[Congressional Record (Bound Edition), Volume 155 (2009), Part 13]
[House]
[Pages 18129-18130]
[From the U.S. Government Publishing Office, www.gpo.gov]




 EXONERATING LIEUTENANT COLONEL JOHN A. BROW AND MAJOR BROOKS S. GRUBER

  The SPEAKER pro tempore. Under a previous order of the House, the 
gentleman from North Carolina (Mr. Jones) is recognized for 5 minutes.
  Mr. JONES. Mr. Speaker, tonight I am on the floor to express my 
thanks to the United States Marine Corps. On April 8 of 2000, the late 
Lieutenant Colonel John A. Brow and the late Major Brooks S. Gruber of 
Jacksonville, North Carolina, were the marine pilots of an M-22 Osprey 
that crashed in Marana, Arizona. The mishap occurred during a training 
mission as part of a test phase to determine the aircraft's operational 
suitability for the Marine Corps. Seventeen other marines were killed 
in the crash.
  From that day until tonight, I have worked with many aviation experts 
in the Corps and outside the Corps who have helped me reach the 
conclusion that these pilots were not at fault for this crash. 
Unfortunately, many inaccurate reports have characterized the cause of 
the mishap as ``pilot error.''
  To set the record straight, in 2009, I asked the Marine Corps to 
include in the official military personnel files of Lieutenant Colonel 
Brow and of Major Gruber a memo which exonerates them from 
responsibility for the mishap. The memo includes 17 facts regarding the 
crash, which were developed based on my review of official 
investigations and public records, as well as from extensive 
discussions with aviation experts. The evidence shows that the fatal 
factors in the crash were the aircraft's lack of a vortex ring state 
warning system and the pilots' lack of critical training regarding the 
extreme dangers of VRS onset in the Osprey.
  Lieutenant Colonel Brow and Major Gruber and their families are 
dishonored by the assertion that the aircrew was at fault for this 
fatal crash.
  Mr. Speaker, I am grateful that the Marine Corps has accepted the 
relevance of these facts. On February 20 of 2009, they included my memo 
in the personnel files of these two marines.
  To finally bring this tragedy to a conclusion and to remove the 
stigma that has been unfairly attached to these two pilots, I've asked 
the Navy to do the right thing, as the Marine Corps did the right 
thing, and include this memo in the official safety investigation 
report on this mishap.
  Mr. Speaker, at this time, I submit for the Record my letter to Rear 
Admiral Arthur J. Johnson, dated June 11, 2009, which includes my 
request and the 17 facts about the crash.

                                    Congress of the United States,


                                     House of Representatives,

                                    Washington, DC, June 11, 2009.
     Rear Admiral Arthur J. Johnson,
     Commander, Naval Safety Center, 375 A Street, Norfolk, VA.
       Dear Rear Admiral Johnson: Thank you for your response to 
     my letter of April 21, 2009. Notwithstanding your regulations 
     regarding the purpose of Naval Aviation Mishap Saftey 
     investigations, I am convinced that the Memorandum of the 
     Record (Memorandum) must be included in the AMB report and 
     JAGMAN investigation as a matter of public record.
       Over the last several years, numerous articles and stories 
     referencing the April 8, 2000 crash of the V-22 Osprey have 
     incorrectly identified Lieutenant Colonel Brow and Major 
     Gruber as the cause of the accident and have brought 
     unmerited mental hardship on their families. I outlined two 
     of these incidents in my previous letter. As a reminder, the 
     press release issued by the Marine Corps attributed the 
     accident to the pilot's ``extremely rapid rate of descent.'' 
     Statements such as this and the incomplete nature of the AMB 
     report and JAGMAN investigation have formed the basis for the 
     public's perception of the role of the pilots in this 
     unfortunate accident and must be supplemented with clarifying 
     language.
       For example, the JAGMAN stated that the aircraft found 
     itself in vortex ring state (VRS) condition with no apparent 
     warning to the aircrew. It was not until after the accident 
     that Naval Air Systems Command called for a new flight 
     limitation, pilot procedures, and a cockpit warning system 
     for VRS. Clearly, the record must reflect this reality.
       Your response stated that safety investigations ``are 
     conducted to determine root causes and identify corrective 
     actions, not to assign blame or document accountability.'' In 
     the case of the Osprey accident, the process of determining 
     root causes and identifying corrective actions led to 
     assigning blame to the pilot and co-pilot by outside 
     organizations because the role of VRS has not been given its 
     proper emphasis. If investigations undertaken after 
     completion of the accident report place the root cause of the 
     accident on other causes, there is reason to acknowledge that 
     and include such a finding in the AMB report and JAGMAN 
     investigation.
       There were many subsequent investigations into the safety 
     of the Osprey and the dangers of VRS. Therefore, the process 
     of investigating this accident is not ``closed to outside 
     influences.'' Insights gained after the completion of an 
     accident report can appropriately be appended to an official 
     safety or investigative report.
       Everyone can appreciate the desire to close an official 
     investigation. However, subsequent developments clearly 
     demonstrate that the accident report was incomplete. There is 
     a legitimate basis for correcting what was determined in 
     order to promote public justice and remove the stigma 
     attached to the pilot and co-pilot.
       In discussions with experts within and outside of the 
     military, additions to closed investigations happen 
     frequently. If you do not agree to place the Memorandum in 
     the AMB report and JAGMAN investigation, I request that you 
     specifically identify whether any of the 17 facts contained 
     in the Memorandum are inaccurate. Inclusion of the Memorandum 
     in the Official Military Personnel Files of these brave 
     Marines is insufficient.
       Thank you for your service to our nation. I look forward to 
     your response.
           Sincerely,
                                                  Walter B. Jones,
                                                Member of Congress
       Enclosure.


                       MEMORANDUM FOR THE RECORD

       Based on my review of official investigations and public 
     records regarding this mishap as well as extensive 
     discussions with aviation experts, I, U.S. Congressman Walter 
     B. Jones, have concluded that the fatal factor in the crash 
     of an MV-22 Osprey on April 8, 2000 in Marana, Arizona was 
     the aircraft's lack of a Vortex Ring State (VRS) warning 
     system as well as the pilots' lack of critical training 
     regarding the extreme dangers of VRS onset in the Osprey. I 
     also believe the Marine Corps has blamed the mishap on the 
     pilots' drive to accomplish the mission and a combination of 
     aircrew human factors. Lieutenant Colonel Brow and Major 
     Gruber and their families are dishonored by the assertion 
     that the aircrew was in any way responsible for this fatal 
     accident. Therefore, I request that the following findings be 
     included in all official records relating to this mishap:
       1. The fatal crash of an MV-22 on April 8, 2000, in Marana, 
     Arizona, was not a result of air crew human factors or pilot 
     error that can be attributed to the late Lieutenant Colonel 
     John A. Brow or the late Major Brooks S. Gruber who 
     competently and professionally performed their duties as 
     United States Marine Corps aviators.
       2. The fatal factor in the crash of an MV-22 on April 8, 
     2000, was the aircraft's lack of a Vortex Ring State (VRS) 
     warning system and the Department of the Navy's failure to 
     provide the pilots with critical training regarding the 
     extreme dangers of VRS onset in the MV-22.
       3. Because of inadequate High Rate of Descent (HROD) and 
     VRS developmental testing, the pilots of the MV-22 involved 
     in the

[[Page 18130]]

     accident on April 8, 2000, were not trained or able to 
     recognize, avoid, or recover from VRS onset in the MV-22.
       4. Had adequate HROD and VRS developmental testing been 
     conducted prior to the Operational Evaluation of April 8, 
     2000, and had a VRS warning system been installed in the 
     aircraft, Lieutenant Colonel Brow and Major Gruber would have 
     been better able to avoid or recover from VRS.
       5. LtCol Brow and Maj Gruber were in formation behind 
     another MV-22. The lead aircraft had overshot its intended 
     approach angle and therefore steepened the approach angle. 
     Unaware of the extreme dangers of VRS onset in the MV-22, 
     LtCol Brow and Maj Gruber slowed their airspeed and descended 
     even quicker, to maintain position on the lead aircraft. 
     Twenty three seconds prior to the crash, the co-pilot of the 
     lead aircraft stated ``If you want you can take it long if 
     you need to or you can wave it off. It's your call. You're 
     hanging dash two out there.'' The lead aircraft pilot decided 
     to continue his rapid descent at a slow forward airspeed, 
     clearly oblivious of the extreme dangers of VRS onset in the 
     MV-22.
       6. Numerous reviews and investigations following the mishap 
     have documented that the pilots of the mishap aircraft were 
     not provided with the necessary and critical knowledge and 
     training to recognize, avoid or recover from the extreme 
     dangers of Vortex Ring State (VRS) onset in the MV-22 and the 
     potential for sudden loss of controlled flight in the MV-22 
     following VRS onset.
       7. After the mishap, Naval Air Systems Command (NAVAIR) 
     called for a thorough investigative flight test program to 
     find the boundaries of VRS, characterize its handling 
     qualities, and establish the basis for a new flight 
     limitation, pilot procedures, and a cockpit warning system.
       8. As a result of testing following the fatal accident, a 
     visual and aural cockpit warning system was developed to 
     alert the aircrew when the aircraft exceeded the NATOPS 
     flight manual's rate-of-descent limit.
       9. On July 27, 2000, the Marine Corps publicly announced in 
     a press release that a combination of ``human factors'' 
     caused the April 8, 2000 crash. The press release went on to 
     implicate the mishap aircraft pilots by stating that 
     ``deviations from the scheduled flight plan, an unexpected 
     tailwind and the pilot's extremely rapid rate of descent into 
     the landing zone created conditions that led to the 
     accident.'' The release also stated that ``although the 
     report stops short of specifying pilot error as a cause, it 
     notes that the pilot of the ill-fated aircraft significantly 
     exceeded the rate of descent established by regulations for 
     safe flight.'' In this Official USMC press release, Marine 
     Corps Commandant Gen. James L. Jones is quoted as saying: 
     ``the tragedy is that these were all good Marines joined in a 
     challenging mission. Unfortunately, the pilots' drive to 
     accomplish that mission appears to have been the fatal 
     factor.''
       10. This clearly damaging language is inaccurate, based on 
     the fact that at the time of the crash, adequate testing of 
     the MV-22 in the High Rate of Descent/Vortex Ring State 
     (HROD/VRS) regime had not been conducted, the MV-22 did not 
     have a VRS warning system, and the pilots did not have 
     adequate knowledge and training to recognize and avoid the 
     extreme dangers of Vortex Ring State (VRS) onset in the MV-22 
     and the potential for sudden loss of controlled flight in the 
     MV-22 following VRS onset.
       11. According to the Government Accountability Office 
     (GAO), the Commander, Operational Test and Evaluation Force's 
     V-22 Operational Evaluation (OPEVAL) report indicated that 
     the MV-22 ``Naval Air Training and Operating Procedures 
     Standardization (NATOPS) manual lacked adequate content, 
     accuracy, and clarity at the time of the accident. 
     Additionally, because of incomplete developmental testing in 
     the High Rate of Descent (HROD) regime, there was 
     insufficient explanatory or emphatic text to warn pilots of 
     hazards of operating in this area. The flight simulator did 
     not replicate this loss of controlled flight regime.'' Also, 
     the preliminary NATOPS manual and V-22 ground school syllabus 
     provided insufficient guidance/warning as to high rate of 
     descent/slow airspeed conditions and the potential 
     consequences.
       12. The Judge Advocate General Manual (JAGMAN) 
     Investigating Officer stated that ``the fact that the 
     aircraft found itself in VRS condition with no apparent 
     warning to the aircrew, but also departed controlled flight 
     is particularly concerning.''
       13. On December 15, 2000, after a second crash of the V-22 
     that year, then-Secretary of Defense Bill Cohen determined 
     that the accident history of V-22 aircraft and other testing 
     issues required an independent, high-level review of the 
     program. He established a Blue Ribbon Panel to review the 
     safety of the V-22 aircraft and to recommend any proposed 
     corrective actions.
       14. This panel was briefed by the Government Accountability 
     Office (GAO) and the contents of this brief were incorporated 
     into a subsequent GAO report. The GAO report cited concerns 
     about the adequacy of development tests conducted prior to 
     the aircraft entering the operational test and evaluation 
     phase and that completion of these tests would have provided 
     further insights into the V-22 Vortex Ring State phenomenon. 
     In particular, the GAO found that developmental testing was 
     deleted, deferred or simulated in order to meet cost and 
     schedule goals.
       15. The original plan to test the flying qualities of the 
     flight control system included various rates of descent, 
     speeds, and weights. This testing would have provided 
     considerable knowledge of MV-22 flight qualities especially 
     in areas related to the sudden loss of controlled flight 
     following VRS onset. To meet cost and schedule targets, the 
     actual testing conducted was less than a third of that 
     originally planned.'' In addition, MV-22 pilots did not 
     understand the optimum use of nacelle tilt to recover from 
     VRS onset. In my opinion, this testing clearly could have 
     prevented this tragic accident by providing the pilots the 
     knowledge and training to either avoid or recover from VRS.
       16. The GAO presentation also revealed that the JAGMAN 
     Investigating Officer opined that the MV-22 Program Manager 
     (PMA-275), Naval Aviation Training Systems (PMA-205) and the 
     Contractor ``needed to expedite incorporation of Vortex Ring 
     State and Blade Stall warnings and procedures into the MV-22 
     NATOPS. The preliminary NATOPS manual and V-22 ground school 
     syllabus provided insufficient guidance/warning as to high 
     rate of descent/slow airspeed conditions and the potential 
     consequences.''
       17. The GAO report also revealed that the Director, 
     Operational Test & Evaluation (DOT&E) stated that ``while the 
     possible existence of VRS in the V-22 was known when flight 
     limits for OPEVAL were established, the unusual attitude 
     following entry into VRS was not expected.'' DOT&E goes on to 
     say ``thus, the first indication the pilot may receive that 
     he has encountered this difficulty is when the aircraft 
     initiated an uncommanded, uncontrollable roll.''
  As of this evening, I have not yet received a response to this 
letter. Again, I want to state that I wrote Rear Admiral Johnson on 
June 11 of 2009, and as of this time, I have not received a response. I 
am very disappointed.
  I hope the Navy will follow the example of the Marine Corps and will 
help properly honor the sacrifices of these brave pilots who gave their 
lives in the service of their country.
  With that, Mr. Speaker, I will ask God to continue to bless our men 
and women in uniform in Iraq and Afghanistan. I want to ask God, in His 
loving arms, to hold the families who have given a child dying for 
freedom in Afghanistan and Iraq, and I will ask God three times: 
Please, God; please, God; please, God; continue to bless America.

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