source GAIA package: Origin key: Sx_MilitaryTimes_M6201310303010304 imported at Fri Jan 8 18:18:08 2016

Investigators have cleared all Marines involved in the 2011 death of an MV-22 Osprey crew chief who fell nearly 200 feet to his death in Afghanistan.

On July 7, 2011, Staff Sgt. Thomas J. Dudley fell from the aircraft during takeoff as its pilots scrambled to evade what they believed to be an impending enemy attack, according to a Marine Corps report detailing the investigation. It was obtained this week by Marine Corps Times through a Freedom of Information Act request.

The crew with Marine Medium Tiltrotor Squadron 264 out of Marine Corps Air Station New River, N.C., had just delivered cargo and 10 passengers, including the commanding general of 2nd Marine Division (Forward), then-Brig. Gen. Lewis A. Craparotta, to a forward operating base in Helmand province. Delivery went flawlessly, according to the report, but once on the ground, things began to unravel.

At the time, the crew was skittish because of rocket-propelled grenade fire they had taken while flying out of the same FOB earlier that day. Dudley, who saw a rocket zip by the aircraft's tail earlier in the morning, had moved to engage the enemy with an M240G machine gun positioned in the Osprey's tail, but he was unable to fire because there were children in the area, investigators determined.

The Osprey exited the area, and was cleared to fly into the FOB a second time a few hours later to transport the general. This time it flew with an armed escort that included one UH-1Y Huey and an AH-1W Super Cobra.

Upon touching down, Dudley escorted the general off the aircraft and the other crew chief, a lance corporal who is not identified in the report, began unloading three 150-pound Pelican cases containing communications equipment.

Both crew chiefs had disconnected from the aircraft's internal communications, although Dudley did not notify the pilots as is standard procedure, the report states. While passengers and cargo were being offloaded, a heavy string of radio traffic came across the pilots' radio from the armed escort. They misinterpreted the flurry of chatter to mean an enemy attack was imminent, investigators reported.

"After completing their mission and while departing the landing zone, the aircrew genuinely, but mistakenly, believed the enemy was preparing to engage them with small arms fire," according to the line of duty determination associated with Dudley's death.

Thinking the crew and aircraft were at risk, the cargo was unloaded, the crew chiefs were aboard and they were cleared for takeoff, the pilots revved the engines. Caught off guard, Dudley scrambled on board. During the chaos that ensued, the crew chiefs — who were not hooked into their communications equipment — didn't have time to strap into their gunners' belts, which tether them to the aircraft when they walk about the cabin during flight, the report states.

The lance corporal struggled with his back to the cargo, pushing it towards the front of the aircraft. Dudley, meanwhile, rushed to the machine gun on the aircrafts' tail in preparation to engage targets. When the aircraft took off and rapidly accelerated as it banked south, the lance corporal was unable to hold the unsecured cargo. Two pelican cases, each weighing about 150 pounds, rocketed towards the tail where they struck Dudley and caused him to flip over the machine gun mount, the report states.

The lance corporal, also nearly ejected from the aircraft, was able to catch "the last part of the aircraft" with his leg, just barely preventing him from following Dudley to his death.

Marines on the ground rushed to Dudley's aid. The first, who had manned a watch tower at the FOB, reached Dudley within 30 seconds but found him nonresponsive and without a pulse. He was carried by stretcher to the battalion aid station, but after 15 minutes of treatment, doctors pronounced him dead. As he was carried to a medical evacuation helicopter 50 Marines lined the rout to render honors. They included the division commanding general, a battalion commander, two sergeants major, and a command master chief, the report states.

Investigators found six causal factors that lead to the accident. They include:

• The aircrew not using their gunner's belts.

• Gear not secured prior to take off.

• Taking off before receiving confirmation from both crew chiefs that they were prepared.

• Anxious mindset due to taking RPG fire earlier in the day.

• Unintentional excitement induced by saturated communications on the radios.

• Relatively inexperienced aircraft commander and co-pilot who were unable to slow things down in the "heat of the moment."

As a result of Dudley's death, investigators recommended revising the MV-22 Naval Air Training and Operating Procedures Standardization manual and standard operating procedures to include a formal challenge and response between the pilot and crew chiefs to ensure crew, cargo and passengers are ready for take-off.

Additionally, tactical and standard operating procedure guides should be adhered to avoid confusing communications in hot landing zones, investigators advised.

They did not recommend any further investigation, or administrative or disciplinary action.