Lack of proficiency, supervisory breakdown led to Harrier crash

HAVELOCK — A Harrier pilot’s lack of proficiency and a supervisory breakdown in his training led to his death in a crash last year, according to a report.

Capt. Alberto N. Bencosme died when the AV-8B Harrier he was flying went down on Dec. 29, 2008, two miles short of the runway just off N.C. 101 outside Havelock.

As a result of the investigation into the crash, Bencosme’s commanding officer at Marine Attack Training Squadron 203 was relieved of his duties. That officer’s name was blacked out in the report, a copy of which was obtained by the Havelock News through the Freedom of Information Act.

“This mishap is the consequence of a tragic chain of events underpinned by layers of supervisory failure,” according to the Manual of the Judge Advocate General report on the crash.

The 658-page report puts blame on “the occurrence of a complete breakdown of supervisory oversight, a failure of interdepartmental checks and balances and individually, failed duty-driven expectations for the application of any reasonable degree of Operational Risk Management by those entrusted to do so.”

The report states that the exact cause of the crash is speculative. Bencosme was attempting to land at Cherry Point after a canopy warning light went off, but that did not contribute directly to the crash, according to the report.

Instead, in cloudy, misty and foggy conditions, Bencosme tried to get the jet into proper position for landing but inadvertently left the flight path. With low altitude on approach, the pilot had little time to recognize his rate of descent, especially with low visibility, and crashed short of the runway, according to the report.

Bencosme, 28, died on impact, according to the report.

In his letter to the Commanding General of the Marine Corps about the crash included in the report, Maj. Gen. James F. Flock, commander of the 2nd Marine Aircraft Wing, writes “other than the canopy warning light, Capt. Bencosme’s aircraft was functioning normally as he attempted to land. Thus, Capt. Bencosme bears the ultimate responsibility for permitting his aircraft to depart controlled flight.”

Still, the report points out that Bencosme had not piloted a Harrier solo for about two months before the crash and had other shortfalls in his flight status.

He was selected to serve in a support role for a flyover at the Outback Bowl in Tampa, Fla., requiring him to fly solo from Cherry Point to McDill Air Force Base in Florida, which was the reason he took off from Cherry Point that day.

The report lists Bencosme’s last Harrier solo flight as Sept. 23, 2008, which meant he would have to complete Naval Air Training and Operating Procedure examinations, complete two flight simulations and fly dedicated Vertical/Short Takeoff or Landing flights to regain his flight currency.

The investigation found no record of Bencosme having completed the exams, yet when the captain was asked about it, he replied that they had been completed. Partially completed open and closed book exams dated Dec. 19, 2008, were found in Bencosme’s personal gear stowed in the jet, the report said.

Bencosme did fly in the rear seat of a two-seat Harrier trainer on Dec. 22, but did not take off or land. The next day, he flew in the front seat of the trainer and made three landings, logging .9 hours of first-pilot time, according to the report.

In considering Bencosme’s qualifications for the formation trip to Florida, the Marine Air Group 14 commander expressed skepticism about the captain’s qualifications. The squadron commander considered the pilot safe. The MAG-14 commander finally gave approval of the request for Bencosme to be part of the group flying to Florida, but the report states the commander was unaware that the recent flights were logged as co-pilot time, not solo time.

The names of those commanders were blacked out in the report obtained by the Havelock News.

“While Capt. Bencosme wasn’t as forthcoming about his circumstances as he should have been, he was surrounded by a cadre of qualified and experienced instructors who knew and were duty-bound to exercise due diligence in the matter,” the report said. “Sadly, no one in the squadron attempted to validate his readiness beyond what was necessary to progress their own immediate task.”

The report states that Bencosme, who had 69.9 hours of solo flight time in the Harrier, was either too inexperienced to recognize his situation at the time of the crash or failed to apply corrective measures during the processes leading up to the crash.

“In essence, he had virtually no instrument experience in the AV-8B, .9 hours of first-pilot time and had not flown formation in the last 97 days — yet he said nothing when thrust into a weather-challenged division flight to an unfamiliar airfield,” the report said. “Furthermore, he raised no concerns with members of the flight after it was poorly briefed, rushed to get airborne.”

The report concludes that Bencosme “was in the line of duty, not due to his own misconduct, when the mishap occurred.”

On the day of the crash, poor weather prompted Bencosme and two other pilots to delay their departure from Cherry Point for almost two hours, according to the report. Shortly after the 11:50 a.m. takeoff, a warning light indicating the jet’s canopy wasn’t shut all the way went off in Bencosme’s plane.

Bencosme and one of his wingmen opted to return to Cherry Point to check out the problem.

The wingman, not identified in the report, knew of Bencosme’s lack of proficiency with instrument flying and thought it would be best if the two planes landed together.

The pilot was leading Bencosme in and both pilots lowered their landing gears together and completed landing checks.

“Landing checks complete,” Bencosme responded to his wingman. That was the last time the wingman heard from Bencosme.

The wingman noted Bencosme in the mirrors and saw the plane “was straight and level and slightly low, about five plane lengths away.”

The wingman noted that the airspeed was too slow for the approach and called for a wave-off of the landing. He then added full power to the throttle and the plane accelerated forward.

There was no similar wave-off call from Bencosme. The wingman asked the Cherry Point control tower if they had Bencosme on radar. They did not.

Cherry Point rescue helicopter Pedro launched at 12:18 p.m. and saw smoke from the crash site just off N.C. 101 in a field.

Pedro crews reported three prominent explosions at the crash site, the last being caused by the ejection seat. Bencosme had died as a result of the impact, and it was determined that the heat from the fire had caused the ejection seat to fire off.

When nearby hunters first arrived at the scene, they noticed Bencosme slumped over in the cockpit but could not reach him because of the fire.

The plane crashed relatively flat, but the jet’s data recording devices were destroyed in the fire and were unavailable to help investigators determine what happened in the final seconds of the flight.