.
“That aircraft commander has that discretion, as per the book, to make those calls,” he added.
A History of Problems
Since 1992, the Osprey has been involved in numerous crashes, accidents and mishaps, leading to more than 60 deaths, though investigations after those crashes have almost uniformly blamed pilot error. Officials have routinely noted that the number of mishaps the aircraft has for every 100,000 hours of flight is not unusual, and chalked the incidents up to heavy usage.
In the last several years, the aircraft has received heightened scrutiny because the services were forced to disclose that the Ospreys have been suffering from a clutch issue for more than a decade that was not known to the public. The problem — called a hard clutch engagement — appeared to be costly but not deadly until June 2022 when it brought down a Marine Corps Osprey, killing five Marines.
Since the crash, the office that manages the Osprey has tried to assure reporters and the public that it has a handle on the hard clutch engagement issue, but unanswered questions about the overall airworthiness of the airframe remain.
The Air Force’s investigation, a summary of which was publicly released last week, found that the Gundham 22 pilots’ choice to keep flying amid the warnings was one of the two causes for the crash.
Shortly before the Air Force released the summary, it allowed the man who oversaw that investigation, AFSOC Commander Lt. General Michael Conley, to speak with reporters.
Conley specifically argued that the pilots should have had more conversations about the choice to keep flying after a third chip warning came up.
“My expectation is that there should have been more conversation about the decision to press on and talk about the risks,” he told reporters, before adding, “Unfortunately, there wasn’t a lot of dialogue.”
Later in the briefing, he also suggested that some in the crew may not have felt comfortable speaking up.
“We train our crew members to interact assertively and speak up when they’re uncomfortable — this did not happen in this case,” he said.
Conley, however, acknowledged that the “chip burn” warnings shouldn’t automatically have caused alarm among the crew members, describing them as “kind of like a check engine light in your car.”
“You could drive your car for 10 years and not get any, or you could drive next week and get three different ones for multiple reasons,” Conley said.
But though the crew didn’t see further indications of a major issue in the minutes leading up to the crash and supporting materials from both the publicly released Accident Investigation Board report and a copy of the internal Safety Investigation Board report obtained by Military.com show that the aircraft’s systems detected vibrations in the driveshaft that was powering one of the Osprey’s proprotors and connected to the gearbox that was chipping. The crew had no way of knowing the onboard systems had spotted the problem.
In a section dedicated to this vibration detection system, the public accident report simply notes that an onboard system “recorded an increase in vibration in the left pylon drive shaft.” The entire section is just a paragraph long.
Meanwhile, the unreleased, internal safety report said that this system detected a 10-fold jump in vibrations after the first chip burn light, and “it steadily persisted for the remainder of the mishap flight.”
However, this system is designed only to show select data to the crew, and these vibrations didn’t meet the criteria, the report noted. As a result, the pilots were unaware that there were more serious issues with the aircraft.
Even as the crew planned to divert the aircraft after discussing the warnings, the flight engineer remarked that “everything looks normal for temperature and pressure.”
Just minutes before they would crash, the pilots told Japanese air traffic controllers that the airport didn’t need to stop traffic for them.
“I don’t want to land right in front of him,” one pilot said. “Our situation is not that dire.”
The fact that systems on the aircraft detected vibrations immediately after the first warning light but failed to report it to the crew was the fourth of 12 findings in the internal safety report.
Conley argued that he didn’t think having the “data being available would have made a significant difference.”
But, at the same time, Air Force officials have acknowledged that the data could be potentially useful to pilots in the future.
Jennifer Gonzalez, an AFSOC spokesperson, said that AFSOC was working with the V-22 Joint Program Office, which oversees the aircraft’s use for all the services “to see if the VSLED data could be helpful and if it would be something we want to provide aircrew to increase safety.”
The result appears to be that, despite having an incomplete technical picture of the issues going on with the aircraft and policies that supported the decision to keep flying, the Air Force’s investigation concluded that the entire Osprey crew was partially at fault for the crash.
“Ultimately, the report has the mishap pilot decision making as a causal factor,” Conley said, before adding that “it is a crew aircraft and they made decisions together.”
Meanwhile, Conley told The Associated Press that “there’s nothing we could have done to detect” the gearbox problem that brought down the aircraft, while also telling reporters that the crew’s decision to keep flying was deadly.
“The investigation indicates that time mattered. … I do believe that there was an alternative ending,” he told reporters last week.
Processing Grief, Remembering the Fallen
In the months following their loved ones’ deaths, family members were left to grieve and wonder what went wrong. Now that the summary of the investigation has been released, new grieving paired with anger has taken root for some family members.
“I enthusiastically believe the crew is being unfairly criticized and graded on a situation in which command withheld critical information, as they have admitted,” said one family member, who requested anonymity. “How can a crew make wise and effective decisions if they aren’t given accurate and up-to-date information for the foundation of their decisions?”
Other family members, like Jim Turnage, the father of Jake Turnage, said that, while they didn’t feel like the report was overtly critical of the crew, he thought his son was put in a tough situation.
“The crew, from my perspective, made choices based on best understood procedures and the best information that they had at the time,” he said. “I think those procedures are going to be adjusted. Because maybe they should have landed earlier, but the checklist said when you have the opportunity, it’s under your discretion to proceed. And as they’re weighing all the things in the moment, they’re making their best decision.”
For the airmen who flew alongside Gundam 22, the reaction and fear of chip burns was even more swift.
One airman from one of the two other Ospreys that accompanied Gundam 22 told investigators that they landed at Marine Corps Air Station Iwakuni after the crash. The two Ospreys were set to return home to Yokota, Japan, but then one of them revealed it had a chip burn warning as well.
“My aircraft commander, called … [and] told them it was the same thing that [Gundam 22] had,” the airman told investigators. “And that’s when we decided we’re not gonna fly back to Yokota that night.”
A maintenance supervisor for the squadron later told investigators that the crews took a train home and the squadron had to go to Iwakuni to do maintenance on the then-stranded Ospreys.
Conley told reporters last week that AFSOC has changed some of its protocol, and crews are now being advised to land as soon as practical after a single chip burn and “as soon as possible” after a second chip burn, he said.
“Before the crash, I didn’t think prop box chips were going to change into a lost rotor system as rapidly as it seems like it might have,” one airman told investigators after the crash, before adding that the investigation results would likely “change the calculus on how I handle a proprotor gearbox chip.”
Last week, Military.com reported that an attorney is representing two of the families as they probe the cause of the crash. That same lawyer, Timothy Loranger, is also representing families of Marines who died in a 2022 V-22 Osprey training crash in California and filed a wrongful death lawsuit in May against Bell Textron and Boeing, which design and manufacture the aircraft, and Rolls-Royce, which designs and manufactures the engines. Another Osprey crash occurred in August 2023, which led to the deaths of three Marines in Australia.
Krautter, whose son Jake Galliher died in the Japan crash, said that many of the mothers who lost loved ones in the Gundam 22 accident as well as other recent crashes stay in touch, referring to themselves as “sisters” who have learned to look out for one another amid the grief.
“I’m now connected with a mom from the Australia crash, I’m now connected with a mom from the California crash. They’ve reached out to say, we know what this is like, and we’re here,” Krautter said.
“We’re all still trying to process, and there’s moms who are carrying this on their shoulders because their sons are being blamed.”
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