At that time, few members of the public would have guessed that the Air Force safety record was not deteriorating.

These tragedies by themselves would have been enough to trigger a review of USAF procedures, but Alan Diehl, a former safety official at Air Force Safety Center, Kirtland AFB, N.M., added to the urgency by writing a scathing letter to the Defense Secretary and members of Congress. In it, he charged that a lack of independence and expertise on Safety Investigation Boards (SIBs) had compromised as many as thirty crash probes.

Nowhere did those warning lights flash more intensely than at Kirtland AFB, where Air Force Safety Center 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 of high-level investigations by an Air Force Blue Ribbon Panel on Aviation Safety, the General Accounting Office, and the Pentagon Inspector General. General Godsey said that the work of the Blue Ribbon Panel was important "to get at the truth behind the accidents." However, he added, "I was trying to put out the positive message that our overall accident record was still good. I was just never effective at cutting through the negative spin."

The Reality

Then, in February 1996, GAO released a report titled "Military Aircraft Safety: Significant Improvements Since 1975." GAO investigators confirmed what USAF safety officials knew all along--that Air Force safety had been improving for many years.

From Fiscal 1975 through 1995 the annual number of Class A mishaps (those involving a fatality, loss of aircraft, or damage worth $1 million or more) for all services decreased from 309 to seventy-six. Air Force Class A mishaps dropped from ninety-nine to thirty-two. The mishap rate--or the number of Class A mishaps per 100,000 flying hours--dropped from about 4.3 to 1.5 for the military as a whole and from 2.8 to 1.44 for the Air Force.

"I think everyone was a little surprised at those findings, and that may be a result of the so-called 'CNN effect,' where we pay more attention to these accidents because they now attract more national news," said William E. Beusse, assistant director for GAO's Military Operations and Capabilities group.

GAO noted that each of the services has taken steps to reduce aviation mishaps, including tracking mishap-investigation recommendations and disseminating safety information in manuals, newsletters, and videos. As noted in the GAO report, the Air Force has also recently instituted a number of reforms to enhance the independence of its investigations.

The Blue Ribbon Panel, which released its report in September, tracked similar improvements in safety since 1975. It found, for instance, that Class A mishaps for fighter/attack aircraft have fallen by 61.5 percent over the past two decades, while aircraft losses and fatalities have been reduced by 51.7 percent and 62.7 percent, respectively.

The panel also noted a perception--even among those involved--that SIBs lacked full independence.

"Notwithstanding [an] overall positive perception regarding the mishap-investigation process, there are too many service members who believe that SIB results are occasionally driven by factors outside of the [SIB] process," the panel's report stated, citing information from a questionnaire developed by the Air Force Military Personnel Center (now the Air Force Personnel Center, after merging with the Air Force Civilian Personnel Management Center). "The fact that a significant portion of those holding these views have had SIB experience is an important consideration in developing recommendations."

Previously, a commander of a numbered air force had the authority to convene an SIB, choosing members from within the numbered air force. Once the SIB investigation was completed, the commander could make changes to the language of the report before it was formally released.

"I think the Air Force realized that no matter how well-intentioned commanders were, it just didn't look right . . . that they could change the language of an accident investigation report and no record would exist 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 panel also recommended that the SIB report precisely reflect the results of the investigation.

Three Options

"So," said General Godsey, "once a Majcom commander is briefed on the SIB report, he has three options: He can concur, concur with his own comments added, or . . . tell the board to go back and reinvestigate if he thinks they missed something. What he can't do is change the report, and the purpose of that was to remove even the perception in anyone's mind of bias or a cover-up."

Even after an SIB report clears the Majcom, it is subjected to a thirty-day review by the Air Force Safety Center. During that review, the director can reopen an investigation. "That's actually happened twice during my tenure, because I've received letters during my review that alleged that pertinent information had been missed," said General Godsey.

The Air Force has also adopted a number of the panel's recommendations aimed at improving the expertise on SIBs. An Air Force Safety Center representative who sits on all Class A investigation boards, for instance, was elevated to the status of a voting member. The Air Force also declared that, after October 1, 1995, all SIB leaders would have to take and pass a board president's course. The center has expanded the number of courses designed to train board members to ensure that Majcoms will have adequate expertise on staff.

"That's a positive development for two reasons," said General Godsey. "First, we all agreed that someone shouldn't be on an investigation board unless he was adequately trained, but often there just weren't sufficient courses available." He continued, "Because the people sent to these courses are also the same ones responsible for instituting safety programs for the wings and squadrons, we get a prevention benefit as well."

The Blue Ribbon Panel specifically rejected suggestions, however, that the Air Force create a totally independent accident investigation organization modeled after the National Transportation Safety Board. While the Federal Aviation Administration regulates commercial and general aviation, accident reports are conducted only by independent NTSB investigators.

Panel members concluded that such adversarial "second guessing" of the chain of command could harm combat readiness.

"We want the Majcom commander to 'buy in' to the safety program, and that's much more likely to happen if he can appoint his own team," said General Godsey. "He also has the same goal of zero mishaps or fatalities; so to imply that this four-star general would want to cover up the cause of an accident is really insulting to his integrity."

Looking Deeper

With board members more thoroughly trained in accident-investigation techniques, Air Force officials hope SIB reports will also get at the possible underlying causes for a disaster. Too often, they say, sterile SIB reports focus on the most obvious causes without digging further into possible unseen contributors.

For example, when an E-3B Sentry Airborne Warning and Control System aircraft crashed near Elmendorf AFB, Alaska, last year [see "Leadership Lapse Cited in AWACS Crash," "Aerospace World," p. 21], the ingestion of geese by the aircraft's engines was cited as the primary cause of the accident. "But what led so many geese to be flying near one of our airfields?" asked General Godsey. "Those are the kinds of indirect causes of accidents that we want to highlight in our reports."

In another incident last year, an Air Force helicopter crashed into a cable during night vision flying in Korea. The direct cause of the accident was obvious, but Safety Center officials dug a little further to unearth fundamental "human factors" problems.

"We found that the unit had only recently transitioned to that type of helicopter, and the fact that they were being pushed very hard in training to get them combat-ready in a hurry was clearly a contributing factor," said General Godsey. "So, in the past, there has been a tendency to want to blame the machine rather than the man. Yet, in a lot of our mishaps, the man has been just as responsible as the machine."

GAO's analysis of data reported by all services showed that human error contributed to seventy-three percent of Class A flight mishaps in Fiscal Years 1994 and 1995. In Air Force mishaps, human error was a factor seventy-one percent of the time. For the Army, the figure was seventy-six percent. According to the Naval Safety Center, human error was a factor in eighty percent of the Navy and Marine Corps Class A mishaps for Fiscal Years 1990 through 1994.

"The fact that nearly three-fourths of accidents have a human error factor doesn't necessarily mean that the human caused the problem," said GAO's Mr. Beusse. "Often, some other problem occurs, but at some point the human could have or should have intervened to change the course of events--and that someone is not always the pilot. It could be anyone from the air traffic controller to the maintenance crew."

That point was tragically highlighted in May 1995, when an F-15 pilot was killed shortly after takeoff from Spangdahlem AB, Germany. Two Spangdahlem mechanics are standing trial for negligent homicide as well as four counts of dereliction of duty. According to Air Force officials, one mechanic failed to install two flight-control rods properly, rendering the fighter uncontrollable. The other mechanic allegedly failed to catch the mistake in a required inspection. [See "F-15 Mechanics Stand Trial," May 1996 "Aerospace World," p. 30.]

Human Factors

To avoid such human errors, all of the services have implemented human factors programs designed to manage and reduce aviation risk. The whole field of human factors got a big boost from the space program, when psychologists for NASA studied ways to improve safety in flight operations.

In 1993, the Air Force established a Crew Resource Management Steering Group. The next year, CRM training programs were required for all Air Force crew members. According to the Blue Ribbon report, however, implementation of the CRM programs was held up by staff reductions resulting from the military drawdown of the 1990s.

"Not all of the Air Force community adopted CRM as they should have, and the Air Force has recently made the director of Operations and Plans the CRM advocate," said General Godsey, who notes that the Air Combat Command recently let a contract to introduce CRM into the fighter arena.

The CRM program, he said, can improve interaction and communication in any crew environment, from multimember bomber crews to single-member fighter crews to a two-member maintenance team changing a tire on the flight line. "We look at human factors as the next pearl that, when polished, will help us reduce our mishaps," he said.

The Air Force and Navy both are also interested in an Operational Risk Management program instituted by the Army. After suffering a disproportionate number of OH-58 helicopter accidents at night, the Army developed a series of flight profiles for predicting whether a mission was low, medium, or high risk. The number of accidents dropped off once a system was developed to assess the risk prior to each OH-58 mission and offer guidance for reducing the risk to acceptable levels. The Army plans to expand use of the risk-management system to include not only other aircraft but also ground vehicles.

"What we want to do is formalize risk management into our education and training programs," said General Godsey, "so from the time someone comes into the Air Force, they are indoctrinated into a risk-management culture. Of course, as the Air Force moves from peacetime to contingency operations to wartime, you'll see the amount of risk people are willing to take rise."

Getting airmen to consider risk carefully, however, is far different from asking them to avoid it. That would go against the grain, experts say, of an organization that has to respect, and in some cases revere, the reasoned risk-taker.

"You want to allow pilots to train hard enough to get a good feel for what their aircraft can do, while at the same time keeping them from getting so close to the edge during training that they significantly increase the danger of a crash, with its attendant loss of life and very expensive equipment," said Mr. Beusse. "In a sense, risk management is an attempt to protect pilots from themselves. These tend to be very motivated, dedicated people. Sometimes they have so much confidence in the aircraft and their own abilities that they push that envelope a little too far."

James Kitfield is a defense correspondent for National Journal in Washington, D.C. His most recent article for Air Force Magazine, "Counterproliferation," appeared in the October 1995 issue.

James Kitfield is a defense correspondent for National Journal in Washington, D.C. His most recent article for Air Force Magazine, "Counterproliferation," appeared in the October 1995 issue.