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Alan Diehl writes to members of Congress |
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After Gen. Joel "Tom" Hall's passionate plea for safety improvements fell on deaf ears, safety problems got worse in the Air Force. From 1991 to 1996, the Air Force suffered 198 major crashes--or one every 11 days. In late 1994, Air Force safety official Alan Diehl was compelled to take action. Diehl wrote key members of Congress, outlining 30 faulty accident investigations, which Diehl called "only the tip of the iceberg." |
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October 18, 1994 The Honorable Ronald V. Dellums Chairman, House Armed Services Committee The Honorable Floyd D. Spence Ranking Minority Member, House Armed Services Committee The Honorable Sam Nunn Chairman, Senate Armed Services Committee The Honorable Strom Thurmond Ranking Minority Member, Senate Armed Services Committee
Gentlemen: I have served as the senior civil servant at the U.S. Air Force Safety Agency since 1987. I have just informed the Secretaries of Defense and the Air Force of a "cover-up" involving the friendly-fire tragedy which recently occurred over Northern Iraq. Unfortunately, this accident was not a isolated incident, but rather a reflection of much larger, systemic, problems with the USAF safety program. These deficiencies have contributed to many of our recent accidents. Note, that over the last three years, the USAF major mishap rate has increased by over 30 percent, while the Navy and Army rates have decreased by 40 and 50 percent respectively. Because of the important oversight roles of your respective committees it is vital that you also receive such information. This letter outlines the scope of the problem, and my qualifications to comment on such matters. It and the attachments provide the critical documentation which you will need to investigate these matters. You can consider this letter to be a sworn affidavit, and I have offered to take a polygraph on it and all materials contained herein. This complex situation is described in several important attachments. The first attachment (Examples of Improper USAF Mishap Investigations) provides a detailed description of the cover-up on the recent shoot-down in Iraq, and dozens of other mismanaged investigations. The second attachment (Problems with the USAF Safety Process) deals with broader issues and explains why the current system does not work. The third attachment is the 1991 letter from USAF Director of Aerospace Safety describing critical safety deficiencies and warning the current Chief of Staff that "we are headed for a disaster." The forth attachment is the Chief of Staff's curt reply effectively dismissing these concerns. Several other attachments include articles and documents related to these issues, as well as letters describing my qualifications. The following paragraphs provide more detailed description of the major attachments to facilitate your review of the complex issues contained in this package. The first attachment (Examples of Improper USAF Mishap Investigations) describes various problems such as: examples of interference with mishap board functions, unreported accidents or incidents, wartime friendly-fire accidents concealed as combat losses, cover-up techniques used in specific situations, lost and/or suppressed evidence, inept methods, abuse of mishap pilots, witnesses, and investigators. This attachment is "privileged" (as defined by Air Force Regulation 127-4 and Air Force Instruction 91-204), because it provides specific names, dates, etc. Such information is normally not released to non-DOD personnel. However, under the 1989 agreement (Attachment 5), you are the only four individuals outside of DOD who may view such information. Because you will need to discuss these matters with other members of your committees as well as your staffs, I have provided a non-privileged description of the 30 cases contained in that sealed envelope. Note two things, these cases are only the "tip-of-the-iceberg", and except where noted all these mishaps resulted in the loss of the aircraft as well as fatalities. Case 1. Is a description of suppressed evidence in the recent friendly-fire tragedy. I was initially asked to participate in this investigation, until I pointed out that we needed to examine certain training program deficiencies. I had informed the accident board of the date when the decision was made not to provide Crew Resource Management (CRM) training for fighter pilots or AWACS crew-members. Basically, CRM teaches crews techniques to improve coordination, situational awareness, and decision making. Note such training has been shown to reduce the types of errors which apparently occurred in this mishap. I was then told the command apparently did not want such matters investigated. I was also reminded that because of the numbers of non-Americans killed, there would be very extensive financial liabilities to the USAF (as you may know our service members' families can never sue the Government). I was later informed somebody else would be taking my place on the investigation. The final board report criticized errors made by crewmembers, but did not mention the command's lack of CRM training. Thus, there appears to be no urgency to provide such training, which in-turn increases the risk of another such tragedy. Case 2. After one catastrophic mid-air collision, the board president decreed that the investigation would not examine issues related to "composite-wings" (which is the USAF Chief of Staff's decision to locate high-speed fighters and slower transports together at small bases). Other investigators felt that this issue was at the crux of the accident, but dared not bring it up again. It is unfortunate when an investigation focuses on the errors made by an inadequately trained enlisted man, while ignoring other problems which were created by senior leaders. Case 3. During an airshow practice a pilot lost control while performing over-aggressive maneuvers. Following the crash the Air Force admitted that his supervisors knew he had a history of such behavior. In another (non-fatal training mishap) a supervisor actually observed a pilot performing dangerous maneuvers, but did not direct him to stop. This suggests the all too familiar pattern of ignoring dangerous behavior of certain individuals, especially when they are well liked, regarded as good flyers, or hold high-rank. Case 4. During an airshow practice, a pilot flew his craft into the ground. It was learned that during an earlier practice session this relatively inexperienced pilot had made a similar error. But rather than reprimanding him, the commander suggested he wanted a "good-show" tomorrow for the crowd. Case 5. A transport crashed on a training flight when it was flown too fast into turbulence. Other crewmembers had previously complained about this pilot's aggressive flying habits, but the commander had failed to adequately counsel/reprimand him. In this and the previous cited cases the mishap boards did not adequately discuss the important role which CRM training might have played in preventing such tragedies. Case 6. The weather was deteriorating and a pilot crashed while maneuvering at low altitude. Because this was a rehearsal for an very important classified mission, a number of senior generals were observing. It was "suggested" that the board might down-play the presents of the generals. Case 7. In this mid-air collision investigation the board president directed that important damaging information about the unit's policies be deleted from my report. This was the only unit in the USAF which routinely performed the dangerous maneuver which caused the accident. Case 8. A transport mishap where the crew was practicing a very dangerous maneuver, one which the group commander should have been aware. The board president played the cockpit voice recorder tapes for the commander before formally interviewing him. Case 9. This aircraft crashed into a populated area. The Board ignored evidence about unusual flying habits of the instructor pilot and possibly instrument errors. The co-pilot had not received CRM training because the former commander of the Air Training Command decided not to emphasize these concepts. Case 10. In this Gulf War fighter crash the unit commander was identified as responsible for the mishap. Two of the junior investigators were immediately "fired" from their regular jobs. General Hall's letter (on page 1) allude to this situation. Case 11. This was the second Gulf War fighter crash which involved the same commander as in Case 10. Another USAF fighter had made a simulated attack on the mishap aircraft without warning them ahead of time. The inexperienced mishap pilot apparently thinking they were under actual attack crashed into friendly territory while taking evasive action. This commander refused to allow the wreckage to be brought back to "his" base. Mishap board investigators were therefore forced to work in a forward area where they came under scud attack. This incident is also improperly listed as a "combat loss" rather than a mishap. Case 12. A Gulf War fighter-pilot dropped a bomb which prematurely exploded (his plane was destroyed but he ejected safely). This was clearly caught by the "gun camera" film of the following aircraft. The cause of premature explosion was a poorly designed and improperly installed fuse - but this mishap was incorrectly listed as a "combat loss", implying that enemy action was involved. Case 13. A two-place fighter crashed after the pilot lost control of the aircraft. The navigator said he intentionally delayed ejecting himself and his pilot (who was killed) because of a strong command directive precluding navigators from initiating dual ejections. In such situations navigators normally initiate dual ejections, but a general officer had established this unusual policy. Apparently this general did not trust navigators' judgment. This directive was suspected of causing other fatal accidents, but nobody survived them to tell their story. Case 14. A transport crashed while practicing dangerous low altitude maneuvers for an airshow. The board did not interview the squadron commander who was responsible for planning this maneuver (they only interviewed his replacement). The previous squadron commander and the board president were reportedly very close personal friends - suggesting that the president was protecting this squadron commander's career. Case 15. A transport crashed because an engine thrust reverser deployed on take-off. The board overlooked a witness statement providing evidence pointing to this cause, and later lost the critical parts, - making it impossible to physically analyze exactly how the various components failed. Cases 16, 17, and 18. Class A Mishaps involve accidents where the computed costs exceed one million dollars, or when the aircraft is destroyed, or is damaged beyond economical repair. These mishaps have always been counted in the Class A Mishap Rate, (which is the basic barometer of USAF flight safety). This year, for the first time, two mishaps (involving QF-106 piloted target aircraft that were destroyed) were not counted as rate-producing mishaps. A T-41 which was damaged beyond economical repair was also not included in this vital statistic. Gen Hall's letter, page 1 - described unsuccessful attempts to pull this kind of scam in previous years. Case 19. A fighter landed gear-up and burned. I and another employee discovered that the USAF records showed the mishap costs were slightly over $900,0000, clearly an inaccurately low figure. We investigated and found real costs exceeded one million dollars, and the USAF reluctantly had to redesignate this as a Class A mishap. But no one is looking into other such cases. Case 20. I "discovered" a wrecked USAF light aircraft hidden in a hanger. When I noted this mishap had not been reported, my escort admitted his command had decided not to report this mishap, and that the wreck was supposed to be concealed until they could find repair parts at various bases around the country. Case 21. A prototype aircraft almost crashed during a test flight. A general officer told me the embarrassing incident was not going to be reported to the Safety Agency (as required by regulation). A member of his staff explained "Congress is looking for cripples" (meaning any program which encounters problems might be canceled). Case 22. A jet fighter hit trees during a landing requiring the pilot to eject. This lieutenant was denied emergency medical treatment until he answered questions about the accident posed by a colonel who was the interim board president. Case 23. A transport crashed during a "spousal orientation flight." Wives were aboard to learn more about their husbands jobs. During the cruise phase, the wives were being allowed to sit in both pilots seats, and one apparently maneuvered the controls sending the aircraft out-of-control. The board decided they would report that one pilot seat was occupied by a spouse, but they would conceal the fact that the second pilot was also not at the controls during this mishap. Case 24. An aircraft crashed after experiencing a major inflight emergency. Some of the crew tried to bailout, while others rode it in (with fatal results). I met with the command's director of safety, and explained that I had previously designed a special bailout system for this aircraft, (Note, we have lost other crews in this weapons system). I then asked that the mishap board contact me for details, but I never heard from them. Case 25. Embarrassing mishaps often lead the services to suppress evidence. When an USAF fighter crashed while practicing an airshow routine, the "gun camera" film was not turned over to the Safety Agency as required by regulation. (Note the pilot survived this mishap.) Case 26. During a cross-country flight of two Navy fighters, the pilot and navigator in one ship removed their flight suits, helmets, and oxygen masks in an apparent attempt to "moon" the crew of the other aircraft. Unfortunately, this "college boy" prank proved fatal when they passed out. Navy records still conceal the real cause of this crash. Case 27. A helicopter crashed into a ridge line. I was asked by the pilot member of the board to participate, but the board president and flight surgeon did not want any expert help. The pilot member reported the president, a colonel, kept insisting the mishap crew was flying illegally (too low according to regulations). He also kept brow-beating a major in headquarters (who controlled that regulation) to agree with his logic. The major told the colonel the crew was legal six times, but finally gave in on the seventh phone call. The pilot member felt the regulations were at least confusing, and needed to be reworked, but the president disagreed. Thus, it appears the president was trying to "railroad" the dead crew - not and unusual occurrence for USAF boards. Case 28. A jet trainer crashed after its wing collapsed. Both pilots ejected, but one received serious injuries. I was recently contacted by a former student pilot in the unit, who stated he had noticed structural problems with that aircraft, (the student had been a USAF mechanical engineer before entering pilot training). He had tried to ground this aircraft before the mishap. He informed his flight leader, but the flight leader had ignored this important information. When the student later tried to visit with the mishap board, he said this flight leader physically restrained and verbally threatened him. Case 29. In recent weeks there have been two nearly tragic incidents involving Air Force crews which are apparently not being thoroughly investigated (possibly because the number of other recent high-visibility mishaps). The first involved a fighter which accidentally dropped a live 2000 pound bomb directly over a large US Army troop formation. Fortunately none of the soldiers were injured when the bomb exploded nearby. Case 30. Two aircraft on a very long-range exercise narrowly missed colliding with a foreign airliner. Both of these incidents appear to have been "hushed-up", which suggests just how bankrupt the USAF safety program is in truth. Remember the thirty cases cited above are only examples. The reasons that such problems occur so regularly are explained by this service's current policies and procedures, which are described in the second attachment, (Problems with the USAF Safety Process). There are numerous problems including: allowing the commands to investigate themselves, the use of non professional investigators on mishap boards, the imposition of unrealistic time constraints, lack of scientific expertise at the Air Force Safety Agency (AFSA), woefully inadequate mishap prevention concepts. This attachment also describes the role played by equipment design deficiencies, as well as providing examples of official misconduct, and instances of waste, fraud, and abuse, etc. This attachment furthermore explains how the current methodology used to calculate mishap economic losses is designed to systematically understate the direct costs, while totally ignoring the equally important indirect costs. Thus, our acknowledged three billion dollar annual DOD safety losses represent only a fraction of the real economic burden. The third attachment is the 1991 letter from Brigadier General Hall (who was then USAF Director of Aerospace Safety) to General McPeak. This very candid document warns the Chief of Staff (on page 1) "...we are headed for a disaster." Hall's heartfelt letter continues (on page 1) "...I have witnessed command manipulation of mishap cost/classification to improve the command statistics/ image, shallow and incomplete investigations into mishap causes, interference by MAJCOM staffs with the investigative board process, and punishment of board members for unpopular findings. All of these result from mature and continuing politicization of the investigation process by having the operating command investigate its own mishaps...Even more troubling is the acceptance by senior leaders of a mishap investigation process which frequently obscures supervisory culpability..." Hall goes on to explain why human factors is the critical USAF issue. The fourth attachment is the McPeak's curt reply which became known to us insiders as the Chief's "April fools joke". After Hall retired, General McPeak ignored all of his sage advice. His replacement (Brig Gen Cole) was located on McPeak's Pentagon staff (contrary to the recommendation in Hall's letter, page 5). When I attempted to inform Cole of critical issues, my supervisors (here at the Safety Agency in Kirtland AFB NM) told me to stop bothering the general. It seems that nobody wants to "rock the boat". But, our dedicated service personnel and the taxpayers deserve better. Thus, somebody must tell America's leaders about this outrageous situation. There are several reasons why I am the individual who has to stand up to these problems. Besides being the senior civilian at the Safety Agency (in terms of date of rank: GS-15 since 1981), I was the only Ph.D. on the staff, (my doctoral training focused specifically on human factors and systems safety while my masters thesis examined aviation safety and cost-benefit analysis). I also have by far the most publications, awards, and general officer briefing experience, etc, (Attachments offer examples). Furthermore, I have the most extensive and diverse professional accident investigation background (having worked for ten years in the Headquarters of both the National Transportation Safety Board, and the Federal Aviation Administration before transferring to the Air Force in 1987). Thus, I know how accidents should be investigated. I have also helped introduce cutting-edge accident prevention concepts. For example, in 1979 I drafted the first US Government recommendation calling for the introduction of Crew Resource Management (CRM) training programs. Such training is now required by the airlines, the US Army, Navy and belatedly by the USAF. This training has been shown to dramatically reduce human factors related mishaps (up to 81 percent). With my encouragement, many USAF senior leaders have tried to implement CRM training in their commands, but bureaucratic bungling, red-tape, and sabotage by some personnel have delayed the effective introduction of this training. This has in-turn contributed a number of our recent catastrophes. Additional information on CRM is contained in several attachments. My criticism should not be construed as an attack on the Air Force as an institution. On the contrary, I have a long-standing commitment to its safety for several personal reasons: My father was a career sergeant who died partly from wartime related illnesses. My Mother has served as a USAF volunteer for over four decades, while my brother and nephew are currently Air Force pilots. I have previously worked as a designer on several innovative USAF projects, e.g. "Redflame" one of the first lasers used in combat, and "Gunship" the AC-130. The Air Force in fact has paid for most of my education through two scholarships, as well as enrollment in ROTC and the Academy. I have also proudly served in the Air Force Reserve, and still have many close friends in the active and reserve components. Be aware that I have to tried unsuccessfully to reform this "system" from within, but (like General Hall) I found my efforts constantly rebuffed. As my criticisms grew more militant, my superiors' responses have also become increasing harsh. This has included: admonishments, threats of formal reprimands and/or suspensions without pay, and most recently outright firing, (effective Oct 1, 1994 supposedly as part of a RIF). But no threats or personal consequences can deter me from exposing these problems. For this "business", which has always been dangerous, has become unnecessarily deadly (largely because of the many incompetents, charlatans, and sycophants who have put "career above country"). This is reflected in the dramatic increase in the USAF class A mishap rate in the last few years since the Gulf War (FY91). Note the advertized figure the over 30 percent increase is in-reality 43 percent. Thus, the Air Force's failure to understand modern safety concepts has resulted in the loss of vast resources and many unnecessary deaths. For these reasons, I hope that you will consider the following urgent actions: 1. Ask the Secretary of Defense to have his Inspector General conduct an internal audit of USAF safety procedures to document the failures described herein. 2. Request the General Accounting Office undertake a detailed analysis of the direct and indirect costs of military mishaps. 3. Have your respective committees launch a highly thorough Congressional inquiry into these issues. Only this will assure the public that our Government wants candid answers to these important problems. Because of career implications, I believe that the truth will only be forthcoming if the witnesses testify and are cross-examined under oath in an open forum. The current recess will obviously preclude such hearings until after the November elections. I feel the current Chief of Staff needs to explain this situation before he is allowed to retire. Our service members, the families of the accident victims, and the American taxpayers are entitled to nothing less. But many of our problems go beyond these leadership failures, and involve the budgetary pressures currently facing the Air Force. For example, in one recent mid-air collision, the aircraft was not carrying enough parachutes for all crewmembers aboard. For them the "hollow force" has already arrived. As a Cadet I was fascinated by the courage and insight of General Billy Mitchell. Sixty-nine years ago he attacked his superiors for their indifference to the safety problems of his era. While I'm no Billy Mitchell, it's obvious that somebody needs to expose the current situation. Please help me protect those who so selflessly protect us all.
Respectfully yours, Alan E. Diehl, Ph.D. 3708 Calle Castano, N.E. Albuquerque, NM 87111 cc. Secretary Perry Secretary Widnall |
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