The Marines Corps' detailed account of a string of bad decisions that led a fighter jet to crash into homes, killing four members of a family, is leaving neighbors wondering what the pilot and his commanders were thinking.
The pilot was initially told to land at a coastal Navy base but - after consulting with other squadron officers - chose a more distant base on a route that took him over densely populated areas. The Dec. 8 crash incinerated two homes, narrowly missing a high school near Marine Corps Air Station Miramar. The pilot ejected safely seconds earlier.
Why did the pilot, Lt. Dan Neubauer, bypass a path over water to Naval Air Station North Island in Coronado, even as the only remaining engine on his F/A-18D Hornet showed low fuel?
Ernie Christensen, a retired Navy rear admiral who once commanded the Top Gun flight school at Miramar, speculated Wednesday that many hours of safe flying may have led officers to believe nothing could possibly go wrong.
"You get inured sometimes in the business of aviation," he said. "There's a well-known saying: thousands and thousands of hours of boredom interspersed with moments of stark terror. ... When all of a sudden something comes up, you say nothing's ever happened before."
Some residents of San Diego's University City area, where the plane crashed, said the Marines involved may have wanted to avoid the hassle of fixing the Miramar-based plane at North Island. Christensen said Marines would never risk crashing for that reason but, "I'm guessing it might have been in the back of their minds."
Motives of the pilot and his ground commanders remained unclear after the Marines briefed reporters and members of Congress Tuesday and the Federal Aviation Administration released recordings that showed the pilot repeatedly passed up offers of a chance to land at North Island.
The Marine Corps did not release its investigative report or recordings of conversations between the pilot and military officers. They declined to make the pilot or others involved in the decision to land at Miramar available for comment Wednesday.
"Landing at North Island was the prudent and correct decision to make in this emergency," Col. John Rupp, operations officer for the 3rd Marine Aircraft Wing at Miramar, said Tuesday. "Unfortunately, that decision was never made."
The Marines relieved four officers from the Miramar-based Marine Fighter Attack Squadron 101 and disciplined nine other Marines and Navy personnel. The pilot was not among them but his actions will be reviewed at Marine headquarters.
The findings disclosed by the Marines exposed a litany of problems.
The Marines knew in July that the jet - which crashed with 340 gallons of fuel in its tanks - may have trouble transferring fuel to the engine. The Marines sent the aircraft on 146 flights after the problem surfaced, lulling maintenance workers into what Rupp called "a state of complacency."
The first engine showed low oil pressure 10 minutes into the 47-minute training flight that took off from the aircraft carrier USS Abraham Lincoln, forcing the pilot to shut it down and prompting authorities on the ship to order him to land at North Island. The pilot chose to return home to Miramar instead.
Rupp said the pilot failed to consult his checklist of emergency procedures and that his commanders in San Diego who blessed his decision assumed he was closer to the base than he actually was.
As he neared Miramar, the pilot burned precious time by circling to his left to line up his approach to the Miramar runway, assuming - incorrectly - that he couldn't turn to his right right because of the inoperative right engine.
The pilot ejected at an altitude of 400 feet, 17 seconds after the left engine failed.
"The pilot stayed with the aircraft until the last possible moment to save lives and minimize damage to the homes in University City," Rupp said.
Ron Belanger, a retired Navy pilot who lives in University City, said the crash highlights a need to improve pilot training for such emergencies. The Marines said the emergency checklist, if it were followed, would have dictated the pilot to land at North Island.
"They have good procedures but they weren't followed," he said. "The fact is, this guy didn't know the checklist. That's scary."