Safety - The Legand and The Myth

When I entered the United States Air Force and reached my first operational squadron I was informed we had our monthly wing safety meetings at the Officer’s Mess at 2:30pm on a Friday afternoon, and it was a mandatory formation.  So off I went, along with a classmate from Nav school who had arrived with me.  Once we were all settled in -- the wing safety officer launched into a report of how unsafe we had been over the past month and what changes were being made to make us less unsafe.

Just a couple of weeks earlier we (well maintenance really) had cut the navigation station out of one of our aircraft when they had used a homemade tool on the fuse panel located on the FS 245 bulkhead and severed the LOX line that ran through the bulkhead and around the Nav Station to the co-pilot’s O2 panel.  The heat must have been pretty intense since all the knobs on the overhead panels had melted and now reached all the way to the floor.  The navigator's station had fallen to the ramp, allowing a really unobstructed, if somewhat windy, view for the Navigator.

Once we were all told how to be safe they opened the bar so we could all have a few beers before we drove home (or walked since I was in the BOQ next door).

In the following 42 years I was associated with our service I can’t count the number of safety meetings, or safety investigation board out-briefs I’ve sat through, or the number of material improvement programs I’ve helped define and push for approval or test, but one fact seems inescapable despite all the lessons we have supposedly learned since Lt. Thomas E. Selfridge became the first statistic in the military’s use of powered flight, human error remains at the center of our most serious accidents.  

Fortunately, most of the time we make a mistake it is minor and forgettable, but sometimes we do really stupid things that kill people.  I’ve yet to figure out how we institutionalize universal sound judgment into a profession that demands we occasionally push ourselves and our aircraft to the extreme.  For that reason, safety boards will exist -- as long as manned flight exists and “pilot (or aircrew) error” will continue to be a leading causal factor.

What really bothers me though is how even the simplest material improvements grow to become monumental efforts, or are quietly dismissed by those with the authority to do so without accountability.  Here are two examples.

Image from Politico used under Fair Use restrictions

In 1996, a modified T-43A carrying Commerce Secretary Ron Brown into Croatia crashed when they flew into terrain during an IMC approach.  One of the findings on that accident was the aircraft was not equipped with a flight data recorder as was standard in commercial aviation.  As a result, the DOD issued guidance to equip all passenger carrying aircraft with the black box but did not fund that guidance.  At the time we (AFSOC) were fielding the MC-130H and AC-130U and neither aircraft was equipped with the flight data recorder.  The rationale was if we crashed it was important the enemy not be able to trace our point of origin.  It wasn’t until we started scattering Talon II’s across the landscape that the issue came back up, but in each funding drill the cost to equip two small fleets never made it above the cut line, pushed down by things like laser cannons.

Next, we come to a crashworthy seat for loadmasters in the cargo compartment.  In two crashes early in the global war on terror, we had loadmasters injured or killed because they did not have a suitable seat to secure themselves to.  So, the SIB recommended we develop one.  How much and how long do you think that should take?  It took over $10M and 10-years and I’m not sure we have all that great a solution today.  I would defer to those flying on the HC or MC-130J to how well it works.  I doubt that AMC or AMC gained units have bought them for their aircraft, but then I’m no longer in the loop on that.

Safety is kind of like a unicorn… or maybe the pot of gold at the end of the rainbow.  We know it is important, but how do you find it, and what do you do with it once you have?