Toward Zero Mishaps

Dec. 1, 2006

Recent emphasis on military flying safety is paying off, particularly for the Air Force, which just completed its safest flying year in every category that matters.

In Fiscal 2006, which ended on Sept. 30, USAF posted its lowest rate of Class A flight mishaps ever, had the fewest aircraft destroyed in accidents, and suffered only one fatality in a flight incident.

Collectively, 2006 was “the best year since we’ve been an Air Force,” declared Maj. Gen. Stanley Gorenc, chief of Air Force safety and commander of the Air Force Safety Center at Kirtland AFB, N.M.

This success came despite an exceptionally high pace of flight operations in support of the Global War on Terrorism and a number of humanitarian missions around the world. The Air Force’s safety record is particularly impressive compared to 2005, when the Air Force suffered its second highest mishap rate of the past decade.

USAF defines a Class A mishap as a noncombat accident that results in a death, a permanent total disability, or damage of at least $1 million. In 2006, the Air Force’s mishap rate plunged to an all-time low of 0.90 Class A mishaps per 100,000 flying hours.

This was an improvement of more than 40 percent compared to the rate of 1.5 in Fiscal 2005 and 1.48 in 2002. Moreover, it far surpasses the 1.55 rate turned in by the Navy, 1.90 for the Marine Corps, and 1.53 for the Army. (However, the other three services typically suffer more mishaps as a result of their heavy use of helicopters and participation in sea-based operations.)

The sharp improvement in flight safety was the result of a major emphasis on the issue from Defense Secretary Donald H. Rumsfeld down to the squadron level, Gorenc said. He noted that “the leadership is focusing on safety as never before” and that Gen. T. Michael Moseley, the Air Force Chief of Staff, is “always pushing us hard.”

Rumsfeld’s Push

Rumsfeld launched the new drive for safety with his order, declared in May 2003, for all the services to cut their accident rates by 50 percent by 2005. (See “A Plague of Accidents,” February 2004, p. 58.) The directive came after the 2002 accident numbers were up, significantly, for all the services.

Military flight accidents that year killed 82 personnel and destroyed 63 aircraft worth nearly $2 billion. The toll in deaths and injuries and damaged or destroyed equipment was even worse when ground mishaps and off-duty accidents were included.

“World-class organizations do not tolerate preventable accidents,” Rumsfeld said in a memo to the service Secretaries and service Chiefs.

Gen. John P. Jumper, then Chief of Staff, had already made the same point, telling Air Force personnel in December 2002 that the service “cannot tolerate, nor sustain, this level of loss.” Though Rumsfeld set a tough goal, Jumper’s was even more demanding—zero mishaps.

Air Force safety levels have steadily improved for six decades, but then, starting about a decade ago, the rates began to resist improvement. The service did set safety records in 2000, before the progress tailed off, and, in many cases, accident rates increased, especially in 2002 and 2005.

The setting of a new record in 2006 came as a welcome development, of course, but it still is not good enough for Air Force leaders. “We have a program throughout our Air Force to build safety consciousness,” Air Force Secretary Michael W. Wynne told defense writers in September. “I believe personally that every airman deserves to go home the same way [the airman] arrived at work,” Wynne said, adding that he includes Air National Guard and Air Force Reserve personnel in that goal.

The best result, clearly, came in the area of aviation fatalities, which fell from 22 in 2002 and 14 in 2005 to just one in 2006. “We hope the string continues,” said Gorenc, “because that’s very, very good.”

That single, flight-related death was a tragic “anomaly,” the safety chief said. The victim was an enlisted ground-support airman who was taking an incentive ride in an F-16. The airman had trouble with his oxygen system and died after being rushed to the hospital.

In an unusual twist in 2006, more Air Force personnel died while flying with the naval services than they did aboard Air Force aircraft. Two airmen were killed in the Feb. 17 midair collision of two Marine Corps CH-53E helicopters over the Gulf of Aden, and one died in a Navy flight training accident.

Gorenc said he also is closely monitoring the number of aircraft destroyed in flight accidents. In 2002, the loss was 19 airplanes, and the figure went up to 22 the following year. Then, in 2004 and 2005, there were record-low losses of 11 aircraft in each year. A new record was set again in Fiscal 2006, when USAF lost eight aircraft—three F-16s, two Predator UAVs, one F-15C, one T-38 trainer, and one C-5 transport.

In a third key area—number of Class A mishaps—the Air Force almost met its ambitious goal of cutting the mishap rate to no more than half of the level in 2002, which was 35. The number in 2006 was 19.

“The bottom line is, in two out of the three things I’m tracking closely on the flight Class A side, we actually did make a 50 percent cut from ’02,” Gorenc said.

Ground Accidents “Trending Up More Than I’d Like”

Beyond the high-profile issue of flight safety, the Air Force and the other services are facing a big challenge in trying to reduce ground accidents, particularly off-duty private motor vehicle (PMV) accidents, which are the biggest killer of young service personnel.

A total of 305 service members died on the highways in the last fiscal year. That is nearly equal to the total US deaths in five years of fighting in Afghanistan.

Reducing ground mishap fatalities is part of the safety challenge issued by Defense Secretary Donald H. Rumsfeld.

Maj. Gen. Stanley Gorenc, Air Force safety chief, is happy to note that there is a “good trend” in motor vehicle safety, particularly for off-duty mishaps. “It’s the on-duty I’m worried about. Those numbers are trending up more than I’d like,” he added.

For on-duty fatalities, the numbers are relatively small, the safety chief said, averaging about 10 a year from all causes. In 2006, there were 12 on-duty fatalities, he noted, including several personnel who died after a physical fitness run.

“Our commanders in the field have noted this and are really re-emphasizing the procedures that we need to go into on-duty to reduce the numbers,” he said.

There are promising signs of improvement off-duty. In Fiscal 2002, the Air Force had 72 off-duty PMV deaths. That dropped to 46 in 2005 and to 44 in 2006, making the Air Force the safest of all the services in this category.

Three Safety Factors

Gorenc attributed the overall safety improvement to three factors: leadership, risk management, and the gradual creation of a safety culture.

Safety begins with top-to-bottom leadership. The input of Rumsfeld and Moseley is important, but Gorenc said, “The guys who are making this happen” are the chiefs of safety and safety officers in the individual flight squadrons.

The second factor he cited was evidence that the average airman is “coming to grasp” the idea of operational risk management (ORM), a Pentagon concept to make commanders and individuals assess the danger in any proposed activity.

Gorenc said that from his experiences as a commander from squadron to group he believes that ORM is “really an issue of risk mitigation. We’re not going to avoid risk in the type of work we’re doing. It’s an issue of how much risk you’re willing to accept.”

If the mission “absolutely needs to be done, you’re going to take the risk,” he continued.

But people should study the potential risk and “not just back into it.” Despite its “operational” label, ORM “is an on- and off-duty issue” and should be called risk mitigation, he said.

Finally, Gorenc said, due to the leadership’s emphasis, the service is experiencing “a slow culture transformation” that is making airmen at all levels determined to “do the right thing” when it comes to safety.

As usual, fighter and attack aircraft—with four of the eight aircraft destroyed—accounted for most of the Class A mishaps.

None of the services achieved Rumsfeld’s 2005 goals in every category, and the Defense Secretary renewed the challenge last June, setting a new target of a 75 percent reduction by 2008.

“We must rededicate ourselves to those goals—and achieve them,” Rumsfeld said. “Too often we excuse mishaps by citing the difficult circumstances in which we operate. We have trained our men and women to operate safely in very trying conditions. There is no excuse for losing lives, given proper planning, attention to detail,” and active involvement of everyone in the chain of command.

“No” to the Status Quo

“Accountability is essential to effective leadership,” Rumsfeld added. The Defense Department “simply will not accept status quo.”

One of the safety center’s key contributions, Gorenc said, are organizational safety assessments, conducted on a routine basis at the center’s initiative or when a commander requests one. An example of the benefit of such an assessment, Gorenc said, was the sharp improvement in flight safety by Air Force Special Operations Command. In Fiscal 2005, “our special operations guys had helicopter problems” that resulted in six mishaps. “This year, AFSOC had zero mishaps.”

He said the improvement was “directly attributed” to the leadership exhibited by the commander of AFSOC, Lt. Gen. Michael W. Wooley, who had the safety center go into his unit and give it an entire scrub down, assessing the culture of the organization.

After that assessment, Gorenc continued, “the commander adopted all of the ideas and recommendations that our folks had. He has taken a proactive approach, and you can see the results.”

Among the other major commands, Air Combat Command topped the list of mishaps with four. But that was a sharp drop from 12 the year before.

Air Education and Training Command, Air Mobility Command, and Pacific Air Forces had three mishaps each; Air Force Materiel Command and Air Force Reserve Command experienced two each; and US Air Forces in Europe and the Air National Guard each posted one mishap in 2006.

Air Force Space Command and the Air Force Academy joined AFSOC in enjoying zero Class As, according to the safety center’s statistics.

Broader Improvement

Defense-wide, the Marine Corps and the Army also showed improvements in flight safety over the previous fiscal year. The Navy had one more Class A flight mishap than in Fiscal 2005.

Although human error, or “aircrew factors,” have traditionally been a major contributor to accidents, Gorenc said that “generally speaking, you’re going to have an accident occurring when people are not following a proper procedure.” That is why training is such an important part of accident reduction, he said.

Accident records for Fiscal 2006 provide some examples of how failure to follow the right procedures can lead to mishaps.

In October 2005, an F-22 Raptor at Hill AFB, Utah, was involved in a Class A incident when the crew chief pulled the nose wheel safety pin while one engine was running. The engine intake suction pulled the flag and pin out of his hand and into the engine, causing $6.8 million in damage.

A tragic example of failure to follow procedures occurred last December, when a maintainer working on a KC-10 at Travis AFB, Calif., failed to properly position a work stand and fell through the gap, suffering fatal injuries.

In March, an F-16 flying out of Hill had an engine compressor stall. Although he was able to restart the engine, the pilot apparently was so preoccupied with the engine emergency that he forgot the cardinal rule: Fly the airplane first. The Falcon slowed down and stalled, forcing the pilot to eject.

In April, a C-5 taking off from Dover AFB, Del., had to shut down one engine. After circling around and while trying to land with a heavy fuel load, the pilot attempted to add power to the dead engine while a good engine on the same side remained in idle. As a result, the Galaxy failed to make it back to the runway and broke up on impact, causing multiple injuries. (See “Aerospace World: Crew Faulted for C-5 Crash,” August p. 17.)

Although the Air Force now has the oldest collection of aircraft in its history—averaging 23.5 years—Gorenc did not see that as a significant safety factor. “Obviously, the aging aircraft issue is a maintenance and operations issue” that the personnel who generate sorties have to monitor very closely, he said. More important than the age of the aircraft, however, is the training of the aircrews, so that they know how to respond if something does go wrong, and the training of the ground crews, so that they can make an accurate determination of whether an aircraft is safe for flight.

“It’s not an issue of if the aircraft is safe,” Gorenc said, because the Air Force is “not going to take it up into the air if it’s not safe.”

Despite last year’s encouraging numbers, Gorenc said he was “certainly going to keep pushing the envelope” to ensure that safety remains a priority.

“I emphasize to the folks in the field that Air Force safety is really about maximizing air combat power,” he said.

Any time there is a safety incident and an aircraft or an airman is lost, it reduces both readiness and combat capability, he explained. Neither the equipment nor the airman can be easily replaced.

Otto Kreisher is a Washington, D.C.–based military affairs reporter for Copley News Service and a regular contributor to Air Force Magazine. His most recent article, “Flight-Test Worries,” appeared in the February issue.