Air-Minded: Standing Up

Several years ago, when I was chief of flight safety for one of the USAF’s major air commands, I was ordered to interfere in an ongoing major aircraft mishap investigation. My mission was to shift the investigation from the track it was on (the right one) to another track (a false one).

Some explanations are in order. The USAF is made up of several major air commands, or MAJCOMs, divided by geography (the USA, Pacific, and Europe) and mission (combat, transportation, materiel, space, training). Each MAJCOM is headed by a four-star general who directs all activities within that command, including the investigation of aircraft mishaps that occur on his watch.

There are two investigations into any aircraft mishap: the mishap investigation and the accident investigation. The mishap investigation is conducted strictly for safety purposes, to find out what happened and recommend ways to prevent similar mishaps in the future. The accident investigation is conducted for legal purposes, to determine fault and liability. Each investigation is independent of the other.

The mishap investigation process is supposed to be pure and disinterested – free from politics, pressure, and influence. If, for example, mishap investigators determine that a bad decision on the part of senior USAF leadership resulted in an aircraft accident, they’re supposed to be able to say so, without fear of consequence.

You’ve probably guessed by now that it doesn’t really work that way. When a pilot crashes at one of our overseas bases in, say, Japan, the Pacific Air Forces commander in Hawaii convenes his own mishap investigation board. There’s no one above him in the chain of command, and no authority outside the chain of command, involved in investigating the crash or overseeing the investigation. The PACAF commander, in this case, would select a PACAF colonel to serve as president of the mishap investigation board, and the PACAF safety staff would then help the president assemble the rest of his board: investigators; pilot, medical, life support, and maintenance advisers; recorders; secretaries; technical experts. With the exception of the technical experts, who are normally outside civilian contractors, all the board members would come from PACAF. They’d all work, in other words, for the four-star commander who convened the board. Should that four-star commander decide to intervene in the investigation, the board’s independence would quickly become theoretical.

USAF pilots are taught to believe in the purity and independence of mishap investigation board findings and recommendations, but most take them with a large grain of salt. This is because of several well-known cases where MAJCOM commanders and other senior USAF leaders compromised the mishap investigation process, pressuring mishap boards into making findings and recommendations that had little to do with the facts. Here are three I’m familiar with:

• In the early 1980s, while practicing a diamond formation loop at the Indian Springs auxiliary base in Nevada, four T-38s belonging to the Thunderbirds aerial demonstration team crashed into the desert, killing all four pilots. The mishap board quickly determined that Thunderbird lead had miscalculated the loop, topping out too low to allow for a safe pullout at the bottom. The MAJCOM commander rejected the initial report and sent the board back to conduct a new investigation. Eventually the mishap board “found” that the load relief cylinder in the lead aircraft’s stabilator control mechanism had jammed, preventing Thunderbird lead from applying enough aft stick to recover from the dive on the backside of the loop (the other three pilots, concentrating on flying tight formation, probably never had a clue anything was going wrong). Not a single USAF pilot who’d flown the T-38 (and all of us had, since it’s used in pilot training) had ever heard of a load relief cylinder. It was obvious to us all that the MAJCOM commander was protecting his boy – his very dead boy.
• In the mid-1980s, two European-based F-4s collided in mid-air. But the collision occurred over the Gulf of Mexico while the unit was deployed to a base in Florida, “chopped” to the command of a US-based MAJCOM. At the time, the use of pilot tactical call signs (nicknames) in radio transmissions had been outlawed by every MAJCOM but the one based in Europe. When the mishap board – convened by the US-based MAJCOM commander – found that the F-4 pilots’ use of tactical call signs created confusion and caused the mid-air collision, pilots everywhere scoffed.
• In the early 1990s, an F-16 assigned to Pope AFB in North Carolina collided with a C-130 assigned to the same base. Both aircraft were in the landing pattern. Although the C-130 crew was able to land safely, the F-16 was so severely damaged its two-man crew was forced to eject, and the unguided F-16 plowed into Army troops waiting to board a USAF transport on the ramp, killing 24, injuring another 100, and destroying the transport aircraft. Prior to the 1990s, fast-moving fighters and slow-moving cargo aircraft were rarely based together, primarily because large speed differentials between aircraft sharing the same landing pattern could lead to exactly this kind of mid-air collision. But in the early 1990s, the then-USAF chief of staff – the boss of the MAJCOM commanders – implemented “composite wings” throughout the USAF, deliberately mixing different types of aircraft at selected bases, Pope AFB among them. The mishap board found, among several other factors, that the policy of mixing F-16s and C-130s at Pope AFB set the stage for this collision. The board’s report was rejected, and, if I recall correctly, the board president’s career ended on the spot. The policy of the USAF chief of staff was Not Open to Question. It’s interesting to note, though, that almost immediately after this accident the USAF quietly realigned its composite wings. Although Pope AFB still has a mix of fighters and cargo aircraft, F-16 fighters were replaced with A-10 fighters, which fly at much slower speeds in the landing pattern.

Outsiders and insiders have long pointed to the possibility of pressure and influence inherent in a system that allows commanding generals to investigate their own accidents with their own subordinates. There’s no way a colonel – and keep in mind that part of the vetting process for colonels being considered for wing commander positions is service on a mishap investigation board – is going to buck the four-star general who can make or break his career. A good friend of mine lost his job trying to convince the USAF to set up a truly independent mishap investigation process. You can read more about that – and several other examples of compromised mishap investigations – here.

So what happened in my case? An F-15 pilot at an overseas air base experienced a flight control problem on takeoff: once airborne, the jet wouldn’t respond to his control inputs, oscillating randomly in pitch, roll, and yaw, and failing to gain altitude. As the jet began to roll inverted he ejected, with barely enough altitude to survive. The F-15 crashed into farmland just beyond the base fence and was totally destroyed.

In the history of the F-15 (up to that point) there had been just four or five similar loss-of-control mishaps, each caused by an obscure and extremely rare failure in the pitch/roll channel assembly. The mishap board determined this to be the cause of the crash, then flew to MAJCOM headquarters to present its report to the four-star. As the MAJCOM chief of flight safety, I was in the room when the boss rejected the board’s conclusions, insisting that the pilot caused the accident. In his own words, the pilot must have “horsed the aircraft off the runway before he had flying speed,” and the brief period of uncontrolled flight prior to the crash was due not to a faulty PRCA but to flying in a partially to fully stalled condition. As an experienced F-15 pilot, I knew this was impossible, and so did the board members (and everyone else in the room who’d ever flown the F-15).

But back to the scene of the accident they went, and after another month of investigation, including several sessions in the full fidelity F-15 simulator at the McDonnell-Douglas factory in St. Louis, the board once again found that the accident was caused by the PRCA. Once again the boss rejected their report. At this point MAJCOM commanders normally fire the old board and convene a new board, but our commander didn’t take that step. He sent the board back once again, basically telling them outright to continue investigating until they came to the correct conclusion.

And he did one more thing. He told my boss, the MAJCOM safety director, to convince the mishap board president that the pilot had caused the accident by muscling the jet into the air before it was ready to fly. And my boss passed that unpleasant task on to me. And I – without any investigative resources or powers, not even the opportunity to go to the mishap air base to interview the pilot and other witnesses or to examine the wreckage – had to pick up the phone and try to talk the board president into imagining a scenario that would satisfy our boss.

Could we sell the PRCA failure if we leavened it with some pilot error? Could the pilot have suffered an engine rollback just as he was getting airborne, and then failed to notice it? Could we talk the pilot into “remembering” something like that? God, my skin crawled as I made those calls – I was ashamed of my boss and even more ashamed of myself – because I knew this was all bullshit. And so did the board president, who refused to change his report and who put his career on the line defending his conclusions. His correct conclusions, as it turned out.

Eventually, the boss accepted the mishap board’s original report, and the colonel kept his job. What finally convinced the four-star was a later accident, a nearly identical F-15 crash in another MAJCOM, once again pinned on the PRCA. I say nearly identical because the other pilot stayed with the jet, trying to get it to fly right, and died in the crash.

And what about me? I didn’t put my career on the line. I didn’t stand up for what I knew to be right. I did as I was told and tried to talk the board president into compromising his report. It’s the one thing I did in my USAF career I’m ashamed of. But I learned from it. I learned to stick to my guns. It isn’t easy, standing up for what you know to be right – doing so cost me a job not long ago – but it’s easier than living with shame.

I also learned what “truth” means, when it comes to aircraft accident investigations, military or civilian. Truth is what a room full of people with conflicting interests will agree to. More on that in a future entry!

— back to the Air-Minded Index