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 proce- dures. 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 mem- bers. 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 let- ter and those three high-profile acci- dents 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 investiga- tion 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 or- der to remove the perceived con- flict 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 proce- dures 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.