Original subtitles

[helicopter fluttering]

[man speaking muffled over radio]

- [Man Over Radio] All right, so currently

I got 13K right now, about 13 1/2, looks good.

- [Man Over Radio] [muffled] you like to cross by

your panel checks, over.

- [Man Over Radio] Looks good to me, yeah.

- [Man Over Radio] You two currently's holding steady.

[helicopter fluttering]

[slow, somber music]

- [Reporter] A Navy helicopter exploded off the coast

of San Francisco, eight crewmen are missing.

- [Reporter] Two military aircraft have gone down

after colliding just north of Hawaii's Oahu island.

[slow, somber music]

- [Reporter] 30 U.S. Marines and a U.S. sailor

were killed today in the crash of a Super Stallion

helicopter on this, the deadliest day for American forces

since the start of the war.

- [Reporter] Five people killed in four crashes

in the course of two years.

Has the worst safety record of any aircraft in the Navy.

[slow, somber music]

- [Mike] Reporters don't have much of an incentive

to write about this stuff except when it's a horror story.

But then there's no follow through.

Well what really happened?

- [Man] Who am I suppose to be faithful to?

Am I suppose to be faithful to a general or a politician?

Where do your loyalties lie?

My suggestion would be my loyalties lie to the Marines

who go die on those aircraft.

- [Nicole] He saw it happening and he called it out.

Unfortunately, he couldn't do anything to change it in time.

[slow, somber music]

- Lieutenant Wesley Van Dorn was 29 years old,

from Greensboro, North Carolina.

Van Dorn was a 2007 graduate

of the United States Naval Academy.

He was one of the Sea Dragon pilots.

And Van Dorn was a father of two.

- Jax, why don't you help Dad?

[toddler babbling]

[Nicole laughing]

He was, I always use the word magnetic.

Why don't you try one more time.

[blowing]

I met him and I just was like, "Wow, there are people

"in the world that are actually awe-inspiring

"and you want to be around."

- Wes had a great relationship with his enlisted guys.

He took care of all of us.

He was just really big on making sure that all of his people

felt welcomed and felt like a family.

- He was rambunctious, he was fun to be around.

You're a better person because of your time spent with him.

He'd talk to me about what we could do better.

What can we do better to be better?

And I think that was a question that racked his brain a lot.

'Cause he wasn't somebody who half-assed anything.

And that's what you should wanna do,

especially if your life's on the line every day.

[people chattering]

- Hey, Mom.

[slow, somber music]

- [Narrator] Wes Van Dorn long-dreamed

of attending a service academy.

He spent hours fishing with his grandfather,

a West Point graduate.

- [Susan] This is fourth, fifth grade,

and on into his high school picture.

- [Narrator] He was 19 when his mother, Susan,

dropped him off at the Naval Academy.

- [Susan] This is day one, quite a day.

He's thrilled here, and he's a little thoughtful here

I would say.

But, he was very excited about his opportunity there.

- [Man] Having been appointed as a midshipman

in the United States Navy, do you solemnly swear

that you will support and defend the Constitution

of the United States against all enemies,

foreign and domestic?

- It was a very moving experience as a parent.

You felt that you had done your best

to bring them to that point and then you were

turning them over to the military

to let them continue to develop and grow as a human being

in the way they wanted to.

- [Man] So help you God.

- [Midshipmen] I do!

[crowd cheering]

[gentle music]

- After he got his wings he said,

"How do you think we should choose an airframe?"

We decided together that the community

that would allow for the best family life.

- [Wesley] Come on little Jeffrey man, come on.

- He decided that he wanted to be defined by his family.

- [Wesley] Look who it is, it's Mommy.

- And one of his other friends, who was in the 53 community

at the time, told him that the hours he worked

allowed him to be home for dinner most nights.

Was that fun?

That he would only deploy once every couple of years.

And so Wes put 53 as his first choice.

[helicopter fluttering]

[serious music]

- Helicopters are awesome, I mean,

to make a school bus fly, lift off the ground,

to beat the air into submission,

it's a whole different glory

than just making a jet go really fast

and flying like a paper plane.

- [Narrator] The two versions of this helicopter

are practically identical.

The Navy uses the MH-53E Sea Dragon.

It drags heavy equipment through the water

to sweep for underwater explosives.

[explosive booming]

[light, tense music]

The Marines use the CH-53E Super Stallion

to move people and gear for critical missions.

[serious music]

The 53 dates back to the Cold War.

It can require about 40 man-hours of maintenance

for just one hour of flight time.

- I have so many nights where you have cried and bled

and sweat and cussed at this helicopter.

The mentality in the MH-53 community is that

we fight a battle against the helicopter.

Basically means, she never wants to fly.

And there'd be that day, that one glorious, beautiful,

sunset bluebird day, where you would get four 53s

all fired up at one time.

And everyone comes and lines the hangars,

and everybody's got their phones out.

[slow, somber music]

The sight to just watch these four giant machines,

all at once just rise up, all the sudden become this agile,

powerful behemoth that's just effortlessly

flying through the sky.

[helicopters fluttering]

It's a sign of just strength.

- We had actually visited several times in Norfolk.

We were walking around and looking at the helicopter,

and we had his son with us, and I said to Wes,

"Do they ever have a day when you can fly your family

"and take us for a ride in the helicopter?"

And I will never forget that because Wes turned to me

and he looked me in the eye and he said,

"Mama, I would never take you up in this piece of crap."

[slow, sorrowful music]

And, I just looked back at him, and I didn't know

what to say because that was what he was flying.

[slow, somber music]

- [Narrator] The Navy 53s entered service in 1986.

In 2010, when Van Dorn checked into his squadron,

known as HM-14, the helicopters were worn out,

and should've been retired.

- The Navy, in the late 90s, had started to come up

with a plan to replace these helicopters.

And then, when that plan goes out the window,

it's kinda like they're in limbo.

- [Narrator] The Navy tried new ships, mine-sweeping gear,

and towing with less powerful helicopters.

Nothing worked as planned, so they were stuck with the 53.

And because the relic helicopter

was destined to be replaced,

money for spare parts and maintenance was hard to come by.

- Commanding officers of the squadrons

are applying pressure down on these guys

to keep the aircraft going with fewer and fewer resources.

And so, out of that, all these bad habits formed

in which guys were taking shortcuts.

And that's when this culture of just get her done

kind of took hold.

- When I checked into HM-14 I was about as green

as it comes to Naval aviation.

Everybody has these preconceived notions

of what aircraft maintenance is

because you've changed a tire on a car, or changed your oil.

That's not what it is.

There's a million preset publications

that are figured out by engineers, and they've decided

this is the way that you're gonna work on this aircraft.

So, [sighing] to put it mildly,

we didn't do that.

It kinda always turned in to a flight hours first,

safety second kind of a thing.

And it was kinda one of those, as long as nothin' messed up

along the way, and as long as too large of a crowd

didn't see it, it was okay.

[helicopter fluttering]

- [Woman] There's gotta be something wrong.

Shit.

[crashing]

- [Narrator] The 53 has a serious accident

more than twice as often as the average military aircraft.

- Holy fuck.

- [Narrator] Three went down in a two-month span in 2012.

Van Dorn's sister squadron lost one on a runway in Bahrain,

and another in a mountain ravine in Oman.

[speaking foreign language]

Van Dorn's unit lost one too, in a radish field in Korea.

- When you have a string of crashes

in a short amount of time, it doesn't necessarily

give you the warm and fuzzies inside.

And you don't get the warm and fuzzies

when you're on an aircraft and it's having these issues.

And I knew aviation wasn't always the safest thing to do,

but at that time I was young and I was wet behind the ears.

I was just learning, so I didn't ask too many questions.

But I really began to realize there were problems

the summer of 2012.

- [Narrator] HM-14 had to ferry four 53s across the country,

to an exercise in San Diego.

- The aircraft I was on kept getting main gear box chips.

That means the gears are coming apart.

We left Norfolk, Virginia with four aircraft,

and by the time we got to California

we only had one aircraft that was up

and able to do the missions for that exercise.

It's not performing to the capability

that was advertised to you.

Why are we having all these problems?

- He would just come home

and he'd have that frustrated look on his face.

What he was most frustrated about was that

he never got to fly.

He would be on a flight schedule, he would go into work,

he would sit there, and he wouldn't get to fly

because something would be broken.

He would text me and keep me kinda updated

and tell me how many hours late

he was going to be that day.

[slow, somber music]

He didn't have a grand theory

on why exactly they were happening,

but they were little things that happened repeatedly

that he thought was perhaps evidence of a bigger trend.

[slow, somber music]

- [Man] Okay, get out.

- [Man] Watch your step, yeah.

- If that shit is full-- - There's the irrigation ditch

- Huh? - The irrigation ditch.

- The 2012 crash in Korea was the first time

that Wes really put two and two together.

- [Narrator] Van Dorn was one of the first on the scene.

The Navy interviewed him

when they opened their investigation.

- [Interviewer] All right, start off by, say your name.

- [Wes] All right, I'm Lieutenant Wes Van Dorn.

- [Interviewer] What was your take as far as

working with the troops?

- [Wes] They're hard-working young kids.

They at least start out motivated.

But they're only gonna do what's asked of 'em.

And then, senior enlisted, seems like they don't really

care about their junior enlisted.

And I think that's a huge issue in our squadron.

- [Narrator] In his testimony, Van Dorn said he was worried

that enlisted sailors were ignoring the step-by-step guides

on how to care for the 53,

books that sailors and Marines call the pubs.

- [Interviewer] Well, do you do the job per the pub?

- [Wes] Well, yeah.

- [Interviewer] Yeah, but did you do the job per the pub,

step one, step two, step three?

- [Wes] Well, no.

"Listen guys, we all know that's not the pub.

"Why are you guys not doing it?"

"Well sir, it's a lotta work to do it that way.

"It's really hard, we've got planes to fly,

"we've got other stuff to do, we got--"

- [Interviewer] Yeah.

- [Wes] There's a reason why we have these pubs.

If our kids aren't being properly taught how to use 'em,

what's the point?

- [Interviewer] So you're suggesting

that the training failure and the cultural failure

has simply been allowed to perpetuate over time.

- [Wes] The officer leadership has been non-existent.

- [Narrator] Van Dorn felt that senior officers

didn't want to admit that there were problems

at the squadron, or with the 53s.

According to military records, he submitted a memo

to superiors saying, skipper after skipper

has continued to fudge numbers

because they didn't want to be the whistleblower.

- You're fighting an uphill battle,

and you're not getting the things you need,

and you're expected to do more with less.

And, when you mix that in with poor maintenance,

it's a recipe for disaster.

[machine whirring]

[slow, somber music]

- [Narrator] The first fatal crash in a 54E came in 1984.

The helicopter broke apart as it was lifting a truck.

Four Marines died.

A mechanic who recorded a tape about his concerns,

died in a crash two years later.

Congress opened an investigation.

By early 1987, 20 people had died in training accidents

on the 53E.

- A Navy helicopter exploded off the coast of San Francisco

in heavy fog Monday, eight crewmen are missing.

Rescuers do not expect to find any survivors.

- There was pieces of debris from the size of a quarter

to as large as a Volkswagen.

- [Narrator] The death toll ticked upward,

both in the military, and at the manufacturer.

- CH-53E, or Super Stallion helicopter as it is called,

crashed here at Sikorsky this morning,

killing all four people on board.

The helicopter went down during a test flight.

- The helicopter full of Marines, and one Navy sailor,

had gone down.

The sailor and 30 U.S. Marines were killed.

- [Reporter] The CH-53 Super Stallion, like this one--

- [Narrator] 31 dead in a single crash.

It made for the deadliest day for U.S. troops

in the entire Iraq war.

25 fatal accidents.

Some were the fault of the pilot,

and others, the helicopter.

By the end of 2013, over 100 service members

had been killed on the 53E,

not one the result of enemy fire.

- The burden of everything that he saw going on

weighed heavily on Wes.

[slow, somber music]

He felt like no matter what he said or what he wrote

or who he complained to, nothing was changing.

- [Wes] If anyone should care about what's happening

on that aircraft, it should be me

and the other pilots, I think.

It makes sense to me,

'cause I'm the one who's gonna get in it

and have something terrible happen if it doesn't go right.

[light, somber music] [birds cawing]

- [Reporter] Tens of millions of Americans face a day

of dangerously cold weather.

- [Reporter] Subzero temperatures blanketing

so much of our country.

Take a look at these wind chills everywhere.

- [Reporter] Minus 40 or even worse,

and that's causing all sorts of problems

including burst pipes and power outages,

and this is no time--

- [Narrator] Besides the cold, it was suppose to be

a routine morning.

If the sailors of HM-14

could get their helicopters in the air,

they'd fly a run-of-the-mill mine sweeping exercise.

- When I showed up at the squadron,

found out one of the air crew members,

their pipes had burst at their house, so I filled in,

because I was one of the only available crewmen

at the squadron at that time.

[helicopter whirring]

- [Narrator] Dylan Boone joined air crewman Brian Collins,

crew chief Justin Godfrey, co-pilot Sean Snyder,

with Van Dorn in the pilot's seat.

Mechanic Chris Humme came in early,

and checked to be sure the freezing temperatures

weren't causing extra problems for the helicopters.

- Normal troubleshooting stuff comes up,

this light popped on, this circuit breaker pops this,

check this, check this, normal stuff.

But everything appeared to be fine.

I had a pretty good rapport with Lieutenant Van Dorn.

He just wanted to know it was good.

He was like, "Humme, just tell me shit's good.

"You're qualified, I trust you."

"Roger that, sir, shit's good, shit's good."

And I slapped him on the back,

and I turned around and I got outta the cockpit

and I walked off the aircraft and it flew away.

[helicopter fluttering]

- One, one, base, we are proceeding to the tow fields.

I'll tell you what, we'll just stop there at 15 feet,

we got plenty of power comin' to 75.

So we're good.

Tracks set in the water.

- [Man Over Radio] Cleared one, roger 84, should be nice.

- It was just a regular training mission.

I guess that's where some of my anger lies.

Because it could've been avoided, should've been avoided.

[wires sizzling]

[swishing]

I felt some heat blow on my neck and turned around

and saw that we had flames and smoke in the cabin.

It was like a flamethrower

that was just eating everything in its path.

[scary music]

And, by the time you know it,

you're just wishing for the fire to go out, and it's not.

And you're just trying to get some air and you can't.

And in a weird, sadistic way you're thankful

that it finally hit something

because it's either you're gonna drown

or the fire's gonna be put out by the water.

And, that was your escape, is a wreck.

[crashing] [water splashing]

I woke up probably about 20 seconds later

about 20 feet under water with the aircraft,

and I swam to the surface.

The water was 40 degrees.

Could hear screams in the distance, didn't know from who.

Eventually, we finally popped a smoke

and our sister aircraft came over

and started radioing for help.

[eerie music]

- [Narrator] The debris field covered the area

of four football fields.

But most of the helicopter quickly sank,

the remnants of the chopper known as Vulcan 5-4-3.

[computer keys clicking]

- One of the newer guys to the squadron comes in

and he says, "4-3's in the water."

I didn't even turn around and I like, "Say what?"

And he said, "4-3's in the water."

And then you just start panicking.

Did I do this?

Did I tell him that shit was good and it wasn't?

And you know you did it right, you just, you don't know.

Because it's a crash, there's a helicopter

that crashed into the ocean

on a day that it's 10 below zero.

And you have this mental picture of these men freezing

in the coldest day, the coldest day that...

[slow, somber music]

- [Dylan] It was the longest 45 minutes of my life.

It was fuckin' cold.

- I got a text message, just said, is Wes okay?

We heard that a 53 went down.

[bold music]

- We're back on the air now with breaking news

where we've learned a military helicopter has gone down

off the coast, five people on board we're told.

- [Reporter] The helicopter went down

about 18 nautical miles off the Virginia Beach coast.

Four of the five helicopter crew members

are already en route to Sentara Norfolk General Hospital.

- Nicole texted me 9-1-1.

I knew I needed to call her.

And, [sniffling]

we just got in the car and started driving

to Virginia Beach.

- I asked a hospital administrator to come back in

and I looked her in the eyes and I said,

"I see these chaplains walking by.

"I don't know what they're here for.

"I've been told that my husband is in surgery.

"But God help you if he's near me

"and I don't get to see him and he dies."

She came back a minute or two later

and she said, "Come with me."

- [Wes] Pool splash, kick, kick, kick.

[child laughing]

Pool splash, pool splash.

- They let me hold his hand

and lay my head on his chest.

And then I saw the, I think he was a neurologist

because he has a little flashlight in his hand

and he kept goin' like this in Wes' eyes.

Hey, bub.

And then he kinda looked at the other doctors

and that's when I knew.

I just, I laid on him for the next seven hours

waiting for his parents to arrive.

And that was when the Navy walked in to notify me

that he had been in a helicopter crash.

[gentle music]

- [Reporter] Let's turn our attention

to that deadly helicopter crash.

Today is a struggle for the community.

- Just kinda sittin' there numb.

My wife came home and I was sitting in, basically, the dark.

And I just couldn't hold it back, I just started bawling

like a child.

I just remember saying over and over again,

"They're dead, they're hurt, they're dead, they're hurt.

"I don't know if I did it, it could've been me.

"What if I did it?"

The mechanic in you, the perfectionist in you,

you just can't stop thinking about,

could I have stopped this?

Could I have changed something that made this different?

[slow, somber music]

- [Narrator] It would be eight months

before Humme knew for sure that he wasn't at fault.

All he knew then was that three sailors

had died in the crash.

[slow, somber music]

Air crewman Brian Collins from Truckee, California, was 25.

He'd just celebrated his first wedding anniversary.

Co-pilot, Sean Snyder, also from California,

was 39, and the father of four.

He was found with the wreckage a week after the accident.

Van Dorn died a month shy of his 30th birthday.

At the Naval Academy's Memorial Hall,

which commemorates graduates who died in the line of duty,

Van Dorn's name was etched into the wall.

He was the first in his class to die.

- Hey Scott, it's Mike Hixenbaugh at the Pilot.

I left a message on your cell.

I was sitting at my desk on January 8, 2014,

and an alert goes out on Twitter from the Navy

saying that a helicopter had crashed

off the coast of Virginia.

- [Narrator] Just two months earlier, military reporter

Mike Hixenbaugh had written his first major article

on the 53.

It detailed its history and problems.

He'd interviewed Navy Captain Todd Flannery,

the East Coast's top helicopter pilot.

- And, he said, "We've come a long way,

"but we still have a long way to go.

"But we're heading in the right direction."

- A military helicopter has gone down off the coast,

five people on board.

- When that alert came through,

the thoughts rushing through my mind are

going back to my interview with Flannery

just two months earlier when he's telling me

that all the problems that they've had

with these helicopters, all of the cultural issues,

the leadership problems, the maintenance issues.

And my mind is racing, thinking, what happened here?

- Good afternoon everyone, I'm Captain Todd Flannery,

Commander, Helicopter Sea Combat Wing Atlantic.

I'm joined by--

- [Mike] I remember asking Flannery that day--

- Today has definitely been a tough day on all of us.

- Whether he felt like these aircraft were safe.

Do you have any concerns

about the safety of these aircraft?

- No, I don't, I do not.

- Even on that day, he maintained that,

"Yes, I believe that these are safe aircraft."

I started working on a story that,

in much more detail than I'd previously done,

told the story of the Sea Dragon.

It was about a month after the crash when it published.

- [Narrator] The front-page spread

caught the attention of Nicole Van Dorn.

- He wasn't just accepting the facts given to him

by the Navy at face value, was inquisitive.

Maybe he's willing to break the mold.

Someone who's professional enough to not just chase a story

that isn't there, but if there is truth to it,

I also want someone who's not afraid to dig deeper.

- It was a day or two after that, late one evening,

I got a text message from a number I didn't recognize,

and it was Nicole Van Dorn.

- My husband expressed to me before he died

that he was really worried about things going on

in the squadron, and he kept copious records,

and I don't know if I have anything,

but I also need a place to bring it all.

- The text sent chills up my spine.

It's a tragedy, it's a guy who sees a problem,

commits to trying to fix it, and the problem kills him.

- I guess from the very beginning I just,

I assumed that if I wanted answers,

really transparent, truthful answers,

I was gonna have to get them myself.

Once the helicopter was recovered

and it was in a hangar, I said, "I wanna see it.

"I wanna know what actually caused the crash.

"If it was Wes' fault, I wanna know it was Wes' fault.

"If it was one of the air crewmen's fault, I wanna know.

"If it was a failing of the airframe, I wanna know."

- I-I-I care not to speculate on that.

- [Narrator] To get the answers she was seeking,

Nicole pressed Captain Flannery for updates.

- He was very kind and he called me a lot,

and when I went to see the wreckage he said,

"The way it's looking is that Wes was not at fault.

"I want you to know that to help you rest easy."

That he did nothing wrong,

that it was just a freak accident.

That's where the truth stopped for me because, I don't,

after everything that Wes had said to me,

and everything that I knew about the airframe,

there was just no way in my mind

that it could've just been a freak accident.

[slow, somber music]

- [Narrator] Navy investigators ruled out

problems with the engines, swashplate, and tail rotor,

issues that had plagued the 53 in the past.

- I took a picture of where I thought everything went wrong.

One of these zip ties is what started everything.

- [Narrator] The confidential Navy report

found that a simple plastic zip tie

unleashed the unlikely chain of events.

[zip tie clicking]

The tiny nylon strap secured a bundle of electrical wires

near a metal fuel tube.

Under constant vibration during flight,

the zip tie cut away the wires' protective insulation,

and wore a hole in the fuel line.

Through that tiny hole, a pressurized mist of jet fuel

escaped into the cabin and arched with the exposed wires.

- So the fire took place here.

The report tells you there was a fireball that happened.

You can see how close to the cockpit it is,

relatively, compared to the size of the helicopter.

- Is there no way of just going.

I asked the captain again, "Are you confident

"in the safety of this aircraft," and he said, "Yes."

- Admittedly it is an aging aircraft,

and requires extensive maintenance,

but continues to perform a vital mission

that no other helicopter

in the U.S. military inventory can accomplish.

- Very hard to think that your son lost his life

because of cracked wiring and a zip tie.

- [Narrator] The Navy ordered the inspection of all 53s

for signs of chafing.

[clicking]

After the first anniversary of the crash,

Wes Van Dorn's story went national.

[slow, somber music]

- Now to an NBC News investigation

in partnership with the Virginian-Pilot newspaper

and the Berkeley Investigative Reporting Program.

- [Reporter] ] Captain Todd Flannery was in charge

of Van Dorn's Sea Dragon squadron.

He took us inside one of the huge helicopters.

But in the case of the Sea Dragon,

it was the worst safety record of any aircraft in the Navy.

- It does.

- Five people killed in four crashes

in the course of two years.

- Yes.

- Those are odds I don't think most of us would wanna take.

- They are not good, those numbers are not good at all.

- How many crashes do we have to have?

- We can't have another crash, we just can't.

[deep, somber music]

- In the days after the story published,

several people kind of came out of the woodwork.

[deep, somber orchestral music]

One of the sources provided documents that showed

that the wiring fuel line problems hadn't been fixed,

the very kind that caused the crash.

[deep, somber orchestral music]

These aircraft were still flying and nothing had changed.

- I got up in the morning,

I'm having a cup of coffee and I read this article,

and I'm like, okay, that's a Marine airplane,

we have a problem.

And I called my Navy counterparts and said,

"We have a problem here and we need to get it fixed."

- [Narrator] No one was more surprised

to learn about the failed inspection effort

than Lieutenant General Jon Davis.

He was named the Marine Corps' top aviator

five months after Van Dorn's crash.

He was responsible for the fleet of Marine 53s.

Now retired, he was the only senior officer

willing to be interviewed for this film.

- Try not to lose my composure, but I was unhappy.

I was concerned.

From hey, we're good to, we're not so good.

An independent person out there taking pictures

found things that aren't in line with what we thought,

people thought the standard should be.

So yeah, I wanted facts, I wanted data, I wanted it quickly.

- [Narrator] Davis grounded the fleet.

Sailors and Marines spent months

looking for signs of chafing,

while pilots were on the sidelines.

- No one's gonna fly until we find out

if we've got a problem out there in the fleet,

which was the responsible thing to do.

Stop, everybody stop.

And no one in the Marine Corp faulted me for that, nobody.

- [Narrator] But there's clear evidence that the Navy

and Marines knew for decades,

even when the 53 was still in prototype stage,

that there was another problem.

The type of wiring on the helicopters was a serious threat.

- This is a piece of Kapton-insulated wire.

It's still made to this day and flies on over a third

of the world's commercial planes.

- [Narrator] The BBC used the Navy's research

when it published a report on a wiring type known as Kapton.

- Kapton is best when young, it's featherweight,

the thickness of only about three human hairs,

flame resistant, tough.

That was the good news, and this is the bad.

[sizzling]

The Kapton insulation can explode like a firework

if it's chafed and rubs against metal.

- [Narrator] Particularly bad for the Navy,

tests showed that the problems get worse

in wet environments.

[sizzling]

- [BBC Reporter] Kapton insulation burned to a crisp.

- [Narrator] In the late 80s, the Navy decided

to discontinue the use of Kapton wire in its aircraft.

But the ban was a half measure.

It applied only to new 53s and repairs,

not to the 151 helicopters built with Kapton.

- If everybody knows that this wiring insulation is bad,

it shouldn't be used, then everybody that's in the chain

of it should know better, and should not let it happen.

- [Narrator] Louis Franecke argued before the Supreme Court

in a case involving an earlier version of the 53.

He sued the manufacturer, claiming a design flaw

led to a pilot's death.

- You can't sue the military for things that go wrong.

- Hand salute.

- Some lieutenant says, "Go run over that hill,"

and you get shot.

Maybe it wasn't the right thing to do,

he should've said, "Run over the other hill,"

and you wouldn't get shot, you can't sue for that.

We all accept that.

But the products are something else.

- [Man] More arching and burning occurred,

which re-tripped this breaker, and caused four more to trip.

- They're not volunteering to be killed

by their own military

or the military products that're supplied.

- [Narrator] Franecke lost the case.

The Court found in favor of the manufacturer.

Like the military, government contractors were now immune

as long as they followed design specs,

and the government had knowledge of potential dangers.

- The families who have lost a loved one

because of a defective military product

have essentially no recourse.

They are the least powerful to ever stop using it

or have something changed.

The game is rigged, it's rigged against them.

The people who are really hurt have no power.

- [Interviewer] Should he still be alive?

- Sure, of course he should be.

He should be alive because that product

shouldn't have that insulation that causes that problem.

Could he have been killed by something else?

Maybe, but that's not what did it.

What did it, is a history of people ignoring

what needed to be done, and should've been fixed.

- [Narrator] Court records show that Sikorsky,

the manufacturer, twice recommended replacing Kapton

on the 53, after learning of safety issues.

That was more than three decades before Van Dorn's crash.

After a third proposal, the Navy decided to explore removal.

Navy safety records reveal that Kapton has been involved

in more than 50 incidents on the aircraft.

One report from 1999 foreshadowed Van Dorn's accident.

- It's almost as if I'm reading

the Safety Investigation Report from Wes' crash.

"The location of the hole on the pipe indicates

"chafing had occurred during normal

"aircraft vibrations in flight."

- One of the plastic zip ties wrapped around the wire bundle

rubbed against the pipe.

Over an unknown period of time,

these components became soaked with fuel,

and they eventually ignited.

Well I'm glad the damage was minor for them.

I wish that would've been our case.

I would take that over, that's shitty.

Why wasn't this, was this ever addressed?

I don't think so.

That was 15 years.

- [Narrator] The investigation into Boone

and Van Dorn's crash never mentions Kapton.

The maintenance log shows that some of the wiring

had been replaced, though not at the site of the explosion.

- [Interviewer] Why would it have still been

on that MH-53E that crashed in Virginia?

- I don't know, I don't know the why.

And I didn't know about Kapton wiring problems, per se.

I knew we had a plan to replace our Kapton wiring by 2019.

- [Narrator] After we interviewed General Davis,

we found a Navy memo from 2009 that sounded the alarm

about Kapton's dangers.

[suspenseful music]

Senior officers signed the document,

approving a plan to only gradually replace Kapton.

One of the signatures belonged to General Davis.

We went back to him and Davis said

he doesn't recall the memo,

but he said that replacing Kapton in phases,

and implementing two other safety measures,

seemed reasonable.

[popping and crackling]

Despite the tests, warnings, and decades of knowledge,

the Navy said it never had enough money

to replace all the wiring in the 53s.

- One of the things Captain Flannery told me

when I sat down with him back in 2013,

was that the Sea Dragon, for several years had been

what he called a "bill payer."

So in other words, funding to say replace Kapton wiring

would be rerouted someplace else.

'Cause the Sea Dragons were gonna go away.

And so that money would be put to some other need,

some other mission, some other more high profile platform.

- [Narrator] The Navy called Kapton the highest ranked

safety risk in the fleet.

But just months before Van Dorn's crash,

the Pentagon diverted funds away from Kapton replacement,

further delaying the effort to remove the deadly wiring.

- How dare you.

[sniffling]

It's just irresponsible.

[slow, somber music]

I just don't see how you can

not maintain the military equipment

that all of these fine people's lives depend on

to the upmost of our ability.

- I look at the moon, it looks like a boat.

My dad's arms, my dad's arms are like a boat too.

I think any widow would tell you

that it doesn't get easier.

The sting is still the same.

My dad looks at me, and I climb onto his lap.

I've had something to connect with Wes through,

which is trying to finish his work

and trying to get his voice out there.

- [Interviewer] How will you know

when your work now is complete?

- I think I'll know that it's complete

when people stop coming to me with concerns.

Night babe, love you.

- [Child] Love you too.

[deep, somber music]

- I read the full story in the Virginia-Pilot.

And I was like, "Van Dorn, I remember that accident,"

and said, "Hey, this may be more than just a Navy issue.

"This may be a 53-wide issue, across both communities,

the Marine Corp and the Navy.

And that kinda prompted me to contact Mike,

and then get in touch with Nicole after that.

- [Narrator] Captain James Skelton flew the Marine version

of the 53 for seven years.

As a quality assurance officer,

he kept a sharp eye on maintenance and safety,

and he found himself at odds with leaders primarily focused

on getting aircraft in the air.

- In the infantry, you can smash a guy for complaining.

Boo hoo, cry me a river, I don't give a damn.

Get your ass back out on the front line.

That's fine, that's how it's suppose to be.

[wind whipping] [sand sprinkling]

But, if you're in the aviation environment,

it doesn't work that way.

The lowest guy should be able to bring up

the biggest problem, to anyone he needs to bring it up to.

- When you start out as a pilot, you're young.

You're a young, impressionable Marine,

you're a first lieutenant, you're definitely in a position

where you're not gonna question authority.

Once you get a little bit older,

and once you become a helicopter aircraft commander,

there's responsibilities imparted on you

that are more than just saying, "Yes, sir."

It's not that you don't say, "Yes, sir,"

'cause you definitely do, and I firmly believe in that.

But you're not just a yes man at that point.

Especially in my ability as a quality assurance officer,

I'm responsible for the ultimate safety of that helicopter

and the Marines that get on it.

You have to have the folks who will stop something

if there's a train wreck about to happen.

[deep, serious music]

- [Narrator] Enlisted Marines in Skelton's unit

complained about a culture

that chose flight hours over safety.

They said they were belittled, humiliated, and slapped down

when they tried to point out safety problems.

More than a dozen wrote letters about their concerns,

and dropped them off on Skelton's desk.

- If they have to come to me as a captain

in a different department, then there's a serious problem.

I decided I was gonna write my own letter,

and I was gonna run it up the chain of command.

What I anticipated would be, "Okay, let's take a time out,

"let's figure out what's happening here.

"Why are these guys so upset,"

it became more of an admonishment from the senior leadership

that we were wrong, that there was a mutiny going on

in the lower ranks and that we needed to

pull our head out of our asses, basically,

and get back out there and do what we're told.

- I've seen this.

- You have? - Yeah.

- [Interviewer] Have you seen the whole packet?

- I remember asking questions about this note.

I wanted to kinda get to the bottom

of whether these are valid or not.

[deep, somber music]

People couldn't corroborate that as far as,

those are accurate complaints.

Could be the complaints of a young guy

out there in one unit. - It looks like

a dozen young guys. - Yeah, yeah.

- [Interviewer] That are complaining about it.

- Yeah, I only saw Skelton's, yeah.

But there, I think, bottom line is, we wanted to go fix,

we needed to fix the 53 community.

What are they saying now?

Really, to me would be, okay, got it.

We had a problem then, are they fixed now, yes or no?

I believe they are fixed now.

So it's easy to go, "Hey, things suck."

So the hard part is figuring out a thoughtful way forward,

getting that funded, and driving it home,

which is exactly what the Marine Corp is doing right now.

[drumming music]

- It was depressing to walk all the way back to your shop

and have to go tell those Marines that their concerns

were not gonna be listened to.

I was disgusted by it, I'm disgusted by it to this day.

Not only was I disgusted with one or two individuals,

I was disgusted with an entire unit.

[drumming music]

This isn't about me, this is about those young Marines

who get on the aircraft, they were failed.

[drumming music]

[water lapping] [gentle music]

- The kind of situation that you are seeing

with the helicopters,

is very typical of things I've seen over the years.

It is basically a predictable consequence

of a screwed-up priority system.

Not predictable, inevitable.

And, because it is inevitable, you can see it ahead of time,

and when you continue this behavior into the future,

it basically boils down to malice aforethought.

- When Chuck Spinney talks about defense cost overruns,

Congress listens, and so do his Pentagon bosses.

[somber orchestral music]

- [Narrator] Chuck Spinney spent more than 25 years

as an analyst in the Pentagon.

- We projected that our monetization costs in 1982

would be here, they actually turned out to be here.

That's a mismatch of 100%.

Now, we can't change this cost--

- [Narrator] In the early 80s, he briefed Congress

on how Pentagon spending was impacting readiness,

and led to parts shortages, disgruntled maintenance crews,

and pilots who were short on flight time.

30 years later, Van Dorn still wrestled

with the same problems.

- If what you're saying is true,

then we not only have a budget problem,

I think that we frankly have

a major problem in national defense.

- The number one priority in the Pentagon

is to pump up the budgets that're associated with

the development and purchasing of new weapons.

Now, if you pump those up, you basically try to hold down

the money that's spent on operating existing weapons.

In terms of readiness, training, buying spare parts,

maintenance, things like that.

And, in the case of the CH-53s, maybe one of those cutbacks

was saying, "Hey, we can live a little longer

"with this shitty wire."

- [Interviewer] Readiness is first and foremost

in the Marine Corp.

- It is.

- [Interviewer] And the CH-53E was not ready.

- It was not ready to do all the things

we needed to do, that's a fact.

- [Interviewer] And what put it in the state that it was in?

- I think, one, we had some budget challenges

inside the Department of Defense.

But the money's being pulled from our

Department of Defense budgets

at the same we're floor deployed and fighting.

So, very challenging environment out there for sustainment.

- [Interviewer] Some people say that the costs

of new weapons are constantly taking away resources

from programs like the 53.

Do you agree with that assessment?

- I don't, I don't, I think that you've gotta balance.

You can't fly the old metal forever.

You have to keep pace with

changing threat requirements out there.

You can't just say, "We're just gonna take care of the old

"and not do the new," so you have to balance that.

- I agree, you do have to modernize,

you have to support the fleet in being.

You have to do both.

But you can't get there from here doin' business as usual.

That's what we've been arguing about for 30 years.

- [Narrator] Spinney was one of a small group

in the Pentagon and on Capitol Hill

focused on military reform.

Another was Pierre Sprey, who spent 20 years

as a weapons analyst and designer.

- The idea that we're having safety problems,

we're having maintenance problems,

just because the total defense budget is not big enough,

is ludicrous.

[dramatic banging]

[dramatic music]

There's plenty of money.

[beeping]

But you can't do what's really needed for the people,

and buy all the glitzy toys that the Congress

and the industry and the generals want.

New stuff means big budgets,

and new stuff means issuing contracts,

and issuing contracts means that high-ranking officers

and high-ranking civilians will have lovely

defense industry jobs when they retire.

That revolving door,

that's incredibly damaging to national defense.

- [Narrator] The problems that come

with a powerful defense establishment,

perpetual war, and its impact on democracy,

were spotted decades ago by war hero

turned president, Dwight Eisenhower.

- [Dwight] Good evening my fellow Americans.

- [Narrator] In his farewell address, he gave it a name.

- We must guard against the acquisition

of unwarranted influence, whether sought or unsought

by the military-industrial complex.

- The military-industrial complex is basically

what some political scientists call

an iron triangle of relationships.

Those three corners being the military, the Congress,

and the contractors.

And how money circulates around that triangle,

is the key to understanding what's going on.

It's basically a little bit like

a bait and switch operation.

You basically downplay the future costs of a new weapon.

They say it'll be easy to maintain, it'll be more effective,

and we estimate it's gonna cost this.

Then the political engineers start distributing that money

as quickly as possible to as many

Congressional districts as possible.

Then, once the true cost of the program

starts to manifest itself,

there's nothing you can do about it,

because the program's got too many vested interests

spread all over the country.

The F-35 is the classic case in point.

- The richest contract in the history

of the Pentagon finally awarded.

The aerospace company Lockheed Martin

have been chosen over Boeing to build a new fighter plane

for the U.S. and Britain.

[deep, pounding music]

- As president, I've continued to make historic investments

to keep our armed forces strong.

- Arbitrary budget cuts have emasculated our military

and harmed our ability dramatically to defend this nation.

[deep, pounding music]

- Let's modernize, we need to respond to evolving threats.

- If I'm president of the United States,

and Congress tries to cut the military,

I will veto that in a millisecond.

[deep, pounding music]

- We've always said we need to increase defense spending

for our armed forces.

- The two year budget agreement I just reached with Congress

will provide $700 billion in defense funding this year.

And next year, we will raise that number to $716 billion.

That's a lot of money.

[audience applauding]

- The same thing's happening again.

They're just throwing money at the Pentagon.

It's guaranteed to get worse, it can't get better

'cause they're rewarding all the kinds of behavior

that created the problem.

- There's zero difference between the two political parties,

none whatsoever, because they're receiving the same money.

The military-industrial complex is highly bipartisan.

As long as they can keep that money

flowing in the right direction,

everything is smooth and hunky-dory.

- That's the kinda craziness we've gotten ourselves into.

- [Interviewer] You're describing a very complex situation.

- Yeah, no shit. [laughing]

But it's making a lot of people rich.

That's the key point, a lot of people are benefiting

from this lunacy.

Generals are going through the revolving doors.

Lieutenant colonels and colonels

are going through revolving doors.

Contractors are making big profits,

and congressmen are basically gettin' lots of pork

in their districts, which enables them to increase

their longevity and power and wealth.

Everybody wins, except of course the soldier

at the pointy end of the spear, and the taxpayer.

[jet engine roaring]

- I love the Navy.

I mean, I come from a big Navy family.

There's chiefs in my family,

there's master chiefs in my family.

There's a lot of pride, and that's all I wanted to do

was just make everybody proud.

- [Narrator] Chris Humme was widely regarded

as one of the top mechanics at HM-14.

He was also the sailor who told Wes Van Dorn

that his helicopter was safe to fly

just two hours before the fire broke out.

He battled nightmares for months.

In the wake of the crash, he grew frustrated

with too much business as usual.

- I'm not a politician, I'm just a mechanic

who saw a lotta things being done the wrong way,

and I tried to voice it.

And I think as a whole, that has a lot to do

with me getting pushed out.

- I've told it politely so many times

that I'm done telling it politely.

Basically, I'm coming clean with,

we're doing illegal maintenance.

[guns tapping]

I get a message, skipper wants to talk to you.

"Come in, sit down," and I realize very quickly

this is not a conversation of anyone wanting to talk about

the letter I wrote other than how inappropriate

the letter that I wrote was.

And I was just dumbfounded, I couldn't believe this.

And then the one that really shocked me

was the command master chief, recommended that I read a book

called "How to Win Friends and Influence People."

[drumming music]

- [Narrator] The Navy questions Humme's credibility.

They say he lied about a maintenance mistake he made

in the aftermath of the crash.

He was disciplined for it.

Later, when he took his daughter to school

instead of going to a lecture about weekend behavior

and personal safety, his commanding officer

had grounds for dismissal.

Humme's career in the Navy was over.

- I just basically point blank asked him,

"Sir, has this got anything to do

"with a lot of the concerns I've raised?

"Some of the issues that I know

"that you've talked to me about

"with some of my ways of approaching things."

Pretty much looked me in the face

and told me that I poked the bear.

I poked the bear too many times

and now I've gotta deal with it.

- The reaction typically of the system is,

this guy is dangerous, this guy might talk to a reporter,

this guy might talk to a congressman.

How do we get rid of him?

And then they're on him like a hawk.

Every time that guy fails to tie a shoelace,

he's up before a board.

You can take anybody and drive 'em outta the service

in three to six months if you're on him like that.

- [Narrator] Humme moved home to Tennessee.

He now works at an auto dealer.

- It's certainly not the excitement of the flight line,

and traveling the world and all that stuff.

It's a desk job in Knoxville.

But, I don't have to worry about towing the company line

and covering stuff up.

[telephone ringing]

Thank you for choosing PALS Knoxville, this is Chris.

- When you ask why individuals can't fix this thing,

most people just say, "It's too much of a risk."

And remember also, they're conditioned culturally

to put faith in the authority of the system.

So even if they see something wrong,

they're biased to say,

"Maybe I just don't see the big picture.

"After all, he's a general and I'm just a lieutenant."

- My commanding officer actually said that directly to me.

He said, "You just don't see the big picture."

Well, my only response to that is,

"If the big picture is people crashing and dying

"and doing things the wrong way,

"then the big picture is wrong."

A broken system killed Wes,

killed Sean, killed Brian, broke Dylan.

I mean, a flawed system did that.

[slow, somber music]

[breathing heavily]

- [Narrator] Dylan Boone was medically separated

and honorably discharged in 2015.

[slow, somber music]

- The scar always gives me trouble with my hair.

- [Narrator] The aftermath of the crash

brought a series of false starts.

Different jobs, different living situations,

and that's on top of the five surgeries.

- [Interviewer] What's it like to survive

a helicopter crash?

- It sucks.

I know there's guys who actually served in war

and actually saw combat who have to deal with

a lot more shit than I deal with,

but when it happens in training, that, it's tainted.

You don't expect to give up your life for this country

because you were given faulty equipment.

[Dylan speaking muffled]

[man speaking muffled by tape squeaking]

- [Man] Class, one, six, one, five, unload!

- It's as simple as the air crewman's creed.

My country has built me the finest aircraft known to man.

- [Man] Troop.

- [Group Of Men] I'm a United States Naval Air crewman.

My country has built me the finest aircraft known to man.

They have entrusted me to use it to keep our country free.

- I used to say that so loud.

I was the loudest person to say it.

I was ate up, I loved it.

- [Man] Hooyah one time.

- [Crewmen] Hooyah!

To every man!

- [Man] Hooyah in group.

- [Crewmen] Hooyah!

- [Man] Hooyah in the crew.

- [Crewmen] Hooyah!

- [Narrator] 3 1/2 years after the accident,

Boone decided to move closer to family in California.

- I'm not gonna pretend that I haven't had those dark nights

and struggles with PTSD.

Three volumes, medical paperwork.

A lot of the time, I'd get a surgery and just get Oxycontin

or Valium or Percocets.

And it was a concoction of coping with physical ailments

and mental instability,

fueled by alcohol and prescription drugs.

They take all the pain away.

Not just your physical pain,

but you don't think about anything

and you really don't care.

[people chattering]

My lowest low.

I don't know if I even wanna answer that,

'cause I'll sound fuckin' crazy.

Lowest low,

gun in hand.

Yeah, lowest low, gun to hand, gun in hand.

Lowest low, gun in hand, barrel to head.

But you know it's like you kinda get to that point

and you never know if you're actually gonna do it

or not, and then,

then you don't and you're kinda,

you're done with the idea.

[birds chirping] [slow, somber music]

Sometimes it's just a bad day

and things continue to roll downhill.

Sometimes it's really hard to find the reason

for why things happen.

And sometimes it feels like

you're damn near close to breaking.

[slow, somber music]

- I think all of the platforms we've had

in the United States Marine Corp, the legacy platforms,

had a bit of readiness challenge,

a severe readiness challenge.

And it manifested itself in about 2014.

I looked at the 53 as being one that was more challenged

than some of the others.

What I didn't understand early on is how to fix the problem.

Right now the world is a pretty dangerous place,

and we got Marines floor deployed at sea and at shore.

- [Narrator] Davis had a dilemma.

He had Marines in Afghanistan and the Middle East

dependent on the 53, and he had concerns

about the condition of the helicopters.

He ordered a study of his 53s in order to figure out

how to get the fleet back on track.

[dramatic music]

The report found that less than a quarter of the helicopters

were mission capable, far below the Pentagon's requirements.

It recommended a complete overhaul,

a reset of the 53 fleet.

- [Interviewer] What took so long?

- I don't know.

I don't know, I just, I can't answer that question.

I can only answer the questions that I dealt with

when I got there.

- [Narrator] Seven months after the report was complete,

the 53's troubling legacy continued.

At a 53 squadron in Hawaii, so few aircraft were available,

Marines considered the flight schedule a running joke.

[slow, somber music]

But on a night in January, 2016,

12 Marines boarded two helicopters

for a training exercise.

Tourists took in luaus.

Security cameras kept watch on vacation homes.

One spotted the choppers just offshore,

and captured the moment they collided in midair.

All 12 Marines were killed instantly.

[slow, solemn music]

The death toll on the 53E climbed to 128.

[slow, solemn music]

- That's terrible, and I think, it's again, I'm heartbroken,

heartbroken that we lose these fine Marines

in a mishap like this.

- [Narrator] The four pilots had barely flown

in the months leading up to the accident.

- [Interviewer] Were they pushed to do something

they weren't ready to do?

- I don't wanna go into that particular mishap,

but I think, yeah, there's no reason

that those two airplanes should've had a collision.

[slow, somber music]

- The fact that a guy has a collision,

and you can obviously blame it on pilot error,

doesn't really mean much if the guy's not gettin' practice.

It's an easy way to deflect the blame.

- [Man] Captain Kennedy,

Captain Brian Kennedy.

Captain Brian T. Kennedy.

- [Narrator] One of the pilots, Brian Kennedy,

was one of Wes Van Dorn's best friends at the Naval Academy.

- When we found out that Brian had also died

in the helicopter crash, it's devastating all over again.

- I went to Brian Kennedy's wedding less than a year ago.

And then I went to the same town

and went to his funeral.

When is it going to be enough?

How many people have to die?

I'm appalled and I'm devastated

but there's a lack of surprise.

Something was gonna happen, I knew it was gonna happen,

I just didn't know exactly what it was going to look like.

- [Narrator] Kennedy's name was inscribed

below that of his friend

at the Naval Academy's Memorial Hall.

They are the only two members of their class

to die in service, not in battle,

but training in an aged helicopter.

[slow, somber music]

[people chattering]

[laughing]

- If you join the military, you inherently know

that some point in time you might die

doing your job, just because of what you've chosen to do.

But that does not leave a blank allowance

for the Navy to kill you.

Not everybody that died for this country

had to die for this country.

[deep, serious music]

- We're lookin' at every single wire.

All the zip ties that were in here is comin' off.

Every piece of tape you see, is a repair we're making.

800 something gripes just on this airframe.

This thing's a workhorse,

and it's gonna continue to be a workhorse

until the Kilo hits the fleet.

[slow, somber music]

- It's been another tragic week for U.S. military aviation.

Five service members have died,

and the accidents are continuing.

[slow, somber music]

- The number of accidents involving maned military aircraft

between 2013 and 2017 spiked 40%, 40%.

[slow, somber music]

- I would reject wave and crisis,

those are mishaps that occurred.

Each one is tragic and we regret each one.

We'll look at 'em carefully.

I'm certainly not prepared to say

that it's a wave of mishaps, or some form of crisis.

No, I'm not prepared to say that.

[slow, somber music]

- If it's not a wave and it's not a crisis,

how do you explain it, General?

[slow, somber music]

- And I understand some of you really great pilots

could use some new CH-53s, is that a correct statement?

You wanna see some new ones, huh?

[audience cheering]

[slow, somber music]

- Only an alert and knowledgeable citizenry

can compel the proper meshing of the huge industrial

and military machinery of defense

with our peaceful methods and goals,

so that security and liberty may prosper together.

[slow, somber music]

[gentle, solemn music]

[somber orchestral music]