I was supposed to write this week about another topic in the “audit gotcha” series, but over the Memorial Day weekend I saw a fantastic documentary on PBS, “The Flintlock Disaster”, and hope you will indulge me in this change of schedule.
Are you familiar with the story of the Marine Fighting Squadron 422 (VMF-422)? Six lives and twenty two airplanes were lost at sea in 1944. Like many aviation accidents, the outcome of this event was completely predictable and avoidable. There are not a lot of resources documenting this disaster in great detail, as much of the information was initially classified and then – allegedly – hidden from the public so please do not take this recounting as a complete and formal report of the event. I am not a military historian nor am I an expert of any kind in military procedures. This post is based on my research of the event and thoughts regarding the safety lessons we can take from it.
I believe that in learning about this tragic incident and applying those lessons to our daily operations, we honor the lives – and deaths – of those who served our country in the Lost Squadron of VMF-422.
VMF-422 was a FU4 Corsair Squadron in the United States Marine Corps. The squadron, which dubbed themselves “The Flying Buccaneers”, was assigned to Tarawa in the South Pacific during World War II. They were expected to be part of Operation Flintlock, a planned naval and marine assault on the Marshall Islands. The Commanding General was Brigadier General Lewie G. Merritt. In the days before Operation Flintlock, Brig. Gen. Merritt was concerned about a possible Japanese bombing of Tarawa, which could destroy the brand new Corsair fleet, and so decided to relocate the fleet to Funafiti, a flight of over 800 miles. In those days, any flight over 100 miles in open water was a pretty serious navigational feat and with single engine airplanes, a navigational lead or escort airplane was usually assigned to assist the flight. Major John S. MacLaughlin, Jr. was the VMF-422 squadron commander. Witnesses and records indicate Maj. MacLaughlin asked Brig. Gen. Merritt for an escort airplane, not once, but twice, and his request was twice denied.
The plan was for the squadron to depart Tarawa and fly about 400 miles to Nanomea for a fuel stop, then continue on to Funafiti. This route was so common it was known among the pilots as a “milk run”. When the Lost Squadron departed Tarawa on January 25, 1944, they had no way of knowing this flight would be anything but routine. The weather report they received before departing indicated nothing remarkable, but within miles of Nanomea, the squadron faced formidable storm clouds. They were past the point of no return. There was no way they’d make it back to Tarawa. The Corsairs were not capable of flying over the storm’s ceiling and the cloud cover reached almost to the sea. The only option was to fly through the storm.
While in the clouds, with visibility near zero and navigational equipment going haywire, the formation got separated. Maj. MacLaughlin flew various headings trying to find a navigational beacon but the pilots towards the rear of the formation were unable to keep up with the strange flight path. Three pilots veered away from the formation. One was never seen again. Another pilot, Lt. John E. Hansen, had decided to go alone to avoid a mid-air crash from the turbulence and close formation flying. He ultimately reached Funafiti and alerted personnel there of the danger the remaining aircraft were in. The personnel at Funafiti had not been advised of the squadron’s planned arrival. In fact, they had been doing radio maintenance, so not only had they not been looking for the squadron, but their equipment wasn’t consistently functioning properly during this time period.
Lt. Walter A. Wilson landed just off the island of Nui, where the natives cared for him until he was rescued by a U.S. destroyer. (Lt. Wilson got the best end of this deal, as the story goes the leader of the native tribe on Nui took a liking to him and was going to “give him a wife”. Lt. Wilson was rescued before the forced marriage occurred.)
Lt. Christian F. Lauesen’s Corsair developed engine trouble and he was forced to land in the water. He had only his life preserver to stay afloat. Lt. Robert C. Lehnert circled Lt. Lauesen until his Corsair ran out of fuel, then he ditched near Lt. Lauesen, planning to use his life raft to keep both of them above water. Lt. Lehnert couldn’t find Lt. Lauesen, who was never seen again. Lt. Lehnert spent two days at sea on a life raft before being rescued.
Meanwhile, the rest of the squadron had hit a break in the storm and continued towards Funafiti, when they approached a second storm. Captain Cloyd R. Jeans asked Maj. MacLaughlin if they should head for Nui. Maj. MacLaughlin agreed and told Capt. Jeans to take over, then flew away from the squadron, never to be seen again.
Capt. Jeans realized they were not going to make it to Funafiti with the fuel available and decided that the remaining aircraft would circle over the next airplane to run out of fuel. Then each pilot would attempt a water landing or bail in the same vicinity, since rescue was more likely if they remained together. One survivor said it took only 40 seconds for the tail of his airplane to disappear under the water. Thirteen men linked arms to hold their rafts together where they survived the shark-infested sea for three days until they were rescued by a Navy PBY Catalina and the destroyer USS Hobby.
At the end of this terrible event, twenty two brand new fighter planes and six men were lost to the Pacific.
What can we learn from this tragedy?
Communication is key: Brig. Gen. Merritt didn’t tell the personnel at the destination to expect the squadron’s arrival. As a result, the destination shut off radios to conduct maintenance. Personnel at Nanomea were not aware of the squadron’s planned fuel stop. In fact they saw the flight on radar but assumed they were some bombers passing by.
Information is critical: The information in the weather reports given to the pilots was supposedly 48 hours old. Radio and navigational data provided to the pilots was incomplete or inaccurate.
Safety must be implemented from the top-down: Maj. MacLaughlin requested an escort, but his request was denied. Brig. Gen. Merritt’s focus was on reconnaissance and he felt the escort airplane was better used for that purpose.
The Commander must be accountable: Brig. Gen. Merritt spent the rest of his life trying to evade responsibility for this event. In a civilian company with a healthy safety culture, any pilot involved in this incident could have voiced concerns or turned down the flight but that was certainly not acceptable in the military culture of the day.
Would your company handle a flight like this differently? Or are “milk runs” met with the same level of disengagement from top management?
The Memorial Day weekend is an obvious time for us to remember and honor those who serve our country and especially those who made the ultimate sacrifice. I want to share with you an organization that provides invaluable care to our servicemen and –women, the Veterans Airlift Command (VAC). The VAC is a charitable organization that provides free air transportation to wounded warriors, veterans, and their families for medical and other compassionate purposes. We are privileged to work in an incredible industry and sometimes that puts us in a unique position to give back to others. I encourage you to look at your operation and see if you have an opportunity to do a flight for the VAC.
And please, never consider a flight to be a “milk run”. No flight is routine.