Flying Safety Has Improved Steadily for Many Years

Official investigations confirm what USAF safety officials knew all along. Flying safety has improved steadily for many years. Flying Safety: The Real Story

HREE major air disasters in 1994 By James Kitfield T set warning lights flashing through- out the Air Force about safety procedures. First, an F-16 crashed into two transports at Pope AFB, N. C., de- stroying the fighter and one transport and killing twenty-three service members. Next came the accidental shoot- down by two F-15s of two US Army UH-60 Black Hawk helicopters over 5 - Class A Flight Mishap Rate, Combined Services

Iraq, killing twenty-six personnel. Fi-

nally, a B-52 performing unauthorized rs maneuvers crashed near Fairchild AFB, 4- Wash., killing four. hou At that time, few members of the ing

public would have guessed that the fly 3 Air Force safety record was not de- 000 teriorating.

These tragedies by themselves would 100, 2 have been enough to trigger a review er p

of USAF procedures, but Alan Diehl, s a former safety official at Air Force Safety Center, Kirtland AFB, N. M., hap added to the urgency by writing a Mis scathing letter to the Defense Secre- tary and members of Congress. In it, he charged that a lack of indepen- 1975 1980 1985 1990 1995 dence and expertise on Safety Investi- Fiscal Year gation Boards (SIBs) had compromised DoD's Class A mishap rate, as many as thirty crash probes. calculated as the number Nowhere did those warning lights of accidents per 100,000 flying hours, declined from flash more intensely than at Kirtland about 4.3 in FY 1975 to 1.5 AFB, where Air Force Safety Center in FY 1995. officials chart accident trends in an effort to prevent mishaps. "That letter and those three high-profile accidents attracted a lot of negative press, and I had a lot of my own concerns," said Brig. Gen. Orin L. Godsey, the Air Force chief of Safety. These events touched off a series

56 AIR FORCE Magazine /June 1996 Class A Flight Mishap Rate, by Service released its report in September, tracked similar improvements in 8- safety since 1975. It found, for in- , Navy/USMC stance, that Class A mishaps for 7- fighter/attack aircraft have fallen by 61.5 percent over the past two de-

hours 6 cades, while aircraft losses and fa-

ing talities have been reduced by 51.7 5

fly percent and 62.7 percent, respec- tively. 000 4 The panel also noted a percep-

100, tion—even among those involved— 3- er that SIB s lacked full independence. p s Air Force "Notwithstanding [an] overall pos- 2- itive perception regarding the mishap- hap investigation process, there are too Mis many service members who believe that SIB results are occasionally driven by factors outside of the [SIB] 1975 1980 1985 1990 1995 process," the panel' s report stated, Fiscal Year Each of the services has also experienced an overall downward trend in its mishap Class A Flight Mishap Rate, USAF Only rate since FY 1975, 9

8 - of high-level investigations by an rs 7

Air Force Blue Ribbon Panel on hou Fighter/Attack

Aviation Safety, the General Ac- ing 6

counting Office, and the Pentagon fly Inspector General. General Godsey 5 said that the work of the Blue Rib- 000 4- bon Panel was important "to get at 100,

the truth behind the accidents." How- er 3- ever, he added, "I was trying to put p out the positive message that our s 2- overall accident record was still good. hap

I was just never effective at cutting Mis through the negative spin." 0 The Reality 1975 1980 1985 1990 1995 Then, in February 1996, GAO re- Fiscal Year leased a report titled "Military Air- craft Safety: Significant Improvements Since 1975." GAO investigators con- may be a result of the so-called 'CNN citing information from a question- firmed what USAF safety officials effect,' where we pay more attention naire developed by the Air Force knew all along—that Air Force safety to these accidents because they now Military Personnel Center (now the had been improving for many years. attract more national news," said Air Force Personnel Center, after From Fiscal 1975 through 1995 William E. Beusse, assistant direc- merging with the Air Force Civilian the annual number of Class A mis- tor for GAO's Military Operations Personnel Management Center). "The haps (those involving a fatality, loss and Capabilities group. fact that a significant portion of those of aircraft, or damage worth $1 mil- GAO noted that each of the ser- holding these views have had SIB lion or more) for all services de- vices has taken steps to reduce avia- experience is an important consider- creased from 309 to seventy-six. Air tion mishaps, including tracking ation in developing recommenda- Force Class A mishaps dropped from mishap-investigation recommenda- tions." ninety-nine to thirty-two. The mis- tions and disseminating safety in- Previously, a commander of a num- hap rate—or the number of Class A formation in manuals, newsletters, bered air force had the authority to mishaps per 100,000 flying hours— and videos. As noted in the GAO convene an SIB, choosing members dropped from about 4.3 to 1.5 for the report, the Air Force has also re- from within the numbered air force. military as a whole and from 2.8 to cently instituted a number of re- Once the SIB investigation was com- 1.44 for the Air Force. forms to enhance the independence pleted, the commander could make "I think everyone was a little sur- of its investigations. changes to the language of the report prised at those findings, and that The Blue Ribbon Panel, which before it was formally released.

AIR FORCE Magazine /June 1996 57 5 - Aviation Fatality Rate, All Services panel also recommended that the SIB report precisely reflect the re-

rs sults of the investigation. 4-

hou Three Options

ing "So," said General Godsey, "once

fly a Majcom commander is briefed on 3 the SIB report, he has three options: 000 He can concur, concur with his own comments added, or. ... tell the board 100, 2 er to go back and reinvestigate if he

p thinks they missed something. What

ies he can't do is change the report, and it l the purpose of that was to remove ta

Fa even the perception in anyone's mind of bias or a cover-up." Even after an SIB report clears the 1975 1980 1985 1990 1995 Majcom, it is subjected to a thirty- Fiscal Year day review by the Air Force Safety Center. During that review, the di- The number of DoD aviation fatalities per 100,000 flying hours fell from about four in FY 1975 to 1.7 in FY 1995. USAF Aviation Fatalities 160

"I think the Air Force realized that no matter how well-intentioned com- manders were, it just didn't look right . . . that they could change the language of an accident investigation report and no record would ex- ist of the original," said GAO's Mr. Beusse. "People should be able to make up their own minds on the legitimacy of the changes." The panel concluded that, in order to remove the perceived conflict of interest, the authority to convene an SIB should rest solely with the commander of the major command (Majcom) involved. The 1975 1980 1985 1990 1995 Fiscal Year

Even before the Army accepted its first aircraft, the service suffered its first fatality when 1st Lt. Thomas E. Selfridge was killed in a crash of the Wright Flyer during tests at Fort Myer, Va., with Orville Wright at the controls on September 17, 1908.

58 AIR FORCE Magazine /June 1996 When a Class A flight mishap occurs, USAF safety mechanisms, including the Air Force Safety Center, Kirtland AFB, N. M., swing into action. The Air Force recently revamped its Safety Investigation Board procedures to combat even the appearance of conflict of interest.

rector can reopen an investigation. istration regulates commercial and direct causes of accidents that we "That's actually happened twice dur- general aviation, accident reports are want to highlight in our reports." ing my tenure, because I've received conducted only by independent NTSB In another incident last year, an letters during my review that alleged investigators. Air Force helicopter crashed into a that pertinent information had been Panel members concluded that cable during night vision flying in missed," said General Godsey. such adversarial "second guessing" Korea. The direct cause of the acci- The Air Force has also adopted a of the chain of command could harm dent was obvious, but Safety Center number of the panel's recommenda- combat readiness. officials dug a little further to un- tions aimed at improving the exper- "We want the Majcom commander earth fundamental "human factors" tise on SIB s. An Air Force Safety to 'buy in' to the safety program, problems. Center representative who sits on and that's much more likely to hap- "We found that the unit had only all Class A investigation boards, for pen if he can appoint his own team," recently transitioned to that type of instance, was elevated to the status said General Godsey. "He also has helicopter, and the fact that they were of a voting member. The Air Force the same goal of zero mishaps or being pushed very hard in training to also declared that, after October 1, fatalities; so to imply that this four- get them combat-ready in a hurry 1995, all SIB leaders would have to star general would want to cover up was clearly a contributing factor," take and pass a board president's the cause of an accident is really said General Godsey. "So, in the course. The center has expanded the insulting to his integrity." past, there has been a tendency to number of courses designed to train want to blame the machine rather board members to ensure that Maj- Looking Deeper than the man. Yet, in a lot of our corns will have adequate expertise With board members more thor- mishaps, the man has been just as on staff. oughly trained in accident-investi- responsible as the machine." "That' s a positive development gation techniques, Air Force offi- GAO's analysis of data reported for two reasons," said General God- cials hope SIB reports will also get by all services showed that human sey. "First, we all agreed that some- at the possible underlying causes for error contributed to seventy-three one shouldn't be on an investiga- a disaster. Too often, they say, ster- percent of Class A flight mishaps in tion board unless he was adequately ile SIB reports focus on the most Fiscal Years 1994 and 1995. In Air trained, but often there just weren't obvious causes without digging fur- Force mishaps, human error was a sufficient courses available." He ther into possible unseen contribu- factor seventy-one percent of the continued, "Because the people sent tors. time. For the Army, the figure was to these courses are also the same For example, when an E-3B Sen- seventy-six percent. According to ones responsible for instituting safe- try Airborne Warning and Control the Naval Safety Center, human er- ty programs for the wings and squad- System aircraft crashed near Elmen- ror was a factor in eighty percent of rons, we get a prevention benefit as dorf AFB, Alaska, last year [see the Navy and Marine Corps Class well." "Leadership Lapse Cited in AWACS A mishaps for Fiscal Years 1990 The Blue Ribbon Panel specifi- Crash," "Aerospace World," p. 21], through 1994. cally rejected suggestions, however, the ingestion of geese by the aircraft's "The fact that nearly three-fourths that the Air Force create a totally engines was cited as the primary of accidents have a human error fac- independent accident investigation cause of the accident. "But what led tor doesn't necessarily mean that the organization modeled after the Na- so many geese to be flying near one human caused the problem," said tional Transportation Safety Board. of our airfields?" asked General GAO's Mr. Beusse. "Often, some While the Federal Aviation Admin- Godsey. "Those are the kinds of in- other problem occurs, but at some

AIR FORCE Magazine/ June 1996 59 Aircraft Loss Rate, All Services Force officials, one mechanic failed to install two flight-control rods prop- 4 erly, rendering the fighter uncon- rs trollable. The other mechanic alleg-

hou edly failed to catch the mistake in a

ing required inspection. [See "F-15 Me-

fly chanics Stand Trial," May 1996

00 "Aerospace World," p. 30.] 0

100, Human Factors

e To avoid such human errors, all of p

ft the services have implemented hu-

ra man factors programs designed to

irc manage and reduce aviation risk. The a

d whole field of human factors got a e big boost from the space program,

troy when psychologists for NASA stud-

Des ied ways to improve safety in flight operations. 1975 1980 1985 1990 1995 In 1993, the Air Force established Fiscal Year a Crew Resource Management Steer-

Since FY 1975, the annual rate of destroyed aircraft per 100,000 USAF Aircraft Losses flying hours has dropped 100 - from 3.1 to 1.3. 90-

80 -

70- point the human could have or should ft have intervened to change the course 60 - of events—and that someone is not ircra always the pilot. It could be anyone 50 - f a

from the air traffic controller to the o maintenance crew." 40 ber

That point was tragically high- m 30 lighted in May 1995, when an F-15 Nu pilot was killed shortly after takeoff 20 from Spangdahlem AB, Germany. 10 Two Spangdahlem mechanics are standing trial for negligent homi- 0 cide as well as four counts of der- 1975 1980 1985 1990 1995 eliction of duty. According to Air Fiscal Year

2,000— Class A Mishap Costs, All Services Army Air Force Navy/USMC

1,500 ii§111 The services put the cost of Class A flight mishaps 1 000 - since 1975 at about $21 billion. The value of Class A losses has been fairly constant over the last six years, ranging from a high of approximately $1.6 billion in FY 1993 to a low of $1.2 billion in FY 1994.

1990 1991 1992 1993 1994 1995 Fiscal Year

60 AIR FORCE Magazine /June 1996 ing Group. The next year, CRM train-

ing programs were required for all Crash Kills Thirty - Five, Including Commerce Secretary Air Force crew members. According to the Blue Ribbon report, however, In the military's most recent high-profile air accident, a USAF CT-43A passen- implementation of the CRM pro- ger jet crashed on April 3 at Dubrovnik, Croatia, killing Commerce Secretary Ronald H. Brown and thirty-four others. The cause of the crash was not readily grams was held up by staff reduc- apparent and raised concerns that the lack of "black boxes" on the military jet tions resulting from the military would hamper the investigation. drawdown of the 1990s. Although the weather was poor and the airport had only a rudimentary radio "Not all of the Air Force commu- beacon, DOD officials stated that the flight was within commercial passenger aircraft restrictions. Extensive review of the wreckage by military and civilian investigators nity adopted CRM as they should has already ruled out rudder and other major equipment failures, according to senior have, and the Air Force has recently USAF officials. DOD expects to issue a more complete report this month. made the director of Operations and The accident prompted Defense Secretary William Perry on April 9 to order Plans the CRM advocate," said Gen- each service to install cockpit voice and flight-data recorders, as well as Global eral Godsey, who notes that the Air Positioning System equipment for precise navigation, as soon as possible on all military aircraft that carry passengers. He also directed the service secretaries to Combat Command recently let a con- report to him on passenger-manifesting procedures because of the initial confu- tract to introduce CRM into the sion over the number and identity of persons aboard the CT-43. fighter arena. The aircraft, a military version of the Boeing 737-200, crashed into Saint John's The CRM program, he said, can Hill, a 2,300-foot peak about 1.8 miles northwest of Dubrovnik's Cilipi Airport. The improve interaction and communi- transport had been flying in what some officials termed the worst storm in a decade, but the aircraft commander, Capt. Ashley J. Davis, and the copilot, Capt. cation in any crew environment, from Timothy W. Schafer, both had substantial experience with the aircraft. They were multimember bomber crews to single- making an instrument approach using the airport's single radio beacon. member fighter crews to a two- The CT-43 was on the correct approach path as it started a twelve-mile-long member maintenance team chang- descent to the airport, according to radar data collected by one NATO aircraft, and it was communicating with the airport tower when contact suddenly was lost. ing a tire on the flight line. "We look USAF Lt. Gen. Howell M. Estes III, Pentagon Operations chief, said the crew at human factors as the next pearl made no calls indicating there was a problem. that, when polished, will help us re- Several commercial aircraft had landed at the airport shortly before the USAF duce our mishaps," he said. jet made its approach. However, the Washington Post reported that Croatian Airlines had diverted some of its flights because of the harsh weather. The Air Force and Navy both are The CT-43 #1149 was one of two used for passenger transportation, while also interested in an Operational Risk another fifteen are used for navigation and cargo training. USAF officials said this Management program instituted by was the first crash for any of its T-43s in 300,000 flying hours during more than the Army. After suffering a dispro- twenty years of service. With only 17,000 flying hours, this particular aircraft was portionate number of OH-58 heli- well short of the 30,000 to 50,000 flying-hour average for other T-43s of that age. General Estes noted that this CT-43, operated by the 86th Airlift Wing, Ramstein copter accidents at night, the Army AB, Germany, had undergone an extensive maintenance overhaul in June 1995. developed a series of flight profiles The aircraft entered operation in 1973, the year before USAF began its policy of for predicting whether a mission was equipping its aircraft with cockpit voice and flight data recorders. USAF officials low, medium, or high risk. The num- stated that the aircraft was used for training until 1988 and was not retrofitted with ber of accidents dropped off once a black boxes because of the expense. At a briefing April 9, a senior USAF official also said that the T-43s were the only passenger aircraft without such recorders. system was developed to assess the Although black boxes are standard today on commercial airliners, the National risk prior to each OH-58 mission Transportation Safety Board (NTSB) has not been able to resolve two recent and offer guidance for reducing the commercial 737 crashes. More than 2,700 Boeing 737s are in service, making it risk to acceptable levels. The Army one of the world's most widely used airliners. It has also been one of the safest. The unresolved crashes, however, have caused the NTSB to focus more closely on any plans to expand use of the risk- 737 crash. The senior Air Force official said that although the lack of recorders management system to include not would "complicate" the CT-43 investigation, with today's technology the service will only other aircraft but also ground "be able to replicate almost the entire realm" of the flight and the lack of black boxes vehicles. "will not preclude us from finding out what happened in the mishap." "What we want to do is formalize The NTSB and Federal Aviation Administration are working with the Air Force Accident Investigation Board, headed by Brig. Gen. (Maj. Gen. selectee) Charles risk management into our education H. Coolidge, Jr., 22d Air Refueling Wing commander, McConnell AFB, Kan. and training programs," said Gen- eral Godsey, "so from the time some- —Suzann Chapman one comes into the Air Force, they are indoctrinated into a risk-manage- hard enough to get a good feel for Beusse. "In a sense, risk management culture. Of course, as the Air Force moves from peacetime to con- what their aircraft can do, while at ment is an attempt to protect pilots tingency operations to wartime, the same time keeping them from from themselves. These tend to be you'll see the amount of risk people getting so close to the edge during very motivated, dedicated people. are willing to take rise." training that they significantly in- Sometimes they have so much confi- Getting airmen to consider risk crease the danger of a crash, with dence in the aircraft and their own carefully, however, is far different its attendant loss of life and very abilities that they push that envelope from asking them to avoid it. That expensive equipment," said Mr. a little too far." • would go against the grain, experts say, of an organization that has to respect, and in some cases revere, James Kitfield is a defense correspondent for National Journal in Washington, the reasoned risk-taker. D. C. His most recent article for Air Force Magazine, "Counterproliferation," "You want to allow pilots to train appeared in the October 1995 issue.

AIR FORCE Magazine / June 1996 61